Helicobacter Pylori— Another Reason to Floss
abstract & commentary
Source: Dowsett SA, et al. Helicobacter pylori infection in indigenous families of Central America: Serostatus and oral and fingernail carriage. J Clin Microbiol 1999;37:2456-2460.
Dowsett and colleagues from the indiana university School of Dentistry studied 242 people in a remote village in Guatemala for the presence and significance of Helicobacter pylori. After informed consent and a medical history, a periodontal exam was done with an average of six oral samples taken per patient for detection of Helicobacter using a nested PCR assay. In addition, a sample of material from under the fingernail of the index finger of the dominant hand was obtained for PCR analysis and a finger-prick of blood was obtained for serology for IgG antibody to Helicobacter (QuickVue—Quidel, San Diego). Subjects ranged in age from 12 to 75 years.
H. pylori was recovered from at least one oral sample in 87% of subjects. The best place to recover it was the periodontal pockets but there did not appear to be a correlation between the depth the sample taken from in the gingival margin and a positive result. Dorsal tongue samples were positive in 56% of people. Fingernail samples were positive in 58% and correlated well with tongue samples.
IgG serology results were positive in 58%. Correlations with a positive antibody test included age (41% of those 12-17 to 65% of those 55-64 years old), a positive mother (P = 0.02) and a positive sibling (correlation coefficient 0.63). The father’s status did not correlate with a positive child as a mother’s did. Gastrointestinal symptoms were described by 29% of subjects in their initial medical history but did not seem to correlate with a positive antibody test.
Comment by Alan D. Tice, MD, facp
Dowsett et al have come up with some interesting information about H. pylori, an organism that is distributed worldwide but about which we have limited knowledge as to its mechanism of transmission. The situation is further complicated by difficulties with medical therapy and an apparent increase in antimicrobial resistance. Whether infection control measures are needed or what they should be are essentially unknown.
Even though it was not recognized until 1983, Helicobacter has taken on more and more significance as a cause of gastric and duodenal ulcers. In addition, it is now recognized by the World Health Organization (WHO) as a type I carcinogen because of its association with gastric adenocarcinoma. There appears to be no animal reservoir, as it has not been recovered from any species other than humans and some rhesus monkeys. Its presence has been associated with close human contact, population crowding, poor sanitation, lack of hot water, and drinking coffee.1
The presence of evidence of H. pylori infection in 87% of people in the village studied is not a surprise as prior studies have documented rates of 41-96%.2 It is clearly a common problem and a cause of disease worldwide. The lack of antibody response in the 29% of villagers from whom the organism was recovered by PCR suggests a much higher carriage rate than determined by serologic studies. This apparent lack of host response suggests an even more ideal circumstance for the organism persistence.
The findings reported in this article confirm the ubiquitous presence of the bacteria as well as the associations within family units and the mother-child relationship, although fathers do not seem to be associated. It also provides strong evidence for the mouth and periodontal pockets as a reservoir for the bacteria. These pockets may well serve as reservoirs for a number of organisms as well, as there have been more than 200 different bacteria recovered from them when detailed microbiology studies are done. It will be interesting to see how many of those organisms have been overlooked as pathogens, such as Helicobacter has. The finding of Helicobacter under the fingernails is also an important link in the path of transmission from human to human. Fingernails can easily be seeded from the mouth or the opposite end of the gastrointestinal tract and would certainly provide a ready means of transmission from person to person.
There are many questions to answer about H. pylori in terms of its epidemiology, significance, treatment, and interruption of transmission. There are, however, some lessons to be learned from this study in Guatemala that are very relevant to developed countries as well. Oral hygiene and possibly flossing may serve to reduce the reservoir of H. pylori and other organisms in the mouth. The findings also reinforce the value of hand washing and suggest that nail care should be a part of it. Further studies are needed as to the relevance of other measures to limit transmission. v
References
1. Brenner HD, Rothenbacher D. Relation of smoking and alcohol and coffee consumption to active Helicobacter pylori infection: Cross sectional study. BMJ 1997;315: 1489-1492.
2. Goodman KJ, Correa P. The transmission of Helicobacter pylori. A critical review of the evidence. Int J Epidemiol 1995;24:875-887.
The best place to recover Helicobacter pylori was from the:
a. fingernails.
b. dorsal tongue.
c. periodontal pocket.
d. blood sample taken.
e. All of the above
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