行政院國家科學委員會補助專題研究計畫成果報告
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早發型牙周炎之基因危險因子的探討
The genetic mar ker s as r isk factor s in ear ly onset per iodontitis
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計畫類別：□ˇ個別型計畫
□整合型計畫
計畫編號：NSC 89－2314
－B －039
－031 －
執行期間：
89 年 08 月
01 日至
90
年 07 月 31 日
計畫主持人：鍾先揚
協同主持人：
蔡吉政本成果報告包括以下應繳交之附件：
□赴國外出差或研習心得報告一份
□赴大陸地區出差或研習心得報告一份
□出席國際學術會議心得報告及發表之論文各一份
□國際合作研究計畫國外研究報告書一份
執行單位：
中國醫藥學院牙醫學系中
華
民
國
90
年
10
月
31
日
一、中文摘要 牙周炎主要由革蘭氏陰性厭氧菌所引 起之感染性疾病。由於這些致病菌和身體 的免疫系統交互作用，導致牙周囊袋的形 成，牙周附連喪失及齒槽骨的吸收。然而 單由牙周致病菌的量及菌種卻無法完全解 釋牙周病的嚴重度。許多的報告顯示，在 自然情況下發生的牙周炎，其進行速度並 不一致。文獻中顯示除了細菌以外，牙周 病的嚴重性尚牽扯到抽煙、牙周解剖構 造、系統疾病、基因等其他因素，其中又 以早發型牙周炎與宿主免疫的變異較為有 關。若干與牙周破壞有密切關係的基因危 險因子如 CD32 (FcγRIIa)、CD16(FcγRIIIb) 等基因的多形性(polymorphism) 與 IgG 之 heavy chain marker (Gm23) 的 (allotype)，或許可以解釋為何個體對牙 周炎的感受性不同，故被視為極有前途的 研究方向。本研究發現在台灣人的 Gm23 以 (+)為主，但有較高比例的成年型牙周炎病 患為 Gm(-)。在血清抗體方面，成年型牙 周炎病患 IgG2 及 IgG3 比對照組高；而在 早發型牙周炎，則以 IgG2 為高。結果顯示 (Gm23)可作為成年型牙周炎的基因危險因 子，但不適用於早發型牙周炎。 關鍵詞：早發型牙周炎、多形性 Abstract
Periodontitis is an infectious disease mainly caused by gram negative anaerobic bacteria. It is the imbalance between destructive versus defensive responses of host immune system to these periopathogenic microbes, which finally cause pocket formation, attachment loss and alveolar bone loss. However, the severity of periodontal disease can not be simply explained by the quantity and composition of periodontal related dental plaque. In addition to the periopathogenic microbes, other possible factors involved in the severity include smoking, tooth morphology, systemic disease and genetic, etc.; associated
evidence of genetic factors in periodontal disease have be shown in early onset periodontitis. In our study, the Gm(+) allotype is dominant in Taiwanese, furthermore, Gm allotype seems to be an valuable risk factor in adult periodontitis but not in early onset periodontitis. The IgG profile in early onset patients in higher in IgG2 compared to controls and in adult periodontitis, IgG2 and IgG3 are both higher in patients.
Keywords: FcγRIIa, FcγRIIIb, Gm23, polymorphism, susceptibility
二、緣由與目的
Periodontitis is an infectious disease which is mainly initiated by gram-negative anaerobics including Porphyromonas gingivalis, Prevotella intermedia and Actinobacillas actinomycetemocomitans et al (Haffajee &
Socransky).1 Interactions of these microbes with host immune system result in tissue destruction manifested by pocket formation and bone destruction. However, the quantity and types of these potentially pathogenic microbes can not fully explain the disease severity. Several twin studies also suggested that greater than 50% variance in several clinical parameters in adult periodontitis might attribute to genetic factors.2 It seems a multifactorial model rather than that of pathogens alone should be considered in the etiology of periodontal diseases. Therefore, the existence of specific microbes seems essential to the initiation of periodontal disease, but other factors such as smoking,, stress, diabetes and genetic variations etc. may influence the final phenotypes of diseases expression.
