臺灣博碩士論文加值系統

研究背景：文獻報告指出紅斑性狼瘡病人的血清中常能檢驗出自體免疫抗體抗心磷脂抗體的存在。抗心磷脂抗體屬於抗磷脂抗體中的一群，主要和血栓的產生有關係。當抗心磷脂抗體要與心磷脂結合時需要磷脂結合蛋白β2 Glycoprotein I 的存在才能和心磷脂結合。近年來也有研究指出β2 Glycoprotein I 上的TLRVYK蛋白序列其實才是抗心磷脂抗體的target antigen。此外，β2 Glycoprotein I 有抑制凝血的功能，若自體免疫抗體和β2 Glycoprotein I結合則會抑制其凝血的功能，進而促進血栓的形成。另一方面，牙周致病菌具有和TLRVYK類似的蛋白序列有可能在感染牙周致病菌的病人身上引發自體免疫抗體的產生，因此本實驗將從自體免疫抗體的角度探討牙周病致病菌的存在與紅斑性狼瘡疾病嚴重程度的相關性。
材料與方法：59位紅斑性狼瘡病人及35位健康者參與實驗。所有受試者皆接受臨床牙周檢查，並收集其唾液，牙菌斑以及血清。紅斑性狼瘡病人依據“systemic lupus erythematosus disease activity index” (SLEDAI)分為疾病活性不穩定31位，穩定28位。爾後利用聚合酶鏈鎖反應偵測唾液及牙菌斑中牙周病致病菌Porphyromonas gingivalis （P. gingivalis）， Treponema denticola （T. denticola），Aggregatibacter actinomycetemcomitans （A. actimomycetemcomitans）的存在，並透過酵素免疫分析法測量其血清中抗心磷脂抗體，以及anti-β2 Glycoprotein I antibodies的含量。再將蒐集的資料進一步進行統計分析。
結果：相較於健康者，紅斑性狼瘡病人的牙周病盛行率較高，anti-β2 Glycoprotein I antibodies 也比較高，並具有統計上的差異性。研究結果也發現無論是不穩定或是穩定紅斑性狼瘡病人，其牙周附連喪失、牙周囊袋深度都比健康者嚴重。另一方面，雖然未達統計上的顯著性，不穩定紅斑性狼瘡疾病的病人若患有牙周病，或是有牙周致病菌的存在都會使血清中傾向於檢測出較高的anti-β2 Glycoprotein I antibodies 。尤其是同時感染兩種細菌時更有抗體值升高的趨勢，並達到統計上的差異性。
結論：本實驗發現紅斑性狼瘡疾病活性不穩定的病人其牙周病破壞與升高的anti-β2 Glycoprotein I antibodies相關，牙周致病菌P. gingivalis和T. denticola可能會引發自體免疫抗體的產生。因此對於臨床上anti-β2 Glycoprotein I antibodies較高的紅斑性狼瘡病人可以建議其接受牙周檢查，若患有牙周病則透過牙周病治療減少牙周致病菌的存在，改善牙周的健康降低由感染而引發的自體免疫抗體產生，或許能改善紅斑性狼瘡病人可能會面臨的臨床併發症。

Introduction: It was reported Systemic Lupus Erythematosus (SLE) patients exhibited higher anti-cardiolipin (anti-CL) antibodies, a class of anti-phospholipid antibodies associated with thrombosis. Anti-CL antibodies required the presence of the plasma phospholipid binding protein, β2-Glycoprotein I (β2GPI), in order to bind cardiolipin molecule. β2-Glycoprotein I has been considered as the actual target antigen for autoimmune antibodies. Pathogenic anti-cardiolipin and anti- β2GPI antibodies could be induced by immunizing mice with Hemophilus influenzae or Neisseria gonorrheae, which bear peptide sequences homologous to the TLRVYK peptide of β2GPI. Periodontal bacteria also bear homologous peptide of TLRVYK; therefore, we hypothesize that periodontal bacteria might induce anti-CL or anti-β2GPI antibodies production through molecular mimicry.
