Features of diagnostics of sialadenosis of parotid salivary glands in patients with gastrointestinal tract pathology associated with Helicobacter pylori

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BACKGROUND

Metabolic imbalance associated with visceral disease is a primary etiopathogenic factor in the development of reactive and dystrophic changes in the salivary glands [1–3].

Clinical signs of sialadenosis (sialosis) include hypertrophy, primarily of the parotid salivary glands (PSGs), with a decrease in their secretory function [3, 4]. According to the guidelines [3], dental treatment of sialadenosis in Russia is aimed at managing symptoms and the underlying systemic disease.

Acid-related diseases (ARDs) caused by Helicobacter pylori (НР) are among the most common in the digestive tract [5, 6]. According to the Maastricht VI Consensus (2022), HP is part of the opportunistic gastric microflora and causes chronic gastritis in 100% of cases, despite an asymptomatic course [6, 7]. Increased pathogen virulence leads to HP-associated inflammation with severe cytotoxic effects on GI cells and the release of proinflammatory cytokines IL-1β, IL-6, and TNF-α into the bloodstream [8–10].

Tabolova (2006) [11] and Mazurova (2011) [12] found that the microbiota of oral mucosa and periodontal pockets is the main extragastric reservoir of HP infections. Orlova (2021) highlighted the association between persistent HP infections and the development and progression of dental diseases [13].

Parakhonsky (2019) emphasizes the significance of salivary diagnostics for the dental treatment of patients with GI disorders [14]. Analysis of oral fluid as a diagnostic medium is a minimally invasive procedure that enables determining further treatment strategy [14–16].

Therefore, assessing the presence of HP in parotid gland secretions is highly relevant for both dentists and gastroenterologists.

This work aimed to improve the diagnosis in patients with parotid sialadenosis and acid-related gastrointestinal diseases associated with Helicobacter pylori.

METHODS

Study design

This was an observational, multicenter, prospective cohort study (Fig. 1).

 

Fig. 1. Study design. PSG, parotid salivary gland; ARD, acid-related disease; HP, Helicobacter pylori; PCR, polymerase chain reaction.

 

Eligibility Criteria

Inclusion criterion: patients with PSG sialadenosis and GI ARDs associated with an HP infection, which was confirmed by immunochromatographic antigen test using fecal samples and serum enzyme-linked immunosorbent assay (ELISA) for anti-H. pylori IgG prior to eradication.

Exclusion criteria: absence of HP infection of the gastrointestinal tract; a history of recent viral infections, autoimmune, cardiovascular, and endocrine diseases, or cancer.

Study Setting

The study was conducted in 2021–2023 at the department of dentistry of the Central State Medical Academy at the Department of Presidential Affairs of the Russian Federation and the department of gastroenterology and hepatology of the Polyclinic № 1 of the Department of Presidential Affairs of the Russian Federation.

Outcomes Registration

The study involved the collection of complaints. Xerostomia and enlarged PSGs were reported. The medical history was used to assess the incidence of relapses and their association with GI diseases.

Physical examination findings were used to assess the size, consistency, and tenderness on palpation in PSGs and regional lymph nodes. During oral examination, the condition and moisture of the mucosa and the presence of resting saliva were assessed.

PSG sialometry was performed in the morning, fasting, using a Lashley capsule following the method described by Simonova (1982). To stimulate salivation, a 5% ascorbic acid solution was used every 30 seconds for 5 minutes. Parotid gland secretion was collected using a graded test tube (Fig. 2).

 

Fig. 2. Sialometry of the right parotid salivary gland duct.

 

Samples were assessed for clarity, inclusions, volume (according to Simonova), and degree of hyposalivation:

• Grade I: 2.0–2.4 mL
• Grade II: 0.9–1.9 mL
• Grade III: 0–0.8 mL.

The clinical presentation of sialadenosis was assessed taking into account xerostomia stages (according to Romacheva, 1987).

The rapid urease test Helicobacter-test was used to detect HP in parotid saliva. For this purpose, a drop of saliva obtained during PSG sialometry was placed on an indicator disk with a diameter of 6 mm (Fig. 3). Blue staining observed within 3 minutes indicated high urease activity and was classified as HP-positive.

 

Fig. 3. Rapid urease test Helicobacter-test for Helicobacter pylori.

 

A PCR test for HP in parotid saliva, based on the presence of DNA fragments in the biological fluid, was performed to confirm the findings. For this purpose, 0.5 mL of saliva was placed in a separate test tube and submitted to the immunological laboratory of the Gabrichevsky Moscow Research Institute of Epidemiology and Microbiology.

