|Year : 2017 | Volume
| Issue : 2 | Page : 82-86
Association of recurrent aphthous stomatitis and psychological stress in school going teenagers of Bhopal city, Central India: A descriptive study
Pooja Khare1, Vijayta Sharva2, Hina Handa2, Khare Amit3, Manish Jain2
1 Department of Oral Medicine and Radiology, Peoples Dental Academy, Bhopal, Madhya Pradesh, India
2 Department of Public Health Dentistry, Peoples Dental Academy, Bhopal, Madhya Pradesh, India
3 Department of Prosthodontics and Crown and Bridge, People's College of Dental Sciences and RC, Bhopal, Madhya Pradesh, India
|Date of Web Publication||28-Dec-2017|
Dr. Pooja Khare
Department of Oral Medicine and Radiology, Peoples Dental Academy, Bhopal - 462 016, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Aims and Objectives: The present study was framed with the intention to find the prevalence of psychological stress and aphthous ulcer in school going teenagers of Bhopal district and to find a correlation between the two and also to find a gender predilection for psychological stress and aphthous ulcer.
Materials and Methods: The present study is a questionnaire-based study, and the questionnaire was derived from Ministry of Social Security, National Solidarity and Reform Institutions. It is a twenty-item scale with eighteen positive and two negative questions. Eight private and eight government schools were chosen, and the students were asked to fill the questionnaire. Students were divided into four categories depending on the level of stress.
Results: Among the study group, 32.4% (382) of males and 46.6% (437) of females suffered from the aphthous. Nearly 84.2% of females and 64.7% males were stressed which was significant.
Conclusion: Stress and aphthous have a positive correlation, and therefore, most of them who had ulcers were found to be stressed. It is therefore need of the present academic curriculum to inculcate stress-free environment for a healthy mind in a healthy body.
Keywords: Psychological stress; recurrent aphthous stomatitis; school going teenager
|How to cite this article:|
Khare P, Sharva V, Handa H, Amit K, Jain M. Association of recurrent aphthous stomatitis and psychological stress in school going teenagers of Bhopal city, Central India: A descriptive study. Indian J Multidiscip Dent 2017;7:82-6
|How to cite this URL:|
Khare P, Sharva V, Handa H, Amit K, Jain M. Association of recurrent aphthous stomatitis and psychological stress in school going teenagers of Bhopal city, Central India: A descriptive study. Indian J Multidiscip Dent [serial online] 2017 [cited 2018 Aug 14];7:82-6. Available from: http://www.ijmdent.com/text.asp?2017/7/2/82/221760
| Introduction|| |
Oral ulceration has plagued humankind since antiquity and perplexed clinicians since the beginnings of organized medicine. Although they are self-healing but still troublesome, these recurrent forms are known as aphthous ulceration, or aphthae. Recurrent aphthous stomatitis (RAS) is one of the most common misdiagnosed and poorly understood mucosal disorders. It has spared no men and women of any age, race, and geographic region. It occurs more frequently in times of stress,, and the stress was identified as the most common factor, leading to recurrent ulcerations in the Indian population. These ulcers have a significant negative impact on the oral health, irrespective of the cause, affecting the quality of life; interfering with eating, speaking, and may result in missed school days. Hence, it is important to know the prevalence of these ulcerations in the school going teenagers. Hence, the aim of this study was to know the prevalence of psychological stress and aphthous ulcers among school going teenager and to know the association between them.
| Materials and Methods|| |
The study was conducted in Bhopal district of Madhya Pradesh in India. Bhopal was divided into four zones, and two government and two private schools were chosen from each zone. Ethical clearance was obtained by the ethical committee of the institution. Prior telephonic permission and appointment were taken from the principals of schools. Simple random sampling method was used, students were selected on lottery basis from the attendance register provided they should be the regular students and the medium of study should be either English or Hindi. Totally, twenty-five students were chosen from each class, and the study sample comprised of 1600 students. 15 government and 5 private school students remained absent on the day of screening. Therefore, total students screened were 1580. Ten questionnaires were rejected because of missing informations and the final students enrolled in the study were 1570 [Diagram 1].
Intraoral examination was conducted by dentist specialized in Oral Medicine and Radiology to check for and aphthous ulcer. Equipment used were mouth mirror and probe with proper illumination. Stress was evaluated through the self-administered questionnaire derived from by Ministry of Social Security, National Solidarity and Reform Institutions, which is 20-item scale with 18 positive and two negative questions. The options were never, rare, often, very often relating to the level of stress on 0–4 scale. Eighteen positive questions were positive scored and two negative ones were reverse scored. The questions reflected the behavior of students in the classroom and their inclination toward the studies.