Materials and Methods: 59 SLE patients and 35 healthy subjects were recruited in this study, and all subjects received periodontal examinations. The disease activity of SLE was classified into mild and moderate to severe groups based on the “systemic lupus erythematosus disease activity index” (SLEDAI). The presence of Porphyromonas gingivalis (P. gingivalis), Treponema denticola（T. denticola）and Aggregatibacter actinomycetemcomitans（A. actimomycetemcomitans）in saliva and plaque sample was detected by polymerase chain reaction. Serum Anti-CL and anti-β2GPI antibodies were examined using the enzyme-linked immunosorbent assay.
Results: Both two groups of SLE patients showed higher prevalence of periodontitis, more severe periodontal destruction and increased titers of serum anti-β2GPI antibodies compared with healthy subjects. Moderate to severe SLE patients with periodontitis seemed to exhibited higher anti-β2GPI antibodies than those without periodontitis. The level of anti-β2GPI antibodies was significantly higher in moderate to severe SLE patients who harboured T. denticola and P. gingivalis intra orally.
Conclusion: Elevated anti-β2GPI antibodies was associated with periodontal severity, especially in moderate to severe SLE patients. T. denticola and P. gingivalis might serve as exogenous antigens that elicit anti-β2GPI antibodies production. Anti-β2GPI antibodies might be used as a biomarker to detect periodontal diseases in SLE patients.

目錄
誌謝 I
中文摘要 II
Abstract IV
目錄 VI
圖表目錄 VIII
第一章 緒論 1
第一節 紅斑性狼瘡(Systemic Erythematosus Lupus) 1
1-1 紅斑性狼瘡 1
1-2 紅斑性狼瘡的臨床表現及診斷 1
第二節 抗磷脂症候群 （Antiphospholipid Syndrome, APS） 3
2-1 抗磷脂症候群 3
2-2 抗磷脂抗體 3
2-3 抗磷脂抗體與血管栓塞的關係 4
第三節 牙周病 6
第四節 牙周病與抗心磷脂抗體的關係 7
4-1 牙周病與抗心磷脂抗體的關係 7
4-2 牙周病致病菌與抗心磷脂抗體的關係 8
第二章 研究目的 10
第三章 實驗材料與方法 11
一、研究對象 11
二、臨床牙周檢查 11
三、細菌收集及藉由聚合酶鏈鎖反應檢測細菌 12
3-1 細菌收集 12
3-2 唾液及牙菌斑處理 12
3-3 聚合酶鏈鎖反應（Polymerase Chain Reaction, PCR） 13
3-4 瓊脂凝膠電泳分析 (Agarose gel electrophoresis) 13
四、血清中抗心磷脂抗體檢測與酵素免疫分析法（ELISA） 14
4-1 血液處理 14
4-2 酵素免疫分析法（ELISA） 14
五、統計分析 15
第四章 結果 17
一、 紅斑性狼瘡病人疾病嚴重程度分類 17
二、 紅斑性狼瘡病人與健康者的牙周健康狀況 17
1. 牙周病盛行率 17
2. 牙周病的嚴重程度 17
三、 紅斑性狼瘡病人與健康者的抗心磷脂抗體、anti-β2 glycoprotein I antibodies 分佈情況 18
1. 抗心磷脂抗體 18
2. Anti-β2 glycoprotein I antibodies 18
3. 抗心磷脂抗體與anti-β2 glycoprotein I antibodies 19
四、 牙周病與抗心磷脂抗體及anti-β2 glycoprotein I antibodies關係 19
1. 紅斑性狼瘡疾病嚴重程度與牙周病和抗心磷脂抗體的相關性 19
2. 紅斑性狼瘡疾病嚴重程度與牙周病和Anti-β2 glycoprotein I antibodies相 關性 19
五、 細菌與抗心磷脂抗體及anti-β2 glycoprotein I antibodies的關係 20
1. 細菌的盛行率 20
2. T. denticola與抗心磷脂抗體及anti-β2 glycoprotein I antibodies的關係 21
3. P. gingivalis與抗心磷脂抗體及anti-β2 glycoprotein I antibodies的關係 21
4. 同時感染P. gingivalis和T. denticola與抗心磷脂抗體及anti-β2 glycoprotein I antibodies的關係 22
六、 紅斑性狼瘡與風險因子的相關性 23
第五章 討論 24
參考文獻 37

圖表目錄

圖 一、紅斑性狼瘡疾病活性不穩定、穩定與健康者牙周破壞的比較 28