To assess the cytokine status of parotid saliva and HP virulence, labeled test tubes containing leftover saliva samples (1 mL) were frozen and submitted to the laboratory of the EFiS Research center in a cooler bag. IL-1β (pg/mL), IL-6 (pg/mL), and TNF-α (pg/mL) levels were assessed using ELISA (Vector Best, Russia).

Subgroup Analysis

Patients with PSG sialadenosis and HP-associated GI ARDs were divided into groups based on the rapid urease test findings (HP in parotid saliva):

• Group I: 7 patients (3 males, 4 females) aged 45.14 ± 8.51 years, negative;
• Group II: 33 patients (6 males, 27 females) aged 47.42 ± 5.85 years, positive.

The control group included 20 apparently healthy individuals aged 45.40 ± 6.54 years.

Ethics Approval

All patients included in the study provided informed consent for medical intervention according to Order of the Ministry of Health and Social Development of Russia No. 390n of April 23, 2012, and Article 20 of Federal Law No. 323 of November 21, 2011.

Statistical Analysis

Sample size calculation: The sample size was not calculated in advance.

Statistical analysis: The findings were processed using Statistica 12.6. Differences were considered significant at p < 0.05.

RESULTS

Control group. There were no complaints in the control group. Physical examination: the face structure is normal; regional lymph nodes and PSGs are not palpable; the vermilion is normal. Oral mucosa: pale pink, moderately moist, with no lesions.

Stimulated PSG sialometry yielded 4.46 ± 0.55 of clear saliva; Helicobacter-test (Fig. 4, а) and PCR for HP were negative.

 

Fig. 4. Findings of Helicobacter-test for Helicobacter pylori in parotid saliva: a, negative; b, positive.

 

The following threshold cytokine levels in parotid saliva were established: 4.87 ± 0.56 pg/mL for IL-1β and 7.96 ± 0.78 pg/mL for IL-6; TNF-α levels were non-significant (0.21 ± 0.02 pg/mL) (Fig. 5).

 

Fig. 5. Cytokine levels in parotid saliva in the control group, Group I, and Group II, pg/mL.

 

Group with a negative rapid urease test for HP in parotid saliva. Patients in Group I complained of dry mouth. According to medical history, during GI ARD exacerbations, all patients experienced excessive thirst and were unable to eat without moistening the oral mucosa with water.

PSGs were not palpable; regional lymph nodes were enlarged (0.5 × 0.5 cm), soft, elastic, and mobile. On intraoral examination, the mucosa was pale pink, insufficiently moist, with foamy salivary secretion.

PSG sialometry yielded 2.08 ± 0.34 mL of clear saliva, corresponding to Grade I–II hyposalivation.

Therefore, the clinical presentation and sialometry findings in Group I corresponded to early-stage xerostomia.

Helicobacter-test showed no staining of the indicator disk in all patients in Group I. The result was considered negative and confirmed by the absence of HP DNA on PCR.

Parotid saliva ELISA revealed a significant increase in proinflammatory cytokine levels: 2.6-fold for TNF-α (p = 0.019), 1.8-fold for IL-1β (p = 0.016), and 2.1-fold for IL-6 (p = 0.029) compared to the control group (Fig. 5).

Group with a positive rapid urease test for HP in parotid saliva. Patients in Group II complained of dry mouth, as well as unilateral (33.3%) or bilateral (66.7%) PSG enlargement. In total, 75.6% of patients reported impaired speech due to dry oral mucosa, excessive thirst, and inability to eat dry food without moistening the oral mucosa with water.

According to medical history, GI ARD exacerbations were associated with the development of an inflammatory component in PSG (sialadenitis), which manifested as painful gland enlargement and purulent discharge from the main duct.

On palpation, this group had enlarged, soft, and non-tender PSGs. Regional lymph nodes were also enlarged (0.5 × 0.5 cm), mobile, and elastic. The oral mucosa was swollen and hyperemic. No resting saliva was detected.

PSG sialometry yielded 0.70 ± 0.15 mL of clear parotid saliva, corresponding to Grade III hyposalivation.

Considering the complaints, intraoral findings, and sialometric data in Group II, the condition was classified as severe xerostomia.

During the rapid urease test for HP in parotid saliva, all patients in Group II showed blue staining of the indicator disk within 3 minutes, indicating a positive result (Fig. 4, b). Notably, the rapid urease test findings were confirmed by PCR for HP DNA in 30 patients (91%).

