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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 5  |  Issue : 2  |  Page : 173-177

Comparative study of occurrence of recurrent aphthous stomatitis during exam stress and relaxed phase in dental college students of Krishna Institute of Medical Sciences


1 Department of Oral Medicine and Radiology, School of Dental Sciences, Karad, Maharashtra, India
2 Department of Oral Medicine Radiology, Krishna Institute of Medical Sciences, Karad, Maharashtra, India

Date of Submission11-Mar-2020
Date of Decision07-May-2020
Date of Acceptance19-May-2020
Date of Web Publication18-Dec-2020

Correspondence Address:
Dr. Mugdha Vijay Karambelkar
Department of Oral Medicine and Radiology, School of Dental Sciences, Karad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_5_20

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  Abstract 


INTRODUCTION: Recurrent aphthous stomatitis (RAS) is a common disease characterized by the development of painful recurring, solitary, or multiple ulcerations. RAS is classified according to different clinical variants as (1) minor (Miculiz's aphthae), (2) major (periadenitis mucosa necrotica), and (3) herpetiform ulcerations.
AIM: The aim was to compare the occurrence of RAS during exam stress and relaxed phase in dental college students.
METHODOLOGY: Selection criteria: (1) Inclusion criteria: All dental students who are willing to participate and exam-going students of year. (2) Exclusive criteria: Students who are not willing to participate in study during exam time. A total of 100 dental students were included in this study. History record and clinical examination was carried out in the Department of Oral Medicine and Radiology. The students were examined twice-during exam period (1 week prior to the exam) and in nonexam period. The data collection was done using a set of questionnaires. Statistical analysis was done using Microsoft Office Excel.
RESULTS: In the present study, the occurrence of RAS was 50%. Majority of the students were in 20–21years age group. Out of fifty students, forty were females (80%) and ten (20%) were males. Stress was the most common factor which accounted for 68%. The most common site of occurrence was labial mucosa. In the present study, as students were under stress of exams once in 6 months, the appearance of RAS was found more (52%), followed by 3 months (38%) and very few students suffer once in a month (10%). In majority of students (82% of cases), RAS healed within a week.
CONCLUSION: Based on the results of our study, the occurrence of RAS in dental college students was high 50%. On comparison of phases, the occurrence of RAS was high during exam period, which shows association with stress.

Keywords: Buccal mucosa, labial mucosa, recurrent aphthous stomatitis, stress


How to cite this article:
Karambelkar MV, Ashwinirani S R, Sande A, Kamala K A. Comparative study of occurrence of recurrent aphthous stomatitis during exam stress and relaxed phase in dental college students of Krishna Institute of Medical Sciences. BLDE Univ J Health Sci 2020;5:173-7

How to cite this URL:
Karambelkar MV, Ashwinirani S R, Sande A, Kamala K A. Comparative study of occurrence of recurrent aphthous stomatitis during exam stress and relaxed phase in dental college students of Krishna Institute of Medical Sciences. BLDE Univ J Health Sci [serial online] 2020 [cited 2021 Jan 16];5:173-7. Available from: https://www.bldeujournalhs.in/text.asp?2020/5/2/173/303971



Ulceration of the oral mucosa is a frequent occurrence producing painful “aphthae,” a term of ancient origin referring to ulceration of any mucosal surface.[1] Recurrent aphthous stomatitis (RAS) is a common disease characterized by development of painful recurring, solitary, or multiple ulcerations. RAS is classified according to different clinical variants as (1) minor (Miculiz's aphthae), (2) major (Periadenitis mucosa necrotica), and (3) herpetiform ulcerations.[2]

RAS mainly occurs on nonkeratinized mucosa as lips, tongue, and buccal mucosa. Predisposing factors include trauma, drugs, stress, nutritional deficiency, and infections.[1] Minor RAS occurs more commonly in females.[2]

Various studies have shown association of stress with RAS.[2] Although its etiology is not well understood, it is multifactorial, and stress could be one possible triggering factor.[3] With this background, the present study was designed to compare the occurrence of RAS during exam stress and relaxed phase (nonexam period) among dental college students.


