SUMMARY Objective: Although the etiopathogenesis of aphthous stomatitis has not been clearly determined yet, genetic and immunopathological factors are blamed. In addition, triggering factors such as foods, trauma, drugs, infections, and stress are also thought to have an effect. In this study, it was aimed to determine the prevalence of aphthous stomatitis in the younger age group and to evaluate its relationship with various personal factors. Material and Methods: 761 university students aged between nineteen and twenty-three were included in our study. A questionnaire consisting of multiple choice questions was applied to all students. Chi-square test was used to compare the groups with and without aphthae. Results: 452 (59.4%) of the students had a history of aphthae, and 212 (31%) of them had a history of more than three aphthae per year. The most common localization of aphthae was the buccal mucosa, the most common type was minor aphthae (82%), and the most common subjective complaint was difficulty in eating. 3.7% of the students had aphthae during the examination. When the groups with and without aphtha were compared; aphtha was statistically significantly higher in women and those with a family history of aphthae. Aphthous history was found to be significantly more common in students who used antibiotics at least four times a year, had a history of herpes once a month or more frequently, had atopic dermatitis, and did not smoke. In order to determine the relationship between periodontal findings and recurrent aphthous stomatitis, a significant correlation was found between dental filling, implant and gingival bleeding and aphtha history, which are among the dental problems questioned in our questionnaire. Conclusion: Our study draws attention to the possible relationship between aphthous stomatitis and gingival bleeding, pain, frequent antibiotic use, herpes simplex infection, and atopic dermatitis.
ABSTRACT Objective: Etiopathogenesis of aphtous stomatitis has not been established clearly how- ever, genetic and immunopathologic factors have been blamed. Moreover, triggering factors like food, trauma, drugs, infections, stress are believed to have an impact. In this study, determination of aphtous stomatitis prevalence in young age group where it is frequently observed and evaluating its association with various personal factors are aimed. Material and Methods: Seven hundred sixty one university students are included to our study. Questionnaire with multiple choice questions as applied to all. Comparison is done using chi square test between groups with and without aphtae. Results: Four hundred fifty two students (59.4%) had a history of aphtae, 212 of whom had 3 or more lesions a year. Most common localization of aphtae was buccal mucosa, most common type was minor aphtae (82%), most common complaint was difficulty in eating. At the time of questionnaire application, 3.7% of students had aphtae. Comparing groups with and without aphtae, aphtae were significantly more in women, with family history of aphtae. Aphtae were significantly more common in students using antibiotics at least four times a year, having herpes at least once every month, having atopic dermatitis, and not smoking. Among questions asked in our questionnaire for determining association of aphthous stomatitis with periodontal findings, a significant association was determined with dental caries, implant and gingival bleeding and history of aphtae. Con- clusion: Our study pays attention to possible association of gingival bleeding, pain, dental caries, frequent use of antibiotics, presence of herpes simplex infections and atopic dermatitis with aphtous stomatitis.
Turkey Clinics J Dermatol 2011;21(2):63-8
Recurrent aphthous stomatitis (RAS) is a solitary or multiple oval disease that occurs periodically in the oral cavity and heals spontaneously.
It is a picture characterized by painful, superficial ulcerations that usually have a red halo around it.1 RAS is mostly seen between the ages of 10-19, and the frequency and severity of the disease decrease with age.2,3 The diagnosis of RAS is made by history and clinical features. and there is no specific laboratory test. Lesions are mostly not related to chewing function; in regions other than the hard palate, maxillary, mandibular and alveolar processes; it is most frequently localized in the tongue, buccal and labial mucosa, soft palate, and oropharynx.4 The most common subjective complaints are pain, dysphagia, and difficulty in eating. There are three clinical types of RAS: major, minor and herpetiform. Minor ulcers are the most common clinical form and are usually less than 5 mm in diameter and heal spontaneously in 1-2 weeks without scarring. Major ulcers may be larger than 1 cm and usually persist for up to 6 weeks and often heal with scarring. Herpetiform aphthae, which are very rare, are small, recurrent, superficial ulcers of a few mm in diameter that occur in groups on the oral mucosa.5
Another classification of RAS, simple and complex aphthosis, has also been reported.6 Complex aphthosis is a complicated clinical picture that defines severe disease. Ulcers are larger, deep and painful, and the presence of three or more aphthae at a time or the development of recurrent ulcers are frequently observed. Although genital ulcerations may accompany complex aphthosis from time to time, Behçet’s disease may not be diagnosed in these patients.4 The severity of this picture has led researchers to conclude that the etiology and clinical features of complex aphthosis are different from RAS.
It is thought that the etiology of RAS may be multifactorial, and studies are continuing on possible causes. In addition to genetic predisposing factors, trauma, emotional stress, diet, microbial agents, nutritional and hematological disorders, hormonal changes, drugs, and atopy are blamed in the etiology. 3 It is discussed that tissue-specific autoimmunity and immune response may also be responsible for RAS.7 RAS cellular immune response is thought to be dominant in its pathogenesis.8
In this study, it was aimed to determine the prevalence of aphthous stomatitis in the late adolescent age group and to evaluate its relationship with various personal variables.
