DOI: 10.15171/mejdd.2016.

49 Original Article 33

The Association between Oral Hygiene and Gastric Pathology

in Patients with Dyspepsia: a Cross-Sectional
Study in Southeast Iran
Leili Zahedi1, Elham Jafari2*, Molook Torabi Parizi3, Sara Shafieipour4, Mehdi Hayat Bakhsh Abbasi5,
Sodaif Darvish Moghadam6 , Mohammad Javad Zahedi6

ABSTRACT
1. Researcher, Kerman Oral and Dental
Diseases Research Center, Kerman Uni- BACKGROUND
versity of Medical Sciences, Kerman, Many studies have reported an association between periodontal infections and some
Iran systemic diseases such as respiratory and cardiovascular diseases. Some studies found
2. Assistant Professor, Pathology and stem a direct association between chronic gastritis caused by Helicobacter pylori (HP) infec-
tion and poor periodontal health.
cells Research Center, Kerman Univer-
sity of Medical Science ,Kerman,Iran METHODS
3. Associate Professor, Kerman Oral and
In a cross-sectional study from November 2014 to December 2015 in Kerman, the
Dental Diseases Research Center, Ker-
largest province in southeast Iran, patients with dyspepsia who were candidate for di-
man University of Medical Sciences, agnostic upper gastrointestinal (GI) endoscopy were included in our study. Decayed,
Kerman, Iran Missing, and Filled Teeth (DMFT) index and Loe plaque index that are two popular
4. Assistant Professor of Internal Medi- indexes in dental epidemiology were used to assess the oral health by a dentist before
cine, Digestive Research Center, Ker- the upper GI endoscopy. According to the Loe plaque index, score: 0= no plaque, score:
1= a film of plaque attaching to the free gingival border and near area of the tooth,
man University of Medical Sciences,
score: 2= moderate reposition of deposits within the gingival pocket, score :3= plenty
Kerman, Iran of soft matter within the gingival pocket±on the tooth and gingival border. Scores ≤1,
5. Associate Professor of Internal Medi- 2 and 3 equal to good, moderate, and poor oral hygiene, respectively. During upper GI
cine, Digestive Research Center, Ker- endoscopy a total of six biopsy samples were taken from fundus, body, and antrum. A
man University of Medical Sciences, pathologist reported these samples according to Sidney’s classification into superficial
gastritis, atrophic gastritis, intestinal metaplasia, and dysplasia.
Kerman, Iran
6. Professor of Internal Medicine, Diges- RESULTS
tive Research Center, Kerman Univer-
According to Sidney’s classification 77 (89.5%) patients had superficial gastritis,
sity of Medical Sciences, Kerman, Iran
3 (3.5%) had atrophic gastritis, and 6 (7%) had intestinal metaplasia. HP was found in
80.2% of the gastric mucosal biopsy samples. There were not statistically significant
relationship between Sidney’s classification, presence of HP in gastric mucosal biop-
sies, and hygiene indicators (p>0.05). No relation was found between the DMFT index
and superficial gastritis, atrophic gastritis, and intestinal metaplasia (p>0.05). Gastric
infection with HP was found in 70%, 75%, and 100% of patients with mild, moderate,
and sever DMFT index, respectively.

CONCLUSION
Our study showed that there might be a relation between poor oral hygiene and gas-
tric precancerous lesions. In addition, HP infection in gastric histopathology might be
* associated with periodontal disease.
Corresponding Author:
Elham Jafari, MD
Pathology and stem cells research center, KEYWORDS: Oralhygiene, Dyspepsia, Chronic gastritis.
Kerman University of Medical Science, Please cite this paper as:
Kerman,Iran. Zahedi L, Jafari E, Torabi Parizi M, Shafiei pour S, Hayat Bakhsh Abbasi M, Darvish-
Telefax: + 98 3432223066 Moghadam S, Zahedi MJ. The Association between Oral Hygiene and Gastric Pathology
Email: [email protected] in Patients with Dyspepsia: a Cross-Sectional Study in Southeast Iran. Middle East J Dig
Dis 2017;9:33-38. DOI: 10.15171/mejdd.2016.49
Received: 03 Sep. 2016
Accepted: 11 De. 2016
INTRODUCTION
Oral health is an important component of general health.1 Many studies
have found an association between periodontal infection and some systemic

