INBDE high-yield · Updated October 2026
High-Yield Medical and Oral Conditions for the INBDE
The INBDE tests two kinds of conditions again and again. The first is the medically complex patient whose care changes in the dental chair: high blood pressure, diabetes, blood thinners, bone drugs, pregnancy, asthma, adrenal insufficiency, transplants and bleeding disorders. The second is the genetic or developmental condition you must recognise from one oral sign.
For the first group, learn the rule that changes what you do. For the second, learn the signature finding. This is the same clinically focused approach we use with students in The Study Boards INBDE course.
160/100confirmed: no elective care, consult the physician
0.04 mgepinephrine limit for at-risk heart patients
70 mg/dLblood glucose at or below this = hypoglycemia
8 weeksexposed bone needed to call it MRONJ
How The Study Boards helps you with these conditions
Practise the decisions, not just the facts
Medically complex patients and syndrome signs appear across the whole exam, not in one chapter. In The Study Boards INBDE course, the faculty-created Modules and Master Files teach the rule that changes your treatment, and you then meet these patients in case-based questions in your daily tasks, the nightly live tests at 9 PM New York time and the Master and Grand Test Series. The course is extremely personalised: red lines and assignments are given to you on the go, it learns from the way you are studying, and faculty are there to assist you. A US-licensed dentist answers your doubts. The same patients also appear in the DLOSCE, which The Study Boards DLOSCE course covers.
Part A
Medically complex patients: what changes in the dental chair
Questions here rarely ask you to define a disease. They ask what you do differently.
| Condition | The number or rule | What changes in the dental chair | Watch for |
|---|---|---|---|
| Hypertension | Below 160/100: no change. Confirmed above 160/100: no elective care, consult the physician.1 | Repeat a high reading before you decide. Limit epinephrine to 0.04 mg if the heart history needs caution (two cartridges of 1:100,000). Avoid epinephrine retraction cord in uncontrolled hypertension.1 | Orthostatic hypotension when the chair comes up: raise the patient slowly. Gingival overgrowth with calcium channel blockers, most often nifedipine.1 |
| Diabetes | Hypoglycemia = blood glucose 70 mg/dL or less.4 | Morning appointments. Do not book at peak insulin action. Confirm the patient has eaten and taken their medicines. Check HbA1c before implants.4 | Hypoglycemia: give 15 to 20 g of fast sugar, recheck in 15 minutes. Slow healing, more infections, periodontitis (the link runs both ways), candidiasis, dry mouth.4 |
| Warfarin | INR 3.0 or less = usual therapeutic range; continue the drug. Simple extraction judged safe at INR 3.5.2 | Do not stop warfarin yourself. Use local measures: pressure, hemostatic agents, sutures, tranexamic acid.2 | Some experts accept an INR up to 4.0 for simple extractions.2 |
| DOACs and antiplatelets | DOACs (apixaban, rivaroxaban, dabigatran): usually no change. Antiplatelets: do not alter.2 | For high-bleeding-risk surgery, the physician may pause a DOAC for 24 to 48 hours. Treat as late as possible after the last dose.2 | Dual antiplatelet therapy after a coronary stent: never stop it early; contact the cardiologist first.2 |
| Bisphosphonates, denosumab (MRONJ) | Osteoporosis doses carry a low risk (about 0.05% on oral bisphosphonates). Cancer doses carry a much higher risk.3 | Before cancer antiresorptives start: extract hopeless teeth and finish surgery first. Osteoporosis patients: routine care, explain the risk.3 | Avoid bone surgery when you can in cancer patients already on these drugs. Drug holidays have no proven benefit.3 |
| Pregnancy | Preventive, diagnostic and restorative care is safe throughout pregnancy.6 | Radiographs are safe at any stage. Local anesthetic with epinephrine (lidocaine, mepivacaine, bupivacaine, prilocaine) may be used. Head higher than feet; pillow under the right hip or turn her slightly to the left.56 | NSAIDs: avoid from 30 weeks and limit from 20 weeks. Tetracyclines: never. Acetaminophen and penicillins are fine.67 |
