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Chapter 20: Rheumatologic and Connective Tissue Disorders
Little: Dental Management of the Medically Compromised Patient, 9th Edition

MULTIPLE CHOICE

1. What is synovial fluid derived from?

a. Osteoblasts
b. Plasma
c. Lysosome
d. Fibroblasts
ANS: B
Synovial fluid is derived from the synovium primarily as an ultrafiltrate of plasma. The
synovium also secretes specialized molecules into the synovial fluid, such as hyaluronic
acid. The cartilage has a high water content and obtains its nutrition solely from the synovial
fluid. Cartilage loss may occur secondarily to synovial inflammation or trauma.

2. What is a pannus?
a. It is excessive proliferative and invasive granulation tissue.
b. It is a drug interaction that interferes with platelet function and causes excessive
bleeding.
c. It is a sudden retrognathia and anterior open bite caused by destruction of the
condylar heads and loss of condylar height.
d. It is worn subchondral bone that becomes polished and sclerotic.
ANS: A GRADESMORE.COM
A pannus is excessive proliferative and invasive granulation tissue. With rheumatoid
arthritis, primary changes occur within the synovium causing edema, followed by
thickening and folding of tissue, a pannus. In addition, marked infiltration of lymphocytes
and plasma cells into the capsule occurs. Eventually, granulation tissue covers the articular
surfaces and destroys the cartilage and subchondral bone through enzymatic activity.

3. What is the primary difference between aspirin and other nonsteroidal antiinflammatory
drugs (NSAIDs) in regard to platelets?
a. Aspirin has no effect on platelets, in contrast to the other NSAIDs, which have a
marked effect on platelets.
b. The effects of aspirin are irreversible for the life of the platelet, whereas the effect
of the other NSAIDs on platelets is reversible.
c. Aspirin will cause prolonged bleeding, while the other NSAIDs will shorten
bleeding time.
d. There are no differences between aspirin and other NSAIDs in regard to bleeding
time.
ANS: B
The effects of aspirin are irreversible for the life of the platelet (10 to 12 days), and this
effect continues until new platelets have replaced the old. The effect of the other NSAIDs on
platelets is reversible and lasts only as long as the drug is present in the plasma. All NSAIDs
can cause a qualitative platelet defect that may result in prolonged bleeding, especially when
given in high doses.

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4. The “gold standard” agent for treatment of patients with early rheumatoid arthritis is
.
a. penicillamine
b. methotrexate
c. infliximab
d. sulfasalazine
ANS: B
The biologic agents etanercept and infliximab (and other TNF- inhibitors) have been
shown to be highly effective in the treatment of patients with early rheumatoid arthritis (RA)
relative to the “gold standard” agent, methotrexate. Although costly and difficult to
administer, etanercept has been shown to significantly reduce symptoms of RA and to more
effectively slow joint damage when compared with methotrexate. Likewise, infliximab,
which also is costly and requires administration by the intravenous route, when used with
methotrexate significantly reduced RA symptoms and slowed joint damage to a greater
extent than that achieved with methotrexate therapy alone.

5. The 2015 joint advisory statement by the American Dental Association (ADA) and the
American Academy of Orthopedic Surgeons (AAOS) indicated that antibiotic prophylaxis
prior to dental treatment should not be considered for .
a. patients with rheumatoid arthritis
b. patients with pins, plates, and screws in joints
c. any patients with any level of infection
d. patients with prosthetic joints
ANS: D GRADESMORE.COM
The joint task force recommends that in general, patients with prosthetic joints are not
recommended to receive prophylactic antibiotics prior to dental treatment. As with any
recommendations, there are caveats and exceptions which must be taken into account in
making the decision to prescribe prophylactic antibiotics prior to dental treatment. Those
factors may include other systemic co-morbid conditions which may render the individual
patient susceptible to infection, prior or existing infection of the prosthetic joint, etc. A
careful, comprehensive review of the patient’s medical conditions and status and possible
consultation with the physician may be in order.

6. Which of the following is the most significant oral complication of rheumatoid arthritis?
a. Salivary gland dysfunction (xerostomia)
b. Burning tongue syndrome (glossodynia)
c. Temporomandibular joint disorder (TMJ) involvement
d. Vesiculobullous lesions
ANS: C
The most significant complication of the oral and maxillofacial complex in rheumatoid
arthritis is TMJ involvement, which is found in 45% to 75% of patients with rheumatoid
arthritis. This may present as bilateral preauricular pain, tenderness, swelling, stiffness, and
decreased mobility of the TMJ, or it may be asymptomatic. Fibrosis or bony ankylosis can
occur. Clinically, patients may present with tenderness over the lateral pole of the condyle,
crepitus, limited opening, and radiographic evidence of structural change. Radiographic
changes initially may show increased joint space due to inflammation of the joint.

