Proinflammatory cytokines and arthroscopic findings of patients withinternal derangement and osteoarthritis of the temporomandibular joint

Bjom-209.qxd

1/30/02 10:01 PM

Page 68

BRITISH

British Journal of Oral and Maxillofacial Surgery (2002) 40, 68–71 © 2002 The British Association of Oral and Maxillofacial Surgeons doi: 10.1054/bjom.2001.0742, available online at http://www.idealibrary.com on

Journal of Oral and Maxillofacial Surgery

Proinflammatory cytokines and arthroscopic findings of patients with internal derangement and osteoarthritis of the temporomandibular joint M. Nishimura, N. Segami, K. Kaneyama, T. Suzuki, M. Miyamaru Department of Oral and Maxillofacial Surgery, Kanazawa Medical University, Ishikawa Prefecture, Japan SUMMARY. This study investigated the correlations between the concentrations of proinflammatory cytokines in synovial fluid and the degree of synovitis on the one hand, and the degree of degeneration of articular cartilage on the other hand, in patients with internal derangement and osteoarthritis of the temporomandibular ␤ (IL-1␤ ␤), tumour necrosis factor-␣ ␣ (TNF-␣ ␣), IL-6 and joint. We measured the concentrations of interleukin-1␤ IL-8 in synovial fluid and the degree of arthroscopic synovitis and degeneration of articular cartilage in 37 joints with internal derangement and osteoarthritis. The correlations between the concentration of each ␤, cytokine and the score of each arthroscopic feature were analysed statistically. The detection rates of IL-1␤ ␣, IL-6 and IL-8 were 57%, 78%, 89% and 70%, respectively. There was a positive correlation between TNF-␣ the IL-6 concentration and the synovitis score (P:0.02). Measurement of IL-6 in synovial fluid might be useful as an indicator of the extent of synovitis. © 2002 The British Association of Oral and Maxillofacial Surgeons

74 years (median 36) and their symptoms had lasted from 1 month to 5 years (median 8 months). Preoperatively, the patients indicated on a visual analogue scale (VAS) of 0–10 the degree of joint pain experienced during mouth opening. The pain score ranged from 3.5 to 9.5 (median 5.4), the higher scores indicating increasing pain.

INTRODUCTION Temporomandibular joints (TMJs) with internal derangement and osteoarthritis tend to be painful with restricted mandibular mobility. There is usually synovitis and degeneration of articular cartilage,1–5 and proinflammatory cytokines5–11 in the synovial fluid. It is thought that proinflammatory cytokines may be involved in the pathogenesis of synovitis and degeneration of articular cartilage in the TMJ. In this study, we measured the concentration of interleukin-1␤ (IL-1␤), tumour necrosis factor-␣ (TNF-␣), IL-6 and IL-8 in synovial fluid and, on a scale of 0–10, the degree of arthroscopic synovitis and degeneration of articular cartilage.

Preparation of synovial fluid samples In each patient, the same surgeon (NS) injected saline (2.0 ml) into the superior joint space with a 21-gauge needle and aspirated the dilute synovial fluid; this was reinjected 10 times before the final sample was drawn. The mean (SD) volume of the samples was 2.0 (0.1) ml. The samples were centrifuged (3000 rpm for 20 minutes at 4⬚C) and were stored at ⫺80⬚C until assayed.

PATIENTS AND METHODS Subjects

Measurement of the proinflammatory cytokines and total protein concentrations

We studied 37 internally deranged TMJs (15 joints) and osteoarthritis (22 joints) in 34 patients (30 women and 4 men) who had arthroscopic lysis and lavage, or open TMJ surgery. Ten of the 15 internally deranged joints had anterior disc displacement without reduction, three had anterior disc displacement with reduction, and in two the disc position was normal as shown by magnetic resonance imaging (MRI). All 22 arthritic joints had anterior disc displacement without reduction and bony changes such as osteophytes, erosion and flattening, shown by MRI. The patients ranged in age from 17 to

One surgeon (MN) measured the concentrations of IL-1␤, TNF-␣, IL-6 and IL-8 using an enzyme-linked immunosorbent assay kit (Quantikine ELISA, R&D Systems, Minneapolis, MN, USA) according to the manufacturer’s instructions. The lowest detectable concentrations of the cytokines were IL-1␤ 0.0625 pg/ml, TNF-␣ 0.008 pg/ml, IL-6 0.009 pg/ml and IL-8 0.975 pg/ml. Protein was assayed with a Bio-RAD protein assay kit (Bio-RAD, Hercules, CA, USA). The total protein concentration was used to compare the concentration of 68