Measurement of stress
Based on the total score of the questionnaire, students were divided into 4 groups – (1) No stress 0–20, (2) low stress 21–40, (3) medium stress 41–60, and (4) high stress 61–80. For statistical analysis, SPSS version 20 (SPSS Pty Ltd, Chicago, IL, USA) was used for the statistical analysis. The statistical tests used were the t-test for continuous variables and the Chi-square test for categorical data. P < 0.05 was considered statistically significant.
| Results|| |
A total of 1570 school students of Class IX to XII comprised the study sample. Eight government and 8 private schools of Bhopal district were involved in the study. In government school, 761 students (48.5%) were surveyed, and in the private schools, 809 (51.5%) were surveyed. Over half of the total student's population was comprised of male students 879 (55.7%) [Table 1].
|Table 1: Demographic details and association of recurrent aphthous stomatitis and psychological stress|
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A modified self-administered questionnaire of Ministry of Social Health to assess the stress level and the presence of recurrent aphthae was distributed to the students and assessed for stress levels. Based on the total score of the questionnaire, students were divided into 4 groups – (1) No stress 0–20, (2) low stress 21–40, (3) medium stress 41–60, and (4) high stress 61–80.
Among the study groups, 32.4% (382) of males and 46.6% (437) of females suffered from the aphthous. Nearly 84.2% of females and 64.7% males were stressed [Table 1].
Out of 761 government school students, 46.1% (351) were found to have aphthous whereas out of 809 private school students, 31.7% (256) were found to have aphthous. Nearly 74.4% (566) of government school students were found to have stress and in case of private schools, prevalence of stress was 72.4% (585) [Table 1].
In the surveyed 16 schools, 29.7% (465) students attended Class IX, 29.8% (467) students attended Class X, 24.8% (389) students attended Class XI, and 15.8% (248) attended Class XII [Table 1].
| Discussion|| |
India, a developing nation, experiences a considerable burden of occult oral disorders necessitating thorough oral care, with RAS being one of them. RAS presents itself as multiple painful ulcers all over the oral cavity. This study was conducted with an effort to determine the prevalence of RAS, among school going teenagers in Bhopal, Madhya Pradesh and to correlate it with the level of stress.
In the present study, we found a point prevalence of 13.7% and lifetime prevalence of 38.7% of aphthous ulcers in school going teenagers. In Indian scenario, Mathew et al. and Bhatnagar et al. reported 2.1% and 1.53% point prevalence of aphthous ulcer which is less than our study results; however, they studied a population with age group ranging from 21 to 40 years and 15–75 years, respectively.
Among the studies conducted overseas, Axéll et al. reported the prevalence of 17.7% in Sweden in the age group of 15 years or more. Kovac-Kovacic et al. studied a Slovenian population of the age range of 25–75 years and reported 9.7% prevalence of aphthous. Ciçek et al. reported the prevalence of 25.5% among Turks with a mean age of 30.4 years. Shulman et al. reported a lifetime prevalence of 40.18% among children and adolescents of the USA. Safadi. reported 78% prevalence of recurrent aphthous in Jordanian population with the age range of 30–68 years. Leonardo et al. reported 78.67% prevalence of recurrent aphthous in a region of Brazil in the age range of 18–76 years. Abdullah et al. reported a lifetime prevalence of 28.2% in a region of Iraq in the age range of 10–79 years. The difference in the prevalence of aphthous among the nations can be attributed to the combination of their social, economic, and geographical characteristics as well as their residents' cultural, religious, and personal values.
The present study showed a female preponderance for aphthous (46.6%) which was statistically significant [Table 1]. This is in accordance with some studies which also showed greater prevalence of aphthous among the females ,, whereas the study conducted by Bhatnagar et al. in North India found increased prevalence of aphthous among males.
As per the reports of some nongovernment organization, one in every two girls in India is undernourished. Deficiency of iron, marginal deficiency of other micronutrients such as iodine, vitamin A, calcium, phosphorus magnesium, and zinc may exist in the undernourished adolescent girls which may lead to mucosal lesions like recurrent aphthous ulcers.,
In our study, the prevalence of aphthous in students in rural area was 47.7% and in students belonging to urban area was 35.2% [Table 1] which is in accordance with the study conducted by Atkin et al., who reported higher prevalence of aphthous in rural areas.
Several studies have reported stress as an etiologic factor for RAS , which was evaluated in the presented study. Authors have reported positive association of stress and aphthous ulcer.,
Our study shows that 73.4% of school going teenagers were stressed [Table 1]. Yacoob et al. conducted a study in the age group of 13–17 years in Malaysia and reported the stress prevalence of 28.13%. Sahoo et al. reported 20% prevalence of stress among the adolescents with mean age of 19.3 years in Ranchi, which is less than our study. However, they studied only male population. Saini et al. conducted a study among the resident doctors of Delhi in the age group of 24–39 years and reported 32.8% prevalence of stress. Koochaki et al. reported a prevalence of 61.3% among the medical college students of Iran. Sani et al. conducted a study among the medical college students of age range 18–26 years in Saudi Arab and reported a prevalence of 71.9% stress among them.
