|Year : 2014 | Volume
| Issue : 2 | Page : 70-74
Status of occurrence of recurrent apthous stomatitis in a group of Libyan patients
Sujata M. Byahatti
Department of Oral Medicine and Radiology, M M's N.G. Halgekar Institute of Dental Sciences and Research Centre, Belgaum, Karnataka, India
|Date of Web Publication||5-Jun-2014|
Sujata M. Byahatti
Department of Oral Medicine and Radiology, M M's N.G. Halgekar Institute of Dental Sciences and Research Centre, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
Aim/Objective: This prospective study had a questionnaire prepared to get the information regarding recurrent apthous stomatitis (RAS) in a group of Libyan patients. Materials and Methods: A questionnaire containing a total of 14 questions giving personal and apthous ulcer details were recorded. All the details of each patient were entered into Microsoft Excel sheet and the details were recoded and interpreted. Results: Among 7500 patients who visit the outpatient department every year 460 (6%) of them who were volunteers and gave a history of RAS were selected in the study group. The age of these patients ranged between 10 and 45 years. Among different types of ulcers, 48 (10%) of them showed major apthous ulcer formation, 404 (88%) of them had minor apthous ulcer formation, whereas 8 (2%) of them had herpetiform ulcers. Among 460 patients with h/o RAS 46 (10%) of them were sufferings from different systemic health problems. Total 120 (26%) of them had triggers before the occurrence of RAS and 325 (70%) patients were without any triggers 15 (4%) of them were not aware of any triggers. When the question was asked about occurrence of RAS whether it is related to stress, 384 (83%) of them correlated it with stress and 76 (17%) of them did not. Different sites with their recurrence and duration of the ulcer were recorded. About 45 (9%) were on different treatment modalities. Among 460 of them, 156 (34%) of them had RAS at the day of examination and 304 of them were free from ulcers 304 (66%). Conclusion: Early detection and management of these patients by finding underlying etiology is essential for better management of these cases.
Keywords: Diagnostic criteria, recurrent apthous stomatitis, stress ulcers
|How to cite this article:|
Byahatti SM. Status of occurrence of recurrent apthous stomatitis in a group of Libyan patients. J Dent Res Rev 2014;1:70-4
|How to cite this URL:|
Byahatti SM. Status of occurrence of recurrent apthous stomatitis in a group of Libyan patients. J Dent Res Rev [serial online] 2014 [cited 2021 Mar 6];1:70-4. Available from: https://www.jdrr.org/text.asp?2014/1/2/70/133940
| Introduction|| |
Recurrent apthous stomatitis (RAS) is a common disease of the oral cavity, affecting about 20% of the world's population,  women are more affected than men, and in the most cases it starts around the first decade of life. The ulcers in these patients present as recurrent, multiple, small, round, or ovoid, with circumscribed margins, having yellow or gray floors and are surrounded by erythematous haloes, present first in childhood or adolescence. 
This disease may manifest itself in three different types. The minor type is characterized by a small ulcer, measuring from 3 to 10 mm in diameter, located in the nonkeratinized mucosa, alone or even in large quantities in the mouth. , The major type is characterized by an extensive and painful ulcer, measuring more than 10 mm in diameter, also present in keratinized mucosa, usually alone, and can take more than 15 days to heal completely, and it may leave scars in the mucosa. The third type is herpes-like, characterized by numerous small ulcers that coalesce, and this is the rarest form of the disease. ,
Until date, very little documentation is reported regarding its occurrence and distribution and types in Libyan population. The following paper reports one such clinical oral finding in detail with its variations in clinical occurrence in the Libyan general population.
| Materials and Methods|| |
A questionnaire containing a total of 14 questions in which five questions giving the personal details of the patient which included name, age, sex, and smoker/nonsmoker, medical history were recorded. The names of these patients were kept confidential. Whereas nine questions related to apthous ulceration (which included whether patient has any history of RAS or no, if they had history of RAS then what are the triggering factors, whether it is related to exam/stress or not, duration of the ulcer present, number of days took for healing, any medication patient taking for the same problem, during their visit whether they had any ulcer in the mouth and site) were recorded.
There are nearly 7500 patients who visit the outpatient department every year among these 460 (6%) of them who were volunteers and gave the history of occurrence of RAS were selected in the study group. The objective of this study was explained to all of them and the questionnaire regarding information about the occurrence of RAS was distributed for further collection of information. Inclusion of all of those cases who were volunteers for the study, irrespective of the occurrence of the RAS was done. Exclusion of those cases who failed to give informed consent was done. All the details of each patient were entered into Microsoft Excel sheet and the details were recoded and interpreted.
| Results|| |
A prospective questionnaire study on the occurrence of RAS in a group of Libyan patients was done at the outpatient Department of Oral Medicine and Radiology, Faculty of Dentistry, Benghazi, Libya. There are nearly 7500 patients who visit the outpatient department every year among these 460 (6%) of them who were volunteers and gave a history of occurrence of RAS were selected in the study group. Among these 460 patients, 309 (67%) were female and 151 (33%) were males. Among 151 male patients, 108 (71%) of them were smokers and 43 (29%) of them were nonsmokers. Among 108 males, 96 (63%) of them had history of RAS.
