Incidence of Helicobacter Pylori in oral aphthous stomatitis

Surender Sharma; Avani Dixit; K Aravinda; Deepa Patil; Rajesh Gupta

doi:10.4103/0976-4003.196810

ORIGINAL ARTICLE

Year : 2016 | Volume : 8 | Issue : 4 | Page : 188-192

Incidence of Helicobacter Pylori in oral aphthous stomatitis

Surender Sharma, Avani Dixit, K Aravinda, Deepa Patil, Rajesh Gupta
Department of Oral Medicine Radiology, Swami Devi Dayal Dental College and Hospital, Golpura, Haryana, India

Date of Web Publication

27-Dec-2016

Correspondence Address:
Avani Dixit
Flat No. 506, Group Housing Society-34, Sector 20, Panchkula, Haryana
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0976-4003.196810

Abstract

Background/Aims: The aim of this study was to determine probable HP infection in oral aphthous samples by RUT in patients with recurrent aphthous stomatitis. Materials and Methods: This in vivo cross-sectional study was approved by the Ethics Committee of Swami Devi Dayal Dental College and Hospital according to the ethical standards. A total of 30 patients with minor recurrent aphthous stomatitis and 20 healthy control groups were included in the study. Results: Out of 30 patients with minor recurrent aphthous stomatitis, including 17 male and 13 female patients, with mean age of 47 and 38 years respectively, 21 patients (70%) were RUT (positive). Out of 20 healthy control groups, 12 males and 8 females, 2 (10%) were RUT (positive) [Table 1]. Conclusion: HP may play a role in the etiology of RAS; also it is likely that RUT may be rapid and reliable for investigation of HP in RAS lesions.

Keywords: Gastritis and peptic ulcer, Helicobacter pylori, oral ulcerations, recurrent aphthous stomatitis

How to cite this article:
Sharma S, Dixit A, Aravinda K, Patil D, Gupta R. Incidence of Helicobacter Pylori in oral aphthous stomatitis. Indian J Dent Sci 2016;8:188-92

How to cite this URL:
Sharma S, Dixit A, Aravinda K, Patil D, Gupta R. Incidence of Helicobacter Pylori in oral aphthous stomatitis. Indian J Dent Sci [serial online] 2016 [cited 2023 May 28];8:188-92. Available from: http://www.ijds.in/text.asp?2016/8/4/188/196810

Introduction

The term recurrent aphthous stomatitis (RAS) refers to the most common inflammatory ulcerative disorder of the oral mucosa.^[1] RAS is characterized by painful superficial ulcers on nonkeratinized or poorly keratinized mucosa and is generally localized.^[2] The etiopathogenesis of RAS is unclear, although many possible predisposing factors have been implicated such as trauma, emotional stress, hormonal state, food hypersensitivity, viruses, bacteria, and immune dysregulation.^[3] It has also been reported that type 1 helper genes are locally overexpressed and cytokines such as interleukin (IL)-2, tumor necrosis factor-α, and IL-6 are systemically produced by circulating mononuclear cells. IL-10 messenger RNA levels were reported to be decreased which suggests the immune system cannot effectively suppress the inflammatory reaction against the oral mucosa.^[4],[5] Previous studies have reported that increased cell-mediated immune responses against certain areas of the oral mucosa secondary to an abnormally regulated cytokine cascade lead to ulceration.^[5] RAS etiopathogenesis may also include genetic factors, and RAS patients have an increased prevalence of HLA-B12 and Behcet's disease, which is a disorder characterized by recurrent aphthous ulcers and is associated with increased HLA-B5 levels.^[6] It has been reported that IL-1β and IL-6 gene polymorphisms are associated with a significant risk for the development of RAS. However, associations between specific IL-10 or IL-12 gene polymorphism and RAS susceptibility were not demonstrated in prior studies.^[7],[8],[9] Studies have shown that a G allele at the −174 position is associated with a higher IL-6 production than a C allele at the same position.^[10] Similar relationships between IL-1β −511 genotype and IL-1β production were also suggested.^[11]

The important etiological agents in the etiopathogenesis of RAS suggested as Helicobacter pylori (HP) in recent years. The HP infection is diagnosed by several methods, both invasive and noninvasive. The sensitivity and specificity of these assays range from 80% to 95% depending on the assay used.

Methodology

This in vivo cross-sectional study was approved by the Ethics Committee of Swami Devi Dayal Dental College and Hospital according to the ethical standards. A total of 30 patients with minor recurrent aphthous stomatitis and 20 healthy control groups were included in the study.