Middle East Journal of Digestive Diseases/ Vol.9/ No.1/January 2017

 34 MRE
Oral Hygiene
of Crohn’s
andDisease
GastricinPathology
Iran in Patients with Dyspepsia

diseasessuch as some respiratory and cardiovascular dis- for diagnostic upper GI endoscopy and were referred to
eases.2,3 So, increasing the awareness about oral health a gastroenterology clinic in AfzalipourHospital were in-
should be one of the healthprograms in order to reduce cluded in our study. Inclusion criteria were dyspeptic pa-
the outcomes of systemic diseases.4 tients withepigastric pain or discomfort who had history
Some studies found a direct association between of anti-dyspeptic therapy without remission and onset of
chronic gastritis caused by Helicobacter pylori (HP) in- dyspepsia after 50 years old.
fection and poor periodontal health. HP is an opportunist Exclusion criteria were: patient with history ofdiabe-
gram negative microorganism that causes some gastro- tes mellitus, cirrhosis, renal failure, cancer, and immuno-
intestinal (GI) diseases in humans via infected foods and suppressive drug consumption.
water.5 More than 50% of the general population world- Demographic data from all the patients were collected
wide have been infected by this organism and the preva- from their medical records and entered to a checklist.
lence of this infection in Iran seems to be 90%.6,7 This Decayed, Missing, and Filled Teeth (DMFT) index
infection is usually asymptomatic and associated with and Loe plaque index that are two popular indexes in
superficial gastritis, which is often reversible by appro- dental epidemiology were used to assessthe oral health
priate anti HP treatment.But persistent infection causes by a dentist before the upper GI endoscopy.In order to
chronic gastritis that can progress to atrophic gastritis, determine DMFT index,the examination method was
intestinal metaplasia, dysplasia, and ultimately gastric based on WHO criteria.That is,the patient sits in dental
adenocarcinoma.6,8 HP is present in saliva, tongue dor- unitand by flat dental mirror and ordering light he/she is
sum, and dental plaque as a natural flora.It seems that assessed for number of extracted teeth due to decayre-
mouth cavity is a suitable reservoir for recurrence of gas- stored teeth and decayed teeth. Dental plaque measuring
tric HPinfection.9 index used in this research was Loa index. According to
Poor dental and oral hygiene such as negligence in the Loe plaque index, score 0=no plaque,score: 1=a film
teeth brushing can be a risk factor for the presence of HP of plaque attaching to the free gingival border and near
in oral cavity.10,11 Rarely, HP in dental plaque is elimi- area of the tooth,score 2=moderate reposition of deposits
nated by anti HPeradication therapy, and this may play a within the gingival pocket,score 3=plenty of soft mat-
role as a source for future reinfection. Therefore, eradi- ter within the gingival pocket±on the tooth and gingival
cation of HP from dental plaques and oral cavity should border. Scores ≤1, 2, and 3 equal to good, moderate, and
be an important part of the comprehensive management poor oral hygiene, respectively.19
of HP-associated GI diseases.12-15 We used SiC index for dividing patients into two
Up to now, the association between gastric pathol- groups according to their DMFT. For this purpose we
ogy and oral hygiene has been reported by limited stud- chose the one third of the population with the highest
ies.16-18 Salazar and colleagues showed that about 70% of DMFT values.The SiC Index is the one third of the study
patients with precancerous lesionsin gastric biopsy had group with the highest DMFT score 20 and the other two
poor oral hygiene.16 In 2014, Boylanand co-workers in a third have mild to moderate DMFT.
study of 262 patients found that periodontal disease was During upper GI endoscopy a total of six biopsy sam-
associated with increased risk of peptic ulcer disease.17 ples were taken from fundus, body, and antrum.After tis-
So, the purpose of this study was to assess the associa- sue processing a pathologist who was notaware about the
tion between oral health and gastric pathology as the first patients’ oral health,reported these samples according to
study in Iran. Sidney’s classification into superficial gastritis, atrophic
gastritis, intestinal metaplasia, and dysplasia.
MATERIALS AND METHODS
Patients’ population Statistical analysis
In a cross-sectional study from November 2014 to De- Chi-square and t tests were used for statisticalanaly-
cember 2015 in Kerman, the largest province in south- sis. SPSS software version 20 was used for data analysis.
east Iran, patients with dyspepsia who were candidate pvalue <0.05 was considered as statistically significant.

