Methotrexate is a dihydrofolate reductase inhibitor often used in the

treatment of malignancies and autoimmune diseases such as

rheumatoid arthritis. It acts by reducing the growth of highly proliferative
cells such as cancer cells and immune cells. Some of the notable side effects
of methotrexate use include hepatotoxicity, mucositis, gastrointestinal
disturbances, and pancytopenia. Methotrexate does not result in tooth
discoloration, so it is the exception.
Key Takeaway:
 Methotrexate use can cause hepatotoxicity, oral ulcerations,
and gastrointestinal disturbances.
 
This patient is taking oral bisphosphonates for an extended period (>3
years) along with a corticosteroid, so she is at an increased risk of
medication-related osteonecrosis of the jaw (MRONJ) following
extractions and bone manipulation. The lack of vascular supply and ability
for the bone remodel increases the risk of bacterial infection, delayed
healing, and ultimately necrosis. The main goal would be to prevent bacterial
ingress into the extraction sites, so an antifungal troche prescription would
not help in preventing this.

A. Pre- and post-operative antibiotics

Antibiotics are a common adjunct to prevent osteonecrosis of the jaws
following extractions in at-risk individuals. Antibiotics prevent bacterial
growth at these sites to allow for healing. It is also a useful tool for non-
invasive treatment if osteonecrosis does occur.

C. 2-month risedronate (Actonel®) drug holiday

The bone remodeling period in humans is between 3-6 months and by 2
months, significant turnover of the bone occurs, and new osteoclast cells
are present. By discontinuing bisphosphonates for this time period, new
osteoclasts can form, allowing for bone remodeling. This can help prevent
osteonecrosis following extractions. While research on the need for drug
holidays is currently debated, it is still a viable choice following discussion
with the patient's physician.

D. Post-operative chlorhexidine (Peridex®) rinse

Similarly to antibiotics, chlorhexidine (Peridex®) rinse is an antibacterial
agent to prevent invasion and infection of the bone by bacteria. Prescribing
post-operative chlorhexidine (Peridex®) rinse will allow for more rapid
healing and prevention of bone necrosis.

Key Takeaway:
 Taking oral bisphosphonates for an extended period of time (>3
years) puts the patient at an increased risk of MRONJ.
 Chlorhexidine, a 2-month risedronate (Actonel®) drug holiday, and
pre- and post-operative antibiotics are great adjuncts to prevent
osteonecrosis.
---------------------------------
Bisphosphonates are a class of medications inhibit osteoclast-mediated
bone resorption. These medications come in two main configurations:
1) Nitrogenous and 2) Non-nitrogenous. These two types
of bisphosphonates differ in their mechanism of action with nitrogen-
containing bisphosphonates having more potency due to the fact that it
forms stronger hydrogen bonds to the enzyme that it is inhibiting.

The most potent bisphosphonate is Zoledronate (Zometa®) and is

nitrogen-containing. It's relative potency compared to other bisphosphonates
is shown in the table below.

Bisphosphon Potency
 ate

Etidronate 1x

Pamidronate 100x

Alendronate 100 - 1000x

Risedronate 1000 -
10,000x

Zoledronate >10,000x

B. Alendronate (Fosamax®)
D. Pamidronate (Aredia®)
Although both alendronate and pamidronate are nitrogen-containing
bisphosphonates, they are not as potent as zoledronate.

C. Etidronate (Didronel®)
Etidronate is a non-nitrogenous bisphosphonate and is significantly
less potent than the other nitrogen-containing bisphosphonates.

Key Takeaway:
 The most potent bisphosphonate is zoledronate (Zometa®) and it is
nitrogen-containing.
 Zoledronate (Zometa®) is over 10,000 times more potent than
etidronate (Didronel®).

Bisphosphonates have a high affinity for metal cations, which if present

gastrointestinal system could interfere with the absorption of oral
bisphosphonates. Fluorine is not a supplement that binds to
bisphosphonates and it would not affect its absorption in the intestines, so it
is the exception.

A. Calcium
C. Iron
D. Magnesium
Bisphosphonates have a high affinity for calcium, magnesium, and iron, as
well as aluminum. It is important that people taking oral bisphosphonates
avoid eating food or supplements containing these cations for at least 1-2
hours after their dose, as they can form complexes and inhibit the absorption
of the medication.

Key Takeaway:
 Bisphosphonates have a high affinity for metal cations which
include calcium, magnesium, iron, and aluminum.
 Fluorine is not a supplement that binds to bisphosphonates and it
would not affect its absorption in the intestines.
The patient in this case is taking alendronate (Fosamax®), which is
a bisphosphonate. Bisphosphonates acts by inhibiting an enzyme
responsible for maintaining osteoclast cytoskeleton dynamics. This prevents
formation of a ruffled border, which is critical in adhering osteoclasts to the
bone surface to allow for resorption. By impeding this function, an increase
in bone density results.

A. Inhibition of RANKL
Denosumab (Prolia®) is a subcutaneous monoclonal antibody that acts as
a RANKL inhibitor, an important ligand for osteoclast differentiation.
Inhibition of RANKL results in less bone remodeling, and bone density
increases. This is not the mechanism of action of bisphosphonates.

C. Estrogen receptor modulation

Estrogen receptors located in bone are involved in signaling pathways that
maintain and increase bone density by activation of osteoblasts. Selective
estrogen receptor modulators (SERMs) are medications that bind to
different estrogen receptors in the body with either agonist or antagonist
functions. Raloxifene (Evista®) is a SERM with agonist activity at bone and
antagonist activity on breast and uterine tissues. It is indicated in the
treatment of osteoporosis in post-menopausal women. Bisphosphonates
do not bind to estrogen receptors.

D. Enhances intestinal absorption of calcium

Vitamin D (calcitriol) is a hormone that increases the intestinal absorption
of calcium by upregulating the number of protein transporters for calcium.
This is a common supplement for post-menopausal women since calcium
makes up the main component of bone. Bisphosphonates
may lower intestinal calcium absorption as they can chelate this ion. The
main mechanism of action of bisphosphonates is not related to
gastrointestinal handling of calcium.

Key Takeaway:
 The mechanism of action fo Alendronate (Fosamax®) is inhibition
of osteoclast function.
 Denosumab (Prolia®) is a subcutaneous monoclonal antibody that
acts as a RANKL inhibitor.
Nitrogen-containing bisphosphonates have a primary mechanism of
action of inhibiting abnormal osteoclast activity and thus bone resorption.
They do not play a role in increasing the function of osteocytes, and
do not increase the amount of osteoid secreted into the bone. By inhibiting
osteoclast function, this allows for the normal balance of bone formation
relative to resorption to be restored, thereby increasing bone density.
Therefore increase in osteoid secretion is the exception.