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7. Which of the following is the most common form of arthritis?

a. Rheumatoid arthritis (RA)
b. Osteoarthritis (OA)
c. Juvenile rheumatoid arthritis (jRA)
d. Psoriatic rheumatoid arthritis (pRA)
ANS: B
Osteoarthritis (OA) is the most common form of arthritis. Almost everyone older than 60
years of age develops OA to some degree. OA usually affects often-used joints, such as
hips, knees, feet, spine, and hands. The TMJ also is affected. Women are affected twice as
often as men; however, men are affected at an earlier age.

8. Which of the following is recommended as a first-line drug for the treatment of

osteoarthritis (OA)?
a. Methotrexate
b. Acetaminophen
c. Celecoxib (Celebrex)
d. Cyclosporine
ANS: B
Acetaminophen frequently is effective in the management of OA and is recommended as a
first-line drug. Aspirin or NSAIDs also are commonly employed when acetaminophen is not
effective. Narcotic analgesics are generally used only for acute flares for short periods.
Intra-articular steroid injections also may be used intermittently to reduce acute pain and
inflammation.
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9. What are the two types of lupus erythematosus?
a. TMJ and OA
b. Autoimmune and prototypical
c. Discoid and a more generalized systemic form
d. Antibody and antinuclear antibodies
ANS: C
There are two types of lupus erythematosus: discoid (DLE), which predominantly affects
the skin, and a more generalized systemic form (SLE), which affects multiple organ
systems. DLE is characterized by chronic, erythematous, scaly plaques on the face, scalp, or
ears. Most patients with DLE have very few systemic manifestations, and the course tends
to be benign. SLE involves the skin and many other organ systems and is the more serious
form.

10. Which of the following is the most common form of psoriatic arthritis?
a. Selective targeting of the distal interphalangeal joints
b. Psoriatic spondylitis
c. An asymmetric oligoarthritis that may involve both large and small joints
d. A symmetric polyarthritis that mimics rheumatoid arthritis except for the absence
of rheumatoid nodules and rheumatoid factor
ANS: C

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The most common form of psoriatic arthritis, with which 30% to 50% of patients are
affected, is an asymmetric oligoarthritis that may involve both large and small joints.
Dactylitis, arising as sausage digits, can be seen in fingers and toes and actually represents
an enthesitis. In the second subset, there is selective targeting of the distal interphalangeal
joints, seen in 10% to 15% of patients. The third subset has a symmetric polyarthritis that
mimics RA in many ways except for the absence of rheumatoid nodules and rheumatoid
factor. The fourth clinical variant is psoriatic spondylitis. Finally, arthritis mutilans is a
destructive, erosive arthritis that affects large and small joints.

11. Giant cell arteritis (GCA) most commonly affects branches of the artery.
a. maxillary
b. carotid
c. superior thyroid
d. inferior thyroid
ANS: B
GCA is a systemic vasculitis involving medium-sized and large arteries, most commonly the
extracranial branches of the carotid artery. GCA is the most common form of vasculitis.
This inflammatory disorder affects women more often than men, almost exclusively after 50
years of age, and the average age is 72 years. Because of the occlusive nature of the
narrowing of the vascular lumen, cranial pain, blindness, transient ischemic attacks (TIAs),
and other strokes are common complications in patients with GCA.

12. Which of the following medications is the usual initial therapy for giant cell arteritis?
a. Glucocorticoids
b. Narcotic analgesics
c. Antidepressants GRADESMORE.COM
d. Methotrexate
ANS: A
The universal treatment for GCA is glucocorticoid therapy. Prednisone (60 mg per day) is
the usual initial therapy. Once the immune response has subsided and symptoms diminish,
the prednisone may be reduced by 10% per week. Adjunctive therapy with aspirin also is
quite helpful.

