Rheumatology 2001; 40: 691-694
© 2001 British Society for Rheumatology
Original Papers |
Radiographic signs of bone destruction in the arthritic temporomandibular joint with special reference to markers of disease activity. A longitudinal study
Departments of Clinical Oral Physiology and Oral Radiology, Institute of Odontology, Karolinska Institutet, Huddinge, Sweden
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Abstract |
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Objective. To investigate the progression of radiographic changes of the temporomandibular joint (TMJ) with reference to plasma levels of interleukin-1ß (IL-1ß), C-reactive protein (CRP) and disease duration.
Methods. Twenty-one patients with chronic inflammatory joint disease and TMJ involvement were included. Individualized tomography of the TMJ was performed twice with an interval of at least 12 months. Blood samples were analysed for IL-1ß and CRP.
Results. Significant progression of the overall grade of radiographic changes occurred during the observation period, whereas erosions showed great interindividual variability. Progression of TMJ bone loss was correlated to raised levels of CRP and, in patients with a diagnosis of rheumatoid arthritis, or with shorter duration, also to plasma IL-1ß.
Conclusion. Progression of overall grade of radiographic changes in the TMJ occurs in patients with chronic inflammatory joint disease. Raised levels of serum CRP are associated with progression of TMJ bone loss.
KEY WORDS: Temporomandibular joint, Erosion, Radiographic progression, CRP, IL-1ß.
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Introduction |
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The temporomandibular joint (TMJ) is only occasionally included in studies of radiographic progression of chronic inflammatory diseases such as rheumatoid arthritis (RA). Longitudinal studies of this joint in adult arthritic patients are even more infrequent. Several scoring systems have been developed to quantify the radiographic changes of joints in RA [1, 2]. For assessment of the TMJ, the scoring system by Larsen et al. [1] has been modified by Rohlin and Petersson [3].
Longitudinal radiographic changes of hands and feet are associated with plasma levels of interleukin-1ß (P-IL-1ß) [4]. In a study of patients with chronic inflammatory joint disease and TMJ involvement, a significantly greater extent of erosions (ER) and grade of radiographic changes (GR) was found in patients with detectable P-IL-1ß than in other patients [5]. In patients with RA, radiographic damage, defined by the number of erosions in the hand and wrist, was more likely to occur when the C-reactive protein (CRP) concentration and erythrocyte sedimentation rate were persistently raised for 12 months or more [6]. In addition, CRP levels were associated with progression of erosions [7]. Disease duration has also been implicated as an important factor in the progression of radiographic changes in RA [8, 9].
We investigated the progression of radiographic changes in the TMJ of patients with chronic inflammatory joint disease and whether progression was related to circulating levels of IL-1ß or CRP or to disease duration.
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Patients and methods |
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Patients
Twenty-one patients with a diagnosis of chronic inflammatory joint disease with TMJ involvement were included in this study. The patients had been referred to our clinic because of TMJ symptoms. The inclusion criteria were a diagnosis of chronic inflammatory joint disease and pain from the TMJ for at least 3 months. All patients gave informed consent and the study was approved by the local ethics committee of Huddinge University Hospital.
All patients were on medication. Nineteen were taking non-steroidal anti-inflammatory drugs, nine were taking disease-modifying anti-rheumatic drugs, nine were taking oral glucocorticosteroids and six were taking methotrexate.
Radiographic examination
Radiographic examination of the TMJ was performed by sagittal individualized tomography [10] at the Department of Oral Radiology, Karolinska Institutet, Huddinge. The examination was repeated with an interval of at least 12 months (mean 33 months, S.D. 13 months).
ER was assessed separately in the lateral, central and medial thirds of the condyle and the temporal component and given a score 0 or 1, yielding a maximum score of 6 per joint. GR was assessed using the index of Rohlin and Petersson [3] and standard reference films.
Radiographs from the first and second examinations were assessed at the same time, and the progression of TMJ bone loss was evaluated. Radiographs with no change between the two examinations were given score 0, slight progression 1, moderate progression 2 and extensive progression 3 (Fig. 1
). The progression score (PROG) for each TMJ could thus be 0–3. The same radiologist analysed all radiographs without information about the laboratory findings. An intra-observer study of PROG scoring was performed. Sixteen joints were evaluated twice with an interval of at least 12 months. To enable comparison of radiographic changes between patients with different lengths of observation period, progression per month was calculated for ER (EPR) and for PROG (PROGR). Progression rates for individuals were calculated by adding the right- and left-side values.
