INTRODUCTION:

Recurrent Aphthous Stomatitis (RAS) is a disorder where there are recurring ulcers in the oral mucosa of patients showing no other signs of disease. This condition is also called as Sutton’s disease, especially in the case of major, multiple or recurring ulcers. RAS resembles various pathological states that show similar clinical manifestations, including immunologic disorders, hematologic deficiencies and allergic conditions. Recurrent aphthous stomatitis (RAS) is a common disorder affecting 5% to 66% of examined adult patient groups. There is a female predominance in some adult and child patient groups.^[1]

The ulceration usually commences in the second decade.^[2] People of higher socioeconomic status may be more commonly affected than those from low socioeconomic groups. RAS present as painful recurrent, multiple, small, or ovoid ulcers, having yellow floors and are surrounded by erythematous haloes, present first in childhood or adolescence.^[3]

The underlying etiology is not clear, though a series of factors are known to predispose to the appearance of oral aphthae, including genetic factors, food allergens, local trauma, endocrine alterations (menstrual cycle), stress and anxiety, smoking cessation, certain chemical products and microbial agents.^[4] Diagnosis is entirely based on history and clinical criteria and no laboratory procedures exist to confirm the diagnosis. RAS may act as a marker for an underlying systemic illness or may also appear as one of the symptoms of Behcet’s disease, and generally no additional body systems are involved, the patients are otherwise well and fit. A genetic predisposition for the development of apthous ulcer is strongly suggested as associations with HLA antigens and RAS have been reported.

Trauma of the oral mucosa may occur due to injections, sharp teeth, dental treatments, or tooth brush injuries can lead to the development of recurrent aphthous ulcers. Certain drugs have been associated with development of RAU; these include angiotensin converting enzyme inhibitor, sodium hypochloride, NSAIDS which also cause oral ulceration similar to RAS. Deficiencies of iron, vitamin B12, and folic acid predispose development 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 trigger the development of RAS.

Some studies^[5]correlate the onset of ulcers with exposure to certain foods, such as cow’s milk, gluten, chocolate, nuts, cheese, azo dyes, flavoring agents and preservatives. The diagnosis of RAS is based on the patient anamnesis and clinical manifestations. There is no specific diagnostic test. Diet is an important factor that predisposes to the development of RAS. There are studies that have reported in the western population. The Indian lifestyle and food habits are in sharp contrast to these population and there are no studies that have reported the role of dietary factors in RAS in this population. Hence the present study was an attempt to understand the various dietary factors that causes RAS with which, individuals can modify their dietary habits and thereby reduce the occurrence of RAS.

MATERIALS AND METHODS:

Study Population:

The study was conducted among patients having Recurrent Aphthous Ulcers during their visits to a Dental College and Hospital, Chennai during the period of July to December 2017. The patients were informed about the questionnaire and its implications. Only patients willing to participate were included in the study. No incentives were provided for participation.

Questionnaire:

The survey instrument was a questionnaire that was structure and designed after reviewing the recent literature and similar questionnaires and based on the objectives of the study taking into consideration sociocultural background of the study population. The questionnaire was designed to be self completed, but assistance was offered if required by a clinical assistant who was not part of the study. The questionnaire was pilot tested on 5 patients who were not included in this study cohort.

The questionnaire included demographic data such as age, gender, dietary habits, tobacco and alcohol consumption. History of another systemic diseases or conditions were also recorded. The second section of the questionnaire were the onset of RAS, size and area of occurrence, frequency of occurrence of RAS, duration of the lesion, symptoms. The third section was that of the triggering factors including Stress, fatigue, Menstruation, dental care, change in brushing habits, infection and diet. The section on diet as a triggering factor was expanded to include if the following factors triggered occurrence of RAS: i) consumption of vegetarian or non-vegetarian food ii) Spicy food iii) Gluten rich food

iv) Consumption of Soft drinks. Patients were also requested to fill in food items that they felt precipitated RAS in the.

Statistical Analysis:

The survey was qualitative and did not test any priori hypothesis. We initially set a target of 50 individuals and the study was halted after 6 months duration to analyze the results. Of the 50 individuals, only 20 questionnaires were completed and included in the results discussion. The results were expressed in percentage. In some cases, responses to open questions were pooled if they reflected similar contents. All collected data were kept confidential and not used except for the study purpose.