| Asthma | Symptoms more than twice a week mean poor control. Ask about hospital or emergency visits and triggers.8 | Confirm today’s dose was taken and keep the rescue inhaler within reach. Use acetaminophen when aspirin or NSAIDs set off the patient’s asthma.8 | Attack: stop, give a beta-2 agonist inhaler and oxygen; if worse, epinephrine and call emergency services. Inhaled steroids can cause oral candidiasis.8 |
| Adrenal insufficiency | The body cannot raise cortisol under stress. Adrenal crisis: hydrocortisone 100 mg IV or IM at once.9 | Plan any extra steroid cover with the physician. Minor to moderate surgical stress: hydrocortisone 25 to 75 mg over 24 hours, usually for 1 to 2 days.9 | Crisis signs: severe weakness, fainting, abdominal pain, vomiting, confusion, low blood pressure.9 |
| Organ transplant | Lifelong immunosuppression. Clear dental infection before the transplant.11 | Discuss every planned procedure with the transplant team. Decide antibiotic cover with them. In dialysis patients, never take BP or inject in the fistula arm.11 | Candidiasis, hairy leukoplakia, Kaposi sarcoma, gingival overgrowth from cyclosporine.11 Heart transplant with valve disease needs infective endocarditis prophylaxis.14 |
| Bleeding disorders | Hemophilia A = factor VIII, B = factor IX, both X-linked. Von Willebrand disease is the most common bleeding disorder.1315 | Extractions and other invasive work only with a hemostasis plan from the hematologist. Use tranexamic acid or EACA plus local measures.12 | Inferior alveolar block is a higher-risk injection: buccal infiltration or intraligamentary anesthesia are low-risk options. Most fillings need no factor cover.12 |
Blood pressure: the three zones to remember
Repeat any high reading before you decide. These zones come from the ADA’s table for adults.1
Below 160/100: treat normally
160 to 180 / 100 to 109: emergency care only, monitor
Above 180/109: physician first
Elective care is fine.Recheck BP every 10 to 15 minutes during emergency care.Refer urgently if the patient has symptoms.
Where students lose the markThe ADA table defers elective care once a repeated reading stays above 160/100. A separate 2017 ACC/AHA statement says delaying elective major surgery may be considered at 180/110 or higher. Read the question: elective dental care or emergency care?1
More detail, condition by condition
Diabetes: the hypoglycemia drill
- Signs: shaking, sweating, fast heartbeat, dizziness, hunger, confusion. Severe: cannot eat or drink, seizures, unconscious.4
- Check glucose with a glucometer. If 70 mg/dL or less, give 15 to 20 g of carbohydrate: 4 glucose tablets, half a cup of juice or regular soda, or 1 tablespoon of sugar or honey.4
- Recheck after 15 minutes and repeat until it is above 70 mg/dL. If the patient cannot swallow or is unconscious, call emergency services.4
- Avoid orange juice in kidney disease because of its potassium.4
MRONJ: the definition and the real risk numbers
All three must be present: current or past antiresorptive therapy (alone or with immune modulators or antiangiogenic drugs); exposed bone, or bone that can be probed through a fistula, for more than 8 weeks; and no history of radiation therapy to the jaws or metastatic disease to the jaws.3
- Osteoporosis, oral bisphosphonates: about 0.05% (5 per 10,000). IV zoledronate for osteoporosis: about 0.02%. Denosumab for osteoporosis: 0.3% after 10 years.3
- Cancer patients on zoledronate: risk clusters below 5%; on denosumab: 0 to 6.9%, mostly below 5%.3
- The mandible is affected more often than the maxilla (75% vs 25%). Most cases follow tooth extraction or other bone surgery.3
- Denosumab does not bind bone; its effect fades within about six months. If the physician pauses it, surgery can be done 3 to 4 months after the last dose and the drug restarted 6 to 8 weeks later.3
Pregnancy: drugs at a glance