Our study reported significant and higher stress in females (84.2%) than males (64.7%) which is in accordance with other studies., However, studies done by Koochaki et al. and Bhasin et al. showed no significant difference of stress levels between the genders. Stress is multifactorial with different factors or combination of factors such as environment, psychology, biology working together with their social, economic, and geographical characteristics as well as their residents' cultural, religious, and personal values. In India, conservative, social, and cultural values could contribute to more stress in females.
Our study showed significant relationship (P = 0.000) between classes (9th, 10th, 11th, and 12th) and stress [Table 1]. The prevalence of stress was higher in class 10th (77.9%) and 12th (89.2%) as compared to class 9th (75.4%) and 11th (68.5%) which is in accordance with the study by Bhasin et al., who reported higher level of stress in 10th and 12th class students as they face tremendous pressure with regard to not only their performance in the board examinatios but also as basis for selection in professional examinations. Our orthodox society and the age old examination pattern emphasizes on the results of these two board examinations which is taken as a measure of their entire academic caliber. This could catalyze the higher levels of negative mental states such as depression and stress among the students belonging to these classes, and that too, just at the beginning of the academic term. The higher stress could probably be the explanation of higher prevalence of aphthous in class 10th (37.5%) and 12th (53.8%) as compared to class 9th (37.4%) and 11th (32.06) which was statistically significant.
In our study, we found statistically significant and higher stress in government school students (74.4%) than private school students (72.4%) [Table 1] which is in accordance with the findings of Augustine et al. and Kumar et al.
Accordingly, we found higher prevalence of aphthous in government school students (46.1%) than in private school students (31.7%) [Table 1]. Due to the high competitive nature of private schools preparing the students for professional entrance examinations, it was expected that stress appraisal among private school students could be high. However, the influence of factors other than academic domain such as living conditions, health of family members, unemployment, and poor financial status of parents could shed some light on the disparities in socioeconomic status (SES) among the subjects. Even though the present study has not looked into SES, it is known that students of government schools usually hail from compromised economic status. Private school students, who come from well to do families and pay a large sum as tuition fee itself. Government school students, on the other hand, cannot afford private school. One recent study among school students of Class VII to XII of Chandigarh also reported similar findings.
Further, our study shows statistically significant high stress in students coming from rural areas (77%) as compared to those coming from urban areas (72.03%) [Table 1]. Some of the factors which contribute to rural stress are limited economic resources, social and cultural values, reduced health status, limited availability of and accessibility to better health-care services which are comparable to stigmatic illness. Rural populations have a higher proportion of vulnerable residents, specifically adolescents and elderly people, who require more health services. Rural health-care facilities generally are small and often provide a limited range of services. The limited resources coupled with the rural value of self-reliance leads residents to either just accept the stress in a stoic manner or reach a point of burnout.
On the contrary, Maggi et al. reported low level of stress in rural area than that of urban area students in Canada whereas Elgar et al. did not find any significant difference in the stress levels of rural and urban school children in the U. K.
Hence, the present study showed that females are more affected by RAS than male. Stress and aphthous have a positive correlation, and therefore, most of them who had ulcers were found to be stressed. It is therefore need of the present academic curriculum to inculcate stress-free environment for a healthy mind in a healthy body.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Embil JA, Stephens RG, Manuel FR. Prevalence of recurrent herpes labialis and aphthous ulcers among young adults on six continents. Can Med Assoc J 1975;113:627-30.
Sibley WK. Neurotic ulcers of the mouth: (Stomatitis neurotica chronica). Br Med J 1899;1:900-1.
Andrews VH, Hall HR. The effects of relaxation/imagery training on recurrent aphthous stomatitis: A preliminary study. Psychosom Med 1990;52:526-35.
Patil S, Reddy SN, Maheshwari S, Khandelwal S, Shruthi D, Doni B, et al
. Prevalence of recurrent aphthous ulceration in the Indian population. J Clin Exp Dent 2014;6:e36-40.
Mathew AL, Pai KM, Sholapurkar AA, Vengal M. The prevalence of oral mucosal lesions in patients visiting a dental school in Southern India. Indian J Dent Res 2008;19:99-103.
] [Full text]
Bhatnagar P, Rai S, Bhatnagar G, Kaur M, Goel S, Prabhat M, et al
. Prevalence study of oral mucosal lesions, mucosal variants, and treatment required for patients reporting to a dental school in North India: In accordance with WHO guidelines. J Family Community Med 2013;20:41-8.