After obtaining a written consent, a detailed case history related to oral ulceration will be recorded, and thorough clinical examination will be carried out when the individual have active ulcerated lesion to confirm the diagnosis. Once the clinical diagnosis is done, the individual is selected to the study group.

They had no chronic illness in both patients and control group. A detailed history (family history of the RAS, time of onset, annual recurrence rate, predisposing factors, number of aphthous lesions in last 3 months, localizations, diameters, and improvement time of the lesions) and complete dermatological examination were performed. Pathergy test, ophthalmologic examination, complete blood counting, routine biochemical tests, serum iron, folic acid, and Vitamin B12 levels were assessed. Hepatitis markers and anti-HIV antibodies were studied. The patients with normal laboratory examination were included in this study. Behcet's disease was excluded from this study. The major and herpetiform RAS was not included in the study.

The diagnosis of recurrent oral aphthous stomatitis was given after taking a detail medical history, by thorough general and oral examination and by excluding or ruling out other deficiency states or other systemic or immunological conditions, through routine and special hematological tests.

The patients were given a questionnaire, which included questions on the presence of gastrointestinal disorders or a positive history of peptic ulcer. Only those who had not consumed any antibiotics in the last month and did not use any steroidal drugs were tested. The active aphthae of these patients were sampled with rapid urease test (RUT).

The samples to be studied include tissue scrapings obtained from the ulcerated lesion using a sterile curette. 10% lidocain spray was applied to oral ulcer of the patient and buccal mucosa of the control. The samples were obtained by scraping the lesion of RAS in patients and buccal mucosa of the controls with a sterile curette.

The collected samples were subjected to RUT for the detection of HP, the kits; helicorapt kit [Figure 1] was obtained from zenith pharmaceuticals.

Figure 1: Helicorapt kit.

Click here to view

RUT kit was stored at +4°C until usage. The scraping samples from ulcer and mucosa were stored at the room temperature then placed into kits.

Color change was checked respectively at the 30^th, 60^th min and at the 4^th h (as recommended by the company).

If the color of the test is yellow or yellow-green, the result is negative but red or pink is considered as a positive test result [Figure 2].

Figure 2: Rapid urease test result.

Click here to view

Grading of the results was be done as strongly positive, positive, and weakly positive. The results obtained were statistically analyzed.

Results

Out of 30 patients with minor recurrent aphthous stomatitis, including 17 male and 13 female patients, with mean age of 47 and 38 years respectively, 21 patients (70%) were RUT (positive). Out of 20 healthy control groups, 12 males and 8 females, 2 (10%) were RUT (positive) [Table 1].

Table 1: Sociodemographic features and rapid urease test results of the patient and control groups

Click here to view

The results obtained were statistically analyzed. The sensitivity and specificity to RUT in RAS patients were significantly higher (Fisher's test P = 0.0066).

We have found that RUT is positive in 70% of the patients and 10% of the control group [Table 1].

RUT positivity in RAS patients was significantly higher than control group.

We think that HP may play a role in the etiology of RAS; also it is likely that RUT may be rapid and reliable for investigation of HP in RAS lesions.

The results of studies with the relation of HP and RAS are controversial. In some studies, it has been said that HP had no role in the pathogenesis of RAS using polymerase chain reaction (PCR) and serology by Mansour-Ghanaei et al.,^[12] Iamaroon et al.,^[13] Shimoyama et al.^[14] and Fritscher et al.,^[15] whereas a positive correlation has been observed between HP and RAS, using PCR and serology by others.^{[4],[8],[16],[17]} However, there has been no clear conclusion in some studies.^[18] This controversy is probably due to methodological and technical differences.

When interpreting our results, it is important to note some of the limitations of our study.

First, we had limited number of patients. Second, another diagnostic method showing the existence of HP as histopathology, PCR, antibody was not used. Therefore, false negative and the positivity of the test had not been possible to evaluate exactly. The major and herpetiform RAS was not included in the study

Review of Literature

HP, previously called “Campylobacter pylori” is a Gram-negative, microaerophilic, motile, spiral-shaped bacterium. It was first isolated by Marshall and Warren, which ushered in a new era in gastric microbiology.^[19] HP belongs to a family of bacteria that colonize the mammalian stomach and is causally linked to chronic gastritis, peptic ulceration, and gastric adenocarcinoma.^[20] This bacterium colonizes over half of the world's population.

