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Pharmacology · patient case with 6 questions

Antihypertensive Review & Gingival Enlargement

demo: 60-year-old male

chief: “My gums have been growing over my front teeth.”

history: Hypertension, benign prostatic hyperplasia, angina.

meds: Nifedipine, prazosin, terazosin, atenolol

findings: Generalized fibrotic enlargement of the interdental papillae, most marked in the anterior maxilla. Plaque index moderate. No bone loss on bitewings.

Question 1

Which medication in this patient's list is the most likely cause of the gingival enlargement?

  1. Nifedipine
  2. Terazosin
  3. Atenolol
  4. Prazosin
Show answer and explanation

Correct answer: A. Nifedipine

  • A. Correct. Nifedipine is a dihydropyridine calcium channel blocker, and CCBs are one of the three classic drug groups causing gingival overgrowth — along with phenytoin and cyclosporine. Amlodipine does the same.
  • B. Terazosin, like prazosin, is an alpha-1 blocker used for hypertension and BPH; it does not cause gingival overgrowth.
  • C. Beta blockers are not associated with gingival overgrowth.
  • D. Alpha-1 blockers are not associated with gingival overgrowth.

Note: The enlargement is drug-influenced, not drug-caused in isolation — plaque is a required cofactor, which is why meticulous hygiene is the first line of management before any surgical reduction.

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Question 2

What is the mechanism of action of atenolol?

  1. Non-selective beta-1 and beta-2 antagonist
  2. Selective beta-1 adrenergic antagonist that reduces heart rate and cardiac output
  3. Alpha-2 agonist acting centrally
  4. Alpha-1 adrenergic antagonist
Show answer and explanation

Correct answer: B. Selective beta-1 adrenergic antagonist that reduces heart rate and cardiac output

  • A. Non-selective blockade describes propranolol, which is why propranolol is avoided in asthma and limits epinephrine dosing more sharply.
  • B. Correct. Atenolol is cardioselective (beta-1), which lowers heart rate and cardiac output while largely sparing bronchial beta-2 receptors.
  • C. Central alpha-2 agonism describes clonidine and methyldopa.
  • D. Alpha-1 antagonism describes prazosin, doxazosin, and terazosin.

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Question 3

Propranolol differs from atenolol in that it:

  1. Blocks calcium channels in vascular smooth muscle
  2. Acts as a partial agonist at beta-1 receptors only
  3. Blocks both beta-1 and beta-2 receptors, allowing unopposed alpha-mediated peripheral vasoconstriction
  4. Is a selective beta-1 antagonist with no pulmonary effect
Show answer and explanation

Correct answer: C. Blocks both beta-1 and beta-2 receptors, allowing unopposed alpha-mediated peripheral vasoconstriction

  • A. Calcium channel blockade is verapamil, diltiazem, and the dihydropyridines.
  • B. Partial agonism describes agents with intrinsic sympathomimetic activity such as pindolol, not propranolol.
  • C. Correct. Propranolol is non-selective. Because beta-2 mediated vasodilation is blocked, epinephrine in local anesthetic can produce unopposed alpha vasoconstriction with a hypertensive response and reflex bradycardia. It also inhibits renin release.
  • D. That describes atenolol and metoprolol.

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Question 4

Prazosin produces its antihypertensive effect by which mechanism, and which adverse effect follows?

  1. Aldosterone antagonism, producing hyperkalemia
  2. Direct arteriolar dilation, producing lupus-like syndrome
  3. Beta-2 agonism, producing tremor and tachycardia
  4. Alpha-1 adrenergic receptor antagonism, producing dizziness, drowsiness, nasal congestion, and palpitations
Show answer and explanation

Correct answer: D. Alpha-1 adrenergic receptor antagonism, producing dizziness, drowsiness, nasal congestion, and palpitations

  • A. Aldosterone antagonism describes spironolactone.
  • B. A lupus-like syndrome is classically associated with hydralazine and procainamide.
  • C. Beta-2 agonism describes albuterol.
  • D. Correct. Alpha-1 blockade relaxes vascular smooth muscle and the bladder neck. First-dose orthostatic hypotension, dizziness, drowsiness, nasal congestion, and palpitations are typical — rise the patient slowly from the dental chair.

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Question 5

Each of the following is a recognized adverse effect of terazosin EXCEPT one. Which is the exception?

  1. Nasal congestion
  2. Dizziness
  3. Orthostatic hypotension
  4. Bleeding
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Correct answer: D. Bleeding

  • A. Nasal congestion follows from loss of alpha-mediated vasoconstriction in the nasal mucosa.
  • B. Dizziness is common with alpha-1 blockade, particularly on standing.
  • C. Orthostatic hypotension, especially the first-dose phenomenon, is characteristic of this class.
  • D. Correct — this is the exception. Alpha-1 blockers do not affect platelet function or the coagulation cascade, so bleeding is not an expected adverse effect.

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Question 6

Rivaroxaban, which the physician is considering adding, works by:

  1. Blocking the P2Y12 ADP receptor on platelets
  2. Selectively blocking the active site of factor Xa
  3. Blocking thrombin directly
  4. Inhibiting cyclooxygenase-1 irreversibly
Show answer and explanation

Correct answer: B. Selectively blocking the active site of factor Xa

  • A. P2Y12 blockade is clopidogrel.
  • B. Correct. Rivaroxaban, like apixaban, is a direct selective factor Xa inhibitor — an anticoagulant, not an antiplatelet.
  • C. Direct thrombin inhibition is dabigatran.
  • D. Irreversible COX-1 inhibition is aspirin.

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