A. Trigger apoptosis of osteoclasts

B. Inhibition of osteoclastic metabolism
Nitrogen-containing bisphosphonates have two main effects on osteoclasts.
One effect is triggering apoptosis of osteoclasts and another is inhibition of
osteoclast metabolism, which interferes with its ability to bind to bone.
Both of these mechanisms will lead to decreased bone resorption.

D. Inhibition of angiogenesis
Nitrogen-containing bisphosphonates inhibit differentiation of stem cells into
endothelial cells and also inhibit their migration. This can prevent the
formation of new blood vessels, leading to deficient healing following bone
trauma, causing osteonecrosis.

Key Takeaway:
 Nitrogen-containing bisphosphonates have a primary mechanism
of action of inhibiting abnormal osteoclast activity.
Osteoporosis is a metabolic bone disorder characterized by decreased
bone density which predisposes the individual to skeletal fracture.
Antiresorptive therapies are often employed to combat decreased bone
density and improve quality of life in affected individuals. These medications
can come with side effects, of which medication-related osteonecrosis of
the jaw (MRONJ) is of particular concern in dentistry. MRONJ is the resulting
disease due to decreased bone turnover and healing after a traumatic event
(eg. dental extraction, implant placement).

Etidronate (Didronel®) is an oral bisphosphonate that can be used to

treat osteoporosis. It is the least potent of all bisphosphonates and is
the least likely to interfere with bone remodeling and cause MRONJ.

A. Zoledronate (Zometa®)
C. Pamidronate (Aredia®)
The table below shows the relative potency of other bisphosphonates
compared to etidronate (Didronel®).

Bisphosphon Potency
ate

Etidronate 1x

Pamidronate 100x

Alendronate 100 - 1000x

 Risedronate 1000 -
10,000x

Zoledronate >10,000x

Zoledronate (Zometa®) and pamidronate (Aredia®) are more potent

bisphosphonates. In addition, they are taken intravenously, which is
associated with higher rates of MRONJ than oral bisphosphonates.

D. Denosumab (Prolia®)
Denosumab (Prolia®) is a monoclonal antibody used to treat osteoporosis
and certain bone cancers. It is a RANKL inhibitor, which decreases bone
resorption with the goal of increasing bone density. Denosumab is delivered
intravenously and has a higher risk of MRONJ compared to oral
bisphosphonates.

Key Takeaway:
 Medication-related osteonecrosis of the jaw (MRONJ) is a side
effect of antiresorptive medications.

 Etidronate (Didronel®) is an oral bisphosphonate that is

the least potent of all bisphosphonates.

The patient presents with a history of hypertension and is

prescribed hydrochlorothiazide (Microzide®), a thiazide diuretic. Thiazide
diuretics reduce blood volume by reducing sodium reabsorption in the distal
convoluted tubules of the kidneys, inducing natriuresis and subsequent
water loss. Hyperkalemia is not an associated side effect of thiazide
diuretics, but it is associated with potassium-sparing diuretics such as
spironolactone (Aldactone®).

A. Dizziness
B. Arrhythmia
D. Xerostomia
Side effects of hydrochlorothiazide may include dizziness, headaches,
xerostomia, hypokalemia, and arrhythmias.

Key Takeaway:
 Potassium-sparing diuretics, such as spironolactone, are associated
with hyperkalemia.
 Side effects of hydrochlorothiazide may include dizziness,
headaches, xerostomia, arrhythmias, and hypokalemia.

The patient presents with a history of a myocardial infarction, and is

currently medicated with rivaroxaban (Xarelto®), an anticoagulant used
to prevent blood clots. Rivaroxaban competitively inhibits clotting factor
Xa, interrupting both intrinsic and extrinsic pathways of the blood
coagulation cascade and thereby preventing thrombus formation.
Rivaroxaban shares the same mechanism of action as apixaban (Eliquis®).

A. Inhibits vitamin K reductase

Inhibition of vitamin K reductase describes the mechanism of action
of warfarin (Coumadin®).

B. Accelerates antithrombin III

Acceleration of antithrombin III activity describes the mechanism of action
of heparin.

C. Direct thrombin inhibitor

Direct inhibition of thrombin describes the mechanism of action
of dabigatran (Pradaxa®).

Key Takeaway:
 Rivaroxaban (Xarelto®) and apixaban (Eliquis®) are both
inhibitors of clotting factor Xa.
 Inhibition of vitamin K reductase describes the mechanism of action
of warfarin (Coumadin®).
The patient is taking rosuvastatin (Crestor®), which is a statin medication
used to reduce his cholesterol and treat his hyperlipidemia. This medication
competitively inhibits the enzyme HMG-CoA reductase, which converts
HMG-CoA to mevalonate. This conversion is a critical step in the production
of cholesterols in the liver.

A. Inhibits angiotensin II receptor

The inhibition of the angiotensin II receptor is the mechanism of action
for angiotensin receptor blockers (ARBs) such as losartan. These
medications promote vasodilation and reduce blood pressure.

C. Inhibits intestinal reabsorption of bile acids

Preventing the intestinal reabsorption of bile acids is the mechanism of
action for bile acid sequestrants such as cholestyramine. These
medications lower low-density lipoproteins.

D. Inhibits calcium channels

The inhibition of calcium channels is the mechanism of action for calcium
channel blockers such as nifedipine. These medications block calcium
influx, which prevents the vasoconstriction of blood vessels and results in a
reduction of blood pressure.

Key Takeaway:
 Statins are a class of medications that lower cholesterol by
inhibiting HMG-CoA reductase, an enzyme that is responsible for
cholesterol synthesis in the liver.
Nitroglycerin (Nitrostat®) is an antihypertensive medication that acts by
causing nitric oxide release and therefore vasodilation and reduced
blood pressure. Blockage of nitric oxide release describes a hypertensive
mechanism of action, so this is the exception.

A. Blockage of alpha 1 receptors

Blockage of alpha 1 receptors describes the mechanism of action of
medications, such as prazosin, terazosin, and labetalol. All of these
medications are antihypertensives that act by causing vasodilation. Alpha 1
receptors are located in blood vessels and cause vasoconstriction when
activated.

C. Blockage of beta receptors

Blockage of beta receptors describes the mechanism of action of beta-
blockers, such as propranolol or metoprolol. Beta receptors are found in the
heart and encourage increased rate and force of contraction which increases
blood pressure.

