Pathway to gleeful mouth is a cheerful tummy & reposeful

mind: A silver lining linkBy,Roshini ShettyMDS, Certified Forensic Odontologist, Certified Laser Dentist, Researcher with patented innovations, Medical writer.

DEPARTMENT OF ORAL & MAXILLOFACIAL PATHOLOGY

• Recurrent Aphthous stomatitis (RAS) is a common & painful oral mucosal pathosis which is a poorly understood clinical entity.

INTRODUCTION

Etiopathogenesis

Thought to be of a multifactorial etiology

Microbial factors

Local & systemic

conditions

Genetic

Nutritional

Immunological

Local trauma

Stress

Drugs

Hormonal change

Precipitating factors

Prevalence of RAS

5% to 25% in the general population[7]

As high as 50% to 80% in selected groups like medical and

dental students.[2,7]

Is there a link?

STUDY

Our study…. …is inspired by various clinical trials [1-9] trying to deliberately improve the quality of life of RAS patients by constant and enthusiastic research into the subject.

• Our Motto being, “ Community improvement by RAS perishment”

1) Assess the prevalence of RAS among medical and paramedical students of a Health University

2) Analyze the stress level in the affected individuals using validated ‘Depression anxiety stress scale’ (DASS)

3) To make a preliminary analysis of the link between gastrointestinal diseases and RAS

PURPOSE OF THE STUDY

Questionnaire based survey1) To assess the prevalence of RAS among health

professionals

• A total of 1400 students between 18-27 years age group studying in medical, dental and various paramedical courses of Yenepoya University were personally interviewed.

METHODOLOGY

2) To record the general details • Students who gave positive history for RAS were

included in the study as study group

• Questionnaire with the questions related to possible predisposing factors, etiological factors and clinical parameters was distributed among these selected subjects to record the details.

3) To assess the Depression, Anxiety and stress level in the study group

• Validated, ‘DASS’ questionnaire was administered to the selected subjects when they had active lesions during the study period.

4) To assess the gastrointestinal health status of subjects in the study group

• ‘Gastrointestinal health questionnaire’ was administered to the selected subjects to record the details.

Depression Anxiety stress

Normal 0-9 0-7 0-14

Mild 10-13 8-9 15-18

Moderate 14-20 10-14 19-25

Severe 21-27 15-19 26-33

Extremely severe 28+ 20+ 34+

DASS SCORING AND GRADING SCALE

SCORE GRADING

0-4 Low priority

5-8 Moderate priority

9+ High priority

GASTROINTESTINAL PROBLEMS SCORING AND GRADING

RESULTS• The data collected was analyzed using

descriptive statistics.

RAS prevalence

Total students in-terviewedStudents with RAS

7.8%Percentage

Percentage of Males vs Females among the study group

MalesFemales

63.4%

Medical Paramedical Dental0

10

20

30

40

50

60

70

Percentage of RAS among medical, paramedical & dental students

Percentage of RAS among medical, paramedical & dental students

70.5%

21.9%

7.6%

Minor RAS Major RAS Herpetiform RAS

0

10

20

30

40

50

60

70

80

90

100

Among the 3 types of RAS in study group

Among the 3 types of RAS in study group

91.54%

8.45%0%

Once in 2 weeks

Once a month

Once in 3 months

Once in 6 months

Once a year

No specific interval

0

5

10

15

20

25

30

35

40

45

Frequency (%)

12%

39%

9%

15%

10%

15%

Total subjects re-lated to diet

Spicy food Acidic food others0

2

4

6

8

10

12

14

16

Related to diet(%)

1%

15.6%

12.6%

2%

Prodromal symptoms prior to ulcer formation

No prodromal symptoms

Itching, irritation or burning prior to ulcer formation

90.6%

Other significant clinical findings obtained

Ulcers to be painfulUlcers interfered with eat-ing and speech

9.4%

87.6%92.3%

• Percentage of students who reported that there was correlation between their RAS and stress was 64% but when DASS was administered to the study group it was found that actually only 48% developed RAS during stress

Percentage of students in the study group who developed RAS during Depression, Anxiety and stress

No link Probable link0

10

20

30

40

50

60

70

80

90

Link between gastrointestinal diseases and RAS

15.6%

84.4%

Low priority Moderate priority High priority0

2

4

6

8

10

12

Severity of gastrointestinal problems (%)

12%

3.6%

0%

DISCUSSION1) Prevalence & significant clinical parameters obtained• Studies[1,2] show high prevalence of RAS in health

professionals as high as 50 to 80 % but our study showed relatively low prevalence of 7.8%

• Similar to previously conducted studies by investigators like Huling LB et al and Koybasi S et al, our study also shows that RAS is painful and interferes with eating and speech thus affecting the quality of life of RAS patients.