The age of these patients ranged between 10 and 45 years. These patients were later divided into three groups, where the first group included the patients between 10 and 21 years of age and second group included the patient's age ranging between 22 and 31 years of age and the third group included 32 and 41 years of age group [Table 1] and [Table 2].
Among different types of ulcers, 48 (10%) of them showed major apthous ulcer formation, 404 (88%) of them had minor apthous ulcer formation, whereas 8 (2%) of them had herpetiform ulcers. Among 48 patients with major apthous ulcer 36 (75%) of them were males and 12 (25%) of them were females.
Among 404 patients with minor apthous ulcer 126 (31%) of them were males and 278 (69%) of them were females.
Among eight patients with herpetiform apthous ulcer 3 (37%) of them were males and 5 (63%) of them were females.
Among 460 patients with a history of RAS 46 (10%) of them were suffering from systemic health problems such as gastritis 15 (3%), diabetes 6 (1%), hypertension (2%), celiac disease (1%), ulcerative colitis 10 (2%), and 24 (5%) of them gave family history of gastritis and remaining 390 (85%) of them had no other systemic problems.
A total of 120 (26%) of them had triggers before the occurrence of RAS and 325 (70%) patients were without any triggers 15 (4%) of them were not aware of any triggers. Stress, trauma, abdominal pain, burning sensation, common cold, gastritis, and menstrual cycle in females were among triggering factors in these patients [Table 3].
When the question was asked about occurrence of RAS whether it is related to stress, 384 (83%) of them correlated it with stress and 76 (17%) of them did not. Among 384 patients, 118 (30%) were males and 266 (70%) were females. Remaining 76 patients in whom 45 (59%) of them were males and 31 (41%) were females.
[Table 4] shows among 460 patients 125 (27%) of them had RAS occurring on the left side of buccal mucosa. Followed by right buccal mucosa 65 (14%), upper labial mucosa 45 (9.7%), lower labial mucosa 35 (7%), and right lateral border of tongue 35 (7%).
Whereas, [Table 5] shows among total of 460 patients 145 (33%) of them had recurrence at the interval of 3 months, followed by 6 months 116 (25%) with least being monthly occurrence 15 (3%).
Duration of the ulcer varied from 2 to 10 days [Table 6]. [Table 7] shows various treatment modalities they were following to get relief from ulcer. About 335 (73%) of them were not on taking any treatment. Whereas 45 (9%) were on top. Hydrocortisone, 20 (4%) of them were using chlohex mouthwash or orabase/top anesthetic and tetracycline tablet crush and place.
Among 460 of them 156 (34%) of them had RAS at the day of examination and 304 of them were free from ulcers 304 (66%). Among 156 of them in which 92 (59%) of them were males and 64 (41%) of them were females.
| Discussion|| |
Recurrent aphthous stomatitis is one of the most common oral mucosal lesions seen in primary care. The Greek term "aphthai" was initially used for disorders of the mouth and is credited to Hippocrates. 
The frequency of aphthous ulcers is up to 25% in the general population, and 3-month recurrence rates are as high as 50%.  RAS is an idiopathic condition in most patients. Whereas our study noted the frequency of occurrence of RAS was 6%. This variation in different studies again depends upon the sample size and also from place to place.
Recurrent apthous stomatitis has been described under three different clinical variants as classified by Stanley in 1972. 
Minor RAS is also known as Miculiz's aphthae or mild aphthous ulcers. It is the most common variant, constituting 80% of RAS. Ulcers vary from 8 mm to 10 mm in size. It is most commonly seen in the nonkeratinized mucosal surfaces such as labial mucosa, buccal mucosa, and floor of the mouth. Ulcers heal within 10-14 days without scarring.
In accordance with the above study our study showed among 460 patients with RAS 404 (88%) of them had minor aphthous ulcer formation. Among 404 patients with minor aphthous ulcer 126 (31%) of them were males and 278 (69%) of them were females. The common sites affected for minor aphthae were right and left buccal mucosa, upper and lower labial mucosa, buccal vestibule, commissure of lip, right lateral, left lateral side, and tip for tongue.
Major RAS is also known as periadenitis mucosa necrotica recurrens or Sutton's disease. It affects about 10-15% of patients. Ulcers exceed 1 cm in diameter. Most common sites of involvement are lips, soft palate, and fauces. Masticatory mucosa like dorsum of tongue or gingiva may be occasionally involved.  The ulcers persist for up to 6 weeks and heal with scarring.
In accordance with the above study our study showed among different types of ulcers 48 (10%) of them showed major aphthous ulcer formation. Among these 48 patients with major aphthous ulcer 36 (75%) of them were males and 12 (25%) of them were females. Buccal vestibule, commissure, dorsal, and lateral surface of tongue and palate where herpetiform ulcers noted.