Immunoglobuin G2 is often the predominant IgG subclass produced in response to bacterial LPS.3,4 Lamster et al. 5 showed that a positive correlation between total IgG in GCF and serum IgG, and described that maintenance of an appropriate level of serum IgG to periopathogens was
critical in controlling the subgingival microflora. The protective role of serum antibody in immune response to periodontitis has further been proven in clinical studies,6 which indicated an inverse relationship between levels of serum antibody specific to
A. a. and the severity of periodontitis. Serum
IgG2 (anti carbohydrate antigen LPS of A. a.)
levels in LJP (localized juvenile periodontits) cases are higher than that of Generalized JP (GJP), adult periodontitis (AP) and age-race matched controls,7 and the levels of IgG2 among Africa-Americans were higher than those among Caucasians regardless of disease status which is an example of race specificity7,8 in immune response. In the same study, no difference between AP, GJP and matched controls were found, and no other IgG subclass concentration was correlated with periodontal diagnosis.
In addition to racial specificity,7,8 numerous studies have also correlated serum concentration of IgG subclass with allotypic determinants on the Ig molecules, the Gm (heavy chain) and Km (light chain) markers. The allele n+ of the γ2 locus (the Gm23 markers) has been associated with a high production of IgG2.9 Lack of this allele related to low levels of serum IgG2 and increased the risk of bacteria infection.10 In contrast, Gm(23)+ patients were reported to be genetically predisposed to RPP11. This response appears to be race specific,12 when about 2/3 Caucasians are positive to Gm(23),12 and 15% of controls and 27% of RPP patients were Gm(23) positive in Korea. Choi et al11 studied the relationship between Gm and Km frequency in EOP and found the frequency of afnb1b3 Gm allotype in RPP, and the frequency of Km(1) allotype in LJP were higher than healthy controls. These two specific allotypes were related to significantly higher IgG2 level to P.g. in RPP, and A.a. in LJP than allotype(-) patients respectively. It was speculated that km(1) and elevated IgG2 level played a protective role in LJP, but Gm(23) and elevated IgG2 level did not provide such protection in RPP. certain CH allotype , not CL(Km), would lessen the competent antibody with A2-VkII variable repertoire and was unable to No data
is available for EOP or AP in Taiwanese or Caucasians yet.
In general, IgG2 has low complement fixing ability and is considered with low affinity (cytophilic) with Fc receptors of phagocytes. On the other hand, IgG1 and 3 show much higher affinity with Fc receptors on PMN.
In adult periodontitis (AP), the association of serum IgG2, Gm(23) allotype, FcγRIIa and FcγRIIIb receptor allotypes were only weakly related to or not related to clinical status in Caucasian groups.13 No data is available for early onset periodontitis (EOP) in Orientals or Caucasians yet.
Since the populations in previous studies of early–onset periodontitis and adult periodontitis were limited to northern European Caucasians, American Caucasians, Africa-American, Japanses and Koreanese, when the probability of race specificity in gene heterogeneity is taken into consideration, it seems appropriate to examine such genetic markers in Taiwaneses to benefit the knowledge of the impact of genetic variation on the susceptibility of periodontal disease.
三、研究報告應含的內容
1. Gener al estimation in Gm allotypes:
No of subjects Patients Controls Adult periodontitis 50 34 Generalized early onset periodontitis 25 30
* Total 139 subjects with their Gm allotype tested. Gm allotype No. of Subjects Percentage (%) _ 22 15.8 + 117 84.2
l The subjects include all samples in control and patient groups with either generalized early onset or adult periodontitis.
allotype is much higher than that of Gm (-) in Chinese population (among these 139 subjects, χ2=64.93, P< 0.0001).
2. Gm allotypes in Adult per iodontitis
Gm allotype
Patients Controls Total
_ 13 3 16
+ 37 31 68
50 34 84
l Patient group presents higher distribution of Gm(-) allotype which might be
considered a relative risk factor in adult periodontitis.
l Frequency of Gm allotype in adult periodontitis (2x2 contingency table):
÷2=3.872, P=0.0491, crude odd ratio=3.6,
95% CI 0.95-13.98.