  Methodology Top


Selection criteria

Inclusion criteria

All dental students who are willing to participate and exam-going students of year.

Exclusive criteria

Students who are not willing to participate in study during exam time.

A total of 100 dental students were included in this study. This research was approved by the Institutional ethics committee of Krishna Institute of Medical Sciences Deemed to be University, Karad. (Ref.No.KIMSDU/IEC/03 / 2018). Informed consent was signed before enrolling the student in the study.

Clinical predesigned pro forma which includes history record and clinical examination was carried out in the Department of Oral Medicine and Radiology. A total of 6 questions were included. The students were examined twice-during exam period (1 week prior to the exam) and in nonexam period. The data collection was done using a set of questionnaires. Questions were related to the previous history of RAS, family history, triggering factor, duration of ulcer, site of ulcer, and history of painful ulcer.

Questionnaire:

  1. Previous history of RAS?
  2. Family history?
  3. What is the triggering factor?
  4. Occurrence of ulcers per year?
  5. Duration of ulcer?
  6. Does the ulcer is painful?


Statistical analysis: Statistical analysis was done using Microsoft Office Excel.


  Results Top


The total number of dental students evaluated in the Department of Oral Medicine and Radiology were 100 from May 2018 to December 2018. All the students were examined twice in a year (during exam period and during nonexam period, or relaxed phase). Out of the 100 students 50 students were clinically diagnosed with RAS during exam time. Therefore, in the present study, the occurrence of aphthous stomatitis was 50%.

The age group of students examined was between 19 and 25 years. Majority of the students were in 20–21 years age group. Out of the fifty students, forty were females (80%) and ten were males (20%) [Table 1].
Table 1: Gender and age distribution

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Association of RAS with various predisposing factors showed stress as the most common factor, which accounted for 68% followed by trauma accounting for 18% [Table 2].
Table 2: Association with predisposing factors

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Occurrence of RAS is another important clinical finding, which showed predilection for certain site in oral mucosa. RAS can affect any site on the oral mucosa such as labial mucosa, buccal mucosa, gingiva, and tongue. In the current study, RAS was most common on labial mucosa accounting for 66%, followed by buccal mucosa, gingiva, and tongue [Table 3] and [Figure 1],[Figure 2],[Figure 3].
Table 3: Site of occurrence of recurrent aphthous stomatitis

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Figure 1: Recurrent aphthous stomatitis on the lower right labial mucosa

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Figure 2: Recurrent aphthous stomatitis on the lower left labial mucosa

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Figure 3: Recurrent aphthous stomatitis on the gingiva

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Examination of number of ulcers is as important as site of ulcers as minor RAS typically present as 1–2 ulcers, major RAS mostly appears as single large ulcer, and herpetiform ulcers are multiple in number. Our study accounted the highest percentage of one or two ulcers (70%) at a time and lesser percentage (22%) of multiple ulcerations [Table 4].
Table 4: Number of ulcers at a time

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Aggravation in the episodes of RAS may be dependent on predisposing factors. In the present study, as students were under stress of exams once in 6 months, the appearance of RAS was found more (52%), followed by 3 months (38%) and very few students suffer once in a month (10%) [Table 5].
Table 5: Time interval between episodes of recurrent aphthous stomatitis

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Generally, RAS heals within 2–6 weeks. The ulcers last for 3–7 days and heal without scarring. In the present study, in most of the students, ulcer healed within a week (82%) [Table 6].
Table 6: Duration of healing of recurrent aphthous stomatitis

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  Discussion Top


Oral ulcer is a very common condition affecting most of the population. RAS is one of the major inflammatory ulcerative conditions affecting oral mucosa. It is prevalent in females than males and affects younger individual. Several predisposing factors are associated with the condition such as stress, trauma, burns, spicy food, menstruation, and other hormonal disturbances. Other associated factors are socioeconomic status, herpes simplex virus, and habits. It shows reverse association with smoking and tobacco chewing.

