自體免疫抗體在牙周病與類風溼性關節炎之間所扮演的角色

The role of autoimmune antibodies between periodontitis and rheumatoid arthritis

錢之琳(Chih-lin Chien)

指導教授 ： 陳漪紋

共同指導教授 ： 郭彥彬(Mark Yen-Ping Kuo)

國立臺灣大學/醫學院/臨床牙醫學研究所/碩士(2016年)

https://doi.org/10.6342/NTU201610332

摘要

研究背景：類風溼性關節炎是一種全身周邊大小多處關節慢性發炎的疾病，現階段致病機轉仍不明，其特點為體內會出現抗瓜胺酸蛋白抗體(anti-citrullinated protein/peptide antibodies，ACPA)，屬於自體免疫疾病之一。典型的症狀為關節的軟硬骨變形(deformity)與侵蝕性破壞(erosion)等，這些破壞與基質金屬蛋白(Matrix metalloproteinase，MMP)與其抑制劑(Tissue inhibitor of MMP，TIMP)是否平衡，以及關節組織、血液中骨代謝相關的細胞激素如介白素1(Interleukin-1，IL-1)、介白素6(Interleukin-6，IL-6)、腫瘤壞死因子α(Tumor necrosis factor α，TNF-α)、前列腺素E2(Prostaglandin E2)有關，與牙周病的疾病進程和破壞機轉雷同；近年來發現介白素17(Interleukin-17, IL-17)對疾病破壞的情況與病程變化亦有一定影響。最常被提出有關致病機轉的論調為瓜胺酸化蛋白大量產生，破壞免疫耐受性(immune tolerance)的平衡進而引發強烈免疫反應，造成進一步發炎與破壞；血清學檢查如抗環瓜胺酸胜肽抗體(Anti-cyclic citrullinated peptide antibodies，Anti-CCP)的檢驗在類風溼性關節炎的診斷分類中佔有決定性的影響，學者們也發現血清中抗突變型瓜胺酸波形蛋白抗體(Anti-mutated citrullinated vimentin antibodies)的高低與疾病活動度、疾病嚴重度、以及治療的成效存在正相關，可以利用抗突變瓜胺酸波形蛋白抗體來監測治療的效果。瓜胺酸化(Citrullination)是人體一種蛋白質轉譯後的修飾作用，在原核生物當中，牙周致病菌P.g被發現是唯一擁有具有能將人類纖維蛋白原(fibrinogen)與烯醇酶(α-enolase)瓜胺酸化的酵素，人們懷疑P.g.菌這項能力可能是牙周病與類風溼性關節炎兩病之間的重要關鍵。因此希望能藉由本次實驗來證明類風溼性關節炎與牙周病的關連性；甚至能提前預警類風溼性關節炎或牙周病病友，得到另一個疾病的可能性並及早就醫。
材料與方法：四十二位類風溼性關節炎患者與四十七位健康者進行抽血檢查，以酵素免疫學分析(ELISA)檢測血液中自體免疫抗體抗環瓜胺酸胜肽抗體(Anti-CCP antibodies)、抗突變型瓜胺酸波形蛋白抗體(Anti-MCV antibodies)的效價、與細胞激素IL-6、ÍL-17、TNF-α濃度；所有受試者由專業牙周病醫師進行全口牙周檢查，並根據美國牙周病學會的診斷分類方法來診斷受試者牙周病嚴重度；同時也進行口水收集，處理後以聚合酶鏈鎖反應(PCR)和瓊脂膠體電泳(Agarose gel electrophoresis)進行口水中細菌的分析，以檢驗牙周病與類風溼性關節炎之間的相關性。
結論：類風溼性關節炎病友的牙周病盛行率與牙周破壞比對照組更為嚴重，且有統計學上顯著差異；所有受試者在牙周囊袋(pocket depth，PD)大於等於4mm百分比與抗環瓜胺酸胜肽抗體(Anti-CCP antibodies)之間，以及牙周臨床附連喪失(clinical attachment level loss, CAL)大於等於4mm與抗突變型瓜胺酸波形蛋白抗體(Anti-MCV antibodies)分別呈現統計學上顯著正相關；顯示牙周發炎與牙周組織破壞的情形確實與類風溼性關節炎血清中抗瓜胺酸蛋白抗體群的效價相關。有趣的是，牙周囊袋大於等於4mm百分比以及牙周臨床附連喪失大於等於4mm百分比，卻分別與血液中IL-17濃度呈現統計學上顯著的負相關，推測血液中細胞激素濃度受到類風溼性關節炎病友臨床用藥相當大的影響。羅吉斯迴歸分析結果顯示牙周附連喪失確實為類風溼性關節炎的風險因子，但IL-6較低反而比較容易得到類風溼性關節炎的結果，可能是因為藥物影響所造成的分析謬誤。