D. Inhibition of angiotensin-converting-enzyme
Inhibition of angiotensin-converting enzyme (ACE) describes the
mechanism of action of ACE inhibitors, such as lisinopril. ACE is part of the
renin-angiotensin-aldosterone system. ACE converts angiotensin I into
angiotensin II, which has many systematic impacts that increase blood
pressure including the release of aldosterone.

Key Takeaway:
 Nitroglycerin (Nitrostat®) is an antihypertensive medication that acts
by causing nitric oxide release.
 Nitroglycerin will cause vasodilation and reduce blood pressure.

The patient’s symptoms are most likely due to the drug interaction
between propranolol and the local anesthetic. The epinephrine within the
local anesthetic cartridge has both alpha-adrenergic effects that produce
vasoconstriction and beta-adrenergic effects that produce vasodilation.

However, with the use of the beta-blocker propranolol, a systemic dose of

epinephrine produces unopposed alpha vasoconstriction, which causes
increased blood pressure, sweating, and feelings of anxiety.
A. Allergy to lidocaine
Symptoms of an allergic reaction to lidocaine would typically include
urticaria, erythema, and edema at the site of injection. In addition, more
severe reactions can cause hypotension, loss of consciousness, and possibly
respiratory distress. None of these symptoms were seen in the patient.

B. Drug interaction with methotrexate

Methotrexate is an antimetabolite chemotherapy drug that reduces folic
acid to tetrahydrofolic acid. This ultimately results in a decrease in nucleic
acid synthesis and works well against rapidly multiplying cells. This
medication does not have adverse drug interactions that would cause the
symptoms stated in the patient.

D. Marijuana use prior to appointment

9-Tetrahydrocannabinol (THC) is the primary source of the effects of
cannabis. There exists potential drug interactions between the THC and
epinephrine in the lidocaine that may cause tachycardia and arrhythmias,
which were not specific to the patient’s case. In addition, these interactions
are much less common than those between propranolol and epinephrine.

Key Takeaway:
 The beta-blocker propranolol can interact with epinephrine and
produce unopposed alpha vasoconstriction, which causes increased
blood pressure, sweating and feelings of anxiety.
Digoxin and other cardiac glycosides are prescribed to help a heart
suffering from congestive heart failure. They work by blocking the
Na+/K+ATPase enzyme in order to increase the influx of calcium ions into
cardiac muscle cells and promote positive inotropy.

A. Competitively antagonizes angiotensin II

Angiotensin II receptor blockers (ARBs), such as losartan, competitively
antagonize angiotensin II and can be used to treat hypertension.
B. Inhibits angiotensin-converting enzyme
Angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril,
inhibit angiotensin-converting enzyme and can also be used to treat
hypertension.

C. Vasodilates smooth muscle in coronary arteries

Vasodilators, such as hydralazine, vasodilate smooth muscle in coronary
arteries and can also be used to treat hypertension.

Key Takeaway:
 Cardiac glycosides work by inhibiting Na+/K+ ATPase.
The patient is taking two medications, clopidogrel and aspirin due to a
history of myocardial infarction. Both drugs act by altering platelet
function.

Clopidogrel acts by inhibiting ADP receptors on the surface of platelets which

are critical in allowing for platelet aggregation. Aspirin functions by
irreversibly binding to COX1 and COX2 which produce thromboxane A2. The
substance thromboxane A2 is usually produced by platelets via COX
enzymes, which allows for platelet aggregation.

A. Quantity
Platelet quantity is affected by certain diseases, such as leukemias or
autoimmune disorders which target platelet count. The medications listed
above do not affect platelet quantity.

B. Size
Platelet size is not affected by aspirin and clopidogrel.

C. Lifespan
The normal platelet lifespan is 3 to 7 days. This is not affected by this
patient’s medication.
Key Takeaway:
 Both clopidogrel and aspirin affect platelet function.
HMG-CoA reductase inhibitors, or statin drugs, have been shown to
significantly increase pulp chamber calcification when compared with
patients that had not taken statins. In addition to lowering serum lipid levels,
statins have been shown to induce differentiation of dentin pulp cells.
Studies suggest the loss of vertical height of the pulp chamber and increased
calcification is due to increased odontoblastic activity.

A. ACE inhibitors
Angiotensin converting enzyme (ACE) inhibitors, used to treat
hypertension, have not been shown to cause calcification of pulp chambers.

B. Beta blockers
Beta blocking agents, primarily used to treat hypertension, have not been
shown to cause calcification of pulp chambers.

C. Factor Xa inhibitors
Factor Xa inhibitors are a class of anticoagulant agents. They have not
been shown to cause calcification of pulp chambers.

Key Takeaway:
 Statin drugs have been shown to significantly increase pulp chamber
calcification when compared with patients that had not taken statins.

This patient is taking hydrochlorothiazide (Microzide®),

a diuretic medication used to treat hypertension and edema.
Hydrochlorothiazide (HCTZ) acts on the distal convoluted tubules of the
kidneys and inhibits the sodium chloride cotransporter system that works to
reabsorb sodium and chloride. The increased ion excretion pulls water with
it, resulting in water loss. This reduces the amount of water in the body and
increases urine output.
A. Beta blocker
Beta blockers are also used to treat hypertension and block beta-
adrenergic receptors to decrease the sympathetic effects of epinephrine,
causing the heart to beat slower and with less contractility. This results in
decreased cardiac output and blood pressure.

C. Calcium channel blocker

Calcium channel blockers are used to treat hypertension and work by
preventing calcium from entering the cells of the heart and arteries. This
allows blood vessels to relax and dilate, resulting in a decreased blood
pressure.

D. ACE inhibitor
Angiotensin-converting enzyme (ACE) inhibitors prevent the enzyme
from converting angiotensin I to angiotensin II, a potent vasoconstrictor.
Angiotensin II also stimulates the adrenal glands to release aldosterone, a
hormone that acts on the kidneys to result in water retention.

Key Takeaway:
 Diuretics are a class of medications that are used to treat hypertension
by reducing the amount of water in the body, which consequently
increases urine output.
 Diuretics, beta blockers, calcium channel blockers, and angiotensin-
converting enzyme (ACE) inhibitors are all classes of medications that
are used to treat hypertension.
A PT (prothrombin time) test measures abnormalities of the extrinsic
coagulation system. The PT can be presented in seconds (average time to
blood clot is 10-13 seconds), or as a ratio - the international normalized
ratio (INR).

