Asthma on two inhalers, with posterior teeth planned for implants

Correct answer: B. Beta-2 adrenergic AGONIST

• A. Muscarinic antagonists such as ipratropium and tiotropium ARE used in obstructive airway disease, but through a different receptor entirely, and neither of these two drugs belongs to that class.
• B. CORRECT. Both are BETA-2 ADRENERGIC AGONISTS. Beta-2 receptors on bronchial smooth muscle are Gs-coupled: stimulation raises cyclic AMP, which relaxes the muscle and relieves bronchoconstriction. They differ only in kinetics — ALBUTEROL is a SHORT-acting beta agonist (SABA), the rescue inhaler that works within minutes and is what you reach for in an office asthma attack; SALMETEROL is a LONG-acting beta agonist (LABA), used twice daily for maintenance and USELESS in an acute attack because of its slow onset. A LABA must never be used without an inhaled corticosteroid.
• C. Beta-1 receptors are predominantly cardiac. A beta-1 agonist such as dobutamine increases heart rate and contractility and does nothing for the airway.
• D. A beta-2 BLOCKER is the opposite of what an asthmatic needs — non-selective beta blockade with propranolol can precipitate severe bronchospasm, which is why it is avoided in asthma.

Note: Dental consequences of chronic inhaler use worth knowing: XEROSTOMIA with raised caries risk from the beta-2 effect on salivary flow; ORAL CANDIDIASIS from the inhaled corticosteroid, prevented by rinsing after each dose; and enamel erosion from the low pH of some formulations. Have the patient bring the rescue inhaler to every appointment, and keep it on the bracket table.

Correct answer: D. Correction of the occlusal plane, by intruding or reducing the supra-erupted opposing teeth

• A. The radiographs are explicitly described as showing good bone height and volume. Grafting solves a problem this patient does not have.
• B. There is no infection and no indication for antibiotics. Prophylaxis at placement is a separate question and does not substitute for restorative planning.
• C. An interim denture may be worn for aesthetics, but it does not correct the supra-eruption and does not resolve the space deficiency.
• D. CORRECT. Years of unopposed function have allowed the opposing teeth to SUPRA-ERUPT into the edentulous spaces, collapsing the occlusal plane and consuming the INTEROCCLUSAL RESTORATIVE SPACE. Place implants under that and there is no room for an abutment and a crown of adequate thickness, the emergence profile is wrong, and the restoration is loaded off-axis. The occlusal plane is corrected first — by orthodontic intrusion, by enameloplasty and crowning of the supra-erupted teeth, or in severe cases by segmental surgery — and the implant position is planned from the RESTORATIVE end result backwards.

Note: What this item adds is the sequencing decision that follows from it. The governing principle in implant dentistry is that treatment is RESTORATIVELY DRIVEN: decide where the tooth must be, then place the fixture to serve it — never the reverse.