Bjom-209.qxd

1/30/02 10:01 PM

Page 69

Proinflammatory cytokines and arthroscopic findings in internal derangement and osteoarthritis of TMJ

the cytokines between samples despite variation in the volumes of synovial fluid aspirated.5,9–11 The concentration of each cytokine was calculated per 100 ␮g of total protein in the fluid. Evaluation of synovitis and degeneration of articular cartilage Immediately after the collection of the samples of fluid, conventional diagnostic arthroscopy of the whole area of the superior joint compartment was conducted and videotaped for about 10 minutes, followed by sweepage with lysis and lavage. The degrees of synovitis and degeneration of articular cartilage were estimated according to the criteria of Murakami et al.,4 i.e. the most pronounced degree of synovitis in the superior compartment was given a score on a scale of 0–10 (Tables 1 & 2). Two oral surgeons gave the scores, Table 1 Arthroscopic intensity of synovitis Grade

Findings

00

Normal pale, almost translucent synovial lining with a fine network of anastomosing small blood vessels Increased vascularity and capillary hyperaemia – mild moderate severe Capillary dilatation and increasing network – mild to moderate severe Contact bleeding occurs on probe palpation – mild to moderate severe Microbleeding and effusion Granulative change, effusion, and debris – mild to moderate severe

01 02 03 04 05 06 07 08 09 10

69

unaware of each patient’s name or condition, by viewing the videotapes. Statistical analysis of correlations The correlations between the concentration of each cytokine and the score of each arthroscopic feature were analysed statistically using the Spearman rank correlation coefficient.

RESULTS The detection rates of cytokines ranged from 57% to 89% (Table 3). The cytokines were not detected in five healthy male volunteers (mean age 29.5 years, data not shown). When joints with internal derangement were compared with osteoarthritic joints, there were no differences in the concentrations of the cytokines, the scores of each arthroscopic feature and the pain scores (data not shown). There was a positive correlation between the IL-6 concentration and the synovitis score (P:0.02) (Table 4; Fig. 1). There were no correlations between the concentration of IL-1␤, TNF-␣ and IL-8 and the scores of synovitis, degeneration of articular cartilage and pain (Table 4).

DISCUSSION In general, IL-1␤, TNF-␣, IL-6 and IL-8, which are proinflammatory cytokines, are induced by inflammatory stimuli12–14 and proinflammatory cytokines have Table 3 Detection rate and concentration of cytokines

Reprinted with permission from Murakami K-I, Segami N, Fujimura K et al. Correlation between pain and synovitis in patients with internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 1991; 49: 1159–1161.

Table 2 Arthroscopic intensity of degeneration of articular cartilage Grade 0 1 2 3 4 5 6 7 8 9 10

Cytokine

Detection rate (%)

IL-1␤ TNF-␣ IL-6 IL-8

Concentration median (range) pg/100 ␮g protein

57 78 89 70

0.018 (0.001–0.112) 0.015 (0.001–0.075) 0.144 (0.005–11.762) 1.127 (0.131–13.470)

Findings Normal articular cartilage Softening on probe palpation – mild moderate to severe Convex/concave surface Fibrillation – mild moderate severe Exposure of bone – mild moderate severe Intracapsular fibrosis

Table 4 Correlation coefficients between the concentrations of cytokines and synovitis, degeneration of articular cartilage and pain scores Cytokines

Correlation with Synovitis score

Degeneration score

Pain score

No.

r

P

No.

r

P

No.

r

P

IL-1␤

21

0.01

0.49

21

0.23

0.53

TNF-␣ IL-6 IL-8

29 33 26

0.01 0.32 0.19

0.59 0.02 0.49

29 33 26

0.07 0.15 0.01

0.62 0.49 0.71

17 24 24 28 22

0.11 0.12 0.12 0.12 0.13

0.67 0.63 0.63 0.53 0.49

Bjom-209.qxd

70

1/30/02 10:01 PM

Page 70

British Journal of Oral and Maxillofacial Surgery

arthroscopic synovitis and degeneration of articular cartilage in the present study. This might be because of the rapid turnover or consumption of cytokines within the joint cavity16 and the presence of cytokine receptor antagonists31,32 which might have a role in the pathogenesis of internal derangement and osteoarthritis in the TMJ.

ACKNOWLEDGEMENT This work was supported by a Grant for Promoted Research from Kanazawa Medical University (S00-11).

