The relationship between gastric-oral Helicobacter pylori and oral hygiene in patients with vitamin B12-deficiency anemia

Porphyromonas gingivalis-Helicobacter pylori co-incubation enhances Porphyromonas gingivalis virulence and increases migration of infected human oral keratinocytes

Background

Porphyromonas gingivalis is part of the subgingival biofilm and a keystone species in the development of periodontitis. Interactions between P.gingivalis and other bacteria in biofilms have been shown to affect bacterial virulence. Helicobacter pylori also inhabits the subgingival biofilm, but the consequences of interactions there with P.gingivalis remain unknown. Here, we investigated how the pre-incubation of P.gingivalis with H.pylori affects P.gingivalis virulence.

Methods

We assayed P.gingivalis internalization by oral keratinocytes (OKs), hemagglutination and biofilm formation to identify alterations in virulence after pre-incubation with H. pylori. Also, we evaluated viability and migration of OKs infected with P. gingivalis, as well as the role of toll-like receptor 4 (TLR4).   In addition, we quantified the mRNA of genes associated with P.gingivalis virulence.

Results

Pre-incubation of P.gingivalis with H.pylori enhanced P.gingivalis biofilm formation, bacterial internalization into OKs and hemagglutination. Infection with pre-incubated P.gingivalis increased OK migration in a manner dependent on the O-antigen and linked to  increased expression of the gingipain RgpB. Also, OK TLR4 participates in these events, because upon TLR4 knock-down, pre-incubated P.gingivalis no longer stimulated OK migration.

Discussion

We provide here for the first time insight to the consequences of direct interaction between P.gingivalis and H.pylori. In doing so, we shed light on the mechanism by which H. pylori presence in the oral cavity increases the severity or progression of periodontitis.

Clinical manifestations of gastrointestinal diseases in the oral cavity

Aim

In this review, several gastrointestinal diseases that dentists may encounter in practice are highlighted and discussed.

Materials and methods

Using MEDLINE (PubMed), a comprehensive review of gastrointestinal diseases and their oral cavity manifestations was performed.

Results

Many gastrointestinal diseases present with oral symptoms that are detectable by dentists and dental hygienists. Often, oral manifestations of the disease may appear before systemic signs and symptoms. Managing patients with these conditions requires dentists to adjust their treatment and/or involve other health professionals.

Conclusion

Care must be taken when providing periodontal therapy or dental implants to patients suffering gastrointestinal diseases who are at high risk of bleeding, infection, or malnutrition, for example. Also, pharmacological therapy for these patients may need to be customized.

Higher Risk of Gastric Helicobacter pylori Infection in Patients with Periodontitis: A Nationwide Population-Based Retrospective Cohort Study in Taiwan

Periodontitis is the most prevalent chronic inflammatory oral disease that is characterized by tooth loss and is commonly associated with several systemic inflammatory diseases. Some epidemiological studies suggest that those suffering from periodontitis might be at a greater risk of developing gastric Helicobacter pylori (Hp) infection; however, evidence that showing the association between periodontitis and the risk of gastric Hp infection is less clear. We conducted a large-scale, population-based study in Taiwan with a 13-year follow-up period to evaluate the risk of gastric Hp in a periodontitis patient cohort. To conduct this study, we used epidemiological data from the Taiwanese Longitudinal National Health Insurance Research Database (NHIRD) from 2000 to 2013. We selected 134,474 participants (64,868 males and 69,606 females with a minimum age of 20 years), with and without periodontitis, and matched patient cohort groups for age, sex, index year, and co-morbidities. The Cox proportional hazards regression model was used to examine the risk of gastric Hp infection in patients with periodontitis. Patients with periodontitis exhibited a higher risk of developing gastric Hp infection compared to those individuals/groups without periodontitis (1.35 vs. 0.87 per 1000 person-years, adjusted the hazards ratio (aHR 1.52), and 95% confidence intervals (CIs) 1.38–1.67, p < 0.001). The risk of gastric Hp infection persisted even after stratifying by age (aHR = 1.96 (1.79–2.13) for 50–64 years and 1.70 (1.49–1.94) for ≥65 years), gender (aHR = 1.20 (1.11–1.29) for men), and presence of comorbidities of hypertension (aHR = 1.24 (1.11–1.38)), hyperlipidemia (aHR = 1.28 (1.14–1.42)), COPD (aHR = 1.45 (1.31–1.61)), CLD (aHR = 1.62 (1.47–1.77)) and CKD (aHR = 1.44 (1.04–1.99)). Overall, our findings showed that periodontitis patients have a greater risk for gastric Hp than individuals without periodontitis. Clinicians should perform regular good oral hygiene practices, along with newer treatments, for patients with periodontitis, especially those at higher risk of gastric Hp infection.

H. Pylori is related to osteoporosis but only in premenopausal female: a cross-sectional study

Background

Recently, an increasing number of studies have focused on the extra-gastrointestinal effects of Helicobacter pylori (H. pylori), including metabolic syndrome, fatty liver, and rheumatic and skin diseases. Osteoporosis is an asymptomatic disease that can eventually lead to fractures and has a significant impact on the quality of life of elderly individuals. Sex is an influential factor that plays a crucial role in the development of osteoporosis. The aim of this study was to investigate the relationship between H. pylori infection and osteoporosis and to identify potential influencing factors.

Methods

We conducted a cross-sectional study of individuals older than 50 years old, who had undergone regular physical examinations at the Beijing Shijitan Hospital Health Examination Center from July to October 2018. We evaluated the associations of osteopenia and osteoporosis with H. pylori infection and related serum markers by using multiple linear regression and logistic regression. Then, we analysed the correlation between sex and potential serum biomarkers.

Results

There were significant relationships between H. pylori infection status and bone density in premenopausal females but not in males (P = 0.381) according to Fisher’s exact test. In females, H. pylori positivity (OR = 0.132, P = 0.023), Body Mass Index (BMI) (OR = 28.163, P = 0.021), and homocysteine (HCY) (OR = 17.218, P = 0.045) were associated with osteoporosis. Calcium had a trend but no statistically significant (OR = 0.060, P = 0.076) relationship with osteoporosis. Furthermore, the waist-to-hip ratio (OR = 5.783, P = 0.029), BMI (OR = 0.152, P = 0.014) and triglyceride levels (OR = 0.201, P = 0.036) were significantly different by sex, after adjusting for age as a confounder.

