Dentomaxillofacial Radiology (2000) 29, 286 290 2000 Macmillan Publishers Ltd.

. All rights reserved 0250 832X/00 $15.00 www.nature.com/dmfr

Experimental induction of rheumatoid arthritis in temporomandibular joint of the guinea pig: a clinical and radiographic study
AF Al-Mobireek*,1, AM-G Darwazeh1 and MB Hassanin1
1

Department of Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia

Objective: To correlate the clinical and radiographic changes at dierent stages of experimentally-induced rheumatoid arthritis (RA) of the TMJ. Methods: Forty eight adult male guinea pigs, aged 4 6 months, were divided into two groups. Arthritis was induced in the experimental animals by intraperitoneal injection of heatinactivated group A Streptococcus pyogenes. Four animals from each group were sacriced and examined clinically and radiographically at intervals of 48 h and 1, 2, 4, 6 and 8 weeks. Results: The main clinical ndings were stiness, crepitation and reduction in mouth opening. Radiographically, the main features were condylar erosion, attening and sclerosis subcortical cyst formation. Conclusion: RA passes through stages that can be correlated clinically and radiographically. Both the clinical and radiographic manifestations in this experimental model are comparable with those previously reported in the small joints of humans. Keywords: arthritis, rheumatoid; temporomandibular joint; temporomandibular joint diseases; guinea pigs

Introduction Rheumatoid arthritis (RA) is a systemic inammatory disease that characteristically involves the synovial tissues.1 The TMJ is reported to be involved in about 70% of cases.2 Clinical signs and symptoms may include stiness, pre-auricular pain, painful ears, joint clicking, crepitation, swelling, tenderness, limitation of movement and reduced mouth opening.3 5 Progressive erosion of the condylar head leading to complete destruction is considered one of the important radiographic features.2 Other radiographic manifestations include cyst-like lesions, narrowing of the joint space and a deep antegonial notch.2,4 6 Nevertheless, there is still considerable disagreement over the clinical and radiographic manifestations of RA.7 Irregularities in the condylar head and articular eminence are considered non-pathognomonic.2
*Correspondence to: AF Al-Mobireek, Department of Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, PO Box 52179 Riyadh 11563, King Saud University, Saudi Arabia Received 1 May 1998; accepted 18 May 2000

Experimental studies of RA in animal models have been reported frequently. RA has been induced by dierent methods such as injection of heat killed Mycobacterium tuberculosis in oil, M. butyricum in complete Freud's adjuvent,8 type II collagen,9 lactobacillus cell wall,10 hydrocarbon,11 Mycoplasma and retroviruses10,12 in addition to total lymphoid irradiation.13 Streptococcal cell wall (SCW)-induced arthritis was rst described by Cromartie and coworkers14 in 1977 who injected an aqueous suspension of cell wall fragments from Group A, B and C streptococci and lactobacilli. Acute inammation occured within 24 h after injection in the peripheral joints.10,14 Although animal models have often been used to study the systemic manifestations of RA and the pathophysiology of the disease in the limbs and viscera, no investigation studied the TMJ manifestations. The purpose of this study was to investigate the clinical and radiographic changes which occur in the TMJ during dierent stages of experimentally-induced RA.

Rheumatoid arthritis AF Al-Mobireek et al

Material and methods Forty eight adult male guinea pigs of strain 2, aged 4 6 months, were obtained from King Khalid University Hospital (KKUH) at King Saud University, Riyadh. The animals were fed standard laboratory chow, fresh vegetables and tap water and the amount consumed daily recorded. The weight was measured at the time of injection, 2 weeks post-injection and then weekly up to and including the day of sacrice. The animals were randomly divided into two equal groups, an experimental and a control group. Rheumatoid arthritis was induced in the experimental animals as described by Cromartie et al.14 A puried culture of group A Streptococcus pyogenes (`Lanceeld group A streptococci') obtained from the microbiology laboratory at KKUH, King Saud University was incubated for 24 h at 378C in ToddHewitt broth (Dico laboratories, Detroit, Michigan, USA). The cells were centrifuged at 5000 r.p.m. for 20 min and washed three times with sterile phosphate buered saline (PBS) and then in distilled water. The cells were heated at 608C for 30 min and tested for sterility by smearing an undiluted suspension on sheep blood agar plates. The cells were subsequently quantied as described by Dische and Shettles.15 Heat-inactivated microorganisms were diluted 1 : 70 in sterile distilled water and the rhamnose content of the suspension estimated.14 The experimental animals were injected intraperitoneally (IP) with 100 mg rhamnose per 100 gm body weight in 0.1 ml of sterile distilled water. Animals in the control group were injected IP with 0.1 ml/100 gm sterile aqueous solution. Four animals from each group were examined and sacriced at intervals, 48 h and 1, 2, 4, 6 and 8 weeks from the time of injection and data were recorded for each TMJ separately. Clinical examination Animals were examined prior to IP injection and on the day of sacrice. Their level of activity was observed and recorded. Mouth opening and degree of stiness on manipulation of the TMJ was assessed. Mouth opening was measured using a digital caliper (Digimatic, Mitutoyo, Tokyo, Japan). A score 0 or 1 was given for easy or dicult manipulation of TMJ, presence or absence of locking, normal or reduced mouth opening and presence or absence of crepitation respectively. A score of 2 was given if the positive nding was bilateral.16 Tomographic examination Animals were anaesthetized with intramuscular injection of ketamine hydrochloride 50 mg/kg (Ketalar, Parke Davis, New York, USA). Anaesthesia was maintained by a booster dose, 10 25 min later, prior to tomography. The animals were placed in a specially constructed cephalostat and a lateral scout lm

