Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelho

Detalhes bibliográficos
Ano de defesa: 2023
Autor(a) principal: Costa, Ana Carolina de Figueiredo
Orientador(a): Gondim, Delane Viana
Banca de defesa: Não Informado pela instituição
Tipo de documento: Tese
Tipo de acesso: Acesso embargado
Idioma: por
Instituição de defesa: Não Informado pela instituição
Programa de Pós-Graduação: Não Informado pela instituição
Departamento: Não Informado pela instituição
País: Não Informado pela instituição
Área do conhecimento CNPq:
Link de acesso: http://repositorio.ufc.br/handle/riufc/75005
Resumo: Rheumatoid arthritis (RA) is an autoimmune disease that affects synovial joints and methotrexate (MX) is considered the first-line treatment. The first chapter of this thesis evaluated the effects of MX on nociception, joint damage, canonical Wnt pathway and glial cells in the trigeminal nociceptive pathway (TNP) of rats with RA in the temporomandibular joint (TMJ). The animals were divided into groups (n=6): Control, RA and RA+MX. RA induction occurred by administration of complete/incomplete Freund's adjuvant and methylated bovine serum albumin (mBSA), followed by three intra-articular injections of mBSA (1x/week). The animals were treated with MX (0.75 mg; 2x/week) for 15 days and euthanized 24 hours after the third injection. Mechanical hyperalgesia, inflammatory parameters in the TMJ, analysis of facial expressions, immunoexpression of c-Fos, Wnt-10b, β-catenin, glutamine synthetase (GS), Iba-1 and microglial morphology in the TNP were evaluated. Arthritic animals showed a significant increase in mechanical hyperalgesia and facial expression scores, intense inflammatory infiltrate in the synovial membrane (SM), degeneration and depletion of proteoglycans in the articular cartilage (AC). Furthermore, there was a significant increase in the immunoexpression of TNF-α, IL-17 in MS and AC, while IL-10 showed a significant increase only in SM. MX reversed all parameters related to nociception, inflammation and joint damage. RA induction promoted an increase in the immunoexpression of c-Fos, Wnt-10b, β-catenin and GS in the trigeminal ganglion (TG) and an increase in the immunoexpression of c-Fos and Iba-1 in the subnucleus caudalis of the trigeminal (Sp5C), as well such as, increased total length and number of microglia branches. MX significantly reduced the immunoexpression of these markers. It is concluded that MX reduces nociceptive behavior, joint damage, number of glial cells in the TNP and immunoexpression of the Wnt/β-catenin pathway in the TG. The second chapter showed a comparative study of the development of RA in the TMJ and knee (K) of rats, which were divided into groups (n=6): TMJ/Control, TMJ/RA-24h, TMJ/RA-7D, K/Control, K/RA-24h and K/RA-7D. Euthanasia occurred 24 hours or 7 days after the third mBSA injection. Mechanical hyperalgesia, cellular influx into synovial fluid, histopathological changes, immunoexpression of metalloproteinase (MMP)-9 and birefringence of collagen fibers in the TMJ and K cartilage were evaluated. There was a reduction in the nociceptive threshold of arthritic animals in both joints and periods of euthanasia. In the TMJ and K, there was a significant increase in cellular influx into the synovial fluid 24 hours after the third injection and in the K/RA-7D group. The TMJ/RA-24h and K/RA-24h groups showed edema, intense inflammatory infiltrate in the SM, hypertrophic chondrocytes, reduced metachromasia, increased MMP-9, reduced total collagen fibers and type I collagen, and increased collagen fibers. type III in AC. In the TMJ/RA-7D group, there was a reduction in these parameters, a fact not observed in the K/RA-7D group. Thus, the nociceptive response is similar in both joints in the acute and chronic phases of RA, however, there is an improvement in joint damage in the TMJ in the chronic phase, suggesting tissue repair.
