Open Journal of Stomatology, 2013, 3, 52-58 OJST Published Online December 2013 (
TNF-α and RANKL facilitates the development of
orthodontically-induced inflammatory root resorption*
Tadashi Kojima, Masaru Yamaguchi#, Tomokazu Yoshino, Mami Shimizu, Kunihiko Yamada,
Takemi Goseki, Kazutaka Kasai
Department of Orthodontics, Nihon University School of Dentistry at Matsudo, Chiba, Japan
Received 29 October 2013; revised 1 December 2013; accepted 13 December 2013
Copyright © 2013 Tadashi Kojima et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: The objective of this study was to de-
termine the levels of tumor necrosis factor-alpha
(TNF-α) and receptor activator of NF-kB ligand
(RANKL) in the gingival crevicular fluid (GCF) in
patients with severe root resorption after orthodontic
treatment. Materials and Methods: Ten patients who
had been receiving orthodontic treatment (5-control
subjects and 5-severe root resorption subjects) par-
ticipated in this study. GCF was collected from all
patients. Subjects with severe root resorption (>1/3 of
the original root length) were identified. Control
group subjects with no loss of the root structure un-
dergoing orthodontic treatment were also identified.
The GCF was collected non-invasively from the me-
sial and distal sides of each of the upper central and
lateral incisors using filter paper strips. The eluted
GCF was used for a Western blot analysis with Anti-
bodies against TNF-α and soluble RANKL (sRANKL) .
Ten male 6-week-old Wistar rats were subjected to
orthodontic force of 50 g to induce a mesially tipping
movement of the upper first molars for 7 days. The
expression levels of TNF-α and RANKL proteins
were determined in periodontal ligament (PDL) by
immunohistochemical analysis. Results: The Western
blot analysis showed that the TNF-α and sRANKL
expressions were significantly higher in the severe
root resorption group than in the control group. In
the experimental tooth movement in vivo, resorption
lacunae with multinucleated cells were observed in
50 g group. The immunoreactivity for TNF-α and
RANKL was detected in PDL tissue subjected to the
orthodontic force on day 7. Conclusion: These re-
sults suggest that TNF-α and RANKL play important
roles in inducing or facilitating the development of
orthodontically-induced inflammatory root resorp-
tion (OIIRR).
Keywords: TNF-α; sRANKL; Orthodontic Root
Resorption; Gingival Crevicular Fluid
Orthodontically-induced inflammatory root resorption
(OIIRR) is an unavoidable pathological consequence of
orthodontic tooth movement. Approximately 5% of or-
thodontic patients are prone to developing more than 5
mm of resorption during orthodontic treatment with fixed
appliances [1]. The condition can be defined as an iatro-
genic disorder that unpredictably occurs after orthodontic
treatment, whereby the resorbed apical root portion is
replaced with normal bone. OIIRR is a sterile inflamma-
tory process that is extremely complex, and involves
various disparate components, including mechanical forces,
teeth and bone, other types of cells, the surrounding ma-
trix, and certain known biologic messengers [2,3].
With regard to the relationship between OIIRR and
receptor activator of NF-kB ligand (RANKL), Yamagu-
chi et al. [4] reported that the compressed PDL cells ob-
tained from patients with severe external apical root re-
sorption exhibit an increased RANKL expression and
osteoclastogenesis in vitro. Nakano et al. [5] reported
that rat PDL induces root resorption via the RANKL/
RANK expression in response to heavy forces in vivo.
Therefore, RANKL plays an important role in root re-
sorption during orthodontic tooth movement.