Axéll T, Henricsson V. The occurrence of recurrent aphthous ulcers in an adult Swedish population. Acta Odontol Scand 1985;43:121-5.
Kovac-Kovacic M, Skaleric U. The prevalence of oral mucosal lesions in a population in Ljubljana, Slovenia. J Oral Pathol Med 2000;29:331-5.
Ciçek Y, Canakçi V, Ozgöz M, Ertas U, Canakçi E. Prevalence and handedness correlates of recurrent aphthous stomatitis in the Turkish population. J Public Health Dent 2004;64:151-6.
Shulman JD. An exploration of point, annual, and lifetime prevalence in characterizing recurrent aphthous stomatitis in USA children and youths. J Oral Pathol Med 2004;33:558-66.
Safadi RA. Prevalence of recurrent aphthous ulceration in Jordanian dental patients. BMC Oral Health 2009;9:31.
Leonardo ML, Diogo M, Arnaldo FC, Fabíola BA, Verônica MS, Gutenbe L, et al
. Prevalence and risk factors for the development of recurrent aphthous stomatitis. Rev. Cir. Traumatol. Buco-Maxilo-fac., Camaragibe 2010;10:61-6.
Abdullah MJ. Prevalence of recurrent aphthous ulceration experience in patients attending piramird dental speciality in Sulaimani city. J Clin Exp Dent 2013;5:e89-94.
Merchant HW, Gangarosa LP, Glassman AB, Sobel RE. Zinc sulfate supplementation for treatment of recurring oral ulcers. South Med J 1977;70:559-61.
Endre L. Recurrent aphthous ulceration with zinc deficiency and cellular immune deficiency. Oral Surg Oral Med Oral Pathol 1991;72:559-61.
Atkin PA, Xu X, Thornhill MH. Minor recurrent aphthous stomatitis and smoking: An epidemiological study measuring plasma cotinine. Oral Dis 2002;8:173-6.
Ross R, Kutscher AH, Zegarelli EV, Silvers H, Piro JD. Relationship of mechanical trauma to recurrent ulcerative (aphthae) stomatitis. N
Y State Dent J 1958;24:101-2.
Wray D, Graykowski EA, Notkins AL. Role of mucosal injury in initiating recurrent aphthous stomatitis. Br Med J (Clin Res Ed) 1981;283:1569-70.
Arun P, Chavan BS. Stress and suicidal ideas in adolescent students in Chandigarh. Indian J Med Sci 2009;63:281-7.
] [Full text]
Gallo Cde B, Mimura MA, Sugaya NN. Psychological stress and recurrent aphthous stomatitis. Clinics (Sao Paulo) 2009;64:645-8.
Yacoob SN, Juhari R, Talib MA, Uba I. Loneliness, stress, self-esteem and depression among Malaysian adolescents. Jurnal Kemanusiaan
Sahoo S, Khess CR. Prevalence of depression, anxiety, and stress among young male adults in India: A dimensional and categorical diagnoses-based study. J Nerv Ment Dis 2010;198:901-4.
Saini NK, Agrawal S, Bhasin SK, Bhatia MS, Sharma AK. Prevalence of stress among resident doctors working in medical colleges of Delhi. Indian J Public Health 2010;54:219-23.
] [Full text]
Koochaki GM, Charkazi A, Hasanzadeh A, Saedani M, Qorbani M, Marjani A, et al.
Prevalence of stress among Iranian medical students: A questionnaire survey. East Mediterr Health J 2011;17:593-8.
Sani M, Mahfouz MS, Bani I, Alsomily AH, Alagi D, Alsomily NY, et al
. Prevalence of stress among medical students in Jizan University, Kingdom of Saudi Arabia. Gulf Med J 2012;1:19-25.
Bhasin SK, Sharma R, Saini NK. Depression, anxiety and stress among adolescent students belonging to affluent families: A school-based study. Indian J Pediatr 2010;77:161-5.
Augustine LF, Vazir S, Rao SF, Rao MV, Laxmaiah A, Nair KM, et al.
Perceived stress, life events & coping among higher secondary students of Hyderabad, India: A pilot study. Indian J Med Res 2011;134:61-8.
] [Full text]
Kumar SN, Sujatha S, Parveen J. Analysis of stress among higher secondary school students. IJEMR 2011;1:2249-585.
Maggi S, Ostry A, Callaghan K, Hershler R, Chen L, D'Angiulli A, et al.
Rural-urban migration patterns and mental health diagnoses of adolescents and young adults in British Columbia, Canada: A case-control study. Child Adolesc Psychiatry Ment Health 2010;4:13.
Elgar FJ, Arlett C, Groves R. Stress, coping, and behavioural problems among rural and urban adolescents. J Adolesc 2003;26:577-88.