Risk factors for Helicobacter pylori

The risk factors for HP include poor social economic status, poor hygiene practice, absence of hygienic drinking water, and unsanitary food preparation.^[21],[22]

Transmission of Helicobacter pylori

The main route of organism entry has been charted as the following – oral to oral, gastro to oral, and fecal to oral. Transmission may occur in a vertical or horizontal mode. Oral carriage of HP may play a role in the transmission of infection.^[22]

Most infections are probably acquired in childhood, although the exact route of transmission is unknown. These bacteria are also found in plaque and feces, so the route of infection could be oral–oral or fecal–oral.^[23],[24]

It has long been speculated that dental plaque might harbor HP and therefore might be a source of reinfection of the gastric mucosa.^[25]

Because of similarities in the histologic characteristics of gastric ulcers and oral aphthous ulcers, it seems reasonable to assume that HP could play a role in the development of recurrent aphthous ulcers.

The pathogenesis of HP infection in humans can be described in three steps:^[19] Entry to, adherence to, and colonization of the human gastric mucosa;^[20] avoidance, subversion, or exploitation of the human immune system; and ^[26] multiplication, tissue damage, and transmission to a new susceptible host or spread to adjacent tissue.^{[19],[20],[26]} A virulence factor is defined by its involvement in one or more of these processes.

Pathogenesis

HP is well adapted to withstand low pH to gain entry to its preferred territory, the mucus layer of the mucous membrane. One of the survival capabilities is its ability to resist mucosa and migration toward epithelial cell. Once there, the bacterium resists the local and systemic immune responses. Colonization persists for life in the host if there is no exposure to antibiotics.^[5] Once it escapes from the lumen, it modifies the bioenvironment in the area and starts releasing collagenases which degrade the collagen in the host enabling more space for the movement of the bacteria. The Fas Ag pathway of apoptosis is activated during HP infection. The combined action of the collagenases and stimulation of apoptosis leads to ulceration of the mucosa.^[8]

Recently, HP has been proposed to be one of the important etiological agents in the pathogenesis of RAS.^[10] It has been showed that patients with recurrent oral ulcerations appear to suffer from active HP infection in a high percentage of cases.^[10]

American College of Gastroenterology (ACG) guidelines states that diagnostic testing should only be performed if treatment of HP infection is intended

Testing only indicated with active peptic ulcer disease or with history of documented peptic ulcer disease, or gastric mucosa-associated lymphoid tissue lymphoma.

The guidelines were previously given in 1998 and revised in August 2007 and published in the American Journal of Gastroenterology.

2007 American College of Gastroenterology guidelines

Uninvestigated dyspepsia: “Test and Treat Strategy.”

Test and treat strategy

Uninvestigated dyspepsia (i.e., unknown if patient has peptic ulcer disease) <55 years age
No “alarm features”
- Bleeding
- Anemia
- Early satiety
- Unexplained weight loss
- Progressive dysphagia
- Odynophagia
- Recurrent vomiting
- Previous esophagogastric cancer.
Still controversy regarding whether to test for HP in
- Functional dyspepsia - a subset of patients with functional dyspepsia benefit from HP eradication
- Nonsteroidal anti-inflammatory drug use
- Iron-deficiency anemia - recent evidence suggests a link between HP infection and unexplained iron-deficiency anemia
- Risk factors for developing gastric cancer.

Family members of patients with ulcer disease or gastric cancer

According to 2007 ACG guidelines “there is no single test that can be considered the gold standard for the diagnosis of HP”
The most appropriate test depends on clinical situation.

Noninvasive tests

Serology: Laboratory-based serology using ELISA to detect IgG or IgA

In young, symptomatic patients may be good alternative. The results depend on pretest probability of HP in population being studied

Inaccurate tests common in elderly, cirrhotics patients
Not useful for follow-up testing since many patients has antibodies for months-years posttreatment
Urea breath test: A urea solution labeled with C14 isotope is given to the patient. The CO₂ subsequently exhaled by the patients contains the C14 isotope, and this is measured. A high reading indicates presence of HP
Fecal antigen test: Detect HP antigens in fecal specimens
PCR: Can detect HP within a few hours. Not routine in clinical use.

