探討非手術牙周治療後牙周狀況改變與血液中脂肪酸、發炎物質的相關性及糖尿病牙周炎之PPAR gamma及Adiponectin的基因易感受性

The correlation between plasma levels of fatty acids, inflammatory mediators, and periodontal condition change after nonsurgical treatment and the genetic susceptibility of PPAR gamma and Adiponectin to diabetic periodontitis

王盛弘(Sheng-Hung Wang)

指導教授 ： 林英助

高雄醫學大學/口腔醫學院/牙醫學研究所/博士(2014年)

https://doi.org/10.6832/KMU.2014.00100

摘要

研究目的: 牙周炎被認為是體內常見的慢性發炎反應之一，而血液中脂肪酸組成與個體的抗發炎反應有密切相關，血液中抗發炎脂肪酸組成與牙周炎相關性的結果一致性不高，東西方族群血液中脂肪酸組成基線是不同，且在亞洲牙周炎族群中的相關性甚少被討論。
多不飽和脂肪酸是PPARγ重要配體之一，PPARγ活化會增強Adiponectin基因的表現與血液中Adiponectin濃度，PPARγ和Adiponectin除了能調節血糖濃度外，與胰島素敏感性、脂質的代謝和發炎反應有關。過去有關PPARγ和Adiponectin的基因多型性與疾病相關探討，多著重於糖尿病發生與糖尿病相關併發症的相關性探討，但對糖尿病牙周炎的基因易感受性仍然不清楚。
我們的研究目的在探討1) 牙周炎經非手術性治療後牙周狀況改善程度與血液中脂肪酸組成和發炎物質 (IL-1?牷BTNF-?恁BIL-6及CRP) 變化的相關性，2) PPARγ rs1801282C>G 與Adiponectin rs16861194A>G、 rs2241767A>G 基因多型性、血液中脂肪酸組成和第二型糖尿病牙周炎的關係。
研究方法: 在高雄醫學大學附設醫院牙周病科門診共收集35位接受非手術性牙周治療患者，測量治療前與治療後3個月全口牙周囊袋深度、牙周附連水平；在高雄醫學大學附設醫院內分泌與新陳代謝科門診收集287位第二型糖尿病患者，以社區牙周指數作為判斷牙周炎的依據。採集10 ml空腹周邊靜脈血液，做為血液中脂肪酸組成、IL-1?牷BTNF-?恁BIL-6、CRP檢測和DNA萃取所需。
血液中脂肪酸組成是以氣相層析經火焰離子化偵測儀方式分析，發炎物質IL-1?牷BTNF-?恁BIL-6及CRP濃度以三明治酵素免疫分析定量測定，基因型以多對引子聚合酶連鎖反應結合螢光探針加以鑑別。最後以統計學方法分析介入治療前與後調查變項間的變化趨勢的相關性，以及第二型糖尿病牙周炎的基因易感受性。
研究結果: 26位牙周炎患者完成本介入性研究，經治療後三個月，血液中IL-6濃度顯著減少且達統計顯著意義，n-3 PUFAs、DPA和DHA重量百分比顯著增加 (分別為p= 0.01、0.019、0.005和0.037)。治療前血液中n-3 PUFAs和DPA與牙周囊袋深度具顯著負相關 (分別為r= -0.52，p<0.01；r= -0.59，p<0.01)，治療後牙周附連水平恢復比例與血液中△n-3 PUFAs/△total PUFAs、△n-3 PUFAs/△n-6 PUFAs、△DHA/△total PUFAs和△(DPA+DHA)/△total PUFAs皆與治療後牙周附連水平恢復比例具顯著正相關 (分別為r= 0.45，p= 0.03；r= 0.05，p<0.01；r= 0.52，p<0.01；r= 0.54，p<0.01)。
糖尿病牙周炎組的HbA1c％有顯著較高於其對照組 (8.1 ± 1.9 vs. 7.5 ± 1.7%，p<0.01)，卡方分析顯示Adiponectin rs16861194A>G基因多型性與糖尿病牙周炎有顯著相關 (??2= 4.5, p= 0.03)，但與Adiponectin rs2241767A>G與PPARγ rs1801282C>G基因多型性與無顯著相關，多變項邏輯式回歸分析顯示Adiponectin rs16861194AA vs. GA+GG基因型有顯著較低的牙周炎風險 (OR = 0.5, 95%CI= 0.25-0.95)。此外在62位完成體內血液中脂肪酸分析個案中，沒有觀察到第二型糖尿病牙周炎與脂肪酸組成有顯著相關性。
結論: 牙周炎患者經非手術性治療後三個月，牙周狀況顯著改善、牙周發炎反應降低，推測血液中n-3多不飽和脂肪酸累積和牙周發炎降低間可能有互相幫助，這結果提供脂肪酸組成參與牙周治療的初步證據。
我們結果顯示Adiponectin rs16861194A>G基因多型性是第二型糖尿病牙周炎的危險因子。在血糖控制好的糖尿病患者中，血液中脂肪酸組成與牙周炎無明顯相關。本研究因人數不夠大、因果關係未能釐清，仍需更多研究加以驗證。

關鍵字

牙周炎 ； 第二型糖尿病牙周炎 ； 非手術性牙周治療 ； 血液中脂肪酸組成 ； n-3 多不飽和脂肪酸 ； 基因易感受性 ； 基因多型性 ； PPAR基因 ； Adiponectin基因 ； 細胞激素