Conclusion

H. pylori positivity, BMI and HCY are associated with osteoporosis in premenopausal females. Chronic inflammation may be involved in the relationship between H. pylori and osteoporosis.

The association between chronic periodontitis and oral Helicobacter pylori: A meta-analysis

BACKGROUND

Epidemiological studies have shown that gastrointestinal Helicobacter pylori (H. pylori) infection is the main cause of chronic gastritis, but the relation between oral H. pylori and chronic periodontitis (CP) remains uncertain. A meta-analysis of published papers was performed to elucidate the correlation between oral H. pylori and CP.

METHOD

To perform this meta-analysis, we searched papers published from 2000 to 2018 on PubMed, OVID, Springer Link, Chinese National Knowledge Infrastructure (CNKI) and Chinese Biology Medicine search engines. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) for the correlation between H. pylori and CP were estimated. Heterogeneity, publication bias and subgroup analyses were also conducted.

RESULTS

A total of 918 papers on oral H. pylori and CP were collected, and 11 papers were in accordance with the inclusion criteria. Oral H. pylori was suggested to be correlated with CP. The results indicated that a H. pylori-positive state significantly increased the risk of CP 3.42 times (OR = 3.42; 95% CI = 2.71-4.31). A diagnostic test using polymerase chain reaction (PCR) showed a higher prevalence of H. pylori (OR = 3.70; 95% CI = 2.66-5.14) than did that using the rapid urease test (RUT) (OR = 3.13; 95% CI = 2.26-4.34).

CONCLUSIONS

This paper demonstrated that CP was potentially correlated with oral H. pylori in adults and that oral H. pylori may be a possible risk factor for CP.

Effects of periodontal therapy on eradication and recurrence of Helicobacter pylori infection after successful treatment

OBJECTIVES

This study aimed to evaluate the effects of periodontal therapy on the efficacy of Helicobacter pylori eradication and on the recurrence of infection after eradication.

METHODS

We conducted a prospective randomized trial on 698 gastric H. pylori-infected patients, of whom 347 received gastric H. pylori treatment alone and 342 received gastric H. pylori treatment plus periodontal therapy. The presence of H. pylori and associated virulence genes were detected by real-time polymerase chain reaction.

RESULTS

After eradication of gastric H. pylori infection, the recurrence of gastric H. pylori was significantly lower in the gastric H. pylori treatment plus periodontal therapy group than in the group receiving gastric H. pylori treatment alone (OR 0.67; 95% CI 0.45 to 0.99), whereas the eradication rate was not significantly different (OR 0.87; 95% CI 0.68 to 0.98). There was a close relationship between the presence of H. pylori in saliva and its presence in the stomach.

CONCLUSIONS

The oral cavity is an important reservoir for gastric H. pylori infection. Adjunctive periodontal therapy could enhance the efficiency of H. pylori treatment and reduce the recurrence of gastric H. pylori infection.

Clinical Comparative Study of the Effects of Helicobacter Pylori Colonization on Oral Health in Children

OBJECTIVE

To isolate Helicobacter pylori (HP) from the dental plaque of a selected group of children and to compare the oral and salivary findings of patients with those of a healthy control group.

METHODS

A total of 70 children aged 5-15 years were included in this study. An intraoral examination was performed for each patient, and dental plaque and saliva specimens were collected for analysis. Oral health conditions, nutritional habits, tooth brushing frequency, saliva pH levels, flow velocity, and buffering capacities were noted. The Kruskal-Wallis test was used for comparison of the DMFT and dft index. The significance level was set at p=0.05.

RESULTS

The prevalence of HP in dental plaque was higher in study group than controls (p<0.05). There were no significant differences between groups with respect to DMFT and dft scores, nutritional habits, tooth brushing frequency, saliva pH level or flow velocity (p>0.05). Meanwhile, the buffering capacity of saliva was lower in HP gastritis patients (p<0.05).

CONCLUSION

There was a high prevalence of HP in dental plaque; thus, the oral cavity may be an important reservoir for HP. Good oral hygiene could be a positive contributor to the treatment of gastritis.

Oral manifestations in vitamin B12 deficiency patients with or without history of gastrectomy

BACKGROUND

The purpose of this study was to compare clinical features of vitamin B12 deficiency patients with a history of gastrectomy to those without a history of gastrectomy.

METHODS

Twenty-two patients with vitamin B12 deficiency were included. Patients' chief complaints, oral manifestations, blood examination results, and past medical histories were reviewed.

RESULTS

Eleven patients had a history of gastrectomy and 11 did not. The chief complaint was glossodynia in all patients. No significant differences were observed between the two groups regarding age, sex, symptom duration, or plasma vitamin B12 level. Erythema and depapillation of the tongue were the most common findings, however less common among patients without a history of gastrectomy. Two patients with a history of gastrectomy and 5 patients without a history of gastrectomy had normal oral mucosa. Patients with a history of gastrectomy were more anemic. Oral symptoms of the majority of patients responded to antifungals and vitamin B12 replacement. The suggested etiologies for vitamin B12 deficiency in the patients without a history of gastrectomy were gastritis, medications, diet, autoimmunity, and early gastric cancer.

CONCLUSIONS

Vitamin B12 deficiency and its associated etiological factors should be considered in patients with glossodynia, even those whose oral mucosa appears normal and who lack a history of gastrectomy.

Periodontal therapy as adjunctive treatment for gastric Helicobacter pylori infection

BACKGROUND

Helicobacter pylori is estimated to affect about half the world's population and is considered as the main cause of chronic gastritis and peptic ulcer disease. Eradication of H. pylori infection accelerates ulcer healing and prevents relapse, reducing incidence of H. pylori-related gastric diseases. Numerous studies have provided evidence that the oral cavity could be a potential reservoir for H. pylori. The presence of oralH. pylori might affect the efficiency of eradication therapy and act as a causal force for its recurrence. Conversely, other investigators have indicated that the colonization and growth of H. pylori differs between the oral cavity and the stomach. Considering the open debate on the topic, it's necessary to clarify whether periodontal therapy is an effective adjunctive treatment for gastric H. pylori infection.

OBJECTIVES

To assess the effects of periodontal therapy plus eradication therapy versus eradication therapy alone for gastric H. pylori infection. The secondary objective is to compare the non-recurrence rate at long-term follow up in different treatment groups.