TNF-α is a cytokine generated by a variety of cells in-
cluding macrophages and PDL cells, and is induced by
exogenous stimulation, endotoxins and pathogens. It is a
substance whose relationship to conditions involving in-
flammatory bone resorption such as periodontal disease
and rheumatoid arthritis is attracting attention. Ustün et
*Competing interests: The authors declare that they have no competing
#Corresponding autho
T. Kojima et al. / Open Journal of Stomatology 3 (2013) 52-58 53
al. [6] reported that TNF-α is involved in inflammatory
bone destruction in patients with periodontal diseases and
rheumatisms. Furthermore, Redlich et al. [7] reported that
the presence of TNF-α aggravates inflammation and
consequent bone destruction. However, little is known
about the relationships between OIIRR and these cyto-
The purpose of this study was to determine the ex-
pressions of TNF-α and soluble RANKL (sRANKL) in
the gingival crevicular fluid (GCF) of patients with ra-
diographic evidence of root resorption. Moreover, the
expression levels of TNF-α and RANKL were investi-
gated in rat root resorption during experimental tooth
movement due to the application of a heavy force (50 g)
using an immunohistochemical analysis.
2.1. Experimental Subjects
Ten subjects were selected from among patients seeking
treatment at the Department of Orthodontics at the Nihon
University School of Dentistry at Matsudo. Two groups
were established, including a control group and a root
resorption group. The control group included five sub-
jects (5 females, mean age: 28.0 ± 5.3 years, mean dura-
tion of treatment: 26.4 ± 3.1 months) with no radio-
graphic evidence of root resorption. The root resorption
group included five subjects (5 females, mean age: 28.9
± 6.1 years, mean duration of treatment: 27.8 ± 3.3
months) with radiographic signs of severe root resorption
of more than 1/3 of the original root length. Informed
consent was obtained from each patient, and the project
was approved by the Ethics Committee of Nihon Univer-
sity School of Dentistry at Matsudo (EC 10-019). All
patients providing their written informed consent.
The selection criteria for the subjects were as follows:
1) a Class I malocclusion with mild crowding (6 mm;
mean 5.4 ± 0.55), 2) four premolar extractions, 3) excel-
lent quality records and, 4) no history or evidence of
tooth injury or wear, as shown on the charts and diagnos-
tic records.
All subjects were in good general health with healthy
periodontal tissues before the orthodontic treatment; the
probing depths were 3 mm, and there was no radio-
graphic evidence of periodontal bone loss. Subjects were
excluded if they received antibiotic therapy during the
treatment or if they had taken anti-inflammatory medica-
tion during the month preceding the start of the study.
2.2. GCF Collection
The method used in this study has been previously de-
scribed by Yamaguchi et al. [8]. GCF was collected from
both the resorption and control groups following ortho-
dontic treatment (debonding). The GCF was collected
from the mesial and distal sides of the upper central and
lateral incisors using filter paper strips (Periopaper, Ora-
flow, Smithtown, NY, USA) inserted 1 - 2 mm into the
gingival sulcus for 60 seconds (Figure 1). After one
minute, a second collection was performed. Care was
taken to prevent mechanical injury to the soft tissue. The
contents were eluted into 1× phosphate buffer saline
(PBS) containing a protease inhibitor (0.1 mM phenyl-
methylsulphonylfluoride) and stored at 30˚C until a
further analysis. The volume of GCF on the paper strip
was measured with a Periotron 8000 (Harco, Tustin, CA,
For the evaluation of the cytokine expression, the pa-
per strips were placed individually in 100 µl of PBS and
then subjected to vortexing 3 times over a 30 minute
period. The strip was then removed and the eluate was
centrifuged for 5 minutes at 3000 × g. The supernatants
were separated and frozen at –30˚C for later use. The
protein concentration in the extract was estimated using
bovine serum albumin as a standard.
2.3. Western Blotting Analysis
The TNF-α and sRANKL expressions in the GCF sam-
ples were determined using a Western blotting analysis.