Invasive testing

Histological examination of biopsy specimens of gastric/duodenal mucosa take at endoscopy
- Endoscopy testing: ACG guidelines state that if endoscopy used, first test of choice is urease test on antral biopsy
- Routine gastric histology: Not necessary and expensive
- If urease test negative, then use histology, culture, noninvasive tests (breath, stool).
  - Serology not reliably distinguish between active and past infection
  - One cost-saving measure: Obtain but delay sending histology pending biopsy urease test.
Biopsy urease test
Campylobacter-like organism (CLO)-test: Based again on urease production by the organism-> NH3 production-> rise in pH≥ change in the color indicator of the kit
- High sensitivity and specificity
- Prompt result.
Culture: No more sensitive than skilled microscopy of histological sections
- Used for antibiotic resistance testing
- Requires selective agars and incubation periods.

Other developing tests

¹³ C bicarbonate serologic assay using two serum specimens: One before meal and next 60 min after ingestion of ¹³ C-urea rich meal
PCR: Only useful in detecting organism when ordinary culture difficult
Salivary assay: Oral cavity can be reservoir
Urinary assay.

Bacteriologic culture and histological staining of tissue are the conventional methods used to detect HP. Although HP culture can be carried out in most laboratories, it has some restrictions, including the long delay (4 days) in obtaining results, the low sensitivity of the culture isolation, and the need for strict transport conditions because of the fastidious nature of the bacterium.^[27] On the other hand, the histological analysis is time-consuming and requires an expert pathologist. The modified Giemsa and Silver stains have good specificity and sensitivity, but false-positive readings can occur in the case of abundant mucus and contaminating organisms resembling HP are present.^[27],[28]

Serologic tests identify circulating IgG or IgA antibodies. However, despite the cost effectiveness, the diagnostic significance of ELISA test is restricted because it cannot differentiate between current and past infections.^[28] Likewise, in the urea breath test, a patient drinks an oral solutions containing urea labeled with carbon 13 or 14. An HP bacterium metabolizes the urea to produce carbon that was absorbed into the bloodstream. The carbon travels through the bloodstream to the lungs. When the lungs exhale the carbon, measurement of carbon 13 or 14 determines the presence or absence of HP infection.

However, false-positive results due to the presence of other enteric bacteria remain as the main disadvantage of the urea breath test.^[20]

The PCR is one of the mostly used molecular techniques for detecting specific pathogens.

Compared with various methods as histological and cultural, PCR offers most sensitivity in detection of HP. It was used for the detection of HP in gastric tissue samples, where it provides a rapid, sensitive, and specific test result and is particularly useful for a gastroenterologist who does not have access to local routine laboratory facilities 13. RUT is one of the invasive tests. The principle is based on abundant urease enzyme produced by HP hydrolyses urea to ammonia. The phenol red indicatoris used in the detection of a consequent rise in the pH of the medium. Several modifications of Christensen's original urea medium have been developed obtaining quick results and improving sensitivity and specificity. Various RUTs are available commercially such as CLO test, HP test, and PyloriTek test providing comparable results with high sensitivity and specificity. However, simpler and cheaper in-house urease test medium giving similar results can be made in most of the dermatology departments as done by us. The sensitivity of test depends on pH of the medium, concentration of urea, indicator used, and temperature of incubation.

Microscopy may be falsely negative in the case quite low number of organisms. RUT yields positive result as HP gets sufficient time to multiply in the urea broth.^[20]

Berry and Sagarand Goh et al. suggest that RUT is the gold standard test for HP infection in gastric biopsy material.^[29],[30] It can be used as a rapid diagnostic technique; also results are obtained within 90 min. Thus RUT, a simple and cheap test, is quite beneficial in tracing HP infection and thereby helps us in treating the patients on time.^[29],[30] Unver et al.^[31] reported 58% positive HP in pharyngeal tissue. Yilmaz et al.^[32] reported that they did not find any positivity with RUT in materials of tonsillectomy, but they reported positivity in 50% with HP antigen in the stool and 56% HP IgG in the blood in the same patients.

Similar to Skinner et al.^[33] reported positivity 28% with HP IgG in blood but did not find any positivity with RUT in tonsillectomy samples in 50 patients. Bitar et al.^[34] reported 78% positive in adenoidectomy samples in 25 patients, but did not find any positivity with PCR. Dagtekin-Ergür et al.^[35] reported RUT is not reliable for investigation of HP in their study other than the stomach.

As a result, HP determination at gastric biopsy specimens with RUT in RAS patients may not always be possible. In this case, RUT may be reliable and rapid for investigation of HP in an oral lesion with RAS patients. Furthermore, RUT positivity may lead the way for use in antibiotic for RAS patients. Broader patient sized studies are needed on this issue.

Financial support and sponsorship

Rapid urease test kit-Helicorapt kit.

Conflicts of interest

There are no conflicts of interest.

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