圖 二、紅斑性狼瘡疾病活性不穩定、穩定與健康者抗心磷脂抗體、Anti-β2 Glycoprotein I antibodies的比較 29
圖 三、Anti-β2 Glycoprotein I antibodies 與ESR及PLT的相關性 30
圖 四、牙周病與紅斑性狼瘡病人不穩定、穩定及健康者在抗心磷脂抗體、Anti-β2 Glycoprotein I antibodies 的相關性 31
圖 五、T. denticola與紅斑性狼瘡病人不穩定、穩定及健康者在抗心磷脂抗體、Anti-β2 Glycoprotein I antibodies 的相關性 32
圖 六、P. gingivalis與紅斑性狼瘡病人不穩定、穩定及健康者在抗心磷脂抗體、Anti-β2 Glycoprotein I antibodies 的相關性 33
圖 七、混合感染P. gingivalis和T. denticola與紅斑性狼瘡病人不穩定、穩定及健康者在抗心磷脂抗體、Anti-β2 Glycoprotein I antibodies的相關性 34

Table 1. Demographic and clinical conditions of the studied cohorts 35
Table 2. Laboratory data of SLE patients 35
Table 3. Association of risk factors with SLE in a logistic regression model. Independent variables include Age, gender, anti-β2GPI abs, clinical attachment loss, and the infection of T. denticola and P. gingivalis 36
Table 4. Association of risk factors with SLE in a logistic regression model. Independent variables include Age, anti-β2GPI abs, clinical attachment loss, and the infection of T. denticola and P. gingivalis 36

1.Tsokos GC. Systemic lupus erythematosus. The New England journal of medicine 2011;365:2110-2121.
2.Bernatsky S, Boivin JF, Joseph L, et al. Mortality in systemic lupus erythematosus. Arthritis and rheumatism 2006;54:2550-2557.
3.Gladman DD, Ibanez D, Urowitz MB. Systemic lupus erythematosus disease activity index 2000. The Journal of rheumatology 2002;29:288-291.
4.Basiri Z, Gholyaf M, Faridnia M, Nadi E, Bairanvand M. The prevalence of anticardiolipin antibody in patients with systemic lupus erythematosus and its association with clinical manifestations. Acta medica Iranica 2013;51:35-40.
5.Love PE, Santoro SA. Antiphospholipid antibodies: anticardiolipin and the lupus anticoagulant in systemic lupus erythematosus (SLE) and in non-SLE disorders. Prevalence and clinical significance. Annals of internal medicine 1990;112:682-698.
6.McClain MT, Arbuckle MR, Heinlen LD, et al. The prevalence, onset, and clinical significance of antiphospholipid antibodies prior to diagnosis of systemic lupus erythematosus. Arthritis and rheumatism 2004;50:1226-1232.
7.Woo KS, Kim KE, Kim JM, Han JY, Chung WT, Kim KH. Prevalence and clinical associations of lupus anticoagulant, anticardiolipin antibodies, and anti-beta2-glycoprotein I antibodies in patients with systemic lupus erythematosus. The Korean journal of laboratory medicine 2010;30:38-44.
8.Levine JS, Branch DW, Rauch J. The antiphospholipid syndrome. The New England journal of medicine 2002;346:752-763.
9.Kaplanski G, Cacoub P, Farnarier C, et al. Increased soluble vascular cell adhesion molecule 1 concentrations in patients with primary or systemic lupus erythematosus-related antiphospholipid syndrome: correlations with the severity of thrombosis. Arthritis and rheumatism 2000;43:55-64.
