Assessment of Prevalence of Recurrent Aphthous Stomatitis in the North Indian Population: A Cross-Sectional Study.

AIM AND
OBJECTIVE: The present study was undertaken for assessing the prevalence of recurrent aphthous stomatitis (RAS) in the North Indian population.
MATERIALS AND METHODS: Assessment of a total of 4255 patients was done over a period of 2 years, who came for a routine dental checkup. Recording of the complete demographic and clinical details of all the patients was done. The prevalence of RAS was assessed. Profile of patients with RAS was assessed separately. A pro forma was made and the type of treatment protocol followed by patients with RAS was also recorded. All the results were recorded in a Microsoft Excel sheet and were analyzed using SPSS software.
RESULTS: Analysis of a total of 4255 patients was done. RAS was found to be present in 800 patients. The overall prevalence of RAS was found to be 18.93%. Significant results were obtained when analyzing age, gender, and occupation as risk factors for RAS. Labial/buccal mucosa involvement occurred in 51.875% of the cases. In 44% of the cases, the size of the RAS was between 1 cm and 3 cm. Home remedy was followed in 17.875% of the cases.
CONCLUSION: A significant proportion of patients in the North Indian population is affected by RAS. In comparison to males, females are more commonly affected. Copyright:

INTRODUCTION

One of the most frequently encountered diseases of oral cavity is recurrent aphthous stomatitis (RAS), also referred to as canker sores. Clinically, the presentation of RAS varies from a single of multiple extremely discomforting ulcerations with no linkage with any other systemic problems. Till now, the cause and the pathogenesis of RAS are not known. A plethora of causative factors have been linked to the occurrence of this pathology, some of which include a genetic tendency, hypersensitivity to certain food products, stoppage of smoking, immunological disturbances, and high-stress levels.[1] There is, however, no presence of any statistical risk analysis for any of these evidences. RAS may also be triggered owing to some immune dysregulations. Bioinformatic analyses carried out on big scales have verified the role played by the immune setup of the individual and the inflammatory process in the establishment of this disease.[234]

With no definitive etiology, RAS is often difficult to treat causing significant pain to the patients. Reappearance of RAS can be attributed to family history, psychosomatic, infectious, hormonal influences, physical trauma, psychological stress, allergies to certain food products, dietary deficiencies (iron, Vitamin B12, and folic acid), and hematological disturbances. RAS is characterized by lack of presence of any specific biochemical and histological changes which make the diagnosis of recurrent aphthous ulcers difficult.[345] Hence, the present study was undertaken for assessing the prevalence of RAS in the North Indian population.

MATERIALS AND METHODS

The present study was planned with the aim of evaluating the prevalence of RAS in the North Indian population. Assessment of a total of 4255 patients was done over a period of 2 years, who came for a routine dental checkup. Recording of the complete demographic and clinical details of all the patients was done. Clinical examination and oral checkup of all the patients were done. Socioeconomic status of all the patients was assessed using the Kuppuswamy scale.[6] According to this scale, socioeconomic status was divided into upper class, middle class, and lower class. The prevalence of RAS was assessed. A criterion defined by Axell in their study on Swedish people was used for the identification and diagnosis of RAS.[7] Profile of patients with RAS was assessed separately. A pro forma was made and type of treatment protocol followed by patients with RAS was also recorded. All the results were recorded in a Microsoft Excel sheet and were analyzed by SPSS software version 16.0 (IBM, Armonk, New York). Chi-square test was used for the assessment of the level of significance. P ≤ 0.05 was considered statistically significant.

RESULTS

In the present research, analysis of a total of 4255 patients was analysed. RAS was found to be present in 800 patients [Graph 1]. The overall prevalence of RAS was found to be 18.93%. Among these RAS patients, the mean age was reported to be 29.86 years. Approximately 60% of the patients with RAS belonged to the age group of 20–30 years. Majority of the patients (67%) were male. Student population was the predominant population affected by RAS (56.375%) in the present study. Significant results were obtained when analyzing age, gender, and occupation as risk factors for RAS as shown in Table 1. Table 2 shows the distribution of RAS patients to the profile of RAS and type of treatment. Labial/buccal mucosa involvement occurred in 51.875% of the cases. In 44% of the cases, the size of the RAS was between 1 cm to 3 cm. In 29.125% of the cases, time period of the resolution was from 2 weeks to 1 month. In 20.75% of the cases, no treatment was done. In 22.25% of the cases, patients followed allopathic treatment. Home remedy was followed in 17.875% of the cases.

Graph 1

Prevalence of recurrent aphthous stomatitis

Table 1

Age- and gender-wise distribution

Parameter	n (%)	P
Age group (years)
<20	48 (6)	0.020 (significant)
20-30	485 (60.625)
31-40	125 (15.625)
41-50	64 (8)
51-60	46 (5.75)
>60	32 (4)
Gender
Males	264 (33)	0.001 (significant)
Females	536 (67)
Occupation
Housewife	2 (0.25)	0.049 (significant)
Student	451 (56.375)
Professional	113 (14.125)
Non-professional	156 (19.5)
Others	78 (9.75)
Nutritional status
Ill nourished	216 (2)	0.281
Moderately nourished	241 (17.625)
Well nourished	343 (80.375)

Table 2

Distribution of recurrent aphthous stomatitis patients to profile of recurrent aphthous stomatitis and type of treatment