The INR allows for easy comparisons between different labs. INR measures
the effectiveness of warfarin (Coumadin®) in patients as a ratio of the
patient's PT to a control PT, both measured in seconds. In healthy
individuals, an INR below 1.1 is considered normal, and 2.0-3.0 is usually
considered the effective therapeutic range for patients taking the
medication.

B. Bleeding time
Bleeding time involves lancing the skin and observing how long it takes to
stop bleeding. While the bleeding time may occasionally be a useful test to
evaluate platelet function, it does not predict bleeding risk and is used much
less commonly today.

C. Partial thromboplastin time

A partial thromboplastin time (PTT) test measures abnormalities of the
intrinsic coagulation system with abnormalities of factors VIII, IX, and XI
being the most common causes for an isolated prolongation of the PTT.

D. Complete blood count

A complete blood count (CBC) is a group of tests that measure the cells
that circulate the bloodstream including red blood cells, white blood cells,
and platelets.

Key Takeaway:
 INR measures the effectiveness of warfarin (Coumadin®).
 INR values of 2.0-3.0 are usually considered
the effectivetherapeutic range for patients
taking warfarin (Coumadin®).

Lisinopril (Zestril®) is an angiotensin-converting enzyme

(ACE) inhibitor that acts by inhibiting angiotensin converting enzyme,
which is part of the renin-angiotensin-aldosterone system that raises blood
pressure and volume. In addition to involvement in this pathway, ACE breaks
down substance-P and bradykinin. These two substances act as irritants
in the lung and can trigger coughing spasms. Therefore use of lisinopril is
associated with development of a cough due to elevated substance-p and
bradykinin.

An alternative medication that can be used when this side effect occurs is
an angiotensin receptor blocker (ARB) such as losartan
(Cozaar®).ARBs work by blocking angiotensin II receptors rather than the
ACE enzyme. ARBs do not result in a cough because the ACE enzyme is still
functioning and can break down substance P and bradykinin.

A. Sitagliptin (Januvia®)
Sitagliptin (Januvia®) is a DPP-4 inhibitor which is used in type II diabetic
patients to slow the inactivation of incretins which promote insulin release. It
is unrelated to the mechanism of an ACE inhibitor and would not be used as
a replacement.

B. Captopril (Capoten®)
Captopril (Capoten®) is an ACE inhibitor and has the same mechanism of
action as lisinopril and would therefore still result in a cough in this patient.

D. Propranolol (Inderal LA®)

Propranolol (Inderal LA®) is a beta blocker which lowers blood pressure
by blocking the beta receptors primarily located in the heart and act
to decrease rate and force of contraction of the heart. Its mechanism is
unrelated to that of lisinopril and it would not be an ideal replacement for an
ACE inhibitor.

Key Takeaway:
 Lisinopril (Zestril®) is associated with development of a cough.
 Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor.

Hydrochlorothiazide (Microzide®) is a diuretic that acts by blocking the

Na/Cl transporter at the distal convoluted tubule. Diuretic medications
promote diuresis, increasing urine output and decreasing fluid volume in the
body. They are often used to treat hypertension, heart failure, and edema.

A. Furosemide (Lasix®): blocks carbonic anhydrase at the proximal

convoluted tubule
Furosemide is a diuretic that acts by blocking the Na/K/2Cl transporter at
the thick ascending loop of Henle.

B. Spironolactone (Aldactone®): blocks epithelial sodium channel (ENaC) at

the collecting duct
Spironolactone is a diuretic that acts by blocking aldosterone receptors at
the collecting duct.

C. Triamterene (Dyrenium®): blocks aldosterone receptors at the collecting

duct
Triamterene is a diuretic that acts by blocking epithelial sodium channels
(ENaC) at the collecting duct.

Key Takeaway:
 Hydrochlorothiazide (Microzide®) is a diuretic that acts by blocking
the Na/Cl transporter at the distal convoluted tubule.

This patient's presentation is most consistent with pseudomembranous

candidiasis, which is an opportunistic fungal infection. It often manifests
after a course of antibiotics which wipe out oral flora that are naturally
protective against fungal overgrowth. Pseudomembranous candidiasis or oral
thrush involves a white removable plaque with a red bed underneath. It can
be accompanied by a burning sensation or foul taste/breath and shows up
most commonly on the buccal mucosa, tongue, or palate.

After the extraction is completed and any granulation tissue is curetted from
the base of the socket, the source of bacterial infection will be removed. In
this scenario, it is acceptable to discontinue the antibiotics to allow for
normal flora to repopulate the oral cavity and use an antifungal
lozenge to kill off the fungi.

A. Proceed with extraction as planned and prescribe prednisolone cream

While the patient's tooth should be extracted, prescribing prednisolone may
help with any inflammation she is experiencing, but it will not treat the
causative candida infection.

B. Finish antibiotics and return to clinic after antibiotics are completed

The patient has developed pseudomembranous candidiasis as an
opportunistic infection due to the antibiotics she has been on. To treat the
fungal infection, the patient should not finish the course of antibiotics.

D. Refer to an oral and maxillofacial surgeon

Referral to an oral and maxillofacial surgeon is not indicated in this case
since pseudomembranous candidiasis can be managed by the dentist.

Key Takeaway:
 Pseudomembranous candidiasis or oral thrush involves a white
wipeable plaque.
 If antibiotics are causing oral thrush, they be discontinued and the
patient should start a clotrimazole (Mycelex®) troche.
This presentation is most consistent with central papillary
atrophy or median rhomboid glossitis. It is a chronic (and usually
asymptomatic) condition that involves a smooth, erythematous zone in the
center of the tongue dorsum. It is currently thought that a chronic fungal
infection leads to atrophy of the papillae in this region. Currently, no
treatment is necessary for asymptomatic median rhomboid glossitis as it is
not dangerous or contagious. Symptomatic lesions (burning, mild pain) can
be treated with an antifungal to help manage symptoms. However, no
treatment is needed at this time since the patient is asymptomatic.

A. Start clotrimazole (Mycelex®) troche

Clotrimazole (Mycelex®) troche is an antifungal medication that can be used
to treat fungal infections. However, this patient is asymptomatic, so no
treatment is indicated at this time.

B. Start valaciclovir (Valtrex®)

Valaciclovir (Valtrex®) is an antiviral medication and would not be effective
in treating this patient's fungal infection.