10.Schenkein HA, Best AM, Brooks CN, et al. Anti-cardiolipin and increased serum adhesion molecule levels in patients with aggressive periodontitis. Journal of periodontology 2007;78:459-466.
11.Pierangeli SS, Harris EN. Probing antiphospholipid-mediated thrombosis: the interplay between anticardiolipin antibodies and endothelial cells. Lupus 2003;12:539-545.
12.Blank M, Krause I, Fridkin M, et al. Bacterial induction of autoantibodies to beta2-glycoprotein-I accounts for the infectious etiology of antiphospholipid syndrome. The Journal of clinical investigation 2002;109:797-804.
13.Farmer-Boatwright MK, Roubey RA. Venous thrombosis in the antiphospholipid syndrome. Arteriosclerosis, thrombosis, and vascular biology 2009;29:321-325.
14.Blank M, Shoenfeld Y. Beta-2-glycoprotein-I, infections, antiphospholipid syndrome and therapeutic considerations. Clinical immunology (Orlando, Fla) 2004;112:190-199.
15.Blank M, Asherson RA, Cervera R, Shoenfeld Y. Antiphospholipid syndrome infectious origin. Journal of clinical immunology 2004;24:12-23.
16.Blank M, Faden D, Tincani A, et al. Immunization with anticardiolipin cofactor (beta-2-glycoprotein I) induces experimental antiphospholipid syndrome in naive mice. Journal of autoimmunity 1994;7:441-455.
17.Blank M, Cohen J, Toder V, Shoenfeld Y. Induction of anti-phospholipid syndrome in naive mice with mouse lupus monoclonal and human polyclonal anti-cardiolipin antibodies. Proceedings of the National Academy of Sciences of the United States of America 1991;88:3069-3073.
18.de Laat B, Pengo V, Pabinger I, et al. The association between circulating antibodies against domain I of beta2-glycoprotein I and thrombosis: an international multicenter study. Journal of thrombosis and haemostasis : JTH 2009;7:1767-1773.
19.Vikerfors A, Johansson AB, Gustafsson JT, et al. Clinical manifestations and anti-phospholipid antibodies in 712 patients with systemic lupus erythematosus: evaluation of two diagnostic assays. Rheumatology (Oxford, England) 2013;52:501-509.
20.Al-Homood IA. Thrombosis in systemic lupus erythematosus: a review article. ISRN rheumatology 2012;2012:428269.
21.Tektonidou MG, Laskari K, Panagiotakos DB, Moutsopoulos HM. Risk factors for thrombosis and primary thrombosis prevention in patients with systemic lupus erythematosus with or without antiphospholipid antibodies. Arthritis and rheumatism 2009;61:29-36.
22.Hamsten A, Norberg R, Bjorkholm M, de Faire U, Holm G. Antibodies to cardiolipin in young survivors of myocardial infarction: an association with recurrent cardiovascular events. Lancet 1986;1:113-116.
23.Shah MA, Shah AM, Krishnan E. Poor outcomes after acute myocardial infarction in systemic lupus erythematosus. The Journal of rheumatology 2009;36:570-575.
24.Vaarala O. Antiphospholipid antibodies and myocardial infarction. Lupus 1998;7 Suppl 2:S132-134.
25.Pierangeli SS, Espinola RG, Liu X, Harris EN. Thrombogenic effects of antiphospholipid antibodies are mediated by intercellular cell adhesion molecule-1, vascular cell adhesion molecule-1, and P-selectin. Circulation research 2001;88:245-250.
26.Berglundh T, Donati M. Aspects of adaptive host response in periodontitis. Journal of clinical periodontology 2005;32 Suppl 6:87-107.
27.Liu YC, Lerner UH, Teng YT. Cytokine responses against periodontal infection: protective and destructive roles. Periodontology 2000 2010;52:163-206.
28.Pussinen PJ, Vilkuna-Rautiainen T, Alfthan G, et al. Severe periodontitis enhances macrophage activation via increased serum lipopolysaccharide. Arteriosclerosis, thrombosis, and vascular biology 2004;24:2174-2180.