| Use | Avoid or limit |
|---|---|
| Acetaminophen; amoxicillin, penicillin, cephalosporins, clindamycin, metronidazole; lidocaine, mepivacaine, bupivacaine, prilocaine with epinephrine6 | Ibuprofen and naproxen: avoid in the first and third trimesters, short use only from 13 to 20 weeks.6 Tetracycline: never. Ciprofloxacin, clarithromycin, levofloxacin, moxifloxacin: avoid. The 2026 consensus statement also lists articaine under “avoid; consult the prenatal care professional”.6 |
The FDA asks prescribers to limit NSAIDs between 20 and 30 weeks and avoid them after 30 weeks; this does not apply to low-dose 81 mg aspirin prescribed by her physician.7 Pregnancy gingivitis and the pregnancy tumour (pyogenic granuloma) come from an exaggerated gum response to plaque.5
Bleeding disorders: the hematologist plan
- Hemophilia A and B are X-linked recessive, so almost all patients are male. They bleed or ooze for a long time after injury, surgery or a tooth being pulled.15
- Extractions, implants, periodontal surgery and biopsies need a personal hemostasis plan made with a hematologist.12
- Tranexamic acid (reduce the dose in kidney disease) or EACA, with sutures, oxidized cellulose or fibrin sealant. Soft diet and gentle brushing near the socket for 3 to 5 days.12
- Gum bleeding in a hemophilia patient is gingivitis, not the bleeding disorder itself. Treat the plaque.12
- Von Willebrand disease: desmopressin for milder forms (usually type 1), antifibrinolytics, or factor replacement for severe forms.13
Endocarditis and joint replacements: who needs antibiotics first?
Infective endocarditis prophylaxis is only for the highest-risk heart patients: prosthetic valves or valve repair material, previous endocarditis, a heart transplant with a structurally abnormal leaking valve, and certain congenital heart disease. Clindamycin is no longer recommended. For patients with joint replacements, the ADA’s 2015 guideline says antibiotics are generally not recommended.14 See our full page on antibiotic prophylaxis and dental trauma guidelines for the INBDE and the drug choices in high-yield antibiotics for the INBDE.
Part B
Genetic and developmental conditions with oral findings
Learn one signature sign for each. The gene and inheritance are listed only where they help you answer a question or counsel a family.
1. Tooth structure: enamel and dentin
| Condition | Key oral sign | Gene / inheritance | Clinical pearl |
|---|---|---|---|
| Amelogenesis imperfecta | Enamel only: thin (hypoplastic, the commonest type), brittle (hypomaturation) or soft (hypocalcified). Small, pitted, discoloured, sensitive teeth that wear fast.16 | Over 20 genes; AD, AR or X-linked (AMELX)16 | Both dentitions affected. Dentin and pulp look normal on the radiograph. |
| Dentinogenesis imperfecta | Blue-grey or yellow-brown translucent (amber) teeth that chip and wear fast; short, thin roots; pulps obliterated.1617 | DSPP, autosomal dominant. Type I occurs with osteogenesis imperfecta (COL1A1/COL1A2).16 | Ask about fractures and blue sclerae: that points to osteogenesis imperfecta. |
| Dentin dysplasia type I | Crowns look normal but teeth are very mobile: short, conical or absent roots (“rootless teeth”), crescent-shaped pulp remnants, periapical radiolucencies in teeth with no caries.17 | Autosomal dominant17 | Normal crowns + periapical lesions in sound teeth = think dentin dysplasia type I. |
| Dentin dysplasia type II | Signs like dentinogenesis imperfecta, but the primary teeth are affected far more than the permanent teeth.16 | DSPP, autosomal dominant16 | Same gene as dentinogenesis imperfecta types II and III. |
| Osteogenesis imperfecta | Dentinogenesis imperfecta.16 | COL1A1/COL1A2 (about 90%); common types AD16 | Easy fractures, blue or grey sclerae, hearing loss in about half of type I.16 |
2. Tooth number and eruption
| Condition | Key oral sign | Gene / inheritance | Clinical pearl |
|---|---|---|---|
| Cleidocranial dysplasia | Primary teeth retained, permanent teeth erupt late, many supernumerary teeth.16 | RUNX2, autosomal dominant16 | Missing or small collarbones: the shoulders can touch in front of the chest. |