SEARCH METHODS

We identified randomized controlled trials (RCTs) by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 8), MEDLINE (1946 to August 2015), EMBASE (1980 to August 2015), and the Chinese Biomedical Database (1978 to August 2015). We also searched both ClinicalTrials.gov and the WHO ICTRP portal in October 2015. We handsearched the reference lists of included studies to identify relevant trials.

SELECTION CRITERIA

RCTs comparing periodontal therapy plus eradication treatment with eradication treatment alone, regardless of language of publication.

DATA COLLECTION AND ANALYSIS

Two reviewers selected the trials that met the inclusion criteria and extracted the details of each study independently. The data were pooled using both fixed-effect and random-effects models and results calculated as odds ratios (OR) with their 95% confidence intervals (CIs) based on an intention-to-treat analysis. However, because there was little difference in the results from these two models, we only reported the results from the fixed-effect model.

MAIN RESULTS

We included seven small RCTs involving 691 participants aged 17 to 78 years in our meta analyses. The primary result showed that periodontal therapy combined with H. pylori eradication treatment increased the eradication rate of gastric H. pylori compared with eradication treatment alone (OR 2.15; 95% CI 1.47 to 3.14; P < 0.0001) in people with H. pylori infection. In addition, periodontal therapy also had benefits on long-term gastric H. pylori eradication. After eradication of H. pylori, the non-recurrence rate of gastric H. pylori infection increased in participants treated with periodontal therapy compared with those who received eradication therapy alone (OR 3.60; 95% CI 2.11 to 6.15; P < 0.00001). According to the GRADE approach, the overall quality of the evidence was 'moderate' for eradication rate of gastric H.pylori and 'low' for non-recurrence rate of gastric H. pylori.

AUTHORS' CONCLUSIONS

Overall, periodontal therapy could increase the efficiency of H. pylori eradication and the non-recurrence rate of gastricH. pylori. In view of the limited number and quality of included studies, it will be necessary to conduct more well-designed, multicenter, and large-scale RCTs to determine the effects of periodontal therapy in eradicating gastric H. pylori and suppressing the recurrence of this bacterium in the stomach.

Periodontal therapy as adjunctive treatment for gastric Helicobacter pylori infection

BACKGROUND

Helicobacter pylori is estimated to affect about half the world's population and is considered as the main cause of chronic gastritis and peptic ulcer disease. Eradication of H. pylori infection accelerates ulcer healing and prevents relapse, reducing incidence of H. pylori-related gastric diseases. Numerous studies have provided evidence that the oral cavity could be a potential reservoir for H. pylori. The presence of oralH. pylori might affect the efficiency of eradication therapy and act as a causal force for its recurrence. Conversely, other investigators have indicated that the colonization and growth of H. pylori differs between the oral cavity and the stomach. Considering the open debate on the topic, it's necessary to clarify whether periodontal therapy is an effective adjunctive treatment for gastric H. pylori infection.

OBJECTIVES

To assess the effects of periodontal therapy plus eradication therapy versus eradication therapy alone for gastric H. pylori infection. The secondary objective is to compare the non-recurrence rate at long-term follow up in different treatment groups.

SEARCH METHODS

We identified randomized controlled trials (RCTs) by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 8), MEDLINE (1946 to August 2015), EMBASE (1980 to August 2015), and the Chinese Biomedical Database (1978 to August 2015). We also searched both ClinicalTrials.gov and the WHO ICTRP portal in October 2015. We handsearched the reference lists of included studies to identify relevant trials.

SELECTION CRITERIA

RCTs comparing periodontal therapy plus eradication treatment with eradication treatment alone, regardless of language of publication.

DATA COLLECTION AND ANALYSIS

Two reviewers selected the trials that met the inclusion criteria and extracted the details of each study independently. The data were pooled using both fixed-effect and random-effects models and results calculated as odds ratios (OR) with their 95% confidence intervals (CIs) based on an intention-to-treat analysis. However, because there was little difference in the results from these two models, we only reported the results from the fixed-effect model.

MAIN RESULTS

We included seven small RCTs involving 691 participants aged 17 to 78 years in our meta analyses. The primary result showed that periodontal therapy combined with H. pylori eradication treatment increased the eradication rate of gastric H. pylori compared with eradication treatment alone (OR 2.15; 95% CI 1.47 to 3.14; P < 0.0001) in people with H. pylori infection. In addition, periodontal therapy also had benefits on long-term gastric H. pylori eradication. After eradication of H. pylori, the non-recurrence rate of gastric H. pylori infection increased in participants treated with periodontal therapy compared with those who received eradication therapy alone (OR 3.60; 95% CI 2.11 to 6.15; P < 0.00001). According to the GRADE approach, the overall quality of the evidence was 'moderate' for eradication rate of gastric H.pylori and 'low' for non-recurrence rate of gastric H. pylori.

AUTHORS' CONCLUSIONS

Overall, periodontal therapy could increase the efficiency of H. pylori eradication and the non-recurrence rate of gastricH. pylori. In view of the limited number and quality of included studies, it will be necessary to conduct more well-designed, multicenter, and large-scale RCTs to determine the effects of periodontal therapy in eradicating gastric H. pylori and suppressing the recurrence of this bacterium in the stomach.

Helicobacter pylori and oral pathology: Relationship with the gastric infection

Helicobacter pylori (H. pylori) has been found in the oral cavity and stomach, and its infection is one of the most frequent worldwide. We reviewed the literature and conducted a Topic Highlight, which identified studies reporting an association between H. pylori-infection in the oral cavity and H. pylori-positive stomach bacterium. This work was designed to determine whether H. pylori is the etiologic agent in periodontal disease, recurrent aphthous stomatitis (RAS), squamous cell carcinoma, burning and halitosis. Record selection focused on the highest quality studies and meta-analyses. We selected 48 articles reporting on the association between saliva and plaque and H. pylori-infection. In order to assess periodontal disease data, we included 12 clinical trials and 1 meta-analysis. We evaluated 13 published articles that addressed the potential association with RAS, and 6 with squamous cell carcinoma. Fourteen publications focused on our questions on burning and halitosis. There is a close relation between H. pylori infection in the oral cavity and the stomach. The mouth is the first extra-gastric reservoir. Regarding the role of H. pylori in the etiology of squamous cell carcinoma, no evidence is still available.