RESULT:

The study was conducted among 20 patients having RAS in the age group of 20-60 years. All the individuals were residents of Chennai, Tamilnadu. Recurrent Aphthous Ulcers were seen to affect females more commonly and there was no age predilection seen. All the patients hail from Tamilnadu and their self reported type of diet was the south Indian style of food. 40% of the individuals had a family history of RAS. The results of the family history, personal history and habits are summarized in Table 1.

Table 1: Demographic data, family history, habits of the respondents.

Age	20-60 years
Dietary habits i) Vegetarian ii) Non-vegetarian	20% 80%
Self Reported Birth Place: Tamilnadu	100%
Family History of RAS	40%
Dietary Style: Indian	100%
Consumption of Alcohol	45%
Smoking	35%
Diabetic	10%
Anemia	85%

The most common site of ulceration was on the buccal mucosa and tongue was the least common site of occurrence. All the individuals experienced the ulceration only once a month (100%) and stated that the ulcerations lasted for about a week. The ulcers were recurrent in 85% of the individuals whereas in 15% they reappeared only after a long time. The results are summarized in Table 2.

Table 2: Duration, Onset and clinical symptoms of RAS

Site of ulceration

i) Buccal mucosa

ii) Lips

iii) Floor of the mouth

iv) Tongue

70%

15%

10%

Frequency of occurrence

Once in a moth

100%

Recurrence

Within 15 days

Appear only after a long time

85%

15%

Intermittent pain

80%

Continuous pain

20%

As far as the triggering factors were concerned, stress was a triggering factor in all the individuals. 21% of the females had RAS during menstruation. The results of the triggering factors are summarized in Table 3.

Table 3: Triggering factors for RAS

Stress	100%
Menstruation	21%
Cheek biting habits	70%
Brushing habits	Nil

The dietary triggering factors were consumption of Gluten rich food (80%) and spicy food. The foods listed that caused RAS were spicy food, preservative containing soft drinks, processed foods. (Table 4) The study results point towards Gluten rich food, Spicy food, Stress and Anemia to be the triggering factors for RAS.

Table 4: Dietary factors precipitating RAS.

Ulceration following consumption of Gluten Rich Food	80%
Everyday consumption of Gluten Rich food	95%
Once a week consumption of gluten rich food	5%
Ulceration after consumption of spicy food	100%
Ulceration after frequent consumption of soft drinks	80%

DISCUSSION:

Recurrent Aphthous stomatitis is a common condition characterized by the repeated formation of benign and non-contagious mouth ulcers in otherwise healthy individuals. Patients usually complain of symptoms such as burning, itching, or stinging, which may precede the appearance of any lesion by some hours; and pain which is worsened by physical contact, especially with certain foods and drinks.^[2] There are very few studies to analyze the role of diet in RAS. The present study was to analyze the role of diet in occurrence of RAS in the south Indian Population.

The results of the study showed that Anemia is one of the causes of Recurrent aphthous ulcers. In India, majority of the lower class population is malnourished and hence suffer from anemia due to inadequate intake of vitamins. Several studies have demonstrated that hematinic deficiency (iron, folic acid, or vitamin B12) are twice as common in RAS patients than in controls.^[6]About 20% of patients with RAS may have a hematinic deficiency, though one U.S. study on the factors affecting RAS did not report any hematinic problem .^[7]Vitamin B1, B2, and/or B6 deficiency was observed in a cohort of Scottish patients with RAS.^[8]This shows that the under-nourished patients are more prone to get RAS.