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Blood sampling and analysis
Repeated venous blood samples were collected and analysed for CRP and P-IL-1ß levels. The concentration of IL-1ß in the samples was determined with an ACETM human IL-1ß ELISA kit (Cayman Chemical Company, Ann Arbor, MI, USA). CRP was analysed with Tina-quant® CRP, an immunoturbidimetric assay (Roche, Basel, Switzerland).
Statistics
The mean and standard deviation were used to describe normally distributed variables on at least an interval scale, and the median and interquartile range (IQR) were used for other variables. The Wilcoxon test was used for testing the significance of differences between the first and second examinations. For analysis of the influence of disease duration in relation to IL-1ß levels, patients were divided into groups by the median duration of TMJ involvement: 
7 vs >7 yr. Spearman's rank correlations (rS) were calculated. A probability level of <0.05 was considered significant.
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Results |
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Patient data, CRP and P-IL-1ß levels, PROG and PROGR are shown in Table 1
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Radiographic progression
ER remained unchanged in 43%, increased in 33% and decreased in 24% of all joints. ER was slightly higher at the second examination, but the difference was not statistically significant for the group as a whole (P=0.274, n=42) or for the RA patients (P=0.842, n=28).
GR per joint was significantly higher at the second examination than at the first (P=0.035, n=42) for the whole group but not for the 14 RA patients (P=0.196, n=28). A PROG value>0 was found in 52% of the 42 joints. For the total group, the mean PROGR in joints with progression was 0.07 (S.D. 0.041), n=22, and mean EPR 0.09 (S.D. 0.105), n=13. For the 14 RA patients, mean PROGR for joints with progression was 0.07 (0.040), n=14, and EPR was 0.11 (0.140), n=7.
No significant correlation was found between local or general disease duration and PROG. In the intraobserver study there was total agreement between the evaluations of PROG in 56% and in 94% of joints when a variation of 1 unit of the progression index was allowed.
Interleukin-1ß and CRP
In the total group, there was a significant correlation between PROG and the median level of CRP (rS=0.57, P=0.007) and between CRP and PROGR (rS=0.55, P=0.009). For the 14 patients with RA, there was a significant correlation between median CRP and PROG (rS=0.55, P=0.043) and between mean P-IL-1ß and PROG (rS=0.59, P=0.027). In the patients with shorter duration of TMJ involvement, there was a significant correlation between mean P-IL-1ß and PROG (rS=0.86, P<0.001, n=11) and between P-IL-1ß and PROGR (rS=0.77, P=0.006, n=11). No statistically significant correlations were found between EPR and any of the laboratory variables.
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Discussion |
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TopAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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To the best of our knowledge, this study is the first longitudinal investigation of radiographic changes in the TMJ in adult patients with RA and other chronic inflammatory diseases, and no direct comparison with previous results can therefore be made. ER showed considerable individual variation during the observation period, whereas GR progressed significantly. Our investigation included the two TMJs, whereas 42–50 joints were assessed in other studies [11–13], which makes comparison with studies of other joints difficult. For the detection of progression in a single joint, none of the current systems was appropriate. de Carvalho [14] reported that in 42% of their observations there was radiographic evidence of progression without a corresponding change in the Larsen grade. We also found radiographic evidence of progression in the absence of change in GR of the TMJ; a new scoring index for bone loss in the TMJ was therefore adopted. Fries et al. [15] showed that progression scores were more variable when read on separate occasions than when determined from paired readings. Therefore, we assessed radiographs from the first and second examinations at the same time.
The correlation between CRP and PROG for the total group is consistent with studies of the hands in RA patients [6, 7] and indicates the usefulness of CRP as a prognostic marker for the TMJ. The positive correlation between P-IL-1ß and PROG in the patients with RA and shorter disease duration indicates the prognostic value of this cytokine. In several longitudinal studies of patients with early RA [10, 11], greater progression rates of radiographic change have been found in the first years after onset than later in the disease. We found no correlation between disease duration and PROG, EPR or PROGR. However, the average general disease duration in our study was 11 yr at the start of the study, and no patient had a shorter general disease duration than 4 yr.
In conclusion, progression of the overall grade of radiographic changes in the TMJ occurs in patients with chronic inflammatory joint disease. Repeated findings of raised levels of CRP are associated with progression of TMJ bone loss.
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Acknowledgments |
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This study was supported by grants from the STI Research and Study Foundation.
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Notes |
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Correspondence to: S. Nordahl, Department of Clinical Oral Physiology, Odontologiska Institutionen, Karolinska Institutet, Box 4064, SE-141 04 Huddinge, Sweden.
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References |
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