Oral Cavity as an Extragastric Reservoir of Helicobacter pylori

Background. Several studies were reported on the prevalence, and relationship between the existence of Helicobacter pylori (H. pylori) in oral cavity and in stomach of patients. The purpose of this study was to systematically review the existing literature on the presence of H. pylori in the oral cavity and its link to gastric infection, the existence of coinfection, and the impact of anti-H. pylori therapy on the dental plaque and vice versa. Method. Two authors independently searched the Medline, EMBASE, Cochrane Library, Web of Science, Google Scholar, and Scopus databases for relevant studies. The articles were analyzed critically and all qualified studies were included. The search was carried out by using a combined text and the MeSH search strategies: using the key words Helicobacter, Helicobacter pylori, and H. pylori in combination with dental plaque, periodontitis, and oral hygiene. Results. The data was presented in 8 tables and each topic separately discussed. Conclusion. Based on the systematic review of the available literature on H. pylori infection and its presence in the oral cavity, it can be concluded that dental plaque can act as a reservoir, and proper oral hygiene maintenance is essential to prevent reinfection. Due to the diversified methods and population groups involved in the available literature, no concrete evidence can be laid down. Further studies are necessary to establish the role of H. pylori in the oral cavity and its eradication on preventing the gastroduodenal infection.

Helicobacter pylori and pregnancy-related disorders

Helicobacter pylori (H. pylori) infection is investigated in gastric diseases even during pregnancy. In particular, this Gram-negative bacterium seems to be associated with hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy. During the last decade, the relationship among H. pylori and several extra-gastric diseases strongly emerged in literature. The correlation among H. pylori infection and pregnancy-related disorders was mainly focused on iron deficiency anemia, thrombocytopenia, fetal malformations, miscarriage, pre-eclampsia and fetal growth restriction. H. pylori infection may have a role in the pathogenesis of various pregnancy-related disorders through different mechanisms: depletion of micronutrients (iron and vitamin B₁₂) in maternal anemia and fetal neural tube defects; local or systemic induction of pro-inflammatory cytokines release and oxidative stress in gastrointestinal disorders and pre-eclampsia; cross-reaction between specific anti-H. pylori antibodies and antigens localized in placental tissue and endothelial cells (pre-eclampsia, fetal growth restriction, miscarriage). Since H. pylori infection is most likely acquired before pregnancy, it is widely believed that hormonal and immunological changes occurring during pregnancy could activate latent H. pylori with a negative impact not only on maternal health (nutritional deficiency, organ injury, death), but also on the fetus (insufficient growth, malformation, death) and sometime consequences can be observed later in life. Another important issue addressed by investigators was to determine whether it is possible to transmit H. pylori infection from mother to child and whether maternal anti-H. pylori antibodies could prevent infant’s infection. Studies on novel diagnostic and therapeutic methods for H. pylori are no less important, since these are particularly sensitive topics in pregnancy conditions. It could be interesting to study the possible correlation between H. pylori infection and other pregnancy-related diseases of unknown etiology, such as gestational diabetes mellitus, obstetric cholestasis and spontaneous preterm delivery. Since H. pylori infection is treatable, the demonstration of its causative role in pregnancy-related disorders will have important social-economic implications.

Effect of periodontal therapy on prevention of gastric Helicobacter pylori recurrence: a systematic review and meta-analysis

AIM

The aim of this review is to assess the effect of dental plaque control and periodontal therapy on prevention of gastric Helicobacter pylori (H. pylori) recurrence.

MATERIALS AND METHODS

We conducted searches of electronic databases, and included controlled trials comparing periodontal treatment and eradication therapy of H. pylori with eradication therapy alone for prevention of recurrence of gastric H. pylori. We used the absence of recurrence of gastric H. pylori after the first 3 months as an outcome measure to determine relative risk of persistence of gastric H. pylori. We estimated the degree of heterogeneity among trial results using Q and I(2) statistics.

RESULTS

Three trials including 298 patients were eligible according to our inclusion criteria. As significant heterogeneity was indicated by the Q statistics (p = 0.04) and I(2) (69%), we used a random-effects model to combine the data. Compared with eradication therapy alone, the adjunction of periodontal therapy significantly reduced the relative risk of persistence of gastric H. pylori by 63% (0.37 [95% CI 0.21-0.64], p = 0.0004) in patients with gastric diseases.

CONCLUSIONS

The adjunction of periodontal treatment to eradication therapy appears to reduce gastric H. pylori recurrence compared with eradication therapy alone among patients with gastric diseases associated with H. pylori. The results of this meta-analysis should be taken with caution because of the limitations in the primary data.

Does the presence of the Helicobacter pylori in the dental plaque associate with its gastric infection? A meta-analysis and systematic review

BACKGROUND

There is a great deal of studies on the relationship between the existence of Helicobacter pylori (H. pylori) in oral cavity (dental plaque) and in stomach of patients, with conflicting results worldwide. The purpose of this study was to systematically review the existing litreature to assess if the dental plaque could be a source of gastric H. pylori infection and to explore the source of heterogeneity around it.

METHODS

We searched all the papers published since 2000 on international (Medline, ISI, Embase) databases using standard keywords. Two researchers evaluated the articles with standard critical appraisal form independently and those articles with the quality acquired greater than 70% were included in the study. The combined results were calculated with weighted average and the source of hetrogeneity was tested by meta-regression (random) model.

RESULTS

Finally, 23 studies were included (1861 patients). The prevalence of co-infection of gastric and dental plaque H. pylori was 49.7% (95% CI 16-83.4%) and the percent of agreement between the dental plaque H. pylori status and the gastric H. pylori was estimated as 82%. Only one study has reported that dental treatment has a preventive effect on the recurrence of gastric H. pylori infection.

CONCLUSION

Co-infection of gastric H. pylori and dental plaque is reported by half of the studies. However, there is not enough evidence for the efficacy of dental treatment on prevention of recurrent gastric H. pylori infection.

The effectiveness of systemic eradication therapy against oral Helicobacter pylori

BACKGROUND

Helicobacter pylori infection is associated with numerous gastroduodenal diseases. The oral cavity could be a potential extragastric reservoir for H. pylori, and oral H. pylori might cause gastric reinfection after the eradication therapy. The aim of the study was to evaluate the presence of H. pylori in oral cavity of patients with gastric H. pylori infection and to examine the effectiveness of the eradication therapy against H. pylori in stomach and in the oral cavity.