C. Start antibiotics
Antibiotics are used to treat bacterial infections, not fungal infections.

Key Takeaway:
 Median rhomboid glossitis can be suspected when an erythematous
zone is in the center of the tongue dorsum.
 Currently, no treatment is necessary for asymptomatic median
rhomboid glossitis.

The patient is taking 0.12% chlorhexidine gluconate (Peridex®), a

broad-spectrum antibacterial mouthrinse commonly used to help reduce
inflammation from gingivitis. This rinse kills bacteria by binding to the
phospholipid membrane and causing cell rupture, reducing the bacterial load
contributing to gingivitis. A rare adverse effect can include mouth
ulceration, but this is not a common finding that would be expected in
someone using the mouth rinse, so this is the exception.

B. Calculus buildup
Calculus buildup is a common side effect of chlorhexidine gluconate
(Peridex®). This rinse promotes the mineralization of plaque and induces
rapid biofilm formation.

C. Altered taste
Chlorhexidine gluconate (Peridex®) temporarily alters the taste
perception of salt and bitterness. This usually lasts a few hours following
use of the oral rinse, and the patient could have altered taste for salt and
bitter if he used the rinse before the oral exam.

D. Extrinsic staining
One of the most common side effects of 0.12% chlorhexidine gluconate
(Peridex®) is rapid brown-yellow staining of teeth, limiting the
medication’s long term use.

Key Takeaway:
 0.12% chlorhexidine gluconate (Peridex®) can cause extrinsic
staining, altered taste, and calculus buildup.
The first line of antibiotics for patients at risk of infective endocarditis is
amoxicillin. Since this patient is already on a course of amoxicillin, which is a
penicillin antibiotic, she should be prescribed an antibiotic of another class.
Out of the options presented, the dentist should prescribe azithromycin
(Zithromax®) instead. This medication is a macrolide antibiotic that inhibits
bacterial protein synthesis and is of a different antibiotic class compared to
amoxicillin.

Route Antibiotic Regimen

Adults Children

Oral Amoxicillin 2g 50
mg/kg

IM or Ampicillin 2g 50
IV mg/kg

Cefazolin or ceftriaxone 1g 50
mg/kg

Allergy to Penicillins

Oral Cephalexin 2g 50
mg/kg
 Azithromycin or 500 15
clarithromycin mg mg/kg

Clindamycin 600 20
mg mg/kg

IM or Cefazolin or ceftriaxone 1g 50
IV mg/kg

Clindamycin 600 20
mg mg/kg

A. Doxycycline (Monodox®)
Doxycycline (Monodox®) is a bacteriostatic antibiotic typically used as an
adjunct in periodontal therapy due to their ability to concentrate well in the
gingival crevicular fluid. It is not recommended in antibiotic prophylaxis.

B. Ampicillin (Ampi®)
Ampicillin (Ampi®) is an intravenous penicillin antibiotic. This medication
should not be used for antibiotic prophylaxis since the patient is already on a
course of penicillin antibiotics. This may result in an additive effect of the
medications, which could be toxic, and intravenous delivery is unnecessary.

D. Metronidazole (Flagyl®)
Metronidazole (Flagyl®) is an antibiotic that works most effectively
against gram negative and positive anaerobic bacteria. This narrow
spectrum of use limits its ability to be an effective monotherapy antibiotic for
prophylaxis of infective endocarditis as the most common offending
organisms are streptococcus and staphylococcus (gram positive, aerobic
species).

Key Takeaway:
 When the patient is currently taking an antibiotic and needs an
antibiotic prior to dental treatment, it should come from another class
of antibiotic.
Fluconazole (Diflucan®) is an oral antifungal medication used to treat
candidiasis. This medication is a strong inhibitor of cytochrome P450, an
enzyme that metabolizes warfarin (Coumadin®). Use of fluconazole in this
patient will increase the bioavailability of warfarin (Coumadin®) and result in
decreased coagulation and increased bleeding.

A. It will lead to an unstable increase in blood glucose levels

Fluconazole (Diflucan®) is available to be prescribed as an oral suspension
that contains sucrose. Although this can increase blood glucose in
patients who have diabetes, it is unlikely to cause an unstable increase in
blood glucose and is not a contraindication for this reason.

B. It exhibits cross-reactivity with metformin (Riomet®)

Fluconazole (Diflucan®) is of an entirely different drug class compared to
metformin (Riomet®), which is an oral hypoglycemic. The chances of cross-
reactivity are extremely slim, and there are no reports of this occurrence.

D. It will prolong the QT interval in this patient

Fluconazole (Diflucan®) has been reported to cause a prolongation of the
QT interval which can lead to torsades de pointes in extreme situations.
This is more likely in patients with congenital long QT syndrome or are on
multiple medications that prolong the QT interval. This patient does not meet
any of these criteria, therefore this is not the reason that fluconazole
is contraindicated for this patient.

Key Takeaway:
 Fluconazole (Diflucan®) is an oral antifungal medication used to
treat candidiasis.
 Fluconazole (Diflucan®) is a strong inhibitor of cytochrome P450,
an enzyme that metabolizes warfarin (Coumadin®).
The patient in this case is demonstrating characteristics signs and symptoms
suggestive of mucormycosis. Mucormycosis is a rare, but serious fungal
infection caused by the Rhizopus and Mucor genera. These fungal spores are
relatively common and while breathed in by many, they will usually only
cause disease in the immunocompromised.

Mucormycosis affecting the head and neck region (rhino-orbito-cerebral

mucormycosis) can present with fever, periorbital swelling, visual problems,
sinusitis, and headache. As the disease spreads hematogenously tissue
necrosis can occur, leading to black lesions (eschars) as seen on the dorsum
of the patient's nose. In addition to many of these characteristic findings, the
patient has poorly controlled diabetes, which is another known risk factor for
the disease.

Treatment of this condition is critical in order to prevent dissemination and

mortality. A combination of antifungal therapy and surgical debridement,
where indicated, is appropriate.

Amphotericin B (Fungizone®) is an antifungal agent given intravenously

to patients fighting a severe fungal infection. This method of delivery allows
for rapid administration and increased bioavailability of the medication to
prevent spread of the infection. The drug works by binding to ergosterol, a
component of fungal cell membranes, to form pores which causes membrane
leakage of electrolytes and cellular death. Amphotericin B has many side
effects including fever, chills, arrhythmias, phlebitis, and nephrotoxicity so its
use is reserved for severe mycoses.