關鍵字

抗環瓜胺酸胜肽抗體 ； 抗突變型瓜胺酸波形蛋白抗體 ； 牙周囊袋 ； 牙周臨床附連喪失 ； 介白素17 ； 類風溼性關節炎

並列摘要

Background: Rheumatoid arthritis (RA) is a symmetric, inflammatory, peripheral polyarthritis of unknown etiology. It typically leads to deformity through the stretching of tendons and ligaments and destruction of joints through the erosion of cartilage and bone, which were related to the balance between matrix metalloproteinase(MMP) and tissue inhibitor of MMP(TIMP), the cytokine expression such as interleukin-1, interleukin-6, tumor necrosis factor alpha(TNF-α), and prostaglandin 2, which were similar with the destructive pattern and pathogenesis of periodontitis. The most unique character of RA is the appearance of anti-citrullinated protein/peptide antibodies (ACPA). Serum examination of anti-cyclic citrullinated peptide antibodies (Anti-CCP antibodies) could be one of the tools for RA diagnosis and classification; researchers discovered that serum examination of anti-mutated citrullinated vimentin antibodies (Anti-MCV antibodies) is a reliable parameter for disease activity and drug-effect monitoring. Given inflammatory disease caused by microbial infection, periodontitis was proved relevant to rheumatoid arthritis not only the pattern of destruction but molecular basis of immunity arousal. Last but not least, Porphyromonas ginigivalis, one of the periodontal pathogens, possess peptidylarginine deiminase (PAD). The enzyme (PPAD) functions on C-terminal arginine into citrulline as humans’ does. Experts suspect this could be a possible link between periodontitis and RA. Therefore, we would love to explore the inter-relationship between periodontitis and RA, seeking for possible connections and establishing risk factor models.
Material and methods: We include 42 well-controlled RA patients as study group and 47 systemic healthy subjects as control group. All subjects were received comprehensive periodontal examination to survey periodontal condition, saliva collection for oral pathogen detection by means of PCR and agarose gel electrophoresis, and peripheral venous blood withdrawal for detection of anti-CCP、anti-MCV autoimmune antibodies, as well as IL-6、IL-17、TNF-α by ELISA.
Results: The prevalence of periodontitis, inflammatory condition and periodontal destruction were more severe in RA group with significant difference.We’ve noticed there’s positive correlation with significant difference between percentage of PD>=4mm and Anti-CCP, so as to percentage of CAL>=4mm and Anti-MCV. There is no doubt that correlation do exists between periodontal inflammation, destruction and serum level of ACPA. On the other hand, some of the results were controversial. We found both percentage of PD>=4mm and CAL>=4mm NEGATIVELY correlated to serum level of IL-17; the stunning results could be owing to drug effect of RA patients. Logistic regression revealed periodontitis could be the risk factor of RA.

並列關鍵字

Anti-CCP antibodies ； Anti-MCV antibodies ； pocket depth ； clinical attachment loss ； interleukin 17 ； rheumatoid arthritis

參考文獻

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