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spelling Costa, Ana Carolina de FigueiredoGondim, Delane Viana2023-11-20T18:41:15Z2023-11-20T18:41:15Z2023COSTA, Ana Carolina de Figueiredo. Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelho. 2023. 145 f. Tese (Doutorado em Odontologia) - Faculdade de Farmácia, Odontologia e Enfermagem, Universidade Federal do Ceará, Fortaleza, 2023. Disponível em: http://repositorio.ufc.br/handle/riufc/75005. Acesso em: 20 nov. 2023.http://repositorio.ufc.br/handle/riufc/75005Rheumatoid arthritis (RA) is an autoimmune disease that affects synovial joints and methotrexate (MX) is considered the first-line treatment. The first chapter of this thesis evaluated the effects of MX on nociception, joint damage, canonical Wnt pathway and glial cells in the trigeminal nociceptive pathway (TNP) of rats with RA in the temporomandibular joint (TMJ). The animals were divided into groups (n=6): Control, RA and RA+MX. RA induction occurred by administration of complete/incomplete Freund's adjuvant and methylated bovine serum albumin (mBSA), followed by three intra-articular injections of mBSA (1x/week). The animals were treated with MX (0.75 mg; 2x/week) for 15 days and euthanized 24 hours after the third injection. Mechanical hyperalgesia, inflammatory parameters in the TMJ, analysis of facial expressions, immunoexpression of c-Fos, Wnt-10b, β-catenin, glutamine synthetase (GS), Iba-1 and microglial morphology in the TNP were evaluated. Arthritic animals showed a significant increase in mechanical hyperalgesia and facial expression scores, intense inflammatory infiltrate in the synovial membrane (SM), degeneration and depletion of proteoglycans in the articular cartilage (AC). Furthermore, there was a significant increase in the immunoexpression of TNF-α, IL-17 in MS and AC, while IL-10 showed a significant increase only in SM. MX reversed all parameters related to nociception, inflammation and joint damage. RA induction promoted an increase in the immunoexpression of c-Fos, Wnt-10b, β-catenin and GS in the trigeminal ganglion (TG) and an increase in the immunoexpression of c-Fos and Iba-1 in the subnucleus caudalis of the trigeminal (Sp5C), as well such as, increased total length and number of microglia branches. MX significantly reduced the immunoexpression of these markers. It is concluded that MX reduces nociceptive behavior, joint damage, number of glial cells in the TNP and immunoexpression of the Wnt/β-catenin pathway in the TG. The second chapter showed a comparative study of the development of RA in the TMJ and knee (K) of rats, which were divided into groups (n=6): TMJ/Control, TMJ/RA-24h, TMJ/RA-7D, K/Control, K/RA-24h and K/RA-7D. Euthanasia occurred 24 hours or 7 days after the third mBSA injection. Mechanical hyperalgesia, cellular influx into synovial fluid, histopathological changes, immunoexpression of metalloproteinase (MMP)-9 and birefringence of collagen fibers in the TMJ and K cartilage were evaluated. There was a reduction in the nociceptive threshold of arthritic animals in both joints and periods of euthanasia. In the TMJ and K, there was a significant increase in cellular influx into the synovial fluid 24 hours after the third injection and in the K/RA-7D group. The TMJ/RA-24h and K/RA-24h groups showed edema, intense inflammatory infiltrate in the SM, hypertrophic chondrocytes, reduced metachromasia, increased MMP-9, reduced total collagen fibers and type I collagen, and increased collagen fibers. type III in AC. In the TMJ/RA-7D group, there was a reduction in these parameters, a fact not observed in the K/RA-7D group. Thus, the nociceptive response is similar in both joints in the acute and chronic phases of RA, however, there is an improvement in joint damage in the TMJ in the chronic phase, suggesting tissue repair.A artrite reumatoide (AR) é uma doença autoimune que afeta as articulações sinoviais e o metotrexato (MX) é considerado o tratamento de primeira escolha. O primeiro capítulo desta tese avaliou os efeitos do MX na nocicepção, dano articular, via canônica Wnt e células gliais na via nociceptiva trigeminal (VNT) de ratos com AR na articulação temporomandibular (ATM). Os animais foram divididos nos grupos (n=6): Controle, AR e AR+MX. A indução da AR ocorreu pela administração de adjuvante completo/incompleto de Freund e albumina de soro bovino metilada (mBSA), seguida de três injeções intra-articulares de mBSA (1x/semana). Os animais foram tratados com MX (0,75 mg; 2x/semana) por 15 dias e eutanasiados 24 horas após a terceira injeção. Foram avaliados a hiperalgesia mecânica, parâmetros inflamatórios na ATM, análise das expressões faciais, imunoexpressão de c-Fos, Wnt-10b, β-catenina, glutamina sintetase (GS), Iba-1 e morfologia microglial na VNT. Os animais artríticos apresentaram significativo aumento da hiperalgesia mecânica e dos escores das expressões faciais, intenso infiltrado inflamatório na membrana sinovial (MS), degeneração e depleção de proteoglicanos na cartilagem articular (CA). Além disso, houve um aumento significativo da imunoexpressão de TNF-α, IL-17 na MS e CA, enquanto que a IL-10 apresentou significativo aumento somente na MS. MX reverteu todos os parâmetros relacionados à nocicepção, inflamação e dano articular. A indução da AR promoveu aumento da imunoexpressão de c-Fos, Wnt-10b, β-catenina e GS no gânglio trigeminal (GT) e aumento da imunoexpressão de c-Fos e Iba-1 no subnúcleo caudal do trigêmeo (Sp5C), bem como, aumento do comprimento total e número de ramificações da microglia. MX reduziu significativamente a imunoexpressão desses marcadores. Conclui-se que o MX reduz o comportamento nociceptivo, dano articular, número de células gliais na VNT e imunoexpressão da via Wnt/β-catenina no GT. O segundo capítulo mostrou um estudo comparativo do desenvolvimento da AR na ATM e no joelho (J) de ratos, que foram divididos nos grupos (n=6): ATM/Controle, ATM/AR-24h, ATM/AR-7D, J/Controle, J/AR-24h e J/AR-7D. A eutanásia ocorreu 24 horas ou 7 dias após a terceira injeção de mBSA. Foram avaliados hiperalgesia mecânica, influxo celular no fluido sinovial, alterações histopatológicas, imunoexpressão de metaloproteinase (MMP)-9 e birrefringência das fibras colágenas na cartilagem da ATM e J. Houve redução do limiar nociceptivo dos animais artríticos em ambas as articulações e períodos de eutanásia. Na ATM e J, houve aumento significativo do influxo celular no líquido sinovial 24 horas após a terceira injeção e no grupo J/AR-7D. Os grupos ATM/AR-24h e J/AR-24h apresentaram edema, intenso infiltrado inflamatório na MS, condrócitos hipertróficos, redução da metacromasia, aumento de MMP-9, redução das fibras colágenas totais e de colágeno tipo I e aumento das fibras colágenas tipo III na CA. No grupo ATM/AR-7D, houve redução desses parâmetros, fato não constatado no grupo J/AR-7D. Desse modo, a resposta nociceptiva é semelhante em ambas as articulações nas fases aguda e crônica da AR, entretanto, há melhora do dano articular na ATM na fase crônica, sugerindo reparo tecidual.Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelhoinfo:eu-repo/semantics/publishedVersioninfo:eu-repo/semantics/doctoralThesisArtrite ReumatoideArticulação TemporomandibularMetotrexatoRheumatoid arthritisTemporomandibular jointMethotrexateCNPQ::CIENCIAS DA SAUDE::ODONTOLOGIAinfo:eu-repo/semantics/embargoedAccessporreponame:Repositório Institucional da Universidade Federal do Ceará (UFC)instname:Universidade Federal do Ceará (UFC)instacron:UFChttps://orcid.org/0000-0002-4983-3439http://lattes.cnpq.br/7939819361342658https://orcid.org/0000-0002-7240-3314http://lattes.cnpq.br/56053576461103602025-11-20ORIGINAL2023_tese_acfcosta.pdf2023_tese_acfcosta.pdfapplication/pdf5057185http://repositorio.ufc.br/bitstream/riufc/75005/1/2023_tese_acfcosta.pdf3119a30627335dde982ea9417a23bba6MD51LICENSElicense.txtlicense.txttext/plain; charset=utf-81748http://repositorio.ufc.br/bitstream/riufc/75005/2/license.txt8a4605be74aa9ea9d79846c1fba20a33MD52riufc/750052023-11-20 15:42:00.831oai:repositorio.ufc.br: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Repositório InstitucionalPUBhttp://www.repositorio.ufc.br/ri-oai/requestbu@ufc.br || repositorio@ufc.bropendoar:2023-11-20T18:42Repositório Institucional da Universidade Federal do Ceará (UFC) - Universidade Federal do Ceará (UFC)false
dc.title.pt_BR.fl_str_mv Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelho
title Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelho
spellingShingle Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelho
Costa, Ana Carolina de Figueiredo
CNPQ::CIENCIAS DA SAUDE::ODONTOLOGIA
Artrite Reumatoide
Articulação Temporomandibular
Metotrexato
Rheumatoid arthritis
Temporomandibular joint
Methotrexate
title_short Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelho
title_full Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelho
title_fullStr Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelho
title_full_unstemmed Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelho
title_sort Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelho
author Costa, Ana Carolina de Figueiredo
author_facet Costa, Ana Carolina de Figueiredo
author_role author
dc.contributor.author.fl_str_mv Costa, Ana Carolina de Figueiredo
dc.contributor.advisor1.fl_str_mv Gondim, Delane Viana
contributor_str_mv Gondim, Delane Viana
dc.subject.cnpq.fl_str_mv CNPQ::CIENCIAS DA SAUDE::ODONTOLOGIA
topic CNPQ::CIENCIAS DA SAUDE::ODONTOLOGIA