A. Clotrimazole (Lotrimin®)
Clotrimazole (Lotrimin®) is an antifungal medication used for localized
infections, such as oral and vulvovaginal candidiasis. It usually is formulated
for topical use as a tablet, troche, or cream. It is not absorbed from the
gastrointestinal tract when taken orally, so it is not effective against invasive
infections.

B. Nystatin (Mycostatin®)
Nystatin (Mycostatin®) is an antifungal medication used for localized,
superficial Candida infections of the oral cavity, skin, vagina, and esophagus.
It can be prepared as a solution or a cream. It is not absorbed orally and
is not given intravenously due to toxic systemic effects.

D. Terbinafine (Terbinex®)
Terbinafine (Terbinex®) is an antifungal used to treat nail and skin
infections. This medication prevents ergosterol synthesis in the fungal cell
membrane. It is used as a cream on the skin, and deeper infections can be
treated with oral tablets. This antifungal is not effective in treating
mucormycosis.

Key Takeaway:
 Mucormycosis is a rare, but serious fungal infection that can occur in
patients who are immunocompromised.
 Amphotericin B (Fungizone®) is an antifungal agent given
intravenously to patients with a severe fungal infection.
Certain medications used for chemotherapy in cancer patients can affect the
bone marrow and suppress the immune system. This permits fungi that
naturally reside in the oral cavity to cause opportunistic infections without an
appropriate immune response from the host.

Roughly 30% of patients undergoing chemotherapy will develop an oral

fungal infection. This incidence decreases to roughly 2% with use of an
antifungal medication. Nystatin (Mycostatin®) is commonly prescribed
prophylactically to these patients to decrease the likelihood of fungal
infections from developing.

B. Acyclovir (Zovirax®)
Acyclovir (Zovirax®) is an antiviral medication commonly prescribed for
herpes simplex virus. Viral infections are not the main concern for patients
undergoing chemotherapy.
C. Amoxicillin (Amoxil®)
Amoxicillin (Amoxil®) is used as a prophylactic antibiotic and is reserved
for patients at risk of certain conditions, such as infective endocarditis or
infection due to severe neutropenia caused by another condition. Patients on
chemotherapy are not considered for antibiotic prophylaxis unless they are
receiving surgical dental treatment and their neutrophil count is less than
1000/mm3.

D. Clindamycin (Cleocin T®)

Since 2021, the American Dental Association (ADA) no longer
recommends Clindamycin (Cleocin T®) to be used as a prophylactic
antibiotic due to the high risk of developing opportunistic Clostridium
difficile infections and its associated high morbidity and mortality.

Key Takeaway:
 It is common in patients who are undergoing chemotherapy to
develop an oral fungal infection.
 Nystatin (Mycostatin®) is commonly prescribed prophylactically to
patients undergoing chemotherapy to decrease the likelihood of fungal
infections from developing.

This patient presents with clusters of vesicles on the vermillion border of his
lip. This presentation is characteristic of recurrent herpes labialis, or
infection with herpes simplex virus (HSV-1), which reactivates from
latency during a period of lowered immunity, such as from stress for this
patient while aggressively practicing for his wrestling tournament.

Recurrent herpes labialis presents as a "cold sore" or blisters and sores on

the vermilion border of the lip. Famciclovir (Famvir®) is an antiviral
medication used to treat the symptoms of recurrent herpes labialis and can
be recommended for this patient.

A. Fluconazole (Diflucan®)
Fluconazole (Diflucan®) is an azole antifungal medication used to prevent
and treat a variety of fungal and yeast infections.

C. Lamivudine (Epivir®)
Lamivudine (Epivir®) is a nucleoside reverse transcriptase inhibitor
(NRTI), which is a class of antiretroviral medications commonly used to
prevent and treat HIV/AIDS.

D. Isoniazid (Tubizid®)
Isoniazid (Tubizid®) is an antibiotic used to prevent and treat tuberculosis,
a serious bacterial infection caused by Mycobacterium tuberculosis.

Key Takeaway:
 Recurrent herpes labialis, or infection with HSV-1 can present with
a cluster of vesicles on the vermillion border of his lip.
 Famciclovir (Famvir®) is an antiviral medication used to treat the
symptoms of recurrent herpes labialis.
Amphotericin B (Fungizone®) is an antifungal agent and has
significant nephrotoxicity which can lead to hypokalemia due to distal
tubular membrane permeability. Hypomagnesemia and hypochloremic
acidosis are also potential electrolyte imbalances due to distal tubular
damage.
A. Peripheral edema
B. Shortness of breath
C. Hypotension
Amphotericin B (Fungizone®) is an antifungal agent known for its
extensive number of side effects, many of which can be significant. These
include drug-induced nausea, vomiting, fever, chills, edema, headache,
dyspnea, hypotension, shaking, hypoxia and nephrotoxicity. For this reason,
amphotericin B is usually limited to severe, life-threatening fungal
infections.

Key Takeaway:
  Amphotericin B (Fungizone®) is an antifungal agent and has
significant nephrotoxicity which can lead to hypokalemia.
 Some side effects of amphotericin B include peripheral edema,
shortness of breath, and hypotension.

Fluconazole (Diflucan®) inhibits fungal cytochrome P450, decreasing

ergosterol synthesis, which results in decreased cell membrane
formation. Ketoconazole can be used for oral/pharyngeal candidiasis, which
is what this patient likely has based upon the history of steroid use and the
presence of a white, wipeable plaque on the tongue and buccal mucosa.

A. Binds to ergosterol and forms pores in the fungal cellular membrane

Amphotericin B (Fungizone®), an antifungal agent, functions via the
primary mechanism of action of binding to ergosterol and forming pores
in the fungal cell membrane. Amphotericin B is reserved for invasive,
systemic fungal infections since it has an extensive number of side effects,
many of which can be serious

C. Competes with uracil and interferes with fungal RNA and protein synthesis
5-fluorocytosine is an antifungal agent that competes with uracil
and inhibits fungal RNA synthesis. This medication is primarily used as
a combination treatment with amphotericin B for meningitis caused
by Cryptococcus neoformans, and is never used alone as it is fungistatic,
not fungicidal.