RAS is classified by Stanley according to the size and healing period that is (1) minor, (2) major, (3) herpetiform. It can appear as a single ulcer or multiple small ulcers (herpetiform ulcers).[4] Minor aphthous ulcers are small (>1 cm in diameter), and heal within 2 weeks without scars. Major ulcer is bigger (>5 cm), mostly single, and heals within 6 weeks. Herpetiform ulcerations are multiple small ulceration (1–3 mm), which heal within weeks.[2]

Clinically, it presents as superficial erosions covered by a gray membrane with necrotic center with clearly defined raised margins surrounded by erythematous halo. The healing takes place within weeks and heals without scaring. The healing is characterized by the abrupt cessation of pain and the appearance of granulation within the decreasing surface exudation.

In the present study, out of the 100 students 50 students showed a positive history of RAS. Similar studies have been reported from India as well as other countries. Whereas studies carried out by George et al.[2] in Kerala population showed that the prevalence of RAS was high among medical students (62.3%). The prevalence rate in our study was more than the study conducted by Rathod et al.[5] It was found that aphthous ulcer is very common in dental students as 220 out of 500 (40%) had a history of RAS. The prevalence of aphthous stomatitis was higher according to Rao et al.[3] (78.1%). However, the prevalence of RAS is very low according to studies reported by Handa et al.[5] from Jaipur, India, and Naito et al. in Japanese population, where prevalence is 26% and 31%, respectively.[6],[7]

In the present study, RAS showed predilection for female gender. In our study, 80% of affected students were females. This result is contradicting to Rao et al.[3] where males are more commonly affected (87%) than females (74%). However, our results were similar to Handa et al.[7] and Rajmane et al.[4] studies where females have predilection for RAS. The predilection for females is associated may be due to hormonal changes, menstruation, etc. Some authors have stated that it is associated with hormonal rates. The incidence of RAS is related to the luteal phase of menstrual cycle and also a decrease in its incidence during pregnancy, thus relating the episodes of RAS to progesterone levels.

In this study, the most commonly affected age group was 20–21 years, which is similar to Rajmane et al.[4] where the age of patients with RAS ranged from 20 to 29 years. However, according to Rathod et al.,[5] the common age group affected by RAS is 19–20 years.

There are several factors associated with the presence of RAS. In the present study, the main predisposing factor is stress (exam related) accounting for 68% followed by trauma accounting about 18%. The students were under higher stress than general population, which represents much higher incidence of RAS in students. These results are similar to George et al.[2] where 46.2% students were under high stress of examination, studies, curriculum, and completion of assignments. Similar results were shown by the study conducted to assess the prevalence of aphthous stomatitis and its association with psychological stress in both medical and dental graduate students by Rao et al.[3] On the other side, smoking and tobacco are supposed to be stress relieving factors, thus in population consuming tobacco shows less prevalence of RAS.[4] In our study, none of the students reported to be using tobacco. This is not relatable as students may not be comfortable to reveal their habit history.

In the present study, the occurrence of RAS also shows predilection for particular site on oral mucosa. Labial mucosa is most commonly affected (66%). The site predilection is contradictory to Rajmane et al.[4] where 54.16% of patients showed occurrence of RAS on buccal mucosa followed by labial mucosa (15.27%).

In the present study, we examined number of ulcers present on oral mucosa during one episode of RAS. Minor RAS typically present as 1–2 ulcers, major RAS mostly appears as single large ulcer, and herpetiform ulcers are multiple in number. Our study accounted the highest percentage of one or two ulcers (70%) at a time and lesser percentage (22%) of multiple ulcerations. This result is similar to George et al.,[2] which shows majority (56 out of 106) of students had single ulcers during each episode of RAS.[4]

In the present study, time interval between episodes of RAS was also recorded, which showed aggravation in of RAS may be dependent on predisposing factors. In the present study, as students were under stress of exams once in 6 months, the episode of RAS was found more (52%), followed by 3 months (38%) and very few students suffer once in a month (10%).