Herpetiform ulceration is characterized by recurrent crops of multiple ulcers; may be up to 100 in number. These are small in size, measure 2-3 mm in diameter. Lesions may coalesce to form large irregular ulcers. These ulcers last for about 10-14 days. Unlike herpetic ulcers, these are not preceded by vesicles and do not contain viral infected cells. These are more common in women and have a later age of onset than other clinical variants of RAS. 
In accordance with the above study our study showed 8 (2%) of them had herpetiform ulcers. Among these eight patients with herpetiform apthous ulcer 3 (37%) of them were males and 5 (63%) of them were females. Dorsal and lateral surface of tongue and palate where herpetiform ulcers noted.
The etiology of aphthous stomatitis is not clear and is probably diverse.  The association between oral ulceration, diarrhea, and weight loss has been noted for 300 years,  and the incidence of recurrent aphthous ulceration (RAU) is high in idiopathic steatorrhea  and coeliac disease.  RAS may be a marker of an underlying systemic illness, such as celiac disease, or may present as one of the features of Behcet disease, in most cases no other body systems are affected and patients remain otherwise fit and well. Because the etiology is unknown, diagnosis is entirely based on history and clinical criteria; no laboratory procedures exist to confirm the diagnosis. ,,,
In our study, 46 (10%) of them were suffering from systemic health problems such as gastritis 15 (3%), diabetes 6 (1%), hypertension (2%), celiac disease (1%), ulcerative colitis 10 (2%), and 24 (5%) of them gave family history of gastritis and remaining 390 (85%) of them had no other systemic problems.
Many factors have already been implicated in the promotion and/or exacerbation of RAS; these include positive family history, local trauma where trauma to the oral mucosa due to local anesthetic injections, sharp tooth, dental treatments, and tooth brush injury may predispose to the development of RAU.  Wray et al.  in 1981 proposed that mechanical injury may aid in identifying and studying patients prone to aphthous stomatitis. Other factors include nutritional deficiency, food hypersensitivity, immune disturbance, smoking cessation, and psychological stress, among others. ,,
In accordance with the above study our study showed 120 (26%) of them had triggers before the occurrence of RAS and 325 (70%) patients were without any triggers 15 (4%) of them were not aware of any triggers.
Stress 35 (29%), common cold 8 (6%), burning sensation 14 (11%), trauma 20 (16%), abdominal pain 16 (13%), menstrual cycle in females 12 (10%), and gastritis 15 (12.5%) were among triggering factors in these patients.
Several studies reveal negative association between cigarette smoking, smokeless tobacco, and RAS. Possible explanations given include increased mucosal keratinization; which serves as a mechanical and protective barrier against trauma and microbes. ,, Nicotine is considered to be the protective factor as it stimulates the production of adrenal steroids by its action on the hypothalamic adrenal axis and reduces production of tumor necrosis factor alpha and interleukins 1 and 6 (IL-1 and IL-6).  Nicotine replacement therapy has been suggested as treatment for patients who develop RAU on cessation of smoking. 
In our study, out of 151 male patients 108 (71%) of them were smokers and 43 (29%) of them were nonsmokers. Among 108 males 96 (63%) of them had history of RAS.
Stress has been emphasized as a causative factor in RAU. It has been proposed that stress may induce trauma to oral soft tissues by parafunctional habits such as lip or cheek biting and this trauma may predispose to ulceration. A more recent study shows lack of direct correlation between levels of stress and severity of RAS episodes and suggests that psychological stress may act as a triggering or modifying factor rather than etiological factor in susceptible RAS patients.  In our study, 35 (29%) of them gave stress as one of the triggering factor in causing RAS.
Medical preparations from herbs and multivitamins, , adhesive pastes,  local antiseptics,  local and systemic antibiotics, , topical nonsteroidal antiinflammatory drugs,  topical corticosteroids,  and even topical and systemic immunomodulators, immunosuppressants, and corticosteroids ,,, were among the treatments given to patients with RAS. Most of these achieve "short-term" therapeutic goals, such as the alleviation of pain, a reduction in the number of ulcers and their size and duration. ,,,,, Very few treatments have achieved "long-term" therapeutic goals, such as reduction of the frequency of RAS and maintenance of remission. ,,,,
In our study, about 335 (73%) of them were not on taking any treatment. Whereas 45 (9%) were on top. Hydrocortisone, 20 (4%) of them were using chlohex mouthwash or orabase/top anesthetic and tetracycline tablet crush and place.
| Conclusion|| |
Recurrent aphthous stomatitis is a common painful ulceration occurring in the oral cavity. The etiopathogenesis of this disease is not clear. Treatment strategies must be directed toward providing symptomatic relief by reducing pain, increasing the duration of ulcer-free periods, and also by accelerating ulcer healing. Although, the sample collected in the above mentioned study is smaller, the larger sample with wider area coverage is essential for understanding the diseases in general.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]