The protein content of the samples was measured using
the Bradford reagent (BIO-RAD, Tokyo, Japan) accord-
ing to the manufacturer’s protocol. The samples were
boiled for 3 minutes with sodium dodecyl sulfate (SDS)
sample buffer (62.5 mM Tris-HCl, pH 6.8, containing
3.3% SDS, 30% glycerol, 5% β-mercaptoethanol and
0.001% bromophenol blue) and the protein (10 µg) sam-
ples were then resolved on 10% SDS-polyacrylamide gel
electrophoresis (PAGE) at 150 V for 1 hour (h). The
proteins were electro transferred from the SDS gels onto
an Amersham Hybond ECL (GE Healthcare UK Ltd
Amersham Place, Little Chalfont, Buckinghamshire, UK)
for the immunoblot analyses. Blocking of nonspecific
antigen-binding sites was performed with 5% nonfat dry
Figure 1. The GCF was sampled at the mesial and
distal sides of the upper central and lateral incisors.
Copyright © 2013 SciRes. OPEN ACCESS
T. Kojima et al. / Open Journal of Stomatology 3 (2013) 52-58
milk in 150 mM NaCl, 50 mM Tris, pH 7.2, 0.05%
Tween 20 (TBST) buffer (Sigma Chemical Co., St.Lois,
MO, USA). The membrane was incubated for 24 h with
anti-TNF-α mouse monoclonal antibodies (R & D Sys-
tems Inc., Minneapolis, MN, USA) diluted at 1:500 and
anti-RANKL rabbit monoclonal antibodies (abcam PLC.,
Tokyo, Japan) diluted 1:1000 in 5% nonfat dry milk-
TBST. Subsequently, the blots were incubated for 2 h
with goat anti-mouse IgG (H+L)-HRP conjugate (BIO-
RAD) diluted at 1:2500 and goat anti-rabbit IgG (H+L)-
HRP conjugate (BIO-RAD) diluted at 1:2000 in 5%
nonfat dry milk-TBST, then developed using an ECL
system (GE Healthcare Limited). Quantification of the
band intensity was performed using the Image J Software
program (NIH, Bethesda, MD, USA).
2.4. Animal Studies
2.4.1. Animals
The animal experimental protocol in this study was ap-
proved by the Ethics Committee for Animal Experiments
at the Nihon University School of Dentistry at Matsudo
(approval No. AP12MD020). A total of ten male 6-
week-old Wistar rats (Sankyo Labo Service, Inc., To-
kyo, Japan. body weight 180 ± 10 g) were used for the
experiments. Animals were maintained at the animal
center of Nihon University School of Dentistry at Ma-
tsudo in separate cages in a 12-hour light/dark environ-
ment at a constant temperature of 23˚C, and were pro-
vided with food and water ad libitum. The health status
of each rat was evaluated by daily body weight monitor-
ing for 1 week before the start of the experiments.
2.4.2. Application of Orthodontic Devices and Tissue
Animals were anaesthetized with pentobarbital sodium
(40 mg/kg body weight) for the application of orthodon-
tic devices. Experimental tooth movement was induced
using the method of Fujita et al. [9], with a closed-coil
spring (wire size: 0.005 inch, diameter: 1/12 inch, Accu-
rate, Inc., Tokyo, Japan) ligated to the maxillary first
molar by a 0.008 inch stainless steel ligature wire (Tomy
International, Inc., Tokyo, Japan). The other side of the
coil spring was also ligated, with the holes in the maxil-
lary incisors drilled laterally just above the gingival pa-
pilla with a #1/4 round burr, using the same ligature wire.
The upper first molar was moved mesially by the closed
coil spring with a force of 50 g (Figure 2). The period of
the experiment was 7 days.