MATERIALS AND METHODS
761 university students aged 19-23 were included in our study. First, the same two dermatologists gave a brief verbal information to the students and a presentation including a photographic description of aphthae for the clinical conditions (aphtha types, atopy, herpes infection, upper respiratory tract infection, rhinitis, eczema, conjunctivitis) questioned in our questionnaire. – it’s been done. In addition, a dentist was informed about gingival bleeding, implants, prostheses and fillings. Our study was conducted in accordance with the principles of the Declaration of Helsinki, and informed consent forms were obtained from the participants. In addition, ethics committee approval was obtained for this study.
Following the age, gender, height, weight information of the students in the multiple-choice survey questions; The presence of aphthae, the frequency, duration, localization, type (minor, major, herpetiform), subjective complaints, and family history of aphthae were questioned. In addition, frequency of use of antibiotics and painkillers, frequency of upper respiratory tract infections, whether or not they are vegetarian, tooth brushing frequency, smoking habits, herpes attack frequency, allergic disease history (drug reaction, urticaria, eczema, atopic dermatitis, etc.) The presence of dental interventions such as rhinitis, conjunctivitis), prostheses, implants, fillings, periodontological complaints such as gingival bleeding and pain and swelling in the gingiva were also questioned. After completing the questionnaires, students with aphthae at that time were examined by the same two dermatologists and evaluated for aphtha type, number, and accompanying findings.
During the statistical evaluation, unanswered questions were not taken into consideration, and the statistical analysis was carried out on the number of students who answered each question. Comparison between groups with and without aphtha was made with the chi-square test. A P value less than 0.05 was considered statistically significant.
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RESULTS
Of the students, 486 (63.86%) were female and 275 (36.14%) were male, with a mean age of 21 ± 2.98 years. It was determined that four hundred and fifty-two (59.4%) students had a history of aphthae and 212 of them had more than three aphthae per year. Four hundred and thirty-two students
119 (37.4%) had a history of aphthae within the last year and 314 (72.6%) had a history of more than one year.
The most common localization of aphthae was the buccal mucosa, followed by lips, tongue, gums (gingiva) and tonsils, respectively. There was a history of minor aphthae (82%), followed by major aphtha (10%) and herpetiform aphthae (8%) the least. While 36.6% of those with aphtha did not have any subjective complaints; Difficulty in eating was found to be the most common complaint among those with subjective complaints (34.5%).
In the examination of the students after the questionnaire, 28 (3.7%) of 743 students were found to have aphthae during the questionnaire. Two of ten students; five students had three and the rest had one aphtha. Nineteen of the students had minor aphthae and the rest had major aphthae. Ten of the aphthae were located on the tongue, 10 on the lip mucosa, and the rest on the tonsils. None of these patients had any findings other than oral aphthae.
A statistical difference was found in the group with aphtha history compared to the group without aphthae in terms of gender and familial history of aphthae (p< 0.001) (Table 1). The history of aphthae was statistically significantly higher in students who used antibiotics at least four times a year, had a history of herpes once a month or more frequently, had atopic eczema, and did not smoke (Table 2). On the other hand, no statistically significant correlation was found between being vegetarian (p= 0.7) and body mass index (p= 0.9) and having aphthae. There was no statistically significant correlation between the use of painkillers at least once a week and the history of aphthae (p= 0.56).
No statistically significant correlation was found between the frequency of having four or more upper respiratory tract infections per year, allergic rhinitis, allergic conjunctivitis, allergic asthma, eczema, urticaria, and drug eruption (p= 0.95), (p= 0.058) , (p=0.93), (p=0.53), (p=0.83), (p=0.07), (p=0.78).
The history of aphthae was significantly higher in patients with dental filling, bleeding gums, pain and swelling in the gums.
found to be excessive (p= 0.02), (p= 0.001), (p= 0.007) (Table 2). A history of more than three aphthae per year was found more frequently in students with gingival pain and swelling, unlike students with gingival bleeding and fillings. However, respectively; There was no statistically significant increase in the frequency of aphthae in students who brush their teeth at least once a day, orthodontic interventions and dental prosthesis (p= 0.21), (p= 0.33), (p= 0.055). In students without implants, aphthae were significantly higher (p= 0.01) (Table 2).
The relationship of all these variables with a history of more than three aphthae per year was also statistically evaluated (Table 2).
ARGUMENT
Although the frequency of RAS is between 5-25% in the general population, this frequency may increase up to 60% in studies conducted with selected groups.9,10 In general, it is reported that the frequency of aphthae is higher in groups with high socioeconomic status, in women, and in students.3, 11 In our study, a group of university students in the age group with the highest incidence of aphthae
It was found that 59% had a history of aphthae, and that the history of aphthae was more common in women, consistent with the literature.
Minor aphthae make up 75-85% of all aphthae. In our study, 82% of aphthae were found to be minor. Genetic predisposition in the etiology of RAS has been discussed for many years. It was found that more than 40% of RAS patients had a history of aphthae in first-degree relatives.12 The higher frequency of aphthae in those with a family history of aphthae in our study supports the genetic effect.