REFERENCES

Fig. 1 Graph correlating the concentrations of IL-6 with the synovitis score.

been detected in the synovial fluid from diseased knee joints.15–20 These cytokines are therefore probably involved in the pathophysiology of rheumatoid arthritis and osteoarthritis.14 The main role of IL-1␤ and TNF-␣ is destruction of the cartilage by degradation of proteoglycan.21–27 IL-6 has little ability to inhibit proteoglycan synthesis or to promote its breakdown.28,29 IL-6 also promotes the production of tissue inhibitor of metalloproteinases but not the production of matrix metalloproteinase,30 so it is thought that IL-6 may act to protect cartilage. IL-8 is induced by IL-1␤ and TNF-␣13 and has powerful leucocyte-attracting and leucocyte-activating properties. It has been reported that proinflammatory cytokines play a part in synovitis and the degeneration of cartilage and bone.5–11 In our study, these cytokines were detected in comparatively high concentrations in synovial fluid from patients with internal derangement and osteoarthritis in the TMJ. IL-6 concentration was significantly positively correlated with the synovitis score. Sandler et al.5 reported that the concentration of IL-6 in synovial fluid correlated with the degree of arthroscopic acute synovitis in patients with internal derangement of the TMJ. Therefore, the concentration of IL-6 in SF might be a useful index of synovitis in TMJs with internal derangement and of osteoarthritis. On the other hand, IL-1␤, TNF-␣ and IL-8, which it has been suggested are concerned with synovitis and degeneration of articular cartilage, did not correlate with the degree of

01. Holmlund A, Hellsing G. Arthroscopy of the temporomandibular joint: occurrence and location of osteoarthrosis and synovitis in a patient material. Int J Oral Maxillofac Surg 1988; 17: 36–40. 02. Merill RG, Yie WY, Langan M. A histologic evaluation of the accuracy of TMJ diagnostic arthroscopy. Oral Surg Oral Med Oral Pathol 1990; 70: 393–398. 03. Quinn JG, Bazan NG. Identification of prostaglandin E2 and leukotriene B4 in the synovial fluid of painful, dysfunctional temporomandibular joints. J Oral Maxillofac Surg 1990; 48: 968–971. 04. Murakami K, Segami N, Fujimura K, Iizuka T. Correlation between pain and synovitis in patients with internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 1991; 49: 1159–1161. 05. Sander NA, Buckley MJ, Cillo JE et al. Correlation of inflammatory cytokines with arthroscopic findings in patients with temporomandibular joint internal derangement. J Oral Maxillofac Surg 1998; 56: 534–543. 06. Shafer DM, Assael L, White LB et al. Tumor necrosis factor-␣ as a biochemical marker of pain and outcome in temporomandibular joints with internal derangements. J Oral Maxillofac Surg 1994; 52: 786–791. 07. Fu K, Ma X, Zhang Z et al. Tumor necrosis factor in synovial fluid of patients with temporomandibular disorders. J Oral Maxillofac Surg 1995; 53: 424–426. 08. Fu KY, Ma XC, Zhang ZK, Pang XW, Chen WF. Interleukin-6 in synovial fluid and HLA-DR expression in synovium from patients with temporomandibular disorders. J Orofac Pain 1995; 9: 131–137. 09. Kubota E, Imamura H, Kubota T et al. Interleukin 1␤ and stromelysin (MMP3) activity of synovial fluid as possible markers of osteoarthritis in the temporomandibular joint. J Oral Maxillofac Surg 1997; 55: 20–27. 10. Kubota E, Kubota T, Matsumoto J et al. Synovial fluid cytokines and proteinases as markers of temporomandibular joint disease. J Oral Maxillofac Surg 1998; 56: 192–198. 11. Takahashi T, Kondoh T, Fukuda M et al. Proinflammatory cytokines detectable in synovial fluids from patients with temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85: 135–141. 12. Whiteside TL. Cytokine measurements and interpretation of cytokine assays in human disease. J Clin Immunol 1994; 14: 327–339. 13. Dinarello CA. Interleukin-1 and interleukin-1 antagonism. Blood 1991; 772: 1627–1652. 14. Arend WP, Dayer JM. Cytokines and cytokine inhibitors or antagonists in rheumatoid arthritis. Arthritis Rheum 1990; 33: 305–315. 15. Nouri AME, Panayi GS, Goodman SM. Cytokines and the chronic inflammation of rheumatic disease. I. Clin Exp Immunol 1984; 55: 295–302. 16. Hopkins SJ, Humphreys M, Jayson MIV. Cytokines in synovial fluid. I. The presence of biologically active and immunoreactive IL-1. Clin Exp Immunol 1988; 73: 422–427.