13. Which of the following is/are true of systemic lupus erythematosus (SLE)?
a. SLE is due to wheat gluten allergy.
b. SLE is more common in women than in men.
c. These patients should be premedicated with antibiotics prior to invasive dental
treatment.
d. A and B
e. B and C
ANS: B
The etiology of SLE is unknown, although it is clearly an autoimmune disease. It
predominantly affects women of childbearing age, with a female-to-male ratio of 5:1; it is
more common and more severe among African Americans and Hispanics than among
whites. On the basis of 2007 American Heart Association guidelines, none of these patients
are recommended for antibiotic prophylaxis for invasive dental procedures.

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14. Which of the following is the most common manifestation of systemic lupus erythematosus
(SLE)?
a. Psychosis
b. Renal abnormalities
c. Heart murmur
d. Arthritis
ANS: D
The most common manifestation of SLE is arthritis, which is seen in nearly three-quarters
of patients. Neuropsychiatric symptoms are common and include organic brain syndrome,
psychosis, seizures, stroke, movement disorders, and peripheral neuropathy. Serious renal
abnormalities occur in less than one third of patients with SLE, although most show some
abnormality on renal biopsy. A clinically detectable heart murmur is found in 18.5% of SLE
patients. Approximately 4% of patients had cardiac valve abnormalities that placed them in
the moderate risk group for endocarditis.

15. Which of the following characteristics is used to distinguish fibromyalgia (FM) from
myofascial pain syndrome (MFP)?
a. Regional rather than widespread muscular pain is associated with FM.
b. The pain in FM is relatively stable and consistent in contrast to MFP.
c. When the muscle pain is primarily due to the FM, it may not respond as well as the
jaw pain from MFP because FM is a systemic and not a local condition.
d. A and B
e. B and C
ANS: E
The pain in FM is relativelyGstR
abAlD
e an
ESdMcO
onRsE
iste
.CntOinMcontrast to MFP, which can vary in
intensity and location depending on which muscles are involved. When the muscle pain is
primarily due to the FM, it may not respond as well as the jaw pain from MFP because FM
is a systemic and not a local condition, and muscle pain is a typical presentation in FM.
Regional pain is found with MFP and needs to be distinguished from the widespread
muscular pain associated with FM.

16. Which of the following is the causative agent of Lyme disease?

a. Hodgkin disease
b. Dust mites
c. Borrelia burgdorferi
d. Helicobacter pylori
ANS: C
Lyme disease is a multisystemic inflammatory disease caused by the tickborne spirochete
Borrelia burgdorferi. The disease was first identified in the United States in 1975 during an
outbreak around Lyme, Connecticut, of an inflammatory condition presumed to be juvenile
rheumatoid arthritis. The classical pattern of Lyme disease is a characteristic macular skin
rash (erythema migrans) that appears within 1 month after the tick (Ixodes dammini) bite.

17. Secondary Sjögren syndrome (SS-2) is characterized by a triad of clinical conditions that
consist of keratoconjunctivitis sicca, a connective tissue disease (usually rheumatoid
arthritis), and .
a. xerostomia

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b. facial palsy
c. a “pencil-in-cup” deformity in patients with interphalangeal joint disease
d. transient ischemic attacks (TIAs)
ANS: A
Secondary SS (SS-2) manifests as the presence of keratoconjunctivitis sicca or xerostomia
in the presence of a diagnosed systemic connective tissue disease. The connective tissue
disorder from which SS develops most commonly is RA; SLE, primary biliary cirrhosis,
fibromyalgia, mixed connective tissue disease, polymyositis, Raynaud’s syndrome, and
several others are among the associated inflammatory conditions.

18. Sicca syndrome (SS) is characterized by enlargement of which of the following salivary
glands?
a. Sublingual
b. Submandibular
c. Parotid
d. Minor accessory
ANS: C
Sicca syndrome is characterized by eye dryness, hyposalivation, and enlargement of the
parotid glands. Secondary outcomes of persistent oral dryness are angular cheilosis,
dysgeusia, secondary infection, and a significantly increased caries rate.

19. The tongue is commonly infected (in as many as 83%) with in patients with
Sicca syndrome (SS).
a. Borrelia burgdorferi
b. Candida albicans
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c. Streptococcus mutans
d. Helicobacter pylori
ANS: B
The tongue is commonly infected with Candida albicans in patients with Sicca syndrome.
Not only must the acute candidal infection be treated, but some type of maintenance therapy
must be provided to prevent recurrence of the fungal infection. As long as the oral
environment is adversely affected by hyposalivation, susceptibility to recurrence of the oral
infection and continued deterioration occur.

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