| Hypohidrotic ectodermal dysplasia | Many missing teeth; the ones present are small and pointed (conical) and erupt late.16 | Mostly EDA, X-linked (boys more severe)16 | Cannot sweat normally, so overheating is dangerous. Sparse, light hair.16 |
| Gardner syndrome (FAP) | Jaw osteomas, supernumerary and unerupted teeth, dental cysts.16 | APC, autosomal dominant16 | The dentist may spot it first. At least 90% of untreated classic FAP becomes colon cancer by age 50: refer.16 |
| Down syndrome | Severe, generalised, fast periodontitis: prevalence close to 100% under age 30. Protruding tongue.2016 | Trisomy 2116 | About half are born with a heart defect; ask the cardiologist whether prophylaxis applies.16 Frequent recalls and caregiver help improve gum health.20 |
3. Jaw cysts and bone lesions
| Condition | Key oral sign | Gene / inheritance | Clinical pearl |
|---|---|---|---|
| Gorlin syndrome (nevoid basal cell carcinoma syndrome) | Multiple odontogenic keratocysts, appearing from adolescence to about age 30.16 | PTCH1, autosomal dominant16 | Basal cell carcinomas, pits on the palms and soles, large head; medulloblastoma in a few children.16 |
| Cherubism | Painless, bilateral, cyst-like swelling of both jaws in early childhood; disturbs tooth development.16 | SH3BP2, autosomal dominant16 | Growth stops at puberty and normal bone slowly replaces the lesions.16 |
| McCune-Albright syndrome | Fibrous dysplasia of the jaws: painless swelling or facial asymmetry; “ground glass” bone on the radiograph.19 | GNAS, somatic (not inherited)19 | Triad: fibrous dysplasia, cafe-au-lait spots, early puberty.19 |
For the radiographic look of these lesions, see radiographic bone lesions for the INBDE.
4. Pigmentation, soft tissue and blood vessels
| Condition | Key oral sign | Gene / inheritance | Clinical pearl |
|---|---|---|---|
| Peutz-Jeghers syndrome | Small dark spots on the lips and inside and around the mouth, from childhood.16 | STK11, autosomal dominant16 | Hamartomatous gut polyps and a high lifetime cancer risk: refer. |
| Neurofibromatosis type 1 | Neurofibromas on or under the skin and along nerves.16 | NF1, autosomal dominant16 | Cafe-au-lait spots, armpit and groin freckling, Lisch nodules in the iris. |
| Sturge-Weber syndrome | Port-wine birthmark on one side of the face (forehead, temple, eyelid).16 | GNAQ, somatic (not inherited)16 | Seizures and glaucoma, usually on the same side as the birthmark.16 |
| Hereditary hemorrhagic telangiectasia | Red telangiectasias, including on the tongue.16 | ENG, ACVRL1; autosomal dominant16 | Frequent nosebleeds; vascular malformations in the lungs, brain or liver. |
5. Early, aggressive tooth loss
| Condition | Key oral sign | Gene / inheritance | Clinical pearl |
|---|---|---|---|
| Papillon-Lefevre syndrome | Aggressive periodontitis that destroys both the primary and permanent dentitions at a very young age.18 | CTSC, autosomal recessive18 | Look at the palms and soles: red, thickened skin (palmoplantar keratoderma).18 |
6. Clefts and craniofacial conditions
| Condition | Key oral sign | Gene / inheritance | Clinical pearl |
|---|---|---|---|
| Van der Woude syndrome | Pits near the centre of the lower lip, with cleft lip and/or palate.16 | IRF6, autosomal dominant16 | Missing teeth in some patients. |
| Treacher Collins syndrome | Small lower jaw and chin, underdeveloped cheekbones, cleft palate in some.16 | Mostly TCOF1, autosomal dominant16 | Down-slanting eyes, notched lower eyelid, ear defects and hearing loss. The airway can be narrow. |
| Crouzon syndrome | Underdeveloped upper jaw (midface).16 | FGFR2, autosomal dominant16 | Early skull suture fusion, bulging eyes. Hands are normal. |
| Apert syndrome | Sunken midface, cleft palate, crowding, missing teeth and irregular enamel.16 | FGFR2, autosomal dominant (mostly new mutations)16 | Fused fingers and toes tell it apart from Crouzon. |
Practise recognition
Spot the syndrome
Pick the sign you see. The answer appears below.