(Optiplainmat, Siemens, Bensheim, Germany) obtained using a Lanex lm-screen combination (Eastman Kodak, Rochester, NY, USA) at 70 kVp and 15 mAs, followed by three lateral slices for each joint, two with the mouth closed and one with the mouth open. Three coronal slices were also made. Corrected tomography was not used because of the relatively small size of the joints. Radiographs were evaluated for the following features : attening of the condyle and/or articular eminence, erosions and/or cystic changes, changes in joint space, sclerosis, osteophytes, remodelling, calcication of the disc, disc displacement and ankylosis. Findings were quantied subjectively into mild, moderate and severe. The changes were recorded for each TMJ separately (eight joints in four animals) and compared with the ndings in the corresponding control group. Results The clinical ndings in the experimental group are summarised in Table 1 and the radiographic changes in the coronal and sagittal planes are shown in Tables 2 and 3 respectively.

287

Table 1 Clinical findings in the experimental group (four animals in each group). Values are per cent Criteria Stiffness Locking Reduction in mouth opening Crepitation Mean reduction in weight 48 h 7ve 7ve 7ve 1 week 7ve 7ve 2.0 5.6 7ve 2.3 2 4 6 8 weeks weeks weeks weeks 7ve 7ve 2.2 +ve 7ve 4.3 4.7 5.2 6.9 +ve +3.8 +ve 7ve 16.7 26.2 29.2 +ve 4 +ve 7ve 8.0 15.8 24.0 33.5 +ve 3.5

7ve 2

7ve +7.4

+ve: present; 7ve: not present

Table 2 Coronal tomographic findings in the eight TMJs of the experimental animals. The values in parenthesis indicate the number of joints affected Group 48 h 1 week 2 weeks 4 weeks 6 weeks* 8 weeks Erosion 7ve 7ve +: (2) +: (5) ++: (3) +: ++: +++: +: ++: +++: Increased Flattening joint space Sclerosis ve ve ve +: (5) ++: (3) Cystic changes

ve ve ve ve: +: ++: (3) ve: (3) +: (2) ++: (5) +: (2) ++: (1) +++:

(1) (4) (3) (1) +: (4) ++: (3) +++: (5) +: (2) ++: (1) +++:

ve ve ve ve ve ve ve: (4) ve: (3) +: (4) +ve: (5) (2) (5) (1) (4) (3) (1) ve: (2) +ve: (6) ve: (1) +ve: (7)

(3) ve: (3) +: (2) +: (5) ve: (2) +: (1) ++:

+: mild; ++: moderate; +++: severe; ve: not present; *: osteophytes were detected in 6/8 of the joints
Dentomaxillofacial Radiology