並列摘要

Objectives: Periodontitis is already recognized as one of common chronic inflammatory diseases. The plasma fatty acid composition is correlated with the individual’s anti-inflammatory response. The roles of plasma n-3 polyunsaturated fatty acids (n-3 PUFAs) in periodontitis were investigated in several studies. However, their conclusions are inconsistent with each other. Significantly different baseline levels of plasma PUFAs are found between Asian and Western population. Till now, no Asian study has reported the correlation between the change in periodontal condition and plasma levels of PUFAs after nonsurgical treatment.
PUFAs are the ligands of peroxisome proliferator-activated receptor gamma (PPARγ). The interaction between PUFAs and PPARγ can increase PPARγ gene expression and plasma concentration of Adiponectin. PPARγ and Adiponectin genes play important roles in regulating blood glucose levels, insulin sensitivity, lipid metabolism, and inflammatory response. Genetic susceptibility of PPARγ and Adiponectin genes to type 2 diabetes mellitus (T2DM) and its complications are already reported in many previous studies, but no such study in T2DM periodontitis.
Our aims were to 1) evaluate the correlation between the changes in plasma levels of fatty acid compositions, inflammatory mediators and periodontal conditions at 3 months after nonsurgical treatment in periodontitis patients without any dietary recommendation, 2) evaluate the relationships between plasma fatty acid profiles, the single nucleotide polymorphisms (SNPs) of PPARγ and Adiponectin genes, and periodontitis in T2DM population.
Materials and methods: Thirty-five patients with periodontitis were recruited in the Department of Periodontology, Kaohsiung Medical University Hospital, Taiwan. Full mouth probing pocket depths (PPDs) and clinical attachment levels (CALs) were measured at baseline and 3 months after the nonsurgical treatment. A total of 287 patients with T2DM were recruited in the Department of Endocriology and Metabolism, Kaohsiung Medical University Hospital, Taiwan. Periodontal conditions (community periodontal index, CPI) were assessed. Peripheral blood samples were collected for genomic DNA extraction and the determination of the plasma levels of fatty acid profiles, inflammatory mediators.
Plasma levels of fatty acids were determined using gas chromatography. Plasma concertrations of IL-1??, TNF-??, IL-6 and CRP were measured using enzyme-linked immunosorbent assay kits. Genotyping of Adiponectin rs16861194A>G and rs2241767A>G and PPARγ rs1801282C>G genes was performed by the GenomeLab SNPstream genotying system. After the data linkage, the correlation in periodontitis patients and genetic susceptibility to T2DM periodontitis were assessed by statistical analysis.
Results: Twenty-six periodontitis patients completed the interventional study. At 3 months post intervention, the plasma IL-6 was decreased and the weight percentages of n-3 PUFAs, DPA, and DHA were significantly higher (p= 0.01, 0.019, 0.005, and 0.037, respectively). At the baseline, PPDs were negatively correlated with plasma n-3 PUFAs and DPA (r= -0.52, p < 0.01, and r= -0.59, p < 0.01, respectively). The recovery percentages of CALs were positively and significantly correlated with plasma △n-3 PUFAs/△total PUFAs, △n-3 PUFAs/△n-6 PUFAs, △DHA/△total PUFAs and △(DPA+DHA)/△total PUFAs (r= 0.45，p= 0.03；r= 0.05，p<0.01；r= 0.52，p<0.01；r= 0.54，p<0.01, respectively).
The level of HbA1c％ was significantly higher in T2DM with periodontitis group than non-periodontitis (8.1 ± 1.9 vs. 7.5 ± 1.7%，p<0.01). The distribution of Adiponectin rs16861194A>G polymorphisms are significant different between T2DM periodontitis and non-periodontitis (??2= 4.5, p= 0.03). However, such difference was not found in Adiponectin rs2241767A>G and PPARγ rs1801282C>G. Adiponectin rs16861194A>G polymorphisms were significantly associated with diabetic periodontitis in T2DM population (adjusted OR= 0.5, 95%CI= 0.25-0.95). T2DM patients carrying Adiponectin rs16861194 AA genotype showed lower risk with periodontits than those with GA+GG genotypes. In the group of well-controlled T2DM patients (n= 62), no significant difference of plasma fatty acid compositions between periodontitis and non-periodontitis was found.
Conclusions: Three months after the nonsurgical treatment, the periodontal status and periodontal inflammation was significantly improved. Reduced inflammation might induce the accumulated plasma n-3 PUFAs. This result could provide the initial evidence for the future periodontal treatment strategy with n-3 PUFAs supplementation.
In genetic susceptibility to diabetic periodontitis, we found that Adiponectin rs16861194A>G polymorphisms can contribute to the periodontitis in T2DM, but no such association was found in Adiponectin rs2241767A>G and PPARγ rs1801282C>G polymorphisms. More studies with large sample size are needed to verify our findings.

並列關鍵字

periodontitis ； type 2 diabetic periodontitis ； nonsurical periodontal treatment ； plasma fatty acids compositions ； n-3 polyunsaturated fatty acids ； genetic susceptibility ； single nucleotide polymorphisms ； peroxisome proliferator-activated receptor gamma gene ； Adiponectin gene ； cytokines

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