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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 34  |  Issue : 4  |  Page : 437-441

Prevalence of recurrent aphthous ulcers (RAUs) in the population of Ludhiana


1 Department of Oral Medicine and Radiology, B.J.S Dental College Hospital and Research Institute, Ludhiana, Punjab, India
2 Pedodontics and Preventive Dentistry, B.J.S Dental College Hospital and Research Institute, Ludhiana, Punjab, India
3 Department of Conservative and Endodontics, SKSS Dental College, Ludhiana, Punjab, India

Date of Submission27-Mar-2021
Date of Decision30-Sep-2021
Date of Acceptance11-Nov-2021
Date of Web Publication09-Dec-2022

Correspondence Address:
Damanpreet K Isher
Professor and Head of the Department, Department of Oral Medicine and Radiology, BJS Dental College Hospital and Research Institute, Ludhiana, Punjab - 141 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_86_21

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   Abstract 


Introduction: Recurrent aphthous ulcer (RAU) is one of the most common oral mucosal disorders characterized by recurrent and painful ulcerations on movable or nonkeratinized oral mucosa. It affects approximately 20% of the general population. These present as recurrent, multiple, small, round, or ovoid ulcers with circumscribed margins, having yellow or gray floors, surrounded by erythematous halos. Aims and Objectives: To compare the prevalence and occurrence of RAU among the age group from 20 to 80 years. To compare the prevalence and occurrence among the gender. To correlate the causes of the recurrent aphthous stomatitis (RAS). To check for tobacco and its role in the occurrence of RAS. Materials and Methods: A cross-sectional study was conducted, and a total of 600 questionnaire forms were distributed and filled by students (undergraduates and postgraduates), staff, skilled workers, and patients reporting to the department over a period of 3 years. Results and Discussions: In total, 71.1% had experienced oral aphthous ulcerations. When both the genders were compared, RAS more commonly affected females (60.33%) than males (39.67%). The regression coefficient for gender revealed that females were more prone to RAS than males. Conclusion: Understanding the prevalence and distribution of recurrent aphthous ulceration among the population of Ludhiana gives an indication of the section of people who suffer from the condition. Based on the results of our study, females were more commonly affected than males, and the second- and third-decades age groups were affected.

Keywords: Behchet's syndrome, herpetiform ulceration, Mikulicz's aphthae, pseudo aphthae, Sutton's aphthae


How to cite this article:
Isher DK, Behl AB, Singh A, Isher PP, Kaur G, Kaur H. Prevalence of recurrent aphthous ulcers (RAUs) in the population of Ludhiana. J Indian Acad Oral Med Radiol 2022;34:437-41

How to cite this URL:
Isher DK, Behl AB, Singh A, Isher PP, Kaur G, Kaur H. Prevalence of recurrent aphthous ulcers (RAUs) in the population of Ludhiana. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2023 Jan 28];34:437-41. Available from: http://www.jiaomr.in/text.asp?2022/34/4/437/363039




   Introduction Top


Recurrent aphthous ulcer (RAU) is one of the foremost common oral membrane diseases characterized by repeated and painful ulcerations on the movable or non-keratinized oral membrane.[1] The term aphthae was derived from the Greek work aphthi, which suggests “to set on fire” or “to inflame” and is believed to have been initially employed by the philosopher Hippocrates to explain the pain related to a typical disorder of the mouth throughout his time (likely, aphthous stomatitis).[2] Aphthous ulcers or recurrent aphthous stomatitis (RAS) are benign cankerous lesions common in the mouth. Since the lesion is multifactorial in origin, it requires careful attention from an oral physician.[3]

It is significant in developed countries occurring in altogether ages, geographic regions, and races.[4] It affects about 20% of the overall population.[5] These occur as repeated, multiple, small, spherical, or ovoid ulcers with circumscribed margins, having yellow or gray floors and are enclosed by an erythematous halo, which appears first in childhood or adolescence.[6] Every region begins as a red macule, less typically a papule, however, not as a blister. It shortly ulcerates and also the ulcer becomes coated by a pyogenic membrane producing the characteristic yellow-white center with surrounding erythematous flare.[7]

RAU is classified phenotypically into three different categories though their classification varies slightly in terms of size and healing time between totally different authors.[8]


   Aims and Objectives Top


The purpose of the study is to compare the prevalence and occurrence of RAU among the age group from 20 to 80 years. To compare the prevalence and occurrence among the gender. To correlate the causes of the RAU. To check for tobacco and its role in the occurrence of RAU.