Rheumatoid arthritis AF Al-Mobireek et al

288

Table 3 Sagittal tomographic findings in the eight TMJs of the experimental animals. The values in parenthesis indicate the number of joints affected Group 48 h 1 week 2 weeks 4 weeks 6 weeks Erosion 7ve 7ve ve: (7) +: (1) +: (7) ++: (1) +: ++: +++: +: ++: +++: Increased Flattening joint space Sclerosis ve ve ve ve ve ve (2) +: (5) (1) (2) +: (2) ++: (3) +++: (1) (5) +: (2) ++: (1) +++: (8) (4) (3) (1) ve ve ve Cystic changes ve ve ve

in one animal in the sagittal projection and in two in the coronal projection. Four week group It was dicult to manipulate the TMJ in all the experimental animals, and the reduction in mouth opening ranged from 4.3% to 6.9%. Mild or moderate erosions and attening of the condylar head and fossa were evident radiographically in all animals. The superior joint space was increased mildly or moderately in all animals. Partial sclerosis of condyle and fossa was found in more than half of the animals, and subcortical cysts in one of them (Figure 1). Six week group It was dicult to TMJ manipulate the TMJ in all animals, and mouth opening was reduced by 0 to 29.7%. Bilateral crepitation was present in three animals and unilateral in one. The radiographic changes were more pronounced compared with those in the 4 week group with severe erosions and attening and a marked increase in the joint space. Osteophyte formation was seen in 12.5% of the joints (Figure 2). Eight week group Two animals had deformed limbs with an altered gait (Figure 3). Crepitation and stiness was obvious in these animals. The radiographic changes were comparable with those seen in the 6 week group animals but less severe (Figure 4).

8 weeks

ve: +: ++: (4) ve: (3) +: (1) ++: +++: (5) +: (2) ++: (1) +++:

ve: (7) ve: (7) +: (1) +ve: (1) +: (7) ve: (6) +: (1) +ve: (2)

(5) ve: (4) ve: (5) (2) +: (3) +ve: (3) (1) +++: (1)

+: mild; ++: moderate; +++: severe; ve: not present

Baseline control group Radiographic examination has shown the condyle projected beyond the surface of the plane of the ramus on the medial side and is directed backwards in the sagittal view. Morphologically, it was oval in the sagittal plane and rounded in the coronal. The radius of the curvature in the coronal projections was almost equal to axial length. The condyle was less convex anteroposteriorly (sagitally) than mediolaterally (coronally) and the long axis of the condyle made a small acute angle with the long axis of the ramus. In the coronal view, the medial pole was slightly pointed and more pronounced than the lateral pole which was blunt and rounded. The mandibular fossa was concave in shape and seemed to be shallower and wider anteroposteriorly than mediolaterally. Forty-eight hour group The clinical ndings are summarised in Table 1. All experimental animals were less active than the control group. The experimental group also had a raised temperature with an average temperature at sacrice of 38.68C compared with 36.88C for the control animals as well as redness of the ears and soles of their feet. Small joints (including TMJ) were tender to manipulation. No radiographic changes were detected in either the experimental or the control animals. One week group There was a minimal reduction of mouth opening in two of the experimental animals by 2.0% and 5.6% respectively (Table 1) but no obvious radiographic changes. Two week group The mouth opening of one animal was reduced by 2.2% (Table 1). Mild condylar head erosion was found
Dentomaxillofacial Radiology

Figure 1 Coronal tomogram of an experimental animal 4 weeks after induction of RA showing cystic changes in the right condyle, and erosions of both TMJs

Figure 2 Coronal tomogram of an experimental animal from the 6week group showing subcortical cyst in the right condyle and erosions of both TMJs

Rheumatoid arthritis AF Al-Mobireek et al

Figure 3 Photograph of the hind limb of an experimental animal from the eight week group showing deformed foot

Figure 4 Coronal tomogram of an experimental animal from the 8week group showing destruction of the left condylar head and sclerosis of the right

Discussion The use of animal models in studying human diseases is intended provide some insight in the pathogenesis, diagnostic criteria and therapy. To the best of our knowledge this is the rst investigation in the English literature to study the clinical and radiographic changes in TMJ following SCW-induced RA. All animals in the experimental group showed evidence of acute inammation, establishing that guinea pigs are susceptible to the induction of RA and therefore a good model. We found arthritic changes similar to RA in humans can be induced within 24 h following a single IP injection of SCW. This tecnique has previously been used to induce RA in rats.14,17,18 It is believed that bacterial debris is one possible cause, probably due to similarity of the peptidoglycan in the streptococci cell wall to human peptidoglycan.19 Hence, cross reacting antibodies may be a possible mechanism for RA.19 We based our diagnostic criteria on features reported in RA, including crepitation, joint stiness, reduced mouth opening and locking.5,7,17 Our data show that RA of the TMJ in guinea pigs is a progressive disease, beginning with acute features that continue for between 5 and 7 days before becoming chronic. In the acute stage, the experimental animals had an elevated temperature, redness of the soles and ears, tender