2.4.3. Tissue Preparation
The experimental period was set at 7 days after tooth
movement was initiated. The animals were deeply anes-
thetized by pentobarbital sodium and then were transcar-
dially perfused with 4% paraformaldehyde in 0.1 M
Figure 2. Experimental tooth movement was performed with a
closed-coil spring (wire size: 0.005 inch, diameter: 1/12 inch)
ligated to the maxillary first molar cleat by a 0.008-inch
stainless steel ligature wire. The other side of the coil spring
was also ligated, with the holes in the maxillary incisors drilled
laterally just above the gingival papilla with a #1/4 round bur,
using the same ligature wire. The upper first molar was moved
mesially by the closed coil spring at 50 g. The period of ex-
periment was performed for 7 days.
phosphate buffer, after which the maxilla was immedi-
ately dissected and immersed in the same fixative for 18
hours at 4˚C. The specimens were decalcified in 10%
disodium ethylenediamine tetraacetic acid (EDTA, pH
7.4) solution for 4 weeks at room temperature, and the
decalcified specimens were dehydrated through a graded
ethanol series and embedded in paraffin using the usual
methods for preparation. Each sample was sliced into 4
μm sections continuous in the horizontal direction, and
then was prepared for hematoxylin and eosin (H.E.)
staining, and also for immunohistochemical staining. The
periodontal tissues in the mesial part of the distal buccal
root of a first upper molar were observed. The one that
was not moved was defined as the control group.
2.4.4. Immunohistochemistry
Immunohistochemical staining was performed as follows.
The sections were deparaffinized and the endogenous
peroxidase activities were quenched by incubation in 3%
H2O2 in methanol for 30 minutes at room temperature.
After washing in tris buffered saline (TBS), the sections
were incubated with a monoclonal anti-TNF-α antibody
(R & D Systems, Inc., Minneapolis, MN, USA; working
dilution, 1:100) and polyclonal anti-RANKL antibody
(Santa Cruz Biotechnology, Inc., CA, USA; working
dilution, 1:100) for 18 hours at 4˚C. TNF-a and RANKL
were stained using the Histofine Simple Stain MAX-Po
(G) kit (Nichirei, Co., Tokyo, Japan) according to the
manufacturer’s protocol. The sections were rinsed with
TBS and the final color reactions were performed using
the 3, 3’-diaminobenzidine tetra-hydrochloride substrate
reagent, and the sections were then counter-stained with
hematoxylin. As immunohistochemical controls, several
Copyright © 2013 SciRes. OPEN ACCESS
T. Kojima et al. / Open Journal of Stomatology 3 (2013) 52-58 55
sections were incubated with 0.01 M phosphate buffered
saline (PBS) instead of the primary antibody. Negative
reactivity was observed for the controls. Positive controls
were performed according to the methods of previous
studies [9,10].
2.4.5. Stati stical Methods
The values in each figure represent the means ± standard
deviation (S.D.) for each group. The data are presented
as the mean ±S.D. The Mann-Whitney U-test was used
to compare the means of the groups.
3.1. Patient Samples
In all patients, the degree of plaque accumulation through-
out the study was minimal, and the subjects’ gingival
health was excellent. Furthermore, the probing depths
remained less than 3 mm at all times throughout the
experimental period, and there was no bleeding on pro-
The mean volumes of GCF obtained from the paper
strips were compared. There were no significant differ-
ences in the mean volumes of GCF between the root re-
sortion group (mean: 0.41 ± 0.05 µl) and the control
group (mean: 0.43 ± 0.05 µl).
3.2. Determination of the TNF-α and RANKL
Expressions Using a Western Blot Analysis
Western blot analysis was performed to detect the
sRANKL and TNF-α expression in the control and re-
sorption groups. Immunoblotting against TNF-α was
detected in both group samples. The intensity of band in
resorption group showed higher than that observed in the
control group (Figure 3(A)). Immunoblotting against
sRANKL was detected in the resorption group. The con-
trol group had less intense bands than the resorption
group (Figure 3(B)).
3.3. Animal Studies
3.3.1. Body Weights during the Experimental Period
The body weights of the rats in both force groups de-
creased transiently on day 1 and then recovered. No sig-
nificant differences between the two groups were ob-
served (data not shown). The amount of tooth movement
was equal between the 50 g groups during the experi-
mental period (7 days) (data not shown).