In the present study, healing of RAS was also given importance. Thus, the time required for healing of ulcer was also recorded. RAS heals within 2–6 weeks. The ulcers last for 3–7 days and heal without scarring. Abrupt cessation of pain and presence of granulation tissue within decreasing surface exudate can be marked as a healing sign of RAS. In the present study, in most of the students, ulcer healed within a week (82%). This result was similar to George et al.[2] where majority of students had single ulcer during each episode and it lasted for 3–5 days.

Management of RAS is important as the condition may be severely painful and produce potential discomfort. There is no specific treatment regimen for RAS. It depends on the severity of condition and predisposing factors. The goal of treatment should be cessation of pain and healing of ulcers. Topical agents are sufficient for treating of mild condition. Topical agents include anesthetic and antiseptic gels, mouth rinses, topical steroids, and topical antibiotics. Pain relief can be achieved by topical application of anesthetic agent such as lidocaine and benzocaine. More severe cases use of topical steroids can achieve the healing. High-potency steroid preparation such as fluocinonide, betamethasone, and clobetasol can be applied directly on the lesion. For larger lesions, application of medicament is done with the help of placement of gauze to deliver the medicament for 15–30 min on the site of lesion. Other agents are topical antibiotics. The most commonly used was topical tetracycline or doxycycline, which is used either as a mouth rinse or can be applied as a paste. The single application of doxycycline hyclate proved decreased pain and speeded recovery.[8]


  Conclusion Top


Based on the results of our study, the occurrence of RAS in dental college students was high accounting for 50%. Majority of the students were in 20–21 years age group. Out of fifty students, forty were females (80%) and ten were males (20%). Stress was the most common factor which accounted for 68% among the students, which was the main predisposing factor for occurrence of RAS. RAS was most common on labial mucosa accounting for 66%, followed by buccal mucosa, gingiva, and tongue.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bruce AJ, Rogers RS 3rd. Acute oral ulcers. Dermatol Clin 2003;21:1-5.  Back to cited text no. 1
    
2.
George S, Baby Joseph B. A study on aphthous ulcer and its association with stress among medical students of an Indian Medical Institution. Int J Contemp Med Res 2016;3:1692-5.  Back to cited text no. 2
    
3.
Rao AK, Vundavalli S, Sirisha NR, Jayasree CH, Sindhura G, Radhika D. The association between psychological stress and recurrent aphthous stomatitis among medical and dental student cohorts in an educational setup in India. J Indian Assoc Public Health Dent 2015;13:133.  Back to cited text no. 3
  [Full text]  
4.
Rajmane YR, Ashwinirani SR, Suragimath G, Nayak A, Rajmane VS, Lohana M. Prevalence of recurrent aphthous stomatitis in Westernpopulation of Maharashtra, India. J Oral Res Rev 2017;9:25-8.  Back to cited text no. 4
  [Full text]  
5.
Rathod U, Kulkarni S, Agrawal V. Prevalence of recurrent apthous ulcers in dental student: A questionnaire based study. Int J Health Sci ?Res 2017;7:80-3.  Back to cited text no. 5
    
6.
Souza PR, Duquia RP, Breunig JA, Almeida HL Jr. Recurrent aphthous stomatitis in 18-year-old adolescents-Prevalence and associated factors: A population-based study. An Bras Dermatol 2017;92:626-9.  Back to cited text no. 6
    
7.
Handa R, Bailoor DN, Desai VD, Sheikh S, Goyal G. A study to evaluate the impact of examination stress on recurrent aphthous ulceration in professional college students in Jaipur district. Minerva Stomatol 2012;61:499-507.  Back to cited text no. 7
    
8.
Vijayabala GS, Kalappanavar AN, Annigeri RG, Sudarshan R, Shettar SS. Single application of topical doxycycline hyclate in the management of recurrent aphthous stomatitis. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:440-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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