METHODS

Fifty-six patients with chronic periodontitis and gastric H. pylori were enrolled in the study. Gastric H. pylori infection was determined using (13) C-urea breath test before and 3 months after eradication therapy. The presence of the oral H. pylori was assessed using polymerase chain reaction before and 3 months after eradication therapy. The 1-week eradication therapy consisted of amoxycilin 1 g, clarithromycin 500 mg, and proton pump inhibitor 20 mg twice a day.

RESULTS

Of 56 subjects with gastric infection, 23 (41.1%) harbored H. pylori in the oral cavity. Eradication rate in stomach was 78.3%, whereas in the oral cavity, H. pylori was not detected from any sample after the eradication therapy.

CONCLUSION

Almost half of the patients with gastric H. pylori harbored the bacterium in the oral cavity. After the eradication therapy, H. pylori was not detected in the oral cavity, what suggests high effectiveness of the therapy protocol in the oral cavity, or it is possible that oral H. pylori is of a transient character.

Screening test for anti-Helicobacter pylori activity of traditional Chinese herbal medicines

AIM

To evaluate the anti-Helicobacter pylori (H. pylori) activity of 50 traditional Chinese herbal medicines in order to provide the primary evidence for their use in clinical practice.

METHODS

A susceptibility test of water extract from 50 selected traditional Chinese herbal medicines for in vitro H. pylori Sydney strain 1 was performed with broth dilution method. Anti-H. pylori activity of the selected Chinese herbal medicines was evaluated according to their minimum inhibitory concentration (MIC).

RESULTS

The water extract from Rhizoma Coptidis, Radix Scutellariae and Radix isatidis could significantly inhibit the H. pylori activity with their MIC less than 7.8 mg/mL, suggesting that traditional Chinese herbal medicines have anti-inflammatory and antibacterial effects and can thus be used in treatment of H. pylori infection.

CONCLUSION

Rhizoma Coptidis, Radix Scutellariae and Radix isatidis are the potential sources for the synthesis of new drugs against H. pylori.

Presence of Helicobacter pylori in supragingival dental plaque of individuals with periodontal disease and upper gastric diseases

BACKGROUND

Helicobacter pylori is a Gram-negative microorganism which is able to colonize the gastric mucosa and is associated with peptic ulcer, gastric carcinoma, and gastric mucosa-associated lymphoid tissue lymphoma. Several studies have detected this bacterium in the oral cavity, suggesting it as a potential reservoir. The aim of this study was to investigate the presence of H. pylori in the oral cavity of individuals with periodontal disease and gastric diseases.

METHODS

115 individuals, with mean age 49.6 (±5.8) years, were divided in 4 groups: (A) with gastric diseases and periodontal disease; (B) with gastric diseases and no periodontal disease; (C) without gastric diseases and without periodontal disease, (D) without gastric diseases and with periodontal disease. Supra and subgingival plaque samples were collected from posterior teeth of the individuals with sterile paper points, and prepared for Polymerase Chain Reaction analysis. Fisher's exact test was used for detecting statistical differences between groups (p<0.05).

RESULTS

H. pylori was detected in supragingival plaque of 9/36 (25%) of group A, 1/31 (0.3%) of group B, 0 (0%) of group C and 3/36 (8.3%) of group D. No subgingival samples were positive for H. pylori. There was a statistically higher prevalence of H. pylori in groups A and D when compared to B and C (p<0.05).

CONCLUSION

H. pylori was detected in the supragingival plaque, but not in the subgingival plaque, of individuals with periodontal disease and upper gastric diseases. There was an association between the supragingival colonization of H. pylori and oral hygiene parameters such as the presence of plaque and gingival bleeding.

Oxidative stress induced mechanisms in the progression of periodontal diseases and cancer: a common approach to redox homeostasis?

There is documented evidence of significant associations between cancer of the lung, kidney, pancreas, hematological and oral cancers and periodontal diseases of the supporting structures of the teeth. Enhanced lipid peroxidation, raised levels of TBARS and the oxidative stress marker malondealdehyde have been detected in breast cancer with reduced antioxidant capacity, also characteristic of periodontal diseases. Antioxidants could overcome this deficit and attenuate disease progression by down regulating glutathione detoxification/redox buffering system and inhibiting key transcription factors. Periodontal disease may be a critical marker of a susceptible immune system, or initiate cancer risk with a pro-oxidant inflammatory profile.

Effect of dental plaque control on infection of Helicobacter pylori in gastric mucosa

BACKGROUND

Data on the role of dental plaque in the transmission of Helicobacter pylori have varied. Furthermore, there has been few reports on the relationship between dental plaque control and H. pylori infection of gastric mucosa. The purpose of this study was to elucidate this potential relationship.

METHODS

The (13)C urea breath test was conducted on 56 subjects who received dental plaque control and 51 subjects who did not.

RESULTS

The prevalence of H. pylori in the gastric mucosa was 19.64% in patients who received dental plaque control, which was significantly lower than in those without dental plaque control (84.31%).

CONCLUSION

Long-term professional dental plaque control was associated with less gastric reinfection by H. pylori, suggesting that dental plaque control may help to prevent H. pylori-induced gastric disease or reinfection.

Detection of Helicobacter pylori, Enterococcus faecalis, and Pseudomonas aeruginosa in the subgingival biofilm of HIV-infected subjects undergoing HAART with chronic periodontitis

This study compared the frequency of Helicobacter pylori, Enterococcus faecalis, and Pseudomonas aeruginosa in the subgingival microbiota of HIV-seropositive and HIV-seronegative subjects with periodontitis or clinically healthy periodontal tissues. Fifty-four subjects were distributed into two HIV-seropositive groups (chronic periodontitis [HCP = 13] and periodontal health [HH = 10]) and two HIV-seronegative groups (chronic periodontitis [CP = 17] and periodontal health [H = 14]). The detection of bacterial species was carried out by polymerase chain reaction (PCR). CP patients showed significantly more periodontal destruction, inflammation, and supragingival plaque than HCP patients (P < 0.05). All species were detected at a higher prevalence in CP and HCP than H individuals (P < 0.01). In the HIV groups, H. pylori was significantly more prevalent in periodontitis compared to healthy patients (P < 0.01). A higher frequency of E. faecalis and P. aeruginosa was observed in the subgingival biofilm of HH than H subjects (P < 0.01). Moreover, E. faecalis was detected significantly more often in HIV-seropositive compared to HIV-seronegative patients, regardless of periodontal status (P < 0.01). These data indicate that H. pylori is frequently detected in the subgingival microbiota of periodontitis subjects. In contrast, HIV-seropositive patients with either periodontitis or periodontal health present a high prevalence of E. faecalis.