3. Gm allotypes in Gener alized ear ly onset per iodontitis:
Gm allotype
Patients Controls Total
_ 5 4 9
+ 20 60 80
25 64 89
l Frequency of Gm allotype in generalized early onset periodontitis (2x2
contingency table), Fisher exact test:.P=0.1097, not significant
statistically.
l In this disease category, the control group includes both subjects of age > and < 35 years, since the Gm allotype does not change with age.Gm (-) seems not a risk factor in generalized early onset
periodontitis.
4. Gm allotypes in Adult vs.Gener alized onset per iodontitis:
Gm allotype
adult G-EOP Total
_ 13 5 18
+ 37 20 57
50 25 75
l Frequency of Gm allotype in adult Vs, G-EOP (2x2 contingency table):
÷2=0.329, P=0.5663, not significant
statistically.
l Gm allotype can not postpone the onset of a generalized early onset periodontitis in any periodontitis susceptible
individuals.
5. IgG profile in adult per iodontitis: see appendix 1.
l In IgG profiles, patient group presents statistically higher IgG2 and IgG3 level in serum.
l In this disease category, the patient and control groups are all subjects of age > 35 years.
6. IgG profile in gener alized ear ly onset per iodontitis:
see appendix 2.
l Patient group has more female than control group.
l Patient group shows higher serum IgG2 level than control group.
l In this disease category, the patient and control groups are all subjects of age < 35 years.
7. Effect of Gm(23) allotype on the IgG2 level in the patient groups in adult and gener alized ear ly onset per iodontitis. See appendix 3.
l Only one Gm(-) sample in the control group in G-EOP and no comparison is studied for this group.
l Based on the above information, Gm allotype seems not to affect the IgG2 level in each specific group.
l Assumption could be made in two different ways:
1. In control group, there are some other genetic or immune factors that could
be protective enough to prevent the occurrence of periodontitis, therefore,
no dramatic difference in IgG2 level could be expected between the two Gm allotypes. Even there is some protection from Gm(+), as statistics shows higher Gm(-) in patient group than in control group, however, once
passing the time point of subacute infection, no difference in IgG2 level
2. In patient group, once the disease is established and diagnosed, the
microbial challenge has overwhelmed the possible effect of Gm allotype on IgG2 level, then, no difference could be found between the twot Gm allotypes.
8. The role of Gm(23) allotype on IgG2 level in adult per iodontitis and its clinical relationship:
Assumption: In adult periodontitis, patient group presents higher frequency of Gm(-) allotype than control group, which might suggest that Gm(+) allotype provides some kind of protection when individuals facing similar perio-microbial challenge.
However, once the adult periodontitis is diagnosed, the higher IgG2 and IgG3 in serum can only been expected as a normal immune response, which does not seem enough to halt the occurrence and progression of periodontal disease.
五、參考文獻
1. Haffajee AD, Socransky SS: Microbial etiological agents of destructive periodontal diseases. Periodontology 2000 1994; 5:78-111.
2.Michalowicz BS, Aeppli D, Virag JG, Klump, Hinrichs JE, DG, Bereuter JP, Conry NL, Segal NL, Bouchard Jr, Pihlstrom BL: Periodontal findings in adult twins. J Periodontol 1991;62:293-299
3.Schenck K, Michaelsen T: IgG subclass distribution of serum antibodies against lipopolysaccharide from Bacteriodes gingivalis in periodontal healthy and disease. Acta Pathol Microbiol Immunol. Scand. Sect. C.1987;95:41-46.
4.Whitney C, Ant J, Moncla B, Johnson B, Page RC, Engel D: Serum immunoglobulin G antibody to Porphyromonnas gingivalis in rapidly progressive periodontitis; titer, avidity and subclass distribution. Infect Immun; 1992;60:2194-2200.
5. Lamster IB, Celenti R, Ebersole JL: The relationship of serum IgG antibody titers to periodontal pathogens to indicatiors of the host response in crevicular fluid. J Clin Periodontal 1990;17:419-425.