joints and reduced activity compared with the control animals. They also lost weight which may be attributed to dehydration. In the chronic phase, reduction in mouth opening and stiness were early signs of TMJ involvement. The magnitude of reduction, however, was very small conrming previous observations that it is likely to be overlooked or underestimated clinically.2,5 7,17 Crepitation, indicating TMJ destruction, has been reported in many studies to be associated with RA but was a late manifestation in our study. The clinical ndings in the TMJ in the chronic stage were in agreement with previous studies.5 7,17 Maintenance of mouth opening despite TMJ destruction has been explained by Parker20 as a feature of consistent adaptation of the masticatory system; the degree of adaptation determines the consequent pathological manifestations. Accordingly, adaptability drives homeostasis or, in other words, the balance between orthofunction and parafunction. The capacity for adaptation may vary from one person to another and also in the same person at dierent times. It is also aected by other factors such as gender and the ability to cope with stress.14 Ogus7 proposed a healing phase where the symptoms subside and the articular surfaces become remodeled and attened followed by an arthritic phase. Most probably, the healing phase is the homeostasis which is the outcome of adaptation. Furthermore, the function of the rheumatoid joint has been reported to show remarkable changes not only from day to day but also during the day.3,6,21 Our data shows that experimental animals grew more slowly compared with controls, as in juvenile RA.22 This could be attributed to change in food and water consumption and decreased mobility. One of the main radiographic changes in the TMJ was bone erosion, particularly in the condylar head, consistent with previous reports.4 7,17,21,23 Mild erosion was the rst radiographic change detected in the 2 week experimental animals. Other bone abnormalities were directly related to the duration of the condition. In general, sclerosis and subchondral cysts were signs of relatively advanced disease. Larheim and associates66 reported that destruction and an irregular hollowedout appearance of the condyles are characteristic features of RA. They also considered narrowing of the joint space to be an important diagnostic feature. Our data conrm that cyst-like lesions are associated with advanced bony destruction.6,7 Although attening is not regarded as a manifestation of RA in some reports,17 we have shown that it is one of the features of experimentally-induced RA. Similarly, Ogus77 described attening as more frequent in RA patients. This discrepancy may be attributed to the process of remodeling of the human TMJ, and other dierences such as age, race and gender.17 Moreover, these studies were cross-sectional rather than longitudinal. Our animal model has shown that the clinical manifestations of RA, including TMJ tenderness and slight reduction in the mouth opening developed without apparent radiographic bony changes. A

289

Dentomaxillofacial Radiology

Rheumatoid arthritis AF Al-Mobireek et al

290

moderate reduction in the mouth opening was associated with more marked bone changes at 6 weeks, while a severe reduction and crepitation were associated with more extensive changes. Paradoxically, milder radiographic changes were observed at 8 weeks although stiness and crepitation were still evident. Whether radiographic and clinical manifestations of RA in man is correlated is still to be proved. Longitudinal clinical studies are urgently needed. While osteophytosis is reported to be a main radiographic feature of osteoarthritis, it is relatively rare in RA, and therefore, may be one feature in dierentiating the courses of the two conditions. It is accepted that the osteoarthritis is alternatively destructive and reparative.20 On the other hand, RA is both progressive and destructive with a more intermittent aggressive phases.24 Studies demonstrated that complex motion tomography, such as hypocycloidal, can reveal the bony changes more clearly than more simpler
References
1. Smith CA, Arnett FC. Epidemiologic aspects of rheumatoid arthritis. Clin Orthop 1991: 265: 23 35. 2. Syrja nen SM. The temporomandibular joint in rheumatoid arthritis. Acta Radiol 1985: 26: 235 243. 3. Lamont-Havers RW. The arthritis of the temporomandibular joint. Dent Clin North Am 1966: 10: 621 226. 4. Avrahami E, Segal R, Solomon A, Gark A, Horowitz I, Caspi D. Direct coronal high resolution computed tomography of the temporomandibular joints in patients with rheumatoid arthritis. J Rheumatol 1989: 16: 298 301. 5. Holmund AB, Gynther G, Reinholt FB. Rheumatoid arthritis and disk derangement of the temporomandibular joint. Oral Surg Oral Med Oral Pathol 1992: 73: 273 277. 6. Larheim TA, Storhaug K, Tveito L. Temporomandibular joint involvement and dental occlusion in a group of adults with rheumatoid arthritis. Acta Odontol Scand 1983: 41: 301 309. 7. Ogus H. Rheumatoid arthritis of the temporomandibular joint. Br J Oral Surg 1975: 12: 275 284. 8. Battisto JR, Smith RN, Beckman K Sternlight M, Walles WL. Susceptibility to adjuvant arthritis in DA and F344 rats. Arthritis Rheum 1982: 25: 1194. 9. Yoo TJ, Tomoda K, Herondez AD. Type II collagen-induced autoimmune inner ear lesions in Guinea pigs. Ann Otol Rhinol 1984: 93 (suppl.113): 3 5. 10. Brahn E. Animal models of rheumatoid arthritis, clues to etiology and treatment. Clin Orthop 1991: 265: 42 53. 11. Wooley PH, Seibold JR, Whalen JD, Chapdelaine JM. Pristaneinduced arthritis: The immunologic genetic features of an experimental murine model of autoimmune disease. Arthritis Rheum 1989: 32: 1022. 12. Hernadez AD, Cremer MA, Stuart JM, Kang HA. The immune response of Guinea pig to type II collagen: Poor cross-reactivity with homologous type II collagen accounts for resistance to collagen induced arthritis. Immunology 1988: 63: 619 624. 13. Trentham DE. Collagen arthritis as a relevant model for rheumatoid arthritis. Arthritis Rheum 1982: 25: 911 916. 14. Cromartie WJ, Craddock JG, Schwab JH, Anderle SK, Yang CH. Arthritis in rats after systemic injection of streptococcal cells or cell walls. J Exp Med 1977: 146: 1585 1602.