Huling LB, Baccaglini L, Choquette L,Feinn RS. Effect of stressful life events on the onset and duration of recurrent aphthous stomatitis. J Oral Pathol Med. 2012 ;41(2):149-52.

Koybasi S et al.Recurrent aphthous stomatitis: investigation of possible etiologic factors. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 229– 232

• Tharakji B et al have related diet and RAS. In our study, we found 12.6% subjects reported history of RAS on consumption of spicy food

• Since relation between prodromal symptoms & RAS was high in our study, effective intervention during this stage could prevent ulcers from progressing further.

Tharakji B et al.Effects of dietary habits on the development of RAS. Nigerian medical journal;2012;53: 194

2) Stress relation• Many investigators[2,3,4] have tried to find out the

correlation of RAS and stress with varying results

• In our study we found that the number of people who assume that their RAS is related to stress is more compared to people whose RAS & stress has the most probable correlation

• Few past studies conducted during 1977 [5,6]have reported that stress in the form of lecturer-student relationship and working environment in health professionals have contributed as a main role as a stressor and subsequent development of RAS

• These studies report high occurrence of stress related RAS among dental students but our study shows that prevalence as well as stress related RAS was least among dental students.

• More interactive learning, structured curriculum and a more friendly lecturer-student relationship in the recent times may have contributed to the low level of stress related RAS occurrence

3) Gastrointestinal health & RAS relation• Various studies[1,7,8] show variable results in regard to the

association of RAS with gastrointestinal problems with few showing well established convincing evidence linking the both while others concluding no apparent etiological link between the two.

• In our study, we found moderately high percentage of students with RAS presumably due to associated gastrointestinal problems with moderate severity.

• As RAS are most of the times treated without a definite

diagnosis, we emphasize the need to search & screen for underlying systemic illness in the differential diagnosis of RAS, so that it would immensely contribute to permanently cure RAS rather than a symptomatic treatment.

CONCLUSION

There are many intriguing aspects in the relationship of stress, gastrointestinal problems and RAS, the major part of which has to be unveiled still through more dedicated studies in future.

THANKYOU

“A goal is a dream with a deadline.” Napoleon Hill

• Hope our dream to prevent RAS occurrence will meet the deadline soon with success.

3rd Prize in 33rd Annual conference of Indian Association of Biomedical Scientists

REFERENCE1)Koybasi S et al.Recurrent aphthous stomatitis: investigation of possible etiologic factors. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 229– 232

2)Safadi R. Prevalence of recurrent aphthous ulceration in Jordanian dental patients. BMC Oral Health 2009; 9:31

3) Huling LB, Baccaglini L, Choquette L,Feinn RS. Effect of stressful life events on the onset and duration of recurrent aphthous stomatitis. J Oral Pathol Med. 2012 ;41(2):149-52.

4)Gaphor M. Clinical observation of recurrent aphthous stomatitis in Sulaimania.J Bagh Coll Dentistry 2009; 21(1): 74-79

5) Gallo et al. Academic stress and RAS in health professionals. Clinics;1977:67(2):135

6) Willcock SM, Daly MG, Tennant CC and Allard BJ. Burnout and psychiatric morbidity in new medical graduates. The Medical Journal of Australia 2004; 181(7): 357 – 360.

7)Field E & Allan R. Review article: oral ulceration aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic. Aliment Pharmacol Ther 2003; 18: 949–962.

8)Yaşar S, Yaşar B, Abut E, Serdar Z.Clinical importance of celiac disease in patients with recurrent aphthous stomatitis. Turk J Gastroenterol. 2012 Feb;23(1):14-8.

9)Tharakji B et al.Effects of dietary habits on the development of RAS.Nigerian medical journal;2012;53: 194