Choose a sign above to reveal the condition.
Dentin dysplasia type I
Short or absent roots and crescent-shaped pulp remnants. The crowns look normal, which separates it from dentinogenesis imperfecta.
Gorlin syndrome
PTCH1, autosomal dominant. Multiple odontogenic keratocysts, basal cell carcinomas, palmar and plantar pits.
Peutz-Jeghers syndrome
STK11, autosomal dominant. Refer for gut and cancer screening.
Cleidocranial dysplasia
RUNX2, autosomal dominant. Missing or underdeveloped collarbones are the giveaway outside the mouth.
Papillon-Lefevre syndrome
CTSC, autosomal recessive. Both dentitions are lost to aggressive periodontitis.
Gardner syndrome (FAP)
APC, autosomal dominant. Refer to a gastroenterologist: colon cancer risk is very high without treatment.
Check yourself
Three quick questions
Written by our faculty for this page. Not real exam items.
Question 1
A 58-year-old man needs a routine filling. His blood pressure is 168/102 mmHg on two readings, and he has no symptoms. What do you do?
ADo the filling with plain local anesthetic
BPostpone the filling and refer him to his physician
CSend him to the emergency department now
Show answer
Answer: B A confirmed reading above 160/100 means no elective care and a physician consultation. He has no symptoms and is below 180, so he does not need emergency referral.1
Question 2
A 70-year-old woman has taken oral alendronate for osteoporosis for 4 years. Tooth #30 cannot be restored. What is the best plan?
AStop alendronate for 6 months, then extract
BExtract the tooth now, after explaining the low MRONJ risk
CLeave the tooth to avoid any surgery
Show answer
Answer: B Osteoporosis doses carry a low MRONJ risk, and the 2022 AAOMS paper found no proven benefit from drug holidays. Inform her and treat the infection source.3
Question 3
A 9-year-old has lost most of his primary teeth to periodontitis. His palms and soles are thick and red. Which gene is involved?
ACTSC
BRUNX2
CPTCH1
Show answer
Answer: A Palmoplantar keratoderma with early loss of both dentitions is Papillon-Lefevre syndrome, caused by CTSC.18
We teach the INBDE
How to prepare: our full plan
Conditions like these are spread across Oral Health Management, Diagnosis and Treatment Planning, and the pathology and genetics foundation areas. Study them in context, then test yourself.
INBDE
INBDE Premium BoardsBuilt by US-licensed dentists, as set out on the course blueprint:
- 12 sequenced course sections and 35,000+ focused questions
- Master Files on clinically relevant topics
- Grand Test Series of 8-hour mock exams
- Live tests every night at 9 PM New York time
Plan
Keep studying from hereRelated guides from our faculty:
Quick answers
Frequently asked questions
What are the high-yield INBDE topics for medically complex patients?
Blood pressure cut-offs for elective care, hypoglycemia management in diabetes, warfarin and DOAC bleeding rules, MRONJ risk with bisphosphonates and denosumab, safe drugs in pregnancy, asthma attacks, adrenal crisis, transplant patients and bleeding disorders. Questions focus on what you change in treatment.
Should I stop a patient’s blood thinner before an extraction?
Usually no. The ADA summary says most patients on warfarin in range or on DOACs need no change, and antiplatelet drugs should not be altered. Use local measures. Any pause is decided by the prescribing physician.2
Do I need to memorise genes for the INBDE?