Artrite Reumatoide
Articulação Temporomandibular
Metotrexato
Rheumatoid arthritis
Temporomandibular joint
Methotrexate
dc.subject.ptbr.pt_BR.fl_str_mv Artrite Reumatoide
Articulação Temporomandibular
Metotrexato
dc.subject.en.pt_BR.fl_str_mv Rheumatoid arthritis
Temporomandibular joint
Methotrexate
description Rheumatoid arthritis (RA) is an autoimmune disease that affects synovial joints and methotrexate (MX) is considered the first-line treatment. The first chapter of this thesis evaluated the effects of MX on nociception, joint damage, canonical Wnt pathway and glial cells in the trigeminal nociceptive pathway (TNP) of rats with RA in the temporomandibular joint (TMJ). The animals were divided into groups (n=6): Control, RA and RA+MX. RA induction occurred by administration of complete/incomplete Freund's adjuvant and methylated bovine serum albumin (mBSA), followed by three intra-articular injections of mBSA (1x/week). The animals were treated with MX (0.75 mg; 2x/week) for 15 days and euthanized 24 hours after the third injection. Mechanical hyperalgesia, inflammatory parameters in the TMJ, analysis of facial expressions, immunoexpression of c-Fos, Wnt-10b, β-catenin, glutamine synthetase (GS), Iba-1 and microglial morphology in the TNP were evaluated. Arthritic animals showed a significant increase in mechanical hyperalgesia and facial expression scores, intense inflammatory infiltrate in the synovial membrane (SM), degeneration and depletion of proteoglycans in the articular cartilage (AC). Furthermore, there was a significant increase in the immunoexpression of TNF-α, IL-17 in MS and AC, while IL-10 showed a significant increase only in SM. MX reversed all parameters related to nociception, inflammation and joint damage. RA induction promoted an increase in the immunoexpression of c-Fos, Wnt-10b, β-catenin and GS in the trigeminal ganglion (TG) and an increase in the immunoexpression of c-Fos and Iba-1 in the subnucleus caudalis of the trigeminal (Sp5C), as well such as, increased total length and number of microglia branches. MX significantly reduced the immunoexpression of these markers. It is concluded that MX reduces nociceptive behavior, joint damage, number of glial cells in the TNP and immunoexpression of the Wnt/β-catenin pathway in the TG. The second chapter showed a comparative study of the development of RA in the TMJ and knee (K) of rats, which were divided into groups (n=6): TMJ/Control, TMJ/RA-24h, TMJ/RA-7D, K/Control, K/RA-24h and K/RA-7D. Euthanasia occurred 24 hours or 7 days after the third mBSA injection. Mechanical hyperalgesia, cellular influx into synovial fluid, histopathological changes, immunoexpression of metalloproteinase (MMP)-9 and birefringence of collagen fibers in the TMJ and K cartilage were evaluated. There was a reduction in the nociceptive threshold of arthritic animals in both joints and periods of euthanasia. In the TMJ and K, there was a significant increase in cellular influx into the synovial fluid 24 hours after the third injection and in the K/RA-7D group. The TMJ/RA-24h and K/RA-24h groups showed edema, intense inflammatory infiltrate in the SM, hypertrophic chondrocytes, reduced metachromasia, increased MMP-9, reduced total collagen fibers and type I collagen, and increased collagen fibers. type III in AC. In the TMJ/RA-7D group, there was a reduction in these parameters, a fact not observed in the K/RA-7D group. Thus, the nociceptive response is similar in both joints in the acute and chronic phases of RA, however, there is an improvement in joint damage in the TMJ in the chronic phase, suggesting tissue repair.
publishDate 2023
dc.date.accessioned.fl_str_mv 2023-11-20T18:41:15Z
dc.date.available.fl_str_mv 2023-11-20T18:41:15Z
dc.date.issued.fl_str_mv 2023
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dc.identifier.citation.fl_str_mv COSTA, Ana Carolina de Figueiredo. Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelho. 2023. 145 f. Tese (Doutorado em Odontologia) - Faculdade de Farmácia, Odontologia e Enfermagem, Universidade Federal do Ceará, Fortaleza, 2023. Disponível em: http://repositorio.ufc.br/handle/riufc/75005. Acesso em: 20 nov. 2023.
dc.identifier.uri.fl_str_mv http://repositorio.ufc.br/handle/riufc/75005
identifier_str_mv COSTA, Ana Carolina de Figueiredo. Participação da via canônica WNT no efeito protetor do metotrexato em ratos com artrite na articulação temporomandibular e análise comparativa à artrite em joelho. 2023. 145 f. Tese (Doutorado em Odontologia) - Faculdade de Farmácia, Odontologia e Enfermagem, Universidade Federal do Ceará, Fortaleza, 2023. Disponível em: http://repositorio.ufc.br/handle/riufc/75005. Acesso em: 20 nov. 2023.
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