D. Inhibits 1,3-Beta-glucan synthase which stops the creation of glucan in

the fungal cell wall
The antifungal class of echinocandins inhibit 1,3-Beta-glucan
synthase and inhibits beta-glucan synthesis in the fungal cell wall.
Beta-glucans can comprise 30-60% of a fungal cell wall mass in Candida.
Echinocandins include caspofungin and micafungin which are approved for
the treatment of esophageal candidiasis and invasive candidiasis.
Key Takeaway:
 Fluconazole (Diflucan®) inhibits fungal cytochrome P450,
decreasing ergosterol synthesis, which results in decreased cell
membrane formation.
 The presence of a white, wipeable plaque on the tongue and buccal
mucosa is a common sign of candidiasis.
The patient in this case is presenting with signs and symptoms
of inflammatory papillary hyperplasia (IPH). IPH is a benign, reactive
inflammatory lesion of the oral mucosa that can be induced
by Candida yeast due to a denture that is not removed or cleaned frequently
enough. It presents as small papules on the hard palate and can be
accompanied by redness or burning. To treat this patient, an antifungal
medication such as fluconazole (Diflucan®) rinse can be used.

B. Metronidazole (Flagyl®) rinse

Metronidazole (Flagyl®) is an antibiotic and is used to treat bacterial
infections, including skin and vaginal infections. It is not effective
for Candida infections.

C. Chlorhexidine (Peridex®) rinse

Chlorhexidine (Peridex®) rinse is an antibacterial oral rinse, often used to
treat gingivitis. It also has some antifungal properties and can be used as a
denture disinfectant for patients with denture stomatitis.

D. Wipe with cotton

Inflammatory papillary hyperplasia is a benign, reactive lesion that cannot be
wiped off with cotton. It must be treated with an antifungal medication.

Key Takeaway:
 Inflammatory papillary hyperplasia (IPH) can be induced
by Candida yeast.
  To treat inflammatory papillary hyperplasia (IPH),
an antifungalmedication, such as fluconazole (Diflucan®) rinse, can
be used.

The patient presents with a history of infective endocarditis and is planned to

undergo dental surgery. Antibiotic prophylaxis is recommended to prevent
risk of infective endocarditis of patients at risk. Since the patient has an
allergy to penicillin, the next most recommended antibiotic is 500 mg of
oral azithromycin.

B. Amoxicillin
C. Ampicillin
D. Penicillin V
Amoxicillin, ampicillin, and penicillin V are drugs in the penicillin class.
As the patient is allergic to penicillins, these drugs are contraindicated in this
case.

Key Takeaway:
 When patients have a history of infective endocarditis, antibiotic
prophylaxis is recommended.
 In patients with an allergy to penicillin, the next most recommended
antibiotic is 500 mg of oral azithromycin.
Tetracycline chelates (binds to) divalent cations such as calcium and
magnesium and therefore less of the antibiotic is absorbed when taken with
milk products which are rich in calcium. This is the exception.

A. Hepatotoxicity
High doses of tetracycline can induce fatty liver disease and can result
in hepatotoxicity, failure, and death.

B. Tooth discoloration in children

Tetracycline is contraindicated in pregnant women and children 8 years of
age and younger because tetracycline concentrates in developing dentition
leading to discoloration of the teeth.

D. Fanconi syndrome, a renal acidosis

Tetracycline can cause Fanconi syndrome, a type II renal tubular acidosis,
which disrupts reabsorption of many ions in the proximal convoluted tubule.

Key Takeaway:
 Tetracycline is associated with hepatotoxicity, tooth discoloration in
children, and fanconi syndrome.
 When tetracycline is taken with milk products it decreases the
absorption of the antibiotic.

Infective endocarditis is a possible complication that can arise after dental

procedures of susceptible patients. This can come as a result of bacteremia,
or bacteria circulating in the bloodstream, which allows the bacteria to
attach to abnormal valves or the inner lining of the heart. Antibiotic
prophylaxis is indicated in certain patients who are at higher risk for
developing infective endocarditis. These patients include those with
prosthetic material following heart repair, with certain congenital heart
diseases, or with a previous history of infective endocarditis. Patients
with Tetralogy of Fallot, a type of cyanotic congenital heart disease, are at
much higher risk of developing infective endocarditis and should take
antibiotic prophylaxis before dental procedures.

B. Calcific aortic stenosis

Calcific aortic stenosis is a disease in which the aortic valves thicken and
stiffen, limiting valve function and decreasing cardiac output. Calcific aortic
stenosis is not an indication for antibiotic prophylaxis

C. History of total joint replacement

Patients with a history of total joint replacement do not require antibiotic
prophylaxis for dental procedures. If it is deemed necessary to prevent
prosthetic joint infection, it would be most appropriate for the patient’s
orthopedic surgeon to recommend and prescribe the antibiotics.

D.Mitral Valve prolapse

Mitral valve prolapse is a condition in which the one or both leaflets of the
mitral valve may not close properly when the heart is contracting, leading to
the backward flow of blood into the left atrium. Mitral valve prolapse is
generally asymptomatic to mild in manner and is not an indication for
antibiotic prophylaxis

Key Takeaway:
 Antibiotic prophylaxis before dental treatment is indicated for
patients that have unrepaired cyanotic congenital heart disease such
as Tetralogy of Fallot.

Azoles, like clotrimazole and fluconazole, inhibit the biosynthesis of sterols

such as ergosterol, which is a necessary component of the fungal cell
membrane. Without ergosterol, the cell membrane becomes porous and
damaged, which results in fungal cell death.

A. Inhibits DNA and protein synthesis in fungi

5-Flucytosine inhibits both protein and DNA synthesis in fungi. It only works
on fungal cells that are actively replicating and dividing.

C. Inhibits cell wall formation of fungi

Echinocandins, like caspofungin, inhibit glucan synthase which weakens
the cell wall of fungi.

D. Interacts with fungal membrane sterols physicochemically

Polyenes, like nystatin and amphotericin, directly interact with sterols in the
cell membrane to form channels that lead to leakage through the cell wall.
Key Takeaway:
 The mechanism of action for the drug clotrimazole is inhibiting sterol
biosynthesis in fungal cells.
Drug-induced immune hemolytic anemia is a rare presentation of
anemia and has been found to be associated with penicillins
like amoxicillin and cephalosporins. The anemia is caused by the drug
triggering the immune system to attack its own red blood cells and can
present with cyanosis, indicated by this patient’s blue tint of her lips.
Discontinuing the drug usually resolves the anemia.

B. Clindamycin
Clindamycin is associated with a risk for clostridium difficile colitis, also
known as pseudomembranous colitis. The risk seems to be higher in
elderly, recently hospitalized, and in those with weakened immune systems.

C. Azithromycin
Azithrmycin is associated with a risk for QT prolongation in patients and
can cause arrhythmias, especially in those on vasoconstrictors. If a patient is
allergic to amoxicillin and pre-procedure antibiotics are indicated,
azithromycin is an alternative prescription.