Learn the gene only where it is the classic link, such as RUNX2 in cleidocranial dysplasia, PTCH1 in Gorlin syndrome, APC in Gardner syndrome, STK11 in Peutz-Jeghers syndrome and CTSC in Papillon-Lefevre syndrome. The oral sign and the inheritance pattern matter more.
Is dental treatment safe during pregnancy?
How does The Study Boards help you prepare for medically complex patients on the INBDE?
Our INBDE course teaches these patients through case-based questions, Master Files and nightly live tests at 9 PM New York time. Students who complete the course have a 99% first-attempt pass rate. See the INBDE course blueprint.
Not sure where to start?
Message us on WhatsApp. Our Admin Team with Dr. T and Dr. Kaur will contact you over WhatsApp.
References
- American Dental Association. Oral Health Topics: Hypertension (BP thresholds for dental care, epinephrine limit, orthostatic hypotension, calcium channel blocker gingival overgrowth). ada.org
- American Dental Association. Oral Health Topics: Oral Anticoagulant and Antiplatelet Medications and Dental Procedures. ada.org
- Ruggiero SL, et al. American Association of Oral and Maxillofacial Surgeons’ Position Paper on Medication-Related Osteonecrosis of the Jaws: 2022 Update. J Oral Maxillofac Surg. 2022;80(5):920-943. aaoms.org (PDF)
- American Dental Association. Oral Health Topics: Diabetes. ada.org
- American Dental Association. Oral Health Topics: Pregnancy. ada.org
- Oral Health Care During Pregnancy Expert Workgroup. Oral Health Care During Pregnancy: A National Consensus Statement (revised edition, 2026). National Maternal and Child Oral Health Resource Center. mchoralhealth.org (PDF)
- US Food and Drug Administration. FDA recommends avoiding use of NSAIDs in pregnancy at 20 weeks or later (15 October 2020). fda.gov
- University of Washington School of Dentistry. Oral Health Fact Sheet for Dental Professionals: Adults with Asthma. dental.washington.edu
- Bornstein SR, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389. academic.oup.com
- NHS Specialist Pharmacy Service. What steroid supplementation is required for a patient with primary adrenal insufficiency undergoing a dental procedure? (2019; UK practice). sps.nhs.uk
- Dental management of patients with renal diseases or undergoing renal transplant. Saudi Dent J. 2024. PMC10897630
- Srivastava A, et al. WFH Guidelines for the Management of Hemophilia, 3rd edition. Haemophilia. 2020;26(Suppl 6):1-158 (dental care recommendations). wfh.org (PDF)
- Centers for Disease Control and Prevention. About Von Willebrand Disease. cdc.gov
- American Dental Association. Oral Health Topics: Antibiotic Prophylaxis Prior to Dental Procedures (AHA 2021 and ADA 2015 guidance). ada.org
- MedlinePlus Genetics (US National Library of Medicine). Hemophilia. medlineplus.gov
- MedlinePlus Genetics condition summaries: amelogenesis imperfecta, dentinogenesis imperfecta, osteogenesis imperfecta, cleidocranial dysplasia, hypohidrotic ectodermal dysplasia, familial adenomatous polyposis, Down syndrome, Gorlin syndrome, cherubism, Peutz-Jeghers syndrome, neurofibromatosis type 1, Sturge-Weber syndrome, hereditary hemorrhagic telangiectasia, Van der Woude syndrome, Treacher Collins syndrome, Crouzon syndrome, Apert syndrome.
- Ye X, et al. Dentin dysplasia type I: a dental disease with genetic heterogeneity. Oral Dis. 2019. PMC7818184
- Papillon-Lefevre syndrome: clinical presentation and management options. Clin Cosmet Investig Dent. 2015. PMC4507741
- Dumitrescu CE, Collins MT. McCune-Albright syndrome. Orphanet J Rare Dis. 2008;3:12. PMC2459161
- Ferreira R, et al. Prevention and Periodontal Treatment in Down Syndrome Patients: A Systematic Review. PLoS One. 2016. PMC4927059
Current as of October 2026. This page is for exam study. Clinical decisions for a real patient should follow current guidelines and the patient’s physician.