   Materials and Methods Top


A cross-sectional study was conducted, wherein a questionnaire consisting of 22 questions was prepared and distributed to patients of a reputed dental institute in Ludhiana, Punjab. The participants of the survey were chosen randomly. The subjects were interviewed and asked to fill out a questionnaire, especially prepared for this project. It included questions related to sociodemographics, nutritional status, medical history, family history of ulcers, stress, and any associated etiological factors. The inclusion criteria were history of aphthous ulcers and willingness to participate, while exclusion criteria included systemic disorders, gastric problem, tobacco usage, and traumatic ulcers. The data was recorded and analyzed using multiple backward step regression analysis tests. The P value for the significance of the variable was kept ≤0.05. The prevalence of RAUs between categories of age, gender, adverse oral effects, and family history of recurrent aphthous ulcerations was also compared. The ethical clearance was taken from the institutional ethical clearance committee (the ethical clearance approval no. BJSDC/EC/04, dated: 15/12/2016) with prior informed consent from the participants. All procedures followed were by the ethical standards of the responsible committee on human experimentation and with Helsinki's declaration of 1964 and later versions.


   Results Top


A total of 600 questionnaires were surveyed over a period of 3 years. Out of these, 71.1% had experienced oral aphthous ulcerations. It was seen that the highest proportion, 50.17% of subjects, belonged to the age group of 20–30 years followed by 20.83% from the age group of 30–40 [Table 1]. However, the lowest proportion was 0.83% of subjects belonging to the age group of 70–80 years. The ratio of males to females was 238:362 [Figure 1]. When both the genders were compared, it was found that RAS more commonly affected females (60.33%) than males (39.67%) [Table 2]. The regression coefficient for sex (−0.21, P = 0.04) revealed that females were more prone to RAU than males [Table 3].
Figure 1: Proportion of patients according to gender

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Table 1: Distribution of patients according to the age

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Table 2: Distribution of patients according to the gender

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Table 3: Probability of patients affected with RAU: Yes=1; no=0

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It was seen that 92.33% of subjects were poorly nourished, while 7.67% of subjects affected were well-nourished [Figure 2]. Regression coefficient of nutritional status (−0.21, P = 0.05) revealed that poorly nourished subjects are more prone to RAS than well-nourished ones [Table 3]. The present study revealed a positive family history of RAU in 94.83% of subjects [Table 4]. Regression coefficient of family history (0.22, P = 0.000) revealed that family history had a significant role in RAS [Table 3]. Similarly, tobacco (smoking/chewing) had a significant role in causing the disease. Regression coefficient of tobacco (0.33, P = 0.000) revealed that tobacco smokers/chewers were more prone to RAS [Table 3].
Figure 2: Proportion of patients according to the nutritional status

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Table 4: Distribution of patients according to the family history

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The value of constant 0.98 indicates that by keeping all the variables constant, RAS would likely increase. In the first run model, the value of r-square came to be 0.086, which was slightly reduced to 0.082 in the final run model. This indicated that four significant variables (sex, tobacco, nutritional status, family history) explain the 8.2% variation in the probability of disease. However, the contribution of nonsignificant variables (stress and gastric problems) was only 0.4% [Table 3] [Figure 3].
Figure 3: Proportion of patients according to history of gastric problem