motions.23,25,26 The use of corrected tomography or CT will show the changes better,17,25 and their use is therefore highly recommended whenever possible. The coronal views in this study provided a clear view of the bone components and thus demonstrated the changes more vividly. They also enabled visualisation of lateral and medial aspects of the TMJ. Sagittal views, however, are useful for investigating the joint space and the related bony structures.17 Both coronal and sagittal views should be considered in the assessment of rheumatoid arthritis. The results of the present investigation reveal that in experimentally-induced RA, there are progressive changes which can be correlated clinically and radiographically. Further histopathological and biochemical studies are needed to ascertain the exact nature of the changes produced. The role of gender and genetics in RA needs further investigations.

15. Dische A, Shettles LB. A specic color reaction of methyl pentose and a spectrophotometer micromethod for their determination. J Biol Chem 1984: 175: 590. 16. Goupille P, Fouquet B, Cotty P, Goga D, Mateu J, Valat J. The temporomandibular joint in rheumatoid arthritis. Correlation between clinical and computed tomography features. J Rheumatol 1990: 9: 1285 1291. 17. Clark RL, Cuttino JT, Anderle SK, Cromartie WJ, Schwab JH. Radiologic analysis of arthritis in rats after systemic injection of streptococcal cell walls. Arthritis Rheum 1979: 22: 25 35. 18. Wilder RL, Calandra GB, Garvin AJ, Wright KD, Hansen CT. Strain and sex variation in the susceptibility to streptococcal cell-induced polyarthritis in the rat. Arthritis Rheum 1982: 25: 1046 1072. 10. Harris ED. Pathogenesis of rheumatoid arthritis. Clinic Orthop 1984: 182: 14 23. 20. Parker MP. A dynamic model of etiology in temporomandibular disorder. J Am Dent Assoc 1990: 120: 283 290. 21. Larheim TA, Tveito L, Dale K, Ruud F. Temporomandibular joint abnormalities in rheumatoid arthritis: Comparison of dierent radiographic methods. Acta Radiol Diag 1981: 22: 703 707. 22. Zide MF, Carlton DM, Kent JN. Rheumatoid disease and related arthropathies. Systemic ndings, medical therapy and peripheral joint surgery. Oral Surg Oral Med Oral Pathol 1986: 61: 119 125. 23. Larheim TA, Bjrnaland T, Smith HJ, Asperstrand F, Kolbenstvedt A. Imaging temporomandibular joint abnormalities in patients with rheumatic disease. Oral Surg Oral Med Oral Pathol 1992: 73: 494 501. 24. Muir CB, Goss AN. The radiologic morphology of painful temporomandibular joint. Oral Surg Oral Med Oral Pathol 1990: 70: 355 359. 25. Bashiri H, Yale SH. Comparative radiography of articially created mandibular condyle defects. J Prosth Dent 1985: 54: 263 271. 26. Raustia AM, Pyhtinen J. Morphology of the condyles and the mandibular fossa as seen by computed tomography. J Prosth Dent 1990: 63: 77 82.

Dentomaxillofacial Radiology