Is the presence of Helicobacter pylori in dental plaque of patients with chronic periodontitis a risk factor for gastric infection?

BACKGROUND

Helicobacter pylori is considered to be a pathogen responsible for gastritis and peptic ulcers, and a risk factor for gastric cancer. A periodontal pocket in the teeth of individuals with chronic periodontitis may function as a reservoir for H pylori.

OBJECTIVE

The present study was undertaken to evaluate whether the presence of H pylori in the dental plaque of patients with and without periodontitis correlates with gastric involvement.

METHODS

A total of 101 patients with dyspepsia were included in the present study. Subjects were divided into periodontitis and nonperiodontitis groups. For the detection of H pylori in dental plaque, samples were collected from two teeth using a periodontal curette. Subgingival plaque was obtained by inserting two sterile paper points into periodontal pockets for 20 s. This was followed by an upper gastrointestinal endoscopy and antral biopsies.

RESULTS

Sixty-five per cent of patients had dental plaque positive for H pylori and more than 50% harboured the bacteria in their stomach. Periodontitis patients had a significantly higher percentage of H pylori in their dental plaque (79% versus 43%; P<0.05) and the stomach (60% versus 33%; P<0.05) than patients with no periodontitis. Additionally, 78% of patients from the periodontitis group versus only 30% from the nonperiodontitis group had a positive test result for the coexistence of H pylori in both dental plaque and the stomach.

CONCLUSION

Patients with poor oral hygiene have a higher prevalence of H pylori in dental plaque and in the stomach. This finding suggests that the oral cavity may be a reservoir for H pylori, and potentially a source of transmission or reinfection.

Detection of Helicobacter pylori by polymerase chain reaction in the subgingival biofilm and saliva of non-dyspeptic periodontal patients

BACKGROUND

Helicobacter pylori has been associated with the development of peptic ulcers and gastric cancer. Although the oral cavity may be a source of transmission, it is unknown whether it acts as a permanent reservoir for this bacterium, particularly in the presence of periodontal disease. The purpose of this study was to evaluate the prevalence of H. pylori by polymerase chain reaction (PCR) in the subgingival biofilm and saliva of subjects with periodontitis.

METHODS

Samples were obtained from 56 periodontally healthy subjects and 169 subjects with chronic periodontitis. DNA was extracted from the samples, and the detection of H. pylori was carried out by PCR using the JW22/23 primers.

RESULTS

In general, H. pylori was detected in 24% of all samples evaluated. A significantly higher prevalence of H. pylori was observed in subgingival biofilm samples (33.3%) compared to saliva samples (20%) (P <0.05). H. pylori was detected significantly more often in the saliva and subgingival samples from subjects with periodontitis (23.5% and 50%, respectively) compared to samples from periodontally healthy subjects (7.3% and 11.4%, respectively; P <0.05).

CONCLUSION

H. pylori was detected frequently in the oral microbiota of subjects with periodontitis, suggesting that periodontal pocketing and inflammation may favor the colonization by this species.

Neural tube defects, micronutrient deficiencies, and Helicobacter pylori: a new hypothesis

BACKGROUND

Previous findings for the Texas Neural Tube Defects Project suggested that while maternal access to nutrients is adequate, bioavailability of nutrients to the fetus is compromised in NTD-affected pregnancies. Helicobacter pylori could cause nutrient loss to the fetus. Folate, B12, and ferritin are depleted in H. pylori infection; these same deficiencies are related to NTD risk.

METHODS

Using H. pylori IgG ELISA Test System, we tested for H. pylori serum antibodies in participants in the population-based case-control study component of the Texas Neural Tube Defect Project conducted along the Texas-Mexico border. Case-women had pregnancies affected by NTD (anencephalus, spina bifida, encephalocele) and resided and delivered in one of the 14 Texas-Mexico border counties from 1995 through 2000. Control-women were study area residents delivering normal live births during the same period.

RESULTS

Of 225 case- and 378 control-women, 103 cases and 156 controls provided questionnaire and H. pylori antibody data. H. pylori seropositivity was modestly associated with NTD-affected pregnancies (OR 1.4; 95% CI: 0.8-2.4). ORs of 2.0 or greater were seen in women younger than age 25 and with less than 7 years education.

CONCLUSIONS

Our findings intimate that H. pylori could play a role in NTD causation in certain populations. While results did not provide compelling support for this proposal, subgroup findings prompt us to advocate an evaluation of this hypothesis in developing nations among populations with higher prevalence of H. pylori, marginal nutrient intake, and young childbearing age.

Comparison of different methods to detect Helicobacter pylori in the dental plaque of dyspeptic patients

The aim of this study was to compare different methods of detection of Helicobacter pylori (H. pylori) in the dental plaque of dyspeptic patients. After recording the clinical indices, culture and polymerase chain reaction (PCR) methods were performed on plaque samples, while rapid urease test in addition to these tests was carried on gastric samples from 67 dyspeptic patients who attended for an upper gastrointestinal endoscopy. Forty-seven of 67 patients were H. pylori-positive in gastric biopsy material whereas the microbial dental plaque from 19 patients demonstrated H. pylori positivity detected by PCR. Among the patients, 25.4% harbored H. pylori both in the stomach and in microbial dental plaque. No significant correlations were found among the presence of H. pylori in the stomach, in plaque, and clinical variables (P > 0.05). Although oral hygiene was observed optimal and the mean of pocket depth was not found to be higher, the prevalence of H. pylori was observed to be higher in dental plaque. According to our results, PCR technique gave the highest detection rate both in gastric biopsy and in dental plaque compared to the other methods used.

Persistence of Helicobacter pylori in the oral cavity after systemic eradication therapy

AIM

The present study aimed to evaluate if the oral cavity of chronic periodontitis patients can harbor Helicobacter pylori after systemic eradication therapy.

MATERIALS AND METHODS

Samples of 30 patients (15 with gingivitis and 15 with chronic periodontitis) positive for H. pylori in the stomach were evaluated. Samples were collected 3 months after triple systemic antibiotic therapy from saliva, microbiota from the dorsum of the tongue, supra- and sub-gingival plaque as well as gastric biopsies. DNA of each sample was extracted by the boiling method and used as a template in polymerase chain reaction with the primers JW22/23.

