Diploma of the Faculty of Dental Surgery (MFDS) Medical and Pharmacological Foundations Syllabus

What is the immediate sequence of management for anaphylaxis (after recognition)?

Call for help/999, remove the trigger, lay the patient flat with legs raised (sit up if breathing difficulty), give IM adrenaline, high-flow oxygen, and monitor airway, breathing and circulation. Repeat adrenaline after 5 minutes if needed.

State the adult chest compression rate, depth and compression:ventilation ratio in basic life support.

Rate $100\text{-}120$ compressions per minute, depth $5\text{-}6\ \text{cm}$, with a compression-to-ventilation ratio of $30{:}2$.

Outline the DRS ABC sequence used at the start of adult basic life support.

D - Danger (check it is safe), R - Response (shout and shake), S - Shout for help, A - Airway (head tilt/chin lift), B - Breathing (look, listen, feel for up to 10 seconds), C - Circulation/Compressions (start CPR if not breathing normally).

What rhythms are shockable on a defibrillator/AED?

Ventricular fibrillation (VF) and pulseless ventricular tachycardia (pulseless VT) are shockable. Asystole and pulseless electrical activity (PEA) are non-shockable.

State the dose and route of glucose for a CONSCIOUS hypoglycaemic patient who can swallow.

Give $15\text{-}20\ \text{g}$ of fast-acting oral glucose - e.g. glucose tablets, $200\ \text{mL}$ of fruit juice, or a glucose gel/drink - and repeat after 10-15 minutes if symptoms persist, followed by a longer-acting carbohydrate.

How is severe hypoglycaemia in an unconscious or uncooperative dental patient managed?

Do NOT give anything by mouth. Give intramuscular glucagon $1\ \text{mg}$ IM (or IV glucose if trained and access available), maintain airway, give oxygen, call 999, and give oral carbohydrate once the patient recovers consciousness.

What is the immediate management of a generalised (tonic-clonic) seizure in the dental chair?

Protect the patient from injury, do not restrain or put anything in the mouth, place items aside, maintain the airway, give oxygen, and time the seizure. If it lasts longer than 5 minutes (status epilepticus) give buccal midazolam and call 999.

State the buccal midazolam dose used for a prolonged convulsive seizure in an adult.

Buccal midazolam $10\ \text{mg}$ given into the buccal cavity for prolonged ($>5$ minutes) or repeated seizures, with the dose reduced in smaller adults/children. Call 999 for status epilepticus.

Describe the features and management of vasovagal syncope (a simple faint).

Features: pre-syncope with pallor, sweating, nausea, slow weak pulse, then transient loss of consciousness. Management: lay the patient flat and raise the legs to restore cerebral perfusion, loosen tight clothing, give oxygen, and reassure; recovery is usually rapid.

State the drug, dose and route used to relieve an attack of angina in the dental chair.

Glyceryl trinitrate (GTN) $400\text{-}800\ \mu g$ sublingually as spray or tablet, with the patient sitting upright. Give oxygen and rest; the dose may be repeated.

How do you distinguish stable angina from a myocardial infarction during a dental emergency?

Angina pain typically resolves with rest and GTN within a few minutes; in MI the chest pain is more severe, prolonged, not relieved by GTN, often with sweating, nausea, breathlessness and a sense of impending doom. Treat suspected MI as a 999 emergency.

State the immediate drug management of a suspected myocardial infarction in the dental surgery.

Call 999, give high-flow oxygen if hypoxic, give GTN sublingually, and give aspirin $300\ \text{mg}$ to be chewed (unless contraindicated). Keep the patient calm and monitor vital signs/be ready for CPR.

List the minimum emergency drugs recommended for a UK dental practice (Resuscitation Council).

Adrenaline $1{:}1000$ IM, oxygen, glyceryl trinitrate (GTN) spray, salbutamol inhaler, glucagon IM, oral glucose, aspirin $300\ \text{mg}$, and midazolam (buccal/oromucosal) for seizures.