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   Discussion Top


RAU is a common condition of oral mucosa that affects mainly nonkeratinized tissues.[3] The etio-pathogenesis of the disease is considered to be complex, not completely understandable. RAS remains a challenge for clinicians of varied specialties.[9] Learning the prevalence of RAU is very important since it provides insight into the proportion of individuals who are suffering from the condition as well as the attainable causative factors.[10] RAS belongs to a group of chronic, inflammatory, ulcerative diseases of the oral mucous membrane.[9] They can be seen at any age; however, girls and young adults are slightly more prone.[11] Considering the clinical options, three main varieties of RAU are often defined: minor aphthae (Mikulicz's aphthae; MiRAS), major aphthae (Sutton's aphthae; MaRAS), and herpetiform aphthae (HeRAS).[9]

Minor aphthae are shallow, yellow-gray oval, well demarcated, and small (<1 cm; typically, about 3–5 mm in diameter). No vesicle formation is seen during this illness – a distinctive diagnostic feature. Burning may be a preliminary symptom that is followed by intense pain lasting a couple of days. Minor aphthae typically heal immediately without scar formation within 14 days.

Pseudoaphthae, a term coined by Binney, refers to recurrent aphthous-like membrane ulcers of the mouth that are related to nutritional deficiency states. Pseudoaphthae correspond with both minor and major aphthous stomatitis; however, they are characteristically more persistent.

Major aphthous is a severe type of aphthous stomatitis that produces larger (≥ 1cm), more harmful, and deeper ulcers that last longer and recur more often than minor aphthae. Major aphthae are typically multiple. The foremost outstanding feature is the massive size in conjunction with a depressed necrotic center.

Herpetiform ulceration is the least common variant of aphthous stomatitis. Clinically, the ulcers resemble those seen in primary herpes (hence the name herpetiform); the most distinguished feature of the disease is the varied pin-head sized, gray-white erosions that enlarge and coalesce into ulcers. In the beginning, ulcers are 1–2 mm in diameter and occur in clusters of 10–100.[11] RAU may be also one of the symptoms of Behchet's syndrome, a systemic inflammatory disease, where excluding oral and genital lesions, numerous general symptoms can occur.[9]

The first episodes of RAU most often begin during the second decade of life.[12] Throughout this study, the foremost unremarkably affected age group is 20–30 years (50.17%), the prevalence attenuated as the age increased. The result was in accordance with the findings of Davatchi et al.; the peak age of onset is typically the second decade. Studies have shown a rise in the prevalence of RAU within the second and third decades. After the third decade, a decrease in RAU prevalence was determined.[13]

In this study, (60.33%) females were more affected than males (39.67%), indicating that the prevalence of illness is more in females than males [Table 2]. In regard to female predisposition to RAU, some authors have urged that this association is expounded to hormonal rates. The incidence of RAU is related to the secretory phase of the luteal phase and additionally decreases in its incidence throughout gestation, therefore relating the episodes of RAU to progestin levels.[13]

According to literature, the “protective effect” on RAU was noticed in persons who were significant smokers.[14] [Table 5] many studies reveal a negative association between the role of tobacco smoking, smoke-free tobacco, and RAU. Potential explanations given include increased membrane keratinization, which is a mechanical and protective barrier against trauma and microbes. Nicotine is taken into account to be the protecting factor because it stimulates the secretion of adrenal steroids by its action on the hypothalamic adrenal axis and reduces the production of tumor necrosis factor alpha (TNF-∝) and interleukins 1 and 6 (IL-1 and IL-6).[6] The thickness of the mucous membrane is also a very important factor in aphthous inflammation. Usually, ulcers form on the thinner, nonkeratinizing membrane surfaces within the mouth. Factors that decrease the thickness of the mucosa increase the frequency of incidence and factors that increase the thickness of the mucous membrane correlate with reduced ulceration.[15]
Table 5: Distribution of patients according to tobacco smoking/chewing