From the study, it is noted that all the individuals with RAS have a gluten rich diet. Less than 5% of outpatients who initially present with RAS^[9] are prone to have gluten-sensitive enteropathy. Gluten rich diet initiates the formation of RAS. These RAS patients may not always have gastrointestinal symptoms or other clinical features suggestive of GSE but usually have folate deficiency, sometimes reticulin antibodies, particularly IgA class reticulin antibodies and/or antigliadin antibodies.^[10]

Of all the participants in this study, without exception each participant had the habit of taking spicy food that resulted in RAS. This may be due to the individuals having hypersensitive reactions to certain foods.^[11]

More than 40% of RAS patients are seen to have a family history of oral ulceration. Patients with a positive family history of RAS may develop oral ulcers at an earlier age and have more severe symptoms than those with no such history. There is an increased likelihood of a child developing RAS if both parents have ulcers, and there is a high correlation of RAS in identical twins.^[12]No association between RAS and altered female sex corticosteroids was seen.^[13]Psychological illness has been proposed to initiate some episodes of RAS, but there are sparse data to suggest a strong link between psychological stress and RAS, or that RAS causes significant psychological upset^[14] this study supports that stress is one of the leading factors that lead to RAS. Insufficient and irregular sleep patterns might induce and/or aggravate RAS in college students, which could possibly be associated with disturbances in the diurnal secretion cycles of hormones like growth hormone and cortisol. A large number of studies have suggested a relationship between depression and delayed sleep. Some lifestyle habits seem to be associated with RAS or RAS-type ulceration as well as mental health. Although it is the commonest oral mucosal disease, the aetiology of RAS remains undefined. Immune mechanisms are currently considered a major influencing factor, but the psychological state of RAS patients, which is different from the general population, should also not be ignored. Patients with RAS present with a higher degree of stress and anxiety, this can be evaluated by measuring cortisol concentrations in saliva and blood. The study found a close correlation between psychological stress and the onset and duration of RAS. Stress appears to be one of the major predisposing factors to all immune-mediated conditions, including RAS.

Mental health might play a core role in RAS and all habits contributing to mental health might help in reduction of symptoms. Despite the lack of prospective studies on a large patient population with a long follow-up to provide the best evidence, it can still be argued that lifestyle changes are the first and most important step for reduction and control of RAS. In this manner, drug use and their incident adverse reactions can be minimized, which can be especially important to children, patients already on poly-therapy (for example, the elderly), pregnant women, and other special populations. Prevention of recurrence could also reduce the number of hospital visits and save physician work-hours.

Patients suffering from RAS usually are non-smokers, and there is a lower prevalence and severity of RAS among heavy smokers as opposed to moderate smokers.¹⁵ Some patients report an onset of RAS after smoking cessation,^[16] while others report control on re initiation of smoking. Possible explanations given include increased mucosal keratinization; which serves as a mechanical and protective barrier against trauma and microbes.^[17]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 (TNF-α) and interleukins 1 and 6 (IL-1 andIL-6). Nicotine replacement therapy has been suggested as treatment for patients who develop RAU on cessation of smoking.^[18]Smoking has a positive effect on RAS but its ill-effects exceed its positive effects. Hence smoking should be avoided at all cost, no matter how badly affected the patient is by RAS. Other treatment modalities may be used instead. The first line of treatment for RAS is topical medication rather than systemic medication.^[19]The commonly used topical gels were seen to be Mucopain, Zyte and Quadragel.^[20]

Gluten rich diet and spicy food have been proved to have a positive effect on RAS. Hence this study, which is the first of its kind was conducted in order to identify the dietary factors that trigger RAS. Diet plays a vital role in determining the health and quality of life of an individual. Modifications in diet like avoiding processed foods, excessive spicy foods and avoiding gluten rich diet might help in preventing the occurrence of RAS in these patients.

CONCLUSION:

Recurrent apthous stomatitis is a very common, recurrent painful ulceration occurring in the oral cavity. The etiopathogenesis of this disease is yet unclear. Treatment strategies are directed toward providing symptomatic relief by reducing pain, increasing the duration of ulcer-free periods, and accelerating ulcer healing. One such factor that can be regulated or modified from the patient side is diet modification. These can prolong the ulcer free individuals. Also consumption of more natural and nutrient rich foods would not only prevent nutritional deficiencies but also increase ulcer free periods in these patients. The present study has limitations in terms of sample size and identification of more variety from the Indian style of food that might trigger RAS.

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Received on 09.02.2019 Modified on 10.03.2019

Research J. Pharm. and Tech. 2019; 12(7):3479-3482.

DOI: 10.5958/0974-360X.2019.00590.0