EXPLORING THE EFFECTS OF PEPSIN ON SALIVARY PEPTIDOME: INSIGHTS FROM A PROOF-OF-CONCEPT PROTEOMIC PROFILING STUDY USING MALDI-ToF MASS SPECTROMETRY
DOI:
https://doi.org/10.22551/MSJ.2026.02.15Abstract
Pepsin, a component of gastric refluxate, has been investigated as a potential salivary biomarker for gastro-esophageal reflux disease (GERD), although its diagnostic accuracy remains uncertain. This proof-of-concept study aimed to characterize the effects of pepsin on the human salivary peptidome using matrix-assisted laser desorption/ionization-time of flight (MALDI-ToF) mass spectrometry. Materials and methods: Whole saliva samples were collected from ten healthy adult volunteers under fasting conditions and divided into untreated controls and aliquots digested with pepsin at acidic pH. MALDI-ToF MS was used to profile digestion-induced changes in peptide mass patterns. Spectral data were analyzed using multivariate statistical approaches, including principal component analysis (PCA), linear discriminant analysis (LDA), and hierarchical clustering. Results: Pepsin digestion increased peptide signal intensity and spectral complexity compared with controls. PCA demonstrated clear separation between native and digested samples along the first principal component. Ten peptide m/z features showed the strongest association with pepsin exposure based on PCA loadings. LDA and hierarchical clustering further supported this distinction, with the top 15 discriminative m/z features showing consistent enrichment in digested samples despite inter-individual variability. Conclusions: Pepsin exposure induces reproducible remodeling of the salivary peptidome detectable by MALDI‑ToF MS. Although this peptide‑level approach cannot resolve the full diversity of salivary proteoforms, the resulting signatures support the feasibility of identifying markers of reflux‑associated enzymatic activity and provide a basis for future validation in clinical GERD cohorts.
References
1. El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the Epidemiology of Gastro-Esophageal Reflux Disease: A Systematic Review. Gut 2014; 63: 871-880 / doi: 10.1136/gutjnl-2012-304269.
2. Wiklund I. Review of the Quality of Life and Burden of Illness in Gastroesophageal Reflux Disease. Dig Dis 2004; 22: 108-114 / doi: 10.1159/000080308.
3. Gawron AJ, French DD, Pandolfino JE, Howden CW. Economic Evaluations of Gastroesophageal Reflux Disease Medical Management. Pharmacoeconomics 2014; 32: 745-758 / doi: 10.1007/s40 273-014-0164-8.
4. Katz PO, Dunbar, KB, Schnoll-Sussman FH, et al. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2022; 117: 27-56 / doi: 10.14309/ ajg.0000000000001538.
5. Maresova P, Rezny L, Hruska J, et al. Diagnosis and Treatment of Patients with Gastroesophageal Reflux Disease - a Systematic Review of Cost-Effectiveness and Economic Burden. BMC Health Serv Res 2024; 24: 1351 / doi: 10.1186/s12913-024-11781-8.
6. Samuels TL, Johnston N. Pepsin in Gastroesophageal and Extraesophageal Reflux: Molecular Patho-physiology and Diagnostic Utility. Curr. Opin. Otolaryngol. Head Neck Surg 2020; 28: 401-409/ doi: 10.1097/MOO.0000000000000664.
7. Han F, Li X, Song Z, Xie J, Wang N, Yao J. The Association between Salivary Pepsin and Gas-troesophageal Reflux Disease: A Meta-Analysis. Neurogastroenterol Motil 2024; 1-10 / doi: 10.1111/ nmo.14905.
8. Zhang A, Sun H, Wang P, Wang X. Salivary Proteomics in Biomedical Research. Clin. Chim. Acta 2013; 415: 261-265 / doi: 10.1016/j.cca.2012.11.001.
9. Zambonin C, Aresta A. MALDI-ToF/MS Analysis of Non-Invasive Human Urine and Saliva Samples for the Identification of New Cancer Biomarkers. Molecules 2022; 27 / doi: 10.3390/molecules 27061925.
10. MS-Digest, Prospector v.5.22.1,UCSF Mass Spectrometry Facility, University of California, San Francisco. Available at: https://Prospector.Ucsf.Edu/Prospector/Cgi-Bin/Msform.Cgi?Form=msdigest.