While some studies have pointed out that the prevalence of atopy increases in RAS patients,13,14 some researchers have argued that it does not differ significantly from the normal population.15 With the development of RAS, atopy parameters, which are characterized by changes in the immunological response, gradually come to the forefront in the formation of aphthae. suggesting that it may be related.
In our study, the history of aphthae was significantly higher in students with a history of atopic dermatitis, one of the atopy parameters, but no relationship was found between allergic rhinitis and aphthae, and allergic conjunctivitis was found more frequently in students with more than three aphthae per year. This result, like previous studies, is contradictory. There is a need for studies that will be repeated with larger patient groups and enriched with laboratory data.
It is thought that the T-cell-mediated immune response plays an important role in the pathogenesis of RAS, and this immune response develops as a result of a keratinocyte-related antigenic stimulus. Among the possible antigens, bacteria, drugs, food and food additives are frequently counted.16
Drugs are another factor accused in the etiology of RAS, and students’ drug use status and frequency were also questioned in our questionnaire. However, since our study group consisted of a young age group, our survey included preparations of systemic drugs with different names, such as analgesics and antibiotics, which are frequently used in this age group, and a list for other drugs that can be added. According to this; Although a history of antibiotic use at least four times a year was found to be associated with aphthae, no correlation was found between the frequency of painkiller use and aphthae. In another study by Atılganoğlu et al., a relationship was found between analgesics and antibiotics and aphthae.17
The protective effect of smoking against aphthae is frequently mentioned in the literature. The fact that RAS patients are generally non-smokers is associated with the positive effect of nicotine on oral mucosal keratinization.3 The findings of our study also support the literature by pointing out that the frequency of aphthae is significantly lower in smokers (Table 2).
Although there are studies expressing that local physical traumas such as dental treatments, tooth brushing, lip biting, and hard foods can trigger oral ulcers in patients with a predisposition; Contrary to the literature, we did not reach a conclusion in our study that the frequency of aphthae is higher in students who regularly brush their teeth at least once a day.
On the other hand, dental filling was found to be significantly higher in patients with aphthae, while the implant was found to be protective against aphthae. These findings may be related to the condition of dealing with dental problems in the young age group and applying to the physician, in other words, the group with implants at a young age may be more attentive to dental complaints and health than others. Indeed, this protective effect of dental treatments has been mentioned in previous studies. In a study conducted with Behçet’s patients, it was reported that although oral ulcers exacerbated in a short period of time after dental treatments, the number of aphthae decreased over time during the long follow-up period, and oral hygiene was better with dental treatments.19
In our study, the frequency of aphthae was found to be significantly higher in patients with gingival bleeding and complaints of pain and swelling in the gingiva. Gingival bleeding is accepted as a reliable and objective clinical parameter to evaluate the inflammatory conditions of the gingiva, and the absence of gingival bleeding is reported to be one of the strong markers of periodontal health.19,20 In the literature, Behçet’s patients and patients with RAS are together. studies were found, and the periodontal scores of both groups were evaluated. Although periodontal scores were significantly higher in Behçet’s patients than in RAS patients, interleukin (IL) 1 gene polymorphism was found to be higher in both Behçet’s and RAS patients compared to controls. In addition, it has been reported that this gene polymorphism may be a risk factor for the development of periodontitis and/or the formation of an exaggerated autoinflammatory response due to periodontitis in the Behçet and RAS patient groups. 21 It has been reported that plaque formation develops in the first step of periodontitis, and this plaque has been shown to be of bacterial origin. 22 As a result of this bacterial colonization, it is thought that the innate immune system is activated and this situation leads to a systemic immune response in individuals with genetic predisposition.
However, as a result of our study, gingival bleeding, which we found increased in patients with RAS, is not a finding that develops solely due to periodontitis. However, it is the most common clinical finding of periodontitis.22,23 It has been reported that gingival bleeding in periodontitis is also associated with increased dental plaque deposition. In conclusion, it is mentioned that a cycle where poor oral hygiene leads to the development of foci of infection, periodontal infections, and these infectious lesions predispose to the development of aphthae.23,24 The importance of oral hygiene in patients with aphthous stomatitis is also mentioned in the literature.25
CONCLUSION
In this study, the relationship between aphthous stomatitis and some personal variables was investigated. The most important limitation of this study is that most of the data was based on the results of the questionnaire and the students could not be evaluated in terms of hematinic deficiencies and systemic diseases, which are accused in the etiology of aphthae. In addition, the lack of dental examination with periodontal indices and the inability to evaluate the stress levels of the students who have been shown to have a role in the development and frequency of aphthae are other limitations.26 However, the high number of students and the parallelism of the findings with previous studies are important.
RAS is more common in students who use antibiotics frequently, have frequent herpes infections, have fillings in their teeth, gingival bleeding, swelling and pain in the gums, and have atopic dermatitis or allergic conjunctivitis, and female students and those with a family history of RAS. this probability is increasing.
Our study also draws attention to periodontal findings in students with aphthous stomatitis. Therefore, regular dental check-ups and regulation of oral hygiene habits may be beneficial in the follow-up and treatment of RAS patients.
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