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This study showed that nutritional status plays an important role in the incidence of RAU. As per this study, 92.33% of subjects who were poorly nourished were suffering from RAU as compared to only 7.67% of well-nourished subjects [Figure 2]. The nutritional deficiencies related to aphthous inflammation (Vitamin B12, folate, and iron) will all cause a decrease in the thickness of the oral mucous membrane (atrophy) [Figure 4].[15] Furthermore, family history incorporates a vital role in RAU. According to research, youngsters whose parents are RAU positive have 90% likelihood to develop RAU, while the kids of healthy parents have solely 10% likelihood to develop this disease.[16] [Figure 4]. According to the study, patients with a positive case history of recurrent aphthous inflammation are 569 in number [Table 4].
Figure 4: Proportion of patients according to family history

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The etiology of RAU is unknown; however, several attainable predisposing factors are represented within the literature.[17] In recent times, RAU is mentioned as a clinical syndrome that happens through the results of many factors [Table 6].[16] The foremost vital etiological factors are hot and spicy food, stress, trauma, and vitamin deficiency [Figure 5]. In the present study, 23% of patients were suffering from stress [Figure 6]. The mechanism whereby stress might end in RAU episodes is not well understood. It has been observed that raised levels of salivary cortisol of reactive oxygen species within the saliva might cause the onset of the lesions.[18] Owing to stress, patients might begin parafunctional habits that cause traumatic injuries to the area, therefore resulting in an episode[17] [Table 7].
Table 6: Distribution of subjects according to etiology

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Table 7: Distribution of patients according to stress

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According to this study, 51.00% of subjects selected no treatment, followed by 31.17 and 12.17% of subjects selected allopathy and home remedy, respectively, for the treatment of RAU [Figure 7] Regarding the treatment used, Chatt opadhyay and Shetty, in 2011, mentioned topical or intralesional corticosteroids and local anesthetics because the most ordinarily used for palliative treatment, with the aim to provide symptomatic relief in controlling the pain and recurrence.[3]
Figure 5: Proportion of patients according to the etiology

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Figure 6: Proportion of patients according to stress

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Figure 7: Proportion of patients according to treatment

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   Future Prospects and Limitations Top


In near future, we can study the different treatment modalities and management of recurrent aphthous ulcerations in these patients. The primary goals of RAS therapy with minimal side effects can be studied.

We only focused on the population of Ludhiana without considering the treatment modalities.


   Conclusion Top


Understanding the prevalence and distribution of recurrent aphthous ulceration among the population of Ludhiana will give an indication of the proportion of people who suffer from the condition and who need dental management. Based on the results of our study, females are more commonly affected than males and the most common age groups affected in our study are the second and third decades. It is concluded that, although the etiology of recurrent aphthous ulceration is unknown, the role of certain factors like family history, nutritional status, stress, tobacco smoking/chewing, etc., cannot be ruled out.

Declaration of patient consent

The authors certified that they have obtained all appropriate patient consent forms. In the form, patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Kaur D, Behl AB, Isher PP. Oral manifestations of stress-related disorders in the general population of Ludhiana. J Indian Acad Oral Med Radiol 2016;28:262-9.  Back to cited text no. 5
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Rajmane YR, Ashwinirani SR, Suragimath G, Nayak A, Rajmane VS, Lohana M. Prevalence of recurrent aphthous stomatitis in western population of Maharashtra, India. J Oral Res Rev 2017;9:25-8.  Back to cited text no. 13
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Kalpana R. Relation between smoking and recurrent aphthous stomatitis. Oral Maxillofac Pathol J 2016;7:761-2.  Back to cited text no. 14
    
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Patil S, Reddy SN, Maheshwari S, Khandelwal S, Shruthi D, Doni B. Prevalence of recurrent aphthous ulceration in the Indian Population. J Clin Exp Dent 2014;6:e36-40.  Back to cited text no. 17
    
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Huling LB, Baccaglini L, Choquette L, Feinn RS, Lalla RV. Effect of stressful life events on the onset and duration of recurrent aphthous stomatitis. J Oral Pathol Med 2012;41:149-52.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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