11. Humphrey SP, Williamson RT. A Review of Saliva: Normal Composition, Flow, and Function. J Prosthet Dent 2001; 85: 162-169 / doi: 10.1067/mpr.2001.113778.
12. Millipore Corporation. ZipTip® Pipette Tips: Protocol for Peptide Purification and Desalting. Millipore; 2010. Available from: http://www.Millipore.Com/Catalogue/Module/C5737.
13. Perez-Riverol Y, Bandla C, Kundu DJ, et al. The PRIDE Database at 20 Years: 2025 Update. Nucleic Acids Res 2025; 53: D543-D553 / doi: 10.1093/nar/gkae1011.
14. Dongiovanni P, Meroni M, Aiello G, et al. Salivary Proteomic Profile of Young Healthy Subjects. Front Mol Biosci 2023; 10: 1327233 / doi: 10.3389/fmolb.2023.1327233.
15. Shao C, Tian Y, Dong Z, et al. The Use of Principal Component Analysis in MALDI-ToF MS: A Powerful Tool for Establishing a Mini-Optimized Proteomic Profile. Am J Biomed Sci 2012; 4: 85-101 / doi: 10.5099/aj120100085.
16. Balakrishnama S, Ganapathiraju, A. Linear Discriminant Analysis-a Brief Tutorial. In Institute for Signal and Information Processing 1998, 1-8.
17. Nasteski V. An Overview of the Supervised Machine Learning Methods. Horizons 2017; 4: 56.
18. Gronau QF, Wagenmakers, E-J. Limitations of Bayesian Leave-One-Out Cross-Validation for Model Selection. Comput Brain Behav 2019; 2: 1-11 / doi: 10.1007/s42113-018-0011-7.
19. Surdu A, Foia LG, Luchian I, et al. Saliva as a Diagnostic Tool for Systemic Diseases-A Narrative Review. Medicina (Kaunas) 2025; 61 / doi: 10.3390/medicina61020243.
20. Miller CS, Foley JD, Bailey AL, et al. Current Developments in Salivary Diagnostics. Biomark Med 2010; 4: 171-189 / doi: 10.2217/bmm.09.68.
21. Jing W, Luo W, Lou L. Diagnostic Utility of Salivary Pepsin in Laryngopharyngeal Reflux: A Sys-tematic Review and Meta-Analysis. Braz J Otorhinolaryngol 2023; 89: 339-347 / doi: 10.1016/j.bjorl. 2022.10.050.
22. Guo Z, Wu H, Jiang J, Zhang C. Pepsin in Saliva as a Diagnostic Marker for Gastroesophageal Reflux Disease: A Meta-Analysis. Med Sci Monit 2018; 24: 9509-9516 / doi: 10.12659/MSM.913978.
23. Tan JJ, Dai YF, Wang F, et al. Pepsin-Mediated Inflammation in Laryngopharyngeal Reflux via the ROS/NLRP3/IL-1β Signaling Pathway. Cytokine 2024; 178: 156568 / doi: 10.1016/j.cyto.2024.1565 68.
24. Stanforth KJ, Wilcox MD, Chater PI, et al. Pepsin Properties, Structure, and Its Accurate Measurement: A Narrative Review. Ann. Esophagus 2022; 5 / doi: 10.21037/aoe-20-95.
25. Helmerhorst EJ, Oppenheim FG. Saliva: A Dynamic Proteome. J Dent Res 2007; 86: 680-693 / doi: 10.1177/154405910708600802.
26. Schulz BL, Cooper-White J, Punyadeera CK. Saliva Proteome Research: Current Status and Future Outlook. Crit RevBiotechnol 2013; 33: 246-259 / doi: 10.3109/07388551.2012.687361.
27. Aebersold R, Mann M. Mass-Spectrometric Exploration of Proteome Structure and Function. Nature 2016; 537: 347-355 / doi: 10.1038/nature19949.
28. Ceccherini E, Michelucci E, Signore G, et al. The Clinical Utility of the Saliva Proteome in Rare Diseases: A Pilot Study for Biomarker Discovery in Primary Sclerosing Cholangitis. J Clin Med 2024; 13: 544.