D. Erythropoietin
Erythropoietin is a hormone that is released by the kidney to stimulate the
formation of red blood cells in response to low oxygen levels or hypoxia.
Erythropoietin can be elevated in patients with cyanotic heart disease.

Key Takeaway:
 In incredibly rare circumstances, penicillins and cephalosporins can
cause drug-induced immune hemolytic anemia.

The American Dental Association (ADA) and the American Academy of

Orthopedic Surgeons (AAOS) published a joint position statement in 2014
recommending against prescribing antibiotics for prosthetic joint
infection prophylaxis prior to dental procedures. Multiple case-control
studies do not show a significant difference in prosthetic joint infection in
those receiving antibiotic prophylaxis compared to those not receiving
antibiotic prophylaxis. Prescribing antibiotics also presents the potential for
added risk of antibiotic resistance, adverse drug reactions, and added cost.

Should this patient’s orthopedic surgeon make the clinical decision to

prescribe outside of professional guidelines, it is recommended that this
patient be referred to have this medication prescribed by the
recommending provider to avoid potential medico-legal complications.

A. Prescribe the orthopedic surgeon’s recommended antibiotic regimen

While the American Dental Association (ADA) and the American Academy of
Orthopedic Surgeons (AAOS) recommend against prescribing prophylactic
antibiotics for prosthetic joint infection, it is okay for the patient to have
them since her orthopedic surgeon has recommended

According to the American Heart Association

(AHA), prophylaxis against infective endocarditis is reasonable before
dental procedures that involve manipulation of the periapical region of
teeth and the perforation of the oral mucosa, which includes root canal
procedures. Since the patient has a history of infective endocarditis, he
requires antibiotic prophylaxis.

Additional conditions and procedures that require antibiotic

prophylaxis are listed below:
1. Prosthetic cardiac valve (or prosthetic material used for cardiac valve
repair)
2. Cardiac transplant with valvular regurgitation
3. Some congenital heart conditions such as an unrepaired cyanotic heart
disease
 4. Any repaired congenital heart defect with residual shunts or valvular
regurgitation
A. Total joint replacement
B. Mitral valve prolapse
D. Rheumatic heart disease
According to the American Dental Association and the American Heart
association, certain conditions and procedures require antibiotic
prophylaxis while others do not.

A list of conditions and procedures that do not require prophylaxis are

listed below:
1. Joint replacement
2. Mitral valve prolapse (with or without regurgitation)
3. Heart murmurs
4. Rheumatic heart disease
5. Bicuspid valve disease
6. Calcific aortic stenosis
7. All other congenital heart conditions such as atrial septal defect,
ventricular septal defect, and hypertrophic cardiomyopathy

Key Takeaway:
 Those with history of infective endocarditis require antibiotic
prophylaxis.

Based upon the clinical findings of a white, wipeable plaque on the dorsal
tongue as well as the biopsy results, the patient most likely
has candidiasis. Fluconazole (Diflucan®) belongs to a class
of antifungals called azoles and can be used for
oral/pharyngeal candidiasis. It inhibits fungal cytochrome P450, decreasing
ergosterol synthesis, which results in the formation of pores in the cell
membrane. This leads to the destruction and killing of the fungus.

A. Acyclovir (Zovirax®)
Acyclovir (Zovirax®) is an antiviral medication typically used for herpes
zoster or varicella. It functions by competitively inhibiting DNA
polymerase, which terminates the growing viral DNA chain. It would not be
effective for this patient’s fungal infection.

B. Amoxicillin (Amoxil®)
Amoxicillin (Amoxil®) is an antibiotic used to treat various microbial
infections. It functions by inhibiting cell wall synthesis via the protein beta-
lactam, and would not target the patient’s fungal infection.

D. Diphenhydramine (Benadryl®)
Diphenhydramine (Benadryl®) is an antihistamine that works by blocking
the action of histamine, which is a substance that causes allergic
symptoms. This medication is used to relieve symptoms of allergies such as
irritated, red, watery eyes, runny nose, and cough.

Key Takeaway:
 White, wipeable plaque on the dorsal tongue is indicative
of candidiasis.
 Fluconazole (Diflucan®) can be used for
oral/pharyngeal candidiasis.

Ampicillin is the antibiotic of choice for children who cannot take oral
medications. It is given intravenously or intramuscularly in a dose of
50mg/kg, 30 minutes before dental treatment.

B. Azithromycin
Azithromycin is given if the child has a penicillin allergy and can take oral
medications. It is given in a dose of 15mg/kg, 1 hour before dental
treatment.

C. Amoxicillin
Amoxicillin belongs to a class of penicillin drugs and thus should not be
given to patients with a penicillin allergy.

D. Clindamycin
Clindamycin can be given to patients with a penicillin allergy but
generally, azithromycin is preferred due to fewer adverse side effects. It is
given in a dose of 20mg/kg, 1 hour before treatment.

Key Takeaway:
 Ampicillin (intravenous or intramuscular administration) is the
antibiotic of choice for children who cannot take oral medications.

Metronidazole is a commonly prescribed antibiotic that is highly active

against many gram-positive and gram-negative anaerobic bacteria. It is
often used to treat certain sexually transmitted diseases, as well as C.
Difficile and H. Pylori infections.

When taking metronidazole, ethanol and ethanol-containing products

should be avoided as a disulfiram-like reaction can occur due to the drug
interaction. This disulfiram-like reaction is characterized by nausea,
vomiting, tachycardia, and flushing, and is due to an accumulation
of acetaldehyde in the blood. In severe cases, patients can experience
respiratory depression, cardiac dysrhythmias convulsions, and even death.

A. Zinc
Zinc supplements can reduce the absorption of certain drugs
including tetracyclines. There is no interaction between zinc and
metronidazole.

C. Milk
Tetracycline chelates with calcium which can interfere with the absorption
of the antibiotic. There is no interaction between calcium and metronidazole.
In fact, patients are encouraged to take metronidazole with milk as it can
decrease stomach upset.

D. Tyramine
Tyramine is an amino acid that helps to regulate blood pressure. It can
be found in certain foods such as aged cheeses, beers, and cured meats.
Tyramine-containing foods should be avoided when taking monoamine
oxidase inhibitors as the medication can cause tyramine to build up in the
body and precipitate a hypertensive crisis.

Key Takeaway:
 Taking metronidazole and ethanol can result in a disulfiram-like
reaction.
 A disulfiram-like reaction is characterized by nausea, vomiting,
and tachycardia.
23. antibiotic anti fungal/antiviral