3.3.2. Histological Changes in Periodontal Tissues
during Tooth Movement (H.E. Staining)
In the control group (0 g), the rat PDL specimens were
composed of relatively dense connective tissue fibers and
fibroblasts that were horizontally aligned from the root
Figure 3. Western blot analysis for the immunodetection of
TNF-α (A) and sRANKL (B) in the gingival crevicular fluid
(GCF). Lanes 1 to 5—control group; lanes 6 to 10—severe root
resorption group.
cements. The root surface was relatively smooth, with a
few mononuclear and multinucleated osteoclasts (Figure
4(A)). In the 50 g group, there was a coarse arrangement
of fibers and compressed blood capillaries. On day 7,
many root resorption lacunae with multinucleated odon-
toclasts were recognized on the surface of the root (Fig-
ure 4(B)).
3.3.3. Prote i n Expression Le vels of TNF-α and
The immunorectivity of TNF-α and RANKL was exam-
ined on day 7 after tooth movement. TNF-α and RANKL
-positive cells were rarely observed from the control
group (Figures 4(C) and (E)). In the 50 g group, many
TNF-α and RANKL-positive cells and odontoclasts
were observed in the PDL tissues (Figures 4(D) and
Copyright © 2013 SciRes. OPEN ACCESS
T. Kojima et al. / Open Journal of Stomatology 3 (2013) 52-58
Figure 4. Light microscopic images of the effect of orthodontic
force (50 g) on the multinucleated osteoclasts (H.E.) (A, B) and
the expression of TNF-α (C, D) and RANKL (E, F) by odonto-
clasts as determined by immunohistochemistry. Immunoreac-
tivity for TNF-α and RANKL was observed in the odontoclasts
(arrows) in the 50 g group on day 7 (D, F). AB: alveolar bone.
PDL: periodontal ligament. C: cementum. D: dentine. Original
magnification 200×, Bar: 50 μm.
During the process of root resorption, organic matrix
proteins and cytokines are released into the gingival
crevice. The objective of this study was to determine
whether the TNF-α and sRANKL expressions could be
used as biological markers for root resorption related to
orthodontic treatment. The results of this study demon-
strate that differences exist between the levels of these
proteins in the GCF of subjects with severe root resorp-
tion evaluated on radiographs.
GCF was first utilized by periodontists attempting to
develop diagnostic tests for detecting periodontal dis-
eases. This fluid is an osmotically-mediated transudate.
The aqueous component is derived primarily from the
serum; the constituents are derived from the serum, while
the gingival tissues through which the fluid passes, and
the bacteria present in the tissue and crevice [11]. GCF
was chosen for the present study due to its ready accessi-
bility and because its collection poses minimal risk or
harm to the patient. Orthodontic forces induce the
movement of periodontal ligament fluids and with them
any cellular or biochemical products produced from prior
mechanical perturbation. During the course of orthodon-
tic treatment, the exerted forces produce distortion of the
periodontal ligament extracellular matrix, resulting in the
alteration of the cellular shape and cytoskeletal configu-
ration. Such events lead to the synthesis and presence of
extracellular matrix components, tissue degrading en-
zymes, acids and inflammatory mediators in the deeper
periodontal tissues, which induce cellular proliferation
and differentiation and promote wound healing and tis-
sue remodeling [12]. Dudic et al. [13] reported that the
GCF composition changes during orthodontic tooth move-
ment. The levels of inflammatory cytokines, such as IL-1
beta, IL-6 and RANKL are elevated in the gingival
crevicular fluid during human orthodontic tooth move-
ment [14-16]. Therefore, GCF may be a useful tool for
studying OIIRR in a noninvasive manner.
The Western blot results showed that the expressions
of TNF-α and sRANKL in the GCF were significantly
higher in the subjects with severe root resorption than in
the subjects without esorption (Figures 3(A) and (B)). A
recent study demonstrated that the concentrations of
RANKL in the GCF were significantly higher in the
subjects with mild and severe root resorption than in the
controls [17]. The RANK/RANKL system has been sug-
gested to play an integral role in osteoclast activation
during orthodontic tooth movement [18]. Brooks et al.