RESULTS

Eighteen patients (60%) harboured H. pylori in their mouths. Five patients (16.6%) were positive in saliva, two (6.6%) on the dorsum of the tongue, nine (30%) in supra-gingival plaque, 14 (46.6%) in sub-gingival plaque and three (10%) in the stomach. There was no statistically significant difference between study groups.

CONCLUSION

Eradication of H. pylori after therapy was more effective for the stomach than for the mouth (p<0.001). Mouths of patients with gingivitis or with chronic periodontitis, who are positive for H. pylori in their stomachs, may be considered as reservoirs of these bacteria.

Are Dental Plaque, Poor Oral Hygiene, and Periodontal Disease Associated WithHelicobacter pyloriInfection?

BACKGROUND

The microorganism Helicobacter pylori has been closely linked to chronic gastritis, peptic ulcer, gastric cancer, and mucosa-associated lymphoid tissue (MALT) lymphoma. Despite the current treatment regimens that lead to successful management of H. pylori-positive chronic gastritis, the reinfection rate is high. It has been suggested that one of the possible mechanisms of reinfection is the recolonization from dental plaque. The purpose of this study was to determine whether dental plaque, poor oral hygiene, and periodontal disease were risk factors for H. pylori infection.

METHODS

Among the 134 patients, 65 patients who had a positive H. pylori serology or positive rapid urease test or histologic evidence for the presence of H. pylori in antral biopsy specimens were categorized as cases. The remaining 69 patients who were negative for H. pylori serology, the rapid urease test, and histology were controls.

RESULTS

It was found that the association of periodontal disease and poor oral hygiene with H. pylori infection was not significant. There was a higher prevalence of H. pylori in the dental plaque of patients with gastric H. pylori infection than in controls, but both groups had a surprisingly high positive urease test for H. pylori in plaque (89% and 71%, respectively).

CONCLUSIONS

H. pylori in dental plaque is seldom eliminated by H. pylori-eradication therapy, and this may act as a source for future reinfection. Hence, eradication of H. pylori from the dental plaque should be made an important part of comprehensive management of H. pylori-associated gastric diseases.

Oral findings and health status among hospitalized patients with physical disabilities, aged 60 or above

The purpose of the study was to determine oral health status and the prevalence of oral mucosal lesions among hospitalized elderly patients with physical disabilities. The study group consisted of 111 (43 male and 68 female) elderly patients with physical disabilities. Clinical examination and interview methods were employed. Clinical examination revealed that 45.9% of the elderly patients had one or more oral mucosal lesions. Xerostomia (58.6%), coated-hairy tongue (54.1%) and halitosis (46.8%) were the most frequently encountered oral findings and mucosal lesions. As the most interesting finding discovered in elderly patients, macroglossia (30.6%) seems to depend on physical disability. Coated or hairy tongue was commonly related to poor oral hygiene, with both crude odds ratio (OR) of 3.25 (95% CI: 1.26-8.36) (P=0.021) and the logistic regression OR of 3.36 (95% CI: 1.21-9.33) (P=0.020). Halitosis and bruxism were commonly related to dentate patients [logistic regression OR of 0.29 (95% CI: 1.12-0.74) (P=0.009) and 0.21 (95% CI: 0.06-0.74) (P=0.016); respectively]. Increase in dental problems may have negative impacts on chewing, nutrition, aesthetics and phonation in elderly patients. It is particularly noteworthy that physical disability in elderly patients limits their ability to effectively follow oral hygiene procedures.

The recurrence of Helicobacter pylori infection: incidence and variables influencing it. A critical review

The rate of H. pylori recurrence after eradication of the microorganism seems to be relatively low, at least in developed countries, where the mean annual reinfection rate is of approximately 3% per patient-year of follow-up, although the risk of reinfection in some developing regions is considerably higher. Several findings suggest that recrudescence rather than reinfection is likely to be responsible for most cases of recurrence: (i) the recurrences decrease with time and decline sharply after the first year, and (ii) studies using molecular fingerprinting techniques (polymerase chain reaction [PCR]) confirm that the identified microorganisms (before and after therapy) are usually genetically identical. The lower the efficacy of an antibiotic therapy, the greater the likelihood that recurrence occur, again suggesting that in these cases temporary "clearance" has been achieved rather than true eradication. The value of the (13)C-urea breath test after treatment is higher in those patients who suffer a recurrence; therefore, selection of a lower cut-off value may be helpful to maintain the diagnostic accuracy of posttreatment breath test, and thus preventing recrudescences. The observation of a pattern of histological (active) gastritis without the concomitant finding of H. pylori must raise the suspicion of a diagnostic error. Some studies suggest that recurrence is relatively infrequent, even if the patient's spouse is H. pylori-positive, suggesting that the patient's partner does not act as a reservoir for the reinfection. However, other investigators achieve contrary results, although a common exogenous source of H. pylori (for both partner's infection and patient's reinfection) cannot be ruled out. The oral cavity may be a potential source for recrudescence of gastric infection after successful therapy. When peptic ulcer reappears (sometimes with bleeding recurrence) or gastric MALT (mucosa-associated lymphoid tissue) lymphoma relapses after previous H. pylori eradication, recolonization of the gastric mucosa by the organism has almost always occurred.

Sensitivity of Helicobacter pylori to an innate defence mechanism, the lactoperoxidase system, in buffer and in human whole saliva

Helicobacter pylori has frequently been isolated from human dental plaque, and oral spread via saliva is thought to be one of its principal modes of transmission. Among other innate defence systems human saliva contains peroxidase enzymes and lysozyme. The sensitivity of H. pylori to physiological concentrations of lactoperoxidase and its salivary substrate thiocyanate, and different amounts of hydrogen peroxide (H(2)O(2)) was investigated in buffer and in human whole saliva. The effect of lysozyme was also studied in saliva. All tested H. pylori strains, ATCC 43504(T) and five clinical isolates, were efficiently inhibited by the peroxidase system with high concentrations of H(2)O(2) in buffer. The inhibition was stronger at lower pH. However, in human saliva these high concentrations of H(2)O(2) generated less hypothiocyanite, the antibacterial product of the peroxidase system and the effects of the peroxidase system were weaker. Physiological concentration of lysozyme was not bacteriocidal against H. pylori, nor did it enhance the effect of the peroxidase system in saliva. Thus, further studies are needed to enhance the efficacy of peroxidase systems in human saliva to make it more beneficial not only against dental but also against gastric pathogens.