Parameter	Number of patients	Percentage	P
Site
Upper lip	42	5.25	0.008 (Significant)
Lower lip	32	4
Soft palate	166	20.75
Fauces	92	11.5
Labial/Buccal mucosa	415	51.875
Others	53	6.625
Size
<1 cm	215	26.875	0.344
1-3 cm	352	44
>3 cm	233	29.125
Time period of resolution
<2 days	185	23.125	0.711
2 days-2 weeks	199	24.875
2 weeks-1 month	233	29.125
>one month	182	22.75
Treatment
No treatment	166	20.75	0.627
Allopathy	178	22.25
Glycerine	11	1.375
Homeopathy	12	1.5
Home remedy	143	17.875
Others	290	36.25

DISCUSSION

RAS is the most common painful oral pathology witnessed among patients. Clinically, they appear in childhood or adolescence first and present as recurring solitude or multiple, ovoid, or round-shaped ulcers having circumscribed margins, with grayish or yellowish floors and erythematous haloes. Almost 80% of cases of RAS are mild in nature constituting the maximum prevalent form of the disease. RAS may predispose to a number of other oral diseases such as caries and periodontitis due to the inability of the patients to maintain oral hygiene and having dietary restrictions. Owing to high prevalence rates, severe pain, and the compromised quality of life a patient experiences, RAS can be equated to a public health burden.[789] Hence, the present study was undertaken for assessing the prevalence of RAS in the North Indian population.

In the present research, analysis of a total of 4255 patients was analyzed. RAS was found to be present in 800 patients. The overall prevalence of RAS was found to be 18.93%. On average, 5%–66% of individuals suffer from RAS with varying prevalence among populations of different nations and different age sections. In studies conducted on children in the US and Iran, the general prevalence of canker sores was calculated to be around 40% and 25.2%, respectively. Another study reported the prevalence of RAS to be 21.7%. Another previous study reported that 705 patients had RAS. A much greater prevalence of RAS was observed by Safadi in the Jordanian population with figures of 78%, whereas a significantly lower prevalence of 1.53% was calculated by Bhatnagar et al. among the children visiting dental schools of North India.[8910111213]

In the present study, the majority of the patients (67%) were male. Student population was the predominant population affected by RAS (56.375%). Significant results were obtained when analyzing age, gender, and occupation as risk factors for RAS. A few authors have cited hormonal variations to be responsible for a higher female predilection toward RAS. Progesterone levels seem to be related to the occurrence of RAS which can be explained by its increased incidence during the luteal phase of the menstrual cycle and a reduction in its cases during pregnancy.[1415]

In the present study, labial/buccal mucosa involvement occurred in 51.875% of the cases. In 29.125% of the cases, time period of the resolution was between 2 weeks to 1 month. Patil et al. assessed the prevalence of recurrent aphthous ulcerations among Indians. A total of 3244 patients were enrolled in this study who had presented to the department of oral medicine and radiology for various ailments. Of these, 1669 were female and the remaining 1575 were male. A total of 705 patients were diagnosed with recurrent aphthous ulceration (21.7%). Females comprised 56.3% of the cases, whereas males comprised 43.7% of the cases. Most of the patients who were affected belonged to the thirdor fourth decade of life. In almost 386 patients, stress came out to be the causative factor. It was seen that 54.5% of patients did not opt for medicines and even a higher figure of 72.9% of patients felt no need for a dental consultation. As per the results of their study, RAS is a very common oral condition among Indians.[16]

In the present study, in 20.75% of the cases, no treatment was done. In 22.25% of the cases, patients followed allopathic treatment. Home remedy was followed in 17.875% of the cases. Preeti et al. carried out a study with a view to delineate the treatment, diagnosis, and etiology of recurrent aphthous ulcerations. This study involved a total of 4895 patients. It was observed that 161 (3.3%) patients had problems of oral aphthous ulcerations. Out of these, recurrent aphthous ulcerations were observed in 76 (47.2%) patients, and 68 (42.2%) patients had the necessary clinical data for assessment and evaluation. In general, dental surgeons, dermatologists, and otorhinolaryngologists have the initial encounter with these patients.[17] A composite index was proposed by Mumcu et al., which monitored the clinical presentations of oral ulcers in patients who were suffering from RAS and Behcet's disease. They were of the opinion that valuable data with regard to the prognosis and treatment of these diseases can be gathered from such indices.[18] Huling et al. assessed the link between the occurrence, type, and magnitude of stressful events and the onset and duration of RAS episodes. A total of 160 patients were enrolled in this study. A weekly telephonic survey was carried out for 1 year and the data were gathered regarding the appearance of RAS episodes and a detailed record of any kind of stress encountered in the lifestyle during the previous week. Recent Life Changes Questionnaire was used to quantify and validate any stressful episodes which were subsequently segregated into mental or physical stressors. It was observed that the occurrence of RAS (P < 0.001) could be significantly attributed to stressful life events, but the duration of disease could not be attributed to the same. There was an almost three times predisposition in the onset of RAS with a stressful life event. There was no increase in the frequency or duration of RAS with increase in the severity of stress. Stressful incidences may initiate fresh RAS episodes, particularly in patients who have had a history of RAS.[19]

CONCLUSION

Under the lights of above-obtained results, the authors concluded that a significant proportion of patients in the North Indian population is affected by RAS. In comparison to males, females are more commonly affected. However, further cross-sectional studies are recommended.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.