Diagnostic value associated with the combination of saliva pepsin and microorganisms in functional heartburn and gastroesophageal reflux disease

Abstract

Heartburn is a common symptom shared by both gastroesophageal reflux disease (GERD) and functional heartburn (FHB), which can make it challenging to differentiate between the two conditions. However, examining oral manifestations of GERD can be a cost-effective and readily available method to aid in this differentiation process. It may serve as a valuable tool in distinguishing GERD from FHB.

Key Words: Gastroesophageal reflux disease; Gastric acid; Heartburn; Differential diagnosis; Epidemiology; Oral manifestations; Prevalence; Risk factors; Dental erosion; Periodontal diseases

Core Tip: Heartburn is a common symptom in both gastroesophageal reflux disease (GERD) and functional heartburn (FHB), which can make it challenging to differentiate between the two conditions. However, examining oral manifestations of GERD can be a valuable tool in distinguishing GERD from FHB. In a study involving 116 patients with heartburn, the prevalence of dental erosions (DE) and periodontal diseases (PD) was evaluated. The findings suggest that dental evaluation in patients with heartburn can aid in the differential diagnosis of GERD and FHB. The presence of both DE and PD appears to be the most reliable predictor of GERD, while the absence of dental disorders is often observed in cases of FHB.

TO THE EDITOR

We found a recent observational study by Helle et al[1], titled “Dental evaluation is helpful in the differentiation of functional heartburn and gastroesophageal reflux disease”, to be quite interesting. The study included 116 patients with heartburn, with an average age of 54 years, who underwent detailed esophageal function and oral examinations. The objective of the study was to evaluate the prevalence of dental erosion (DE) and periodontal disease (PD) in heartburn patients, and to determine their association with gastroesophageal reflux disease (GERD) and functional heartburn (FHB). This study may be the first to investigate the relationship between dentistry and gastroenterology in this context.

The article utilized several methods to assess esophageal function, including upper gastrointestinal endoscopy, high-resolution esophageal manometry using a 22-channel water-perfused catheter (medical measurement systems solar), and 24-h multi-channel intra-esophageal pH-impedance monitoring. The severity of GERD was determined based on the Lyon consensus criteria, while the diagnosis of FHB followed the Rome IV criteria. Prior to the dental examination, standardized questionnaires were administered to collect information on personal conditions, oral habits, and the presence and frequency of typical or atypical reflux symptoms.

DE was evaluated and scored using the Smith and Knight criteria for tooth wear index, while the severity of periodontitis was quantitatively assessed by calculating the percentage of plaque area to total area. The article highlights that the use of oral indicators for diagnostic assistance is justified by its low cost and wide availability.

Currently, the diagnosis of GERD is mainly made through clinical history, questionnaire scales, diagnostic proton pump inhibitors (PPI) therapy, upper gastrointestinal endoscopy, and reflux monitoring, all of which are widely used in clinical practice. However, these methods have their own advantages and disadvantages, and the sensitivity and specificity of diagnostic PPI treatment and structured questionnaires for GERD diagnosis are not ideal[2]. Furthermore, non-erosive reflux disease is more prevalent than reflux esophagitis in the GERD population, which means that endoscopy can only detect GERD in about 30% of patients with typical reflux symptoms[3]. Reflux monitoring is currently considered the gold standard for diagnosing GERD. For populations with uncertain GERD, the results of other examinations can be used as auxiliary evidence for diagnosis.

We agree with the authors that both oral specialist examination indicators were applied to assist in distinguishing between GERD and FHB. Several studies have discussed and established a clear but variable relationship between DE and GERD[4,5]. The gastric reflux pH is typically < 2.0, which can lead to tooth tissue erosion, depending on the duration and frequency of reflux episodes and the protective function of saliva[6]. DE makes teeth more prone to friction and wear, resulting in changes to the occlusal surface and erosion of tooth material[6]. Jajam et al[7] conducted a study on oral changes in GERD and found a higher prevalence of periodontitis in GERD patients compared to gingivitis, possibly due to their impaired salivary secretion function. Insufficient saliva secretion in GERD promotes the proliferation of bacterias such as Actinobacteria and Porphyromonas, leading to the development of chronic periodontitis[8].

Pepsin is a digestive enzyme produced by gastric chief cells, and its activity remains relatively stable. It exhibits optimal activity at pH 2.0, is inactive but stable at pH 6.5, and becomes completely inactive at pH > 8. Currently, the main method for detecting pepsin is PeptestTM, which is fast, simple, and non-invasive. The principle of PeptestTM is to utilize a highly specific antigen-antibody reaction to capture human pepsin 3, thereby measuring the pepsin content in the subject's saliva[9]. The quantitative analysis of pepsin concentration can be achieved by utilizing a lateral flow device reader.

We propose combining the results of clinical characteristics, pepsin concentration, oral hygiene indicators, and salivary microorganisms to enhance the accuracy of diagnosing GERD and FHB. We are eager to conduct more prospective studies in the future to explore the cellular and molecular pathways underlying microbial interactions. This will improve our understanding of the pathogenesis of GERD and FHB, and aid in the identification of new targets for prevention, diagnosis, and treatment. Ultimately, this will provide more cost-effective and relatively safe options for patients.