Bjom-209.qxd

1/30/02 10:01 PM

Page 71

Proinflammatory cytokines and arthroscopic findings in internal derangement and osteoarthritis of TMJ 17. Hopkins SJ, Meager A. Cytokines in synovial fluid. II. The presence of tumor necrosis factor and interferon. Clin Exp Immunol 1988; 73: 422–427. 18. Waage A, Kaufman C, Espevik T, Husby G. Interleukin-6 in synovial fluid from patients with arthritis. Clin Immunol Immunopathol 1989; 50: 394–398. 19. Di Giovine FS, Nuki G, Duff GW. Tumor necrosis factor in synovial exudates. Ann Rheum Dis 1988; 47: 768–772. 20. Verburgh CA, Hart MHL, Aarden LA, Swaak AJG. Interleukin-8 (IL-8) in synovial fluid of rheumatoid and nonrheumatoid joint effusions. Clin Rheumatol 1993; 12: 494–499. 21. Arner EC, Pratta MA. Independent effects of interleukin-1 on proteoglycan breakdown, proteoglycan synthesis, and prostaglandin E2 release from cartilage in organ culture. Arthritis Rheum 1989; 32: 288–297. 22. Okada Y, Shinmei M, Tanaka O et al. Localization of matrix metalloproteinase 3 (stromelysin) in osteoarthritic cartilage and synovium. Lab Invest 1992; 66: 680–690. 23. Shinmei M, Masuda K, Kikuchi T et al. The role of cytokines in chondrocyte mediated cartilage degradation. J Rheumatol 1989; 16: 32–34. 24. Shinmei M, Masuda K, Kikuchi T et al. Interleukin 1, tumor necrosis factor, and interleukin 6 as mediators of cartilage destruction. Semin Arthritis Rheum 1989; 18: 27–32. 25. Saklatvala J. Tumor necrosis factor alpha stimulates resorption and inhibits synthesis of proteoglycan in cartilage. Nature 1986; 322: 547. 26. Wilbrink B, Nietfeld JJ, Den Otter W et al. Role of TNF alpha, in relation to IL-1 and IL-6 in the proteoglycan turnover of human articular cartilage. Br J Rheumatol 1991; 30: 265–271. 27. Henderson B, Pettipher ER. Arthritogenic actions of recombinant IL-1 and tumor necrosis factor alpha in the rabbit: evidence for synergistic interactions between cytokines in vivo. Clin Exp Rheumatol 1989; 75: 306. 28. Shinmei M, Masuda K, Kikuchi T et al. Production of cytokines by chondrocytes and its role in proteoglycan degradation. J Rheumatol 1991; 18: 89–91. 29. Malfait AM, Verbruggen G, Veys EM et al. Comparative and combined effects of interleukin 6, interleukin 1 beta, tumor necrosis factor alpha on proteoglycan metabolism of human

71

articular chondrocytes cultured in agarose. J Rheumatol 1994; 21: 314–320. 30. Shingu M, Miyauchi S, Nagai Y et al. The role of IL-4 and IL-6 in IL-1-dependent cartilage matrix degradation. Br J Rheumatol 1995; 34: 101–106. 31. Neidel J, Schulze M, Lindschau J. Association between degree of bone-erosion and synovial fluid levels of tumor necrosis factor alpha in the knee-joints of patients with rheumatoid arthritis. Inflamm Res 1995; 44: 217–220. 32. Fang PK, Ma XC, Ma DL, Fu KY. Determination of interleukin-1 receptor antagonist, interleukin-10, and transforming growth factor-␤1 in synovial fluid aspirates of patients with temporomandibular disorders. J Oral Maxillofac Surg 1999; 57: 922–928.

The Authors Masaaki Nishimura DDS Postgraduate Student Natsuka Segami DDS PhD Professor and Chairman Keiseki Kaneyama DDS PhD Assistant Professor Toshikazu Suzuki DDS Postgraduate Student Masahisa Miyamaru DDS PhD Assistant Professor Department of Oral and Maxillofacial Surgery Kanazawa Medical University, Prefecture Ishikawa, Japan Correspondence and requests for offprints to: Dr M. Nishimura, Department of Oral and Maxillofacial Surgery, Kanazawa Medical University, 1-1 Daigaku, Uchinadamachi, Kahoku-gun, Ishikawa 920-0293, Japan. Tel: ;81 76 286 2211; Fax: ;81 76 286 2010; E-mail: [email protected] Accepted 27 August 2001