[19] demonstrated that the expression of RANKL during
the application of orthodontic forces is involved in os-
teoclast precursor signaling. The RANK/RANKL system
may also regulate the natural process of root resorption
in exfoliated primary teeth [20]. Therefore, the RANK/
RANKL system may be involved in the process of root
resorption resulting from the application of orthodontic
Ren et al. [21] reported that the level of TNF-α in the
GCF increases during orthodontic tooth movement. Kook
et al. [22] reported that compression forces induce the
mRNA expression of TNF-α and osteoclastogenesis in
human periodontal ligament (hPDL) cells in vitro. TNF-
α-induced osteoclast recruitment is probably central to
the pathogenesis of disorders involving inflammation
[23]. Therefore, TNF-α may stimulate bone resorption
during orthodontic tooth movement.
Further, to investigate whether TNF-α and RANKL is
involved in root resorption during orthodontic treatment
or not, we induced root resorption by applying excessive
orthodontic force in animal models. The immunoreactiv-
ity for TNF-α was detected in forced PDL tissues, and
the immunoreactions in the 50 g group were higher than
those in the control group on day 7, (Figures 4(C) and
(D)). RANKL immunoreactivity was also strongly de-
tected in the PDL and odontoclasts in the 50 g group
(Figures 4(E) and (F)).
Many investigators have reported that root resorption
is aggravated by increasing force magnitudes [24,25].
Previous studies demonstrated osteoclastic resorption of
roots on the pressure side surfaced of teeth subjected to
heavy orthodontic force (50 g) [25,26]. Therefore, in the
present study, 50 g were used as a strong forces model.
When 50 g of orthodontic forces were applied to the rat
upper first molar for 7 days, many resorption lacunae
with odontoclasts appeared on the root surface after tooth
movement for 7 days (Figures 4(A) and (B)). These
results were consistent with previous studies [24-27].
Nakao et al. demonstrated that the immunoreactivity
Copyright © 2013 SciRes. OPEN ACCESS
T. Kojima et al. / Open Journal of Stomatology 3 (2013) 52-58 57
for RANKL/RANK was detected in odontoclasts with an
orthodontic force of 50 g [5]. Zhou et al. [28] reported
that the mRNA level of RANKL and the RANKL/OPG
mRNA ratio was increased was significantly elevated on
the pressure side. These reports support the results in this
study. Furthermore, Garlet et al. [29] demonstrated TNF-
α and RANKL in compressed PDL of human teeth sub-
jected to rapid maxillary expansion. Bletsa et al. [10]
reported that TNF-alpha was expressed in the alveolar
bone and PDL along the roots of the orthodontically
moved molars and in the gingival of rats. Taken together,
these findings and our present results suggest that TNF-α
and RANKL induced by excessive orthodontic force may
activate osteo/odontoclastogenesis.
Considering the relationships between TNF-α and
RANKL in OIIRR, studies evaluating these correlations
are few. However, recent studies have reported that com-
pression forces induce the mRNA expressions of TNF-α
and RANKL in human periodontal ligament cells in vitro
[30,31]. Furthermore, direct cell-cell contact between
PDL cells and osteoclast precursors synergistically in-
creases the expressions of TNF-α and RANKL genes
related to osteoclastogenesis. Therefore, these factors
may be significant predictive factors for potential in-
flammatory parameters during treatment, and this induc-
tion may contribute to the inflammatory response associ-
ated with the ensuing OIIRR. Further studies are needed
to investigate the relationships between TNF-α and
RANKL during root resorption, including studies with an
increased number of subjects for the statistical analysis
and in vitro studies.
These results suggest that TNF-α and RANKL play im-
portant roles in inducing or facilitating the development
of orthodontically-induced inflammatory root resorption
This research was supported in part by Grants-in-Aid for Scientific
Research from the Japan Society for the Promotion of Science
(23593044, 24890261 and 25463200).
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