29. Lazari LC, Zerbinati RM, Rosa-Fernandes L, et al. MALDI-ToF Mass Spectrometry of Saliva Samples as a Prognostic Tool for COVID-19. J Oral Microbiol 2022; 14: 2043651 / doi: 10.1080/20002297. 2022.2043651.
30. Xiao H, Zhang Y, Kim Y, et al Differential Proteomic Analysis of Human Saliva Using Tandem Mass Tags Quantification for Gastric Cancer Detection. Sci Rep 2016; 6: 22165 / doi: 10.1038/srep 22165.
31. Singhal N, Kumar M, Kanaujia PK, Virdi JS. MALDI-ToF Mass Spectrometry: An Emerging Tech-nology for Microbial Identification and Diagnosis. Front Microbiol 2015; 6: 791 / doi: 10.3389/fmicb. 2015.00791.
32. Clark AE, Kaleta EJ, Arora A, Wolk DM. Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry: A Fundamental Shift in the Routine Practice of Clinical Microbiology. Clin Microbiol Rev 2013; 26: 547-603 / doi: 10.1128/CMR.00072-12.
33. Sujatha S, Jalihal U, Devi Y, et al. Oral PH in Gastroesophageal Reflux Disease. Indian J. Gastroen-terol.Off. J Indian Soc Gastroenterol 2016; 35: 186-189 / doi: 10.1007/s12664-016-0659-7.
34. Bechir F, Pacurar M, Tohati A, Bataga SM. Comparative Study of Salivary PH, Buffer Capacity, and Flow in Patients with and without Gastroesophageal Reflux Disease. Int J Environ Res Public Health 2021; 19 / doi: 10.3390/ijerph19010201.
35. Preetha A, Sujatha D, Patil BA, Hegde S. Oral Manifestations in Gastroesophageal Reflux Disease. Gen Dent 2015; 63: e27-31.
36. Alharthi, R, Mutahar, M, Bartlett, D, Jafari, J, Moazzez, R. Salivary Proteins in Human Acquired Enamel Pellicle (AEP) on Eroded and Uneroded Teeth in Patients with Gastro-Esophageal Reflux Disease (GORD). Dent J 2024; 12: 235.
37. Martini T, Rios D, Cassiano LPS, et al. Proteomics of Acquired Pellicle in Gastroesophageal Reflux Disease Patients with or without Erosive Tooth Wear. J Dent 2019; 81: 64-69 / doi: 10.1016/j.jdent. 2018.12.007.
38. Martini T, Câmara JVF, Dionizio A, et al. Proteomic Analysis of Stimulated Saliva in Gastroesopha-geal Reflux Disease Patients with and without Erosive Tooth Wear: Observational Study. J Dent 2023; 139: 104724 / doi: 10.1016/j.jdent.2023.104724.
Additional Files
Published
Issue
Section
License
Copyright (c) 2026 The Medical-Surgical Journal

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
COPYRIGHT
Once an article is accepted for publication, MSJ requests a transfer of copyrights for published articles.
COPYRIGHT TRANSFER FORM FOR
REVISTA MEDICO-CHIRURGICALĂ A SOCIETĂȚII DE MEDICI ȘI NATURALIȘTI DIN IAȘI /
THE MEDICAL-SURGICAL JOURNAL OF THE SOCIETY OF PHYSICIANS AND NATURALISTS FROM IASI
We, the undersigned authors of the manuscript entitled
_____________________________________________________________________________________
_____________________________________________________________________________________
warrant that this manuscript, which is submitted for publication in the REVISTA MEDICO-CHIRURGICALĂ, has not been published and it is not under consideration for publication in another journal.
- we give the consent for publication in the REVISTA MEDICO-CHIRURGICALĂ, in printed and electronic format and we transfer unconditioned and complete the copyright of this manuscript to the REVISTA MEDICO-CHIRURGICALĂ, in the event of its acceptance.
- the manuscript does not break the intellectual property rights of any other person.
- we have read the submitted version of the manuscript and we are fully responsible for the content.
Names and signatures of authors / copyright owners (the following sequence is the authorship of the article):
- ______________________________/_________________________
- ______________________________/_________________________
- ______________________________/_________________________
N.B. All the authors must sign this form