List the minimum emergency equipment required in a dental practice.

Portable oxygen cylinder with flowmeter, oxygen masks/tubing, pocket mask with oxygen port, self-inflating bag-valve-mask with reservoir, oropharyngeal airways (range of sizes), portable suction with wide-bore aspiration tips, spacer device for inhaler, syringes/needles, AED, and disposable gloves. Drugs/equipment must be checked regularly and an AED available.

What flow rate of oxygen should be delivered in most adult medical emergencies in the dental practice?

High-flow oxygen at $15\ \text{litres/min}$ via a non-rebreathe mask with reservoir (except in hyperventilation, where oxygen is generally not needed).

Describe the management of MILD foreign body airway obstruction (effective cough) in a choking adult.

If the patient can cough effectively, encourage them to keep coughing and do not intervene, but stay with them and monitor in case the obstruction becomes severe.

Describe the management sequence for SEVERE choking (ineffective cough) in a conscious adult.

Give up to 5 back blows between the shoulder blades; if unsuccessful, give up to 5 abdominal thrusts (Heimlich). Alternate 5 back blows and 5 abdominal thrusts. If the patient becomes unconscious, start CPR and call 999.

What is the maximum recommended adult daily dose of paracetamol, and the standard dental dose?

Standard dose is $1\ \text{g}$ (two $500\ \text{mg}$ tablets) every 4-6 hours, to a maximum of $4\ \text{g}$ ($8 \times 500\ \text{mg}$) in 24 hours.

Why are NSAIDs such as ibuprofen often first-line for dental/inflammatory pain, and name three contraindications.

They are effective for inflammatory dental pain through prostaglandin (COX) inhibition. Contraindications/cautions: peptic ulcer/GI bleeding history, asthma (aspirin-sensitive), renal impairment, anticoagulation, and pregnancy (third trimester).

Why is aspirin contraindicated in children under 16 years?

Because of the risk of Reye's syndrome - a rare but serious condition causing acute encephalopathy and liver failure.

Why are opioids (e.g. codeine) generally poor choices for acute dental pain?

They are relatively ineffective for inflammatory dental pain, cause constipation, nausea, sedation and dependence, and codeine has variable metabolism (CYP2D6 polymorphism). NSAIDs/paracetamol are preferred.

What is the first-line antibiotic for a spreading dental infection in a non-penicillin-allergic adult, with dose?

Amoxicillin $500\ \text{mg}$ three times daily (or phenoxymethylpenicillin), with metronidazole $400\ \text{mg}$ three times daily added if there is anaerobic/spreading involvement. First-line management is still drainage/removal of the cause.

State the key principles of antimicrobial stewardship in dentistry.

Antibiotics are an adjunct, not a substitute for operative treatment; prescribe only when there is spreading infection or systemic involvement; use the narrowest effective agent at the correct dose and shortest course; and review/avoid unnecessary prophylaxis to reduce resistance.

Which dangerous interaction occurs between metronidazole and alcohol?

A disulfiram-like reaction - flushing, headache, nausea, vomiting and tachycardia - due to inhibition of acetaldehyde dehydrogenase. Patients must avoid alcohol during and for 48 hours after the course.

Name the legal categories that govern prescribing of medicines in the UK.

General Sales List (GSL), Pharmacy (P) medicines, Prescription-Only Medicines (POM), and Controlled Drugs (regulated under the Misuse of Drugs Act with schedules 1-5).

List the essential elements that must appear on a valid prescription.

Patient's name, address and age (if under 12); date; the drug name, formulation, strength, dose, frequency and quantity/duration; prescriber's signature; and the prescriber's name and address. Controlled drugs require additional specific details.

What is a clinically important interaction between warfarin and commonly prescribed dental drugs?

Metronidazole, miconazole (including oral gel) and some other antibiotics/antifungals potentiate warfarin by inhibiting its metabolism, raising the INR and bleeding risk. NSAIDs also increase bleeding risk. Avoid or monitor INR closely.

