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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]
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
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
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