Middle East Journal of Digestive Diseases/ Vol.9/ No.1/January 2017

 Zahedi et al. 35

Ethics: Table 1: Demographic data

The protocol of our study was approved by Ethic- Variables
Frequency
(percent)
sCommittee of Kerman University of Medical Scienc-
Male 52(60.5)
es. All the participants signed a consent form and their Sex
Female 34(39.5)
data were kept secret.
Illiterate 6(7)
Primary school 24(27.9)
RESULTS Education
High school 23(26.7)
86 patients with dyspepsia consisted of 34 (39.5%) Higher Education 32(38.4)
women and 52 (60.5%) men were included in our study. Age mean
40(13.2)
The mean age of the patients was 40.32 years. The (standadrd deviation )
youngest and the oldest patients were 20 and 63 years
old, respectively.
Table 2: Frequency of oral hygiene indices
The patients were evaluated considering their educa-
Frequency
tion:7% were illiterate,27.9% were at primary school Variables
(percent)
level,26.7% had high school diploma, and 38.4%had No brushing 15(17.4)
higher education. The demographic information about Tooth brushing times Irregular 25(29.06)
sex and education are shown in table 1. per day Once 30(34.9)
The characteristics of the patients including: hygiene Twice 16(18.6)
indicators (the number of teeth brushing per day, floss- Yes 16(18.6)
Dental floss usage
ing, and visiting the dentist), DMFT and,Loe plaque No 70(81.4)
index are summarized in tables 2, and 3. Never 8(9.3)
According to Sidney’s classification 77 (89.5%) pa- 6 month ago 27(31.4)
Last visiting a dentist
tients had superficial gastritis, 3 (3.5%) had atrophic A year ago 20(23.3)
gastritis, and 6 (7%) had intestinal metaplasia. HP was More than one year ago 31(36)

found in 80.2% of the gastric mucosal biopsy samples.

There were not statistically significant relationship be-
Table 3: Frequency of dental &gingival indices
tween Sidney’s classification, presence of HP in gastric
SIC 20(23.3)
mucosal biopsies, and hygiene indicators (p>0.05).The DMFT index
Other 2/3 66(76.7)
relationship between gastritis degree andexistence of
Good 39(45.3)
HP,and also the relationship between DMFT, Plaque
Loe index Moderate 23(26.7)
index, and HP colonization amount are summarized in
Poor 24(27.9)
tables 4, and 5, respectively.
There were not statistically significant associations
between Loe plaque index and superficial gastritis and metaplasia (p>0.05).
intestinal metaplasia (p=0.825). In contrary, there was a Gastric infection with HP was found in70%,75%,
statistically significant relationship between Loe plaque and100% of the patients with mild,moderate, and sever
index, and the presence of atrophic gastritis in gastric DMFT index, respectively.
mucosal biopsies (p=0.001, table 3). Also, the relation There was nostatistically meaningful difference
between Loe plaque index and finding of HP in gastric based on education between the illiterate individuals,
mucosal biopsies was statistically significant (p.value primary school level,high school diploma, and higher
<0.05). HP was found in 66%, 82.6%, and 100% of the education regarding the various degrees of HP.Also
patients with good, moderate, and poor Loe plaque in- the difference between the frequency of HP degrees
dex, respectively. in stomach was not meaningful based on age and sex
No relation was found between the DMFT index (p>0.05).
and superficialgastritis,atrophic gastritis, and intestinal