Parotid saliva ELISA showed a significant increase in proinflammatory cytokine levels compared to the control group: 27-fold for TNF-α (p = 0.003), 4.2-fold for IL-1β (p = 0.041), and nearly 3-fold for IL-6 (p = 0.017) (Fig. 5). Increased levels of these proinflammatory cytokines in parotid saliva indicated high HP virulence [8–10].

DISCUSSION

Thus, patients in Group I with PSG sialadenosis and HP-negative parotid saliva had early-stage xerostomia. Reduced secretory function of PSGs in study participants indicates a reactive aseptic process associated with a 2.6-fold (p = 0.019) and 1.8-fold (p = 0.016) increase in TNF-α and IL-1β levels, respectively, compared to the control group (Fig. 5). Proinflammatory interleukins promoted chemotaxis and facilitated neutrophil and macrophage migration, which increased inflammation [7, 8, 10]. A 2.1-fold increase in IL-6 levels (p = 0.029) (Fig. 5) indicated a chronic disorder [7–10].

Notably, positive results of the rapid urease test Helicobacter-test in parotid saliva in Group II, in patients with PSG sialadenosis GI ARD, were consistent with PCR findings in 91% of cases. This confirms the high diagnostic efficacy of this technique and corresponds to the test sensitivity claimed by the manufacturer.

The analysis for HP in parotid saliva in this group showed a 27-fold increase in TNF-α levels (р = 0.003) compared to the control group, where TNF-α levels were non-significant (Fig. 5). IL-1 and IL-6 levels increased by 3–4 times (Fig. 5), confirming the microorganism›s pathogenic effect and promoting cytotoxicity against PSG cells [9, 10].

All the above initiated free-radical oxidation, resulting in membrane destruction. As a result, patients in Group II had a rapid decrease in PSG functional activity (Grade III hyposalivation) compared to Group I, which, in combination with physical examination findings, corresponded to clinically severe xerostomia.

Therefore, when examining patients with PSG sialadenosis and HP-associated GI ARDs, gastroenterologists and dentists must collaborate to make the diagnosis and determine the treatment strategy.

CONCLUSION

The study indicates that diagnostic evaluation of patients with parotid sialadenosis and Helicobacter pylori–associated acid-related gastrointestinal disease should include a rapid urease Helicobacter test to detect the pathogen in parotid saliva. Elevated levels of proinflammatory cytokines (IL-1, IL-6, TNF-α) in patients with Helicobacter pylori in parotid saliva indicate virulence of the pathogen. The management of patients with parotid sialadenosis and acid-related gastrointestinal diseases, who have Helicobacter pylori and elevated proinflammatory cytokine levels in parotid saliva, requires an interdisciplinary approach at all stages, including diagnosis, treatment, and rehabilitation.

ADDITIONAL INFORMATION

Funding source. The authors state that there is no external financing in this work.

Competing interests. The authors declare that they have no competing interests.

Authors’ contribution. All authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work. T.A. Konovalova — examination of patients, literature review, statistical processing of the results, writing an article; M.V. Kozlova — patient supervision, article preparation and editing; S.A. Chorbinskaya — literature collection and analysis, article editing; K.V. Purveeva — supervision and coordination of patients, article editing.

作者简介

Tatyana Konovalova

Central State Medical Academy at the Department of Presidential Affairs of the Russian Federation

编辑信件的主要联系方式.
Email: konovalovatanya1@gmail.com
ORCID iD: 0009-0000-4318-3511
SPIN 代码: 5498-1350
俄罗斯联邦, Moscow

Marina Kozlova

Central State Medical Academy at the Department of Presidential Affairs of the Russian Federation

Email: profkoz@mail.ru
ORCID iD: 0000-0002-3066-206X
SPIN 代码: 5546-2489

MD, Dr. Sci. (Medicine), Professor

俄罗斯联邦, Moscow

Svetlana Chorbinskaya

Central State Medical Academy at the Department of Presidential Affairs of the Russian Federation

Email: s.chorbinskaya@mail.ru
ORCID iD: 0000-0001-8471-629X
SPIN 代码: 5104-0507

MD, Dr. Sci. (Medicine), Professor

俄罗斯联邦, Moscow

Kermen Purveeva

Polyclinic № 1 of the Department of Presidential Affairs of the Russian Federation

Email: gladki.purveeva@mail.ru
ORCID iD: 0000-0002-7799-1207
SPIN 代码: 8198-0183

MD, Cand. Sci. (Medicine)

Moscow

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