6.Ranney RR, Yanni NR, Burmeister JA, Tew JG: Relationship between attachment loss and serum antibody to Actinobacillus actinomycetemcomitans in adolescents and young adults having severe periodontal destruction. J Periodontol 1982;53:1-7Lindhe J, Hamp SE, Loe H: Plaque induced periodontal disease in beagle dogs. A 4-year clinical, roentgenographical and
histometrical study. J Periodont Res 1975;10:243-255.
7. Lu H, Wang M, Gunsolley JC, Schenkein HA, Tew JG: Serum immunoglobulin G subclass concentrations in periodontally healthy and diseased individuals. Infect Immun 1994;62:1677-1682.
8.Quinn SM, Zhang JB, Gunsolley JC, Schenkein JG, Schenkein HA, Tew JG: Influence of smoking and race on immunoglobulin G subclass concentration in early onset periodontitis patients. Infect Immun 1996;64:2500-2505.
9. Oxelius VA: Serum IgG and IgG subclass contents in different Gm phenotypes. Scand J Immunol 1993;37:149-153.
10. Ambrosino DM, Schiffman G, Gotschlich EC, Schur PH, Rosenberg GA, DeLange GG, van Loghem E, Siber GR: Correlation between G2m(n) immunoglobulin allotype and human antibody response and suspectibility to polysaccharide encapsulated bacteria. J Clin Invest 1985;1935-1942.
11. Choi JI, Ha MH, Kim JH, Kim SJ: Immunoglobulin allotypes and immunoglobulin G subclass responses to Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis in early onset periodontitis. Infect. & Immuno. 1996; 64(10):4226-4230.
12. Schanfield MS:Forensic applications of immunoglobulin allotypes (GM, AM, and KM). In Lee CJ, Gaensslen RE, ed. DNA and other polymorphisms in forensic science. St. Louis: Year Book Publishers, 1990;160-213.
13. Colombo AP, Eftimiadi C, Haffajee AD, Cugini MA, Socransky SS: Serum IgG2 level, Gm(23) allotype and FcγRIIa and FcγRIIIb receptors in refractory periodontal disease. J Clin Periodontol 1998;25:465-474.
Appendix: 1. *mean ±SD 2 *mean ±SD 3. . IgG2 (ug/ml) Patients in Adult Periodontitis
Patients in G-EOP Controls in Adult Periodontitis Gm(-) (number) 4915.48±2880.70 (13) 2274.32±1361.47 (5) 1478.18±534.67 (3) Gm(+) (number) 3983.15±1733.21 (36) 4251.04±2115.08 (19) 2746.13±1310.38 (31) Statistics F=1.20, P=0.29 (Welch) t=1.97, P=0.06 t=1.64, P=0.11 ** One outlier One outlier
*mean ±SD
Patients Controls Statistic
Male/female 23/27 12/22 χ2 =0.95,P=0.33 Age (years) 44.46±5.60 41.91±4.98 t=2.14, P=0.04 IgG1(ug/ml) 9175.75±5182.13 8496.34±6178.30 t=0.55, P=059 IgG2(ug/ml) 4230.50±2106.65 2634.25±1308.27 F=18.08, P=0.0001 (Welch) IgG3(ug/ml) 632.11±455.92 404.00±261.69 F=8.43, P=0.005 (Welch) IgG4(ug/ml) 671.95±408.62 674.53±405.92 t=0.03, P=0.98
Patients Controls Statistic
Male/female 6/22 14/16 χ2 =4.08,P=0.04 Age (years) 30.86±4.44 27.73±3.91 t=2.85, P=0.006 IgG1(ug/ml) 10086.95±5392.82 7841.51±6769.49 t=1.375, P=0.17 IgG2(ug/ml) 3681.05±2056.88 2607.92±1084.20 F=6.05, P=0.02 (Welch) IgG3(ug/ml) 558.02±523.40 568.62±340.70 F=0.01, P=0.93 (Welch) IgG4(ug/ml) 560.94±592.38 557.52±332.30 t=0.03, P=0.98