Prevalence of Helicobacter pylori detected by polymerase chain reaction in the oral cavity of periodontitis patients

Helicobacter pylori is an important gastrointestinal pathogen associated with gastritis, peptic ulcers, and an increased risk of gastric carcinoma. The oral cavity has been indicated as a possible H. pylori reservoir, and may therefore be involved in the reinfection of the stomach which sometimes follows treatment of H. pylori infection. The objective of the present study was to evaluate the prevalence of H. pylori as detected by polymerase chain reaction (PCR) in the oral cavity of periodontitis patients testing positive for this bacterium in the stomach. Thirty adult patients with alterations of the superior digestive tract, testing urease positive after endoscopy and biopsy, were selected. A full-mouth periodontal examination was performed in every patient and the subjects were allocated to two groups: gingivitis (15 patients) and chronic periodontitis (15 patients). Plaque and saliva samples collected from each patient were stored in 0.5 ml of TE buffer. DNA was extracted from the samples by the boiling method and was evaluated for the presence of H. pylori using the PCR method. JW 22/23 primers were used. The DNA of ATCC H. pylori 43629 (positive control) and water (negative control) were used for controlling the reactions. Of the 30 evaluated patients, 13 (43.3%) harbored H. pylori in the mouth. The bacterium was not found on the dorsum of the tongue of any patient, but was found in saliva in three patients (10%), in the supragingival plaque in six patients (20%), and in the subgingival plaque in eight patients (26.6%). The presence of H. pylori was similar in the gingivitis and chronic periodontitis groups. In conclusion, a high percentage of patients harbored H. pylori in their mouth. The bacterium was detected in saliva, supragingival and subgingival plaque, suggesting that these sites may be considered reservoirs for H. pylori in urease-positive patients.

The prevalence of tongue lesions in 5150 Turkish dental outpatients

OBJECTIVE

The aim of this study was to assess the prevalence of nine tongue conditions and relate to data obtained about oral hygiene or habits in Turkish dental outpatients.

SUBJECTS

A total of 5150 subjects (2837 women, 2313 men) were included in this study.

RESULTS

Of the 5150 subjects, 2690 subjects were detected as having tongue lesions with a prevalence of 44.2 and 62.0% for women and men, respectively. The difference was found to be statistically significant (P < 0.0001). There was a strong correlation between tongue lesions and increasing age. There was also a strong association between tongue lesions and smoking, black tea drinking, and fair or poor oral hygiene. Hairy and coated tongue was significantly higher in males. Contrary to this, papillary atrophy was more prominent in women.

CONCLUSION

A strong correlation was found between tongue lesions and age, sex, oral hygiene and habits in Turkish dental outpatients. An efficient oral health program such as the elimination of risk habits and attention to cultural practices may improve tongue hygiene.

Tooth loss, pancreatic cancer, and Helicobacter pylori

BACKGROUND

Poor dental health has been associated with increased risks of oral, esophageal, and gastric cancer and may also be associated with pancreatic cancer. In addition, Helicobacter pylori has been found in dental plaque and has been associated with periodontal disease and pancreatic cancer.

OBJECTIVE

The objective was to investigate prospectively the relation between dentition history and pancreatic cancer in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study cohort in Finland and the association between dentition history and H. pylori seropositivity in a cross-sectional sample of subjects without cancer (n = 475) from the same cohort.

DESIGN

Of the 29,104 male smokers aged 50-69 y in the cohort for whom there were complete data, 174 developed pancreatic cancer from 1985 to 1997. Cox proportional hazard models were used to estimate age-, smoking-, education-, urban living-, and height-adjusted hazard ratios and 95% CIs for pancreatic cancer, and logistic regression models were used to estimate age- and education-adjusted odds ratios for H. pylori carriage.

RESULTS

Tooth loss was positively associated with pancreatic cancer (edentulous compared with missing 0-10 teeth: hazard ratio = 1.63; 95% CI: 1.09, 2.46; P for trend = 0.02) but was not significantly associated with H. pylori seropositivity (edentulous compared with missing 0-10 teeth: odds ratio = 1.30; 95% CI: 0.73, 2.32; P for trend = 0.37).

CONCLUSION

Additional studies are needed to evaluate the association between tooth loss and pancreatic cancer, as well as cancers at other gastrointestinal sites, particularly with respect to possible biological mechanisms.

Oral Helicobacter pylori: can we stomach it?

Helicobacter pylori infection is one of the most common in man. The bacterium primarily resides in the human stomach, where it plays a significant role in gastric disease. If the spread of H. pylori is to be prevented, an understanding of the transmission process is essential. The oral cavity has been proposed as a reservoir for gastric H. pylori, which has been detected by culture and PCR in both dental plaque and saliva. This review will discuss the evidence for the role of the oral cavity in the transmission of gastric H. pylori. Moreover, the difficulties encountered in addressing this topic, possible directions for future research, and the implications for the dental profession are discussed.

Helicobacter pylori infection, vitamin B12 and homocysteine. A review

It has been suggested that there is an association between Helicobacter pylori infection, reduced cobalamin absorption and cobalamin status and, consequently, elevated homocysteine levels. This would offer an explanation why H. pylori infection is associated with coronary heart disease. To date, more than 25 studies have been published that either deal with H. pylori infection and homocysteine, H. pylori infection and cobalamin status, or both. The design of these studies differs widely in terms of definition of H. pylori status, measuring cobalamin status, selection of study cohorts and geographical study areas. Therefore, results are fairly inconclusive at present and do not suggest a major role of H. pylori infection in the development of cobalamin deficiency and elevated homocysteine levels.

Epidemiology and diagnosis of Helicobacter pylori infection

There have been no major breakthroughs in the field of epidemiology and diagnosis of Helicobacter pylori infection over the last year, thus for this reason, these two topics will be treated in the same chapter. Information on the incidence of infection, as in the study of Malaty et al. are now being published from long-term cohort follow-ups. The route of transmission of H. pylori remains controversial, with circumstantial evidence for infection via exposure to animals, contaminated water supplies and oral reservoirs being reported. The value of citric acid to improve urea breath test (UBT) results has been documented. A novel stool test has been released on the market and we are awaiting more information, while detection of antibodies in urine gave satisfactory results. However, the most interesting data comes from the study of McColl et al. who clearly proved on a large sample and a 1-year follow-up that the 'test and treat' strategy using UBT, as proposed in the Maastricht Consensus Report, is definitely the method to use.