29.Silva TA, Garlet GP, Fukada SY, Silva JS, Cunha FQ. Chemokines in oral inflammatory diseases: apical periodontitis and periodontal disease. Journal of dental research 2007;86:306-319.
30.Schenkein HA, Berry CR, Burmeister JA, et al. Anti-cardiolipin antibodies in sera from patients with periodontitis. Journal of dental research 2003;82:919-922.
31.Chen YW, Umeda M, Nagasawa T, et al. Periodontitis may increase the risk of peripheral arterial disease. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery 2008;35:153-158.
32.Karnoutsos K, Papastergiou P, Stefanidis S, Vakaloudi A. Periodontitis as a risk factor for cardiovascular disease: the role of anti-phosphorylcholine and anti-cardiolipin antibodies. Hippokratia 2008;12:144-149.
33.Choi JI, Chung SW, Kang HS, et al. Epitope mapping of Porphyromonas gingivalis heat-shock protein and human heat-shock protein in human atherosclerosis. Journal of dental research 2004;83:936-940.
34.Schenkein HA, Loos BG. Inflammatory mechanisms linking periodontal diseases to cardiovascular diseases. Journal of periodontology 2013;84:S51-69.
35.Schenkein HA, Berry CR, Burmeister JA, Brooks CN, Best AM, Tew JG. Locally produced anti-phosphorylcholine and anti-oxidized low-density lipoprotein antibodies in gingival crevicular fluid from aggressive periodontitis patients. Journal of periodontology 2004;75:146-153.
36.Schenkein HA, Sabatini R, Koertge TE, Brooks CN, Purkall DB. Anti-cardiolipin from periodontitis patients induces MCP-1 production by human umbilical vein endothelial cells. Journal of clinical periodontology 2013;40:212-217.
37.Gunupati S, Chava VK, Krishna BP. Effect of phase I periodontal therapy on anti-cardiolipin antibodies in patients with acute myocardial infarction associated with chronic periodontitis. Journal of periodontology 2011;82:1657-1664.
38.Wise GE, Frazier-Bowers S, D''Souza RN. Cellular, molecular, and genetic determinants of tooth eruption. Critical reviews in oral biology and medicine : an official publication of the American Association of Oral Biologists 2002;13:323-334.
39.Kim MS, Day CJ, Morrison NA. MCP-1 is induced by receptor activator of nuclear factor-{kappa}B ligand, promotes human osteoclast fusion, and rescues granulocyte macrophage colony-stimulating factor suppression of osteoclast formation. The Journal of biological chemistry 2005;280:16163-16169.
40.Miyamoto K, Ninomiya K, Sonoda KH, et al. MCP-1 expressed by osteoclasts stimulates osteoclastogenesis in an autocrine/paracrine manner. Biochemical and biophysical research communications 2009;383:373-377.
41.Wang D, Nagasawa T, Chen Y, et al. Molecular mimicry of Aggregatibacter actinomycetemcomitans with beta2 glycoprotein I. Oral microbiology and immunology 2008;23:401-405.
42.Chen YW, Nagasawa T, Wara-Aswapati N, et al. Association between periodontitis and anti-cardiolipin antibodies in Buerger disease. Journal of clinical periodontology 2009;36:830-835.
43.Chen YW, Iwai T, Umeda M, et al. Elevated IgG titers to periodontal pathogens related to Buerger disease. International journal of cardiology 2007;122:79-81.
44.Purkall D, Tew JG, Schenkein HA. Opsonization of Actinobacillus actinomycetemcomitans by immunoglobulin G antibody reactive with phosphorylcholine. Infection and immunity 2002;70:6485-6488.
45.Ashimoto A, Chen C, Bakker I, Slots J. Polymerase chain reaction detection of 8 putative periodontal pathogens in subgingival plaque of gingivitis and advanced periodontitis lesions. Oral microbiology and immunology 1996;11:266-273.