Middle East Journal of Digestive Diseases/ Vol.9/ No.1/January 2017

 36 MRE
Oral Hygiene
of Crohn’s
andDisease
GastricinPathology
Iran in Patients with Dyspepsia

Table 4: The relationship between digree of gastritis and H.pylori

H.pylori
No Mild Moderate Sever Total P value
Superficial gastritis 17(21.5) 24(30.4) 28(35.4) 10(12.7) 79
Intestinal metaplasia 0(0) 0(0) 3(50) 3(50) 6 0.088
Gastric atrophy 0(0) 1(100) 0(0) 0(0) 1

Table 5: The relationship between DMFT and Plaque indexes with gastric H.pylori grades
H.pylori
Absent (no H.pylori) Mild Moderate Sever P value
Mild to moderate 17(100) 25(100) 16(51.6) 8(61.5)
DMFT 0.001
sever 0(0) 0(0) 15(48.4) 5(38.5)
good 13(76.5) 17(68) 7(22.6) 2(15.4)
Plaque Index moderate 4(23.5) 8(32) 9(29) 2(15.4) 0.001
bad 0(0) 0(0) 15(48.4) 9(69.2)

DISCUSSION inflammatory cytokinesthat lead to induction of systemic

The aim of our study was to assess the association be- chronic inflammation.18
tween oral health and gastric pathology. Due to the best Alasqah research indicated that in patients with
of our knowledge, up to now, there was no research from chronic periodontitis,the prevalence of HP existence in
Iran in this regard in the literature. stomach was higher than patients without periodontitis.23
Our study showed that there was a direct relationship Beliand colleagues in their study on 124 patients with
between the presence of HP in the stomach and unsat- or without gastric HP infection,reported meaningful re-
isfactory dental and gingival indices. Our data are con- lationship between HP infection and patients’periodental
sistent with the literature that suggests oral cavity and status,but there was no meaningful relationship between
oral plaque may be a reservoir for HP leading to the the number of teeth and HP infection.24 In contrast, Ber-
recurrence of gastric infection.9-15 in 2014, Wang and roteranand co-workers found no relationship between
colleaguesreported that simultaneous treatment of peri- HP infection and periodontal disease (Loe and Sillness
odontal disease and oral HP could increase the success indices), dental caries, and dental hygiene.25 In this
rate of the eradication of the gastric HP infection from research,it was specified that periodontal diseases and
61.33% to 82.26%.21 In addition, Zaricand co-workers DMFT indexhad meaningful relationship with gastric
indicated that 77.3% of the patients treated with com- HP infection.Some studies have declared that shift in
bined periodontal disease and anti-HP triple therapy oral flora and systemic inflammation can affect some or-
showed successful eradication of gastric HPcompared gans such as stomach, and pancreas 28 and result in tumor
with 47.6% who underwent triple therapy alone.22 development and growth.16
There were an association between the unpleasant Loe Boylanand colleagues indicated that risk of peptic ul-
plaque index and atrophic gastritis in our study. Atrophic cerincreased with the presence of periodontal disease.18
gastritis is the main precursor lesion of gastric cancer, Salazar and co-workers found that among patients with
and HP infection is the most important cause of atrophic higher grades of periodontal disease, periodontal patho-
gastritis.26 Periodontal disease is associated with altera- gens that measured in plaque were related to gastric pre-
tion in oral microbiome.17 Many studies have shown cancerous lesions attendance.16
higher levels of HP in periodontitis status than in normal Our study didnot show a relation between the DMFT
periodontal condition.25-27 On the other hand periodontal index and gastric histopathology.It seems that the speed
pathogens and disease are associated with high levels of of bacterial colonization effect on teeth is much slower

Middle East Journal of Digestive Diseases/ Vol.9/ No.1/January 2017

 Zahedi et al. 37

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