Why should erythromycin/clarithromycin be used cautiously with certain other drugs?

Macrolides inhibit cytochrome P450 (CYP3A4), increasing levels of drugs such as warfarin, statins (simvastatin - rhabdomyolysis risk), midazolam and others, leading to toxicity.

Define an adverse drug reaction (ADR) and distinguish Type A from Type B reactions.

An ADR is an unwanted/harmful reaction to a drug at normal doses. Type A (augmented): dose-related, predictable extensions of pharmacological effect (e.g. bleeding with warfarin). Type B (bizarre): unpredictable, not dose-related, often immune-mediated (e.g. penicillin anaphylaxis).

What is the Yellow Card Scheme and what should be reported through it?

The MHRA's UK system for reporting suspected adverse drug reactions. Report all suspected ADRs to new (black triangle) medicines and all serious suspected reactions to established drugs, including those for vaccines, medical devices and herbal products.

State the maximum safe doses of lidocaine with and without adrenaline.

Plain lidocaine: approximately $4.4\ \text{mg/kg}$ (max around $300\ \text{mg}$); lidocaine with adrenaline: approximately $7\ \text{mg/kg}$ (max around $500\ \text{mg}$). A $2\%$ solution contains $20\ \text{mg/mL}$, so a $2.2\ \text{mL}$ cartridge contains $44\ \text{mg}$.

How does adrenaline added to a local anaesthetic improve its action?

Adrenaline causes local vasoconstriction, which reduces systemic absorption, prolongs the duration of anaesthesia, increases the depth/success of the block, and reduces operative bleeding.

Which local anaesthetic is associated with methaemoglobinaemia and which patient group should avoid felypressin-containing prilocaine?

Prilocaine in high doses can cause methaemoglobinaemia. Prilocaine with felypressin (Octapressin) is generally avoided in pregnancy because felypressin (a vasopressin analogue) may have oxytocic activity.

Define conscious sedation as used in dentistry.

A technique in which drugs produce a state of depression of the central nervous system enabling treatment, but during which verbal contact with the patient is maintained throughout. The drugs and techniques used should carry a margin of safety wide enough to render loss of consciousness unlikely.

Name the standard agents used for inhalation sedation and IV sedation in dentistry.

Inhalation sedation: nitrous oxide and oxygen (titrated, e.g. up to about $30\text{-}40\%$ $\ce{N2O}$). Intravenous sedation: midazolam (a benzodiazepine), titrated to effect. The reversal agent for midazolam is flumazenil.

What is the reversal agent for benzodiazepine over-sedation, and its key limitation?

Flumazenil reverses benzodiazepine sedation. Its limitation is a shorter half-life than midazolam, so re-sedation can occur and the patient must be monitored after administration.

List two behavioural / non-pharmacological techniques used to manage dental anxiety.

Examples: tell-show-do, acclimatisation/graded exposure, relaxation and breathing exercises, distraction, positive reinforcement, cognitive behavioural therapy (CBT), hypnosis, and good communication/rapport. These should be tried before or alongside pharmacological methods.

What are the main indications for referral for dental treatment under general anaesthesia?

GA is reserved for patients where local anaesthesia and conscious sedation are not feasible - e.g. very young or pre-cooperative children, severe learning disability or special needs, acute spreading infection/trismus preventing LA, failed sedation, or extensive surgical procedures. It must be carried out in a hospital setting with critical-care facilities.

Why should general anaesthesia never be carried out in primary care dental practice in the UK?

Following the Poswillo report and GDC guidance, dental GA must only be provided in a hospital setting with appropriate critical-care/resuscitation facilities and an anaesthetist, because of the risk of death and serious complications.

What pre-operative fasting and escort requirements apply to a patient having IV conscious sedation or GA?

For GA the patient must be appropriately fasted (commonly $6$ hours for food, $2$ hours for clear fluids) with a responsible escort. IV sedation patients also need a responsible adult escort to take them home and stay with them, and must not drive or operate machinery for 24 hours.