Nagihan Bilal1*, M Fatih Karakus2, Mihriban Dalkiran Varkal3, Osman Fatih Boztepe4, Bora Bilal5 and Selman Sarıca1
1Department of Otorhinolaryngology, Faculty of Medicine Kahramanmaras Sutcu Imam University. Turkey
2Ankara Golbası Hasvak State Hospital, Otorhinolaryngology Clinic, Turkey
3Istanbul Sisli Hamidiye Etfal Training and Research Hospital, Psychiatry Clinic, Turkey
4Antalya Medikal Park Hospital, Otorhinolaryngology Clinic, Turkey
5Department of Anesthesiology and Reanimation, Faculty of medicine Kahramanmaras Sutcu Imam University, Turkey
Received: 05 October, 2015; Accepted: 06 January, 2016; Published: 08 January, 2016
Nagihan Bilal, Haydar bey mah, 32120, Sok. Beytepe sitesi 4. Blok no: 13 Kahramanmaras, Turkey, Tel: +90 505 251 36 18; E-mail:
Bilal N, Fatih Karakus M, Varkal MD, Boztepe OF, Bilal B, et al. (2016) An Assessment of the Levels of Anxiety and Depression in Patients with Recurrent Aphthous Stomatitis. Arch Otolaryngol Rhinol 2(1): 001-005. DOI: 10.17352/2455-1759.000011
© 2015 Bilal N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Recurrent aphthous stomatitis; Anxiety; Depression; Psychological features
Backgrounds: There is a lack of valid and reliable studies in literature on both the distinctive and ambiguous relationship between the psychological profile and the occurrence of recurrent aphthous ulcers in the individual.
Objectives: The etiology of recurrent aphthous ulceration (RAU) is not well understood. This study analyzes the psychological treatment of patients with recurrent aphthous using valid, confidential and effective psychological measures.
Materials: In this study we included 50 patients with recurrent aphthous stomatitis who were undergoing no psychiatric treatment, as well as 50 age and gender matched healthy individuals as the control group. The study utilized the Beck Depression Inventory and STAI-S and STAI-T tests, which have been evaluated as valid sources for assessment.
Results: A comparison of the aphthous ulcer group with the control group revealed no significant difference in STAI-S psychiatric scores (p>0.05). In contrast, the scores of the STAI-T of the patients with aphthous ulcers were found to be increased when compared to the control group (p<0.05).
Conclusion: This study proposes a different overview for this area of etiologic research on this disease, based on the significant differences revealed by the STAI-T, which discovered increased anxiety levels in patients. Accordingly, there is need for more investigation into comorbid anxiety disorder and depression in patients with recurrent aphthous stomatitis, and an assessment of treatment with psychological traits, implying that further comparative studies are required to understand the issue.
Recurrent aphthous ulceration (RAU) is one of the most prevalent oral mucosal human diseases. The most comprehensive and largest RAU study performed to date involved a sample of more than 10,000 young adult patients from 21 different countries. The said study demonstrated that 38.7% of male patients and 49.7% of female patients suffered from more than one RAU episode throughout their lives. In addition, nearly 25% of the patients included into the study described experiencing an episode (or episodes) in the 12 months preceding the study [1-3]. However, studies conducted in recent years, suggest a ratio of 40% . It is clinically diagnosed with recurrent, painful yellowish white or grey, single or multiple, and round or oval ulcers with erythematous margins that are mainly confined to non–keratinized oral mucosa [5-8]. RAU lesions can be categorized into three groups on the basis of size, the number of ulcers and the features of the healing process: minor, major and herpetiform ulcerations . The precise etiology and pathogenesis of RAU remains unclear, although several factors are generally considered as crucial in the development of RAU, such as nutrition, drugs, food hypersensitivity, hormones, infections, trauma, tobacco and psychological stress [10,11]. Many local and systemic factors have been associated with the condition, and there is also evidence of a genetic and immunopathogenic basis of RAU . It is also generally accepted that acute psychological disorders (e.g. stress and anxiety) play a role in the development of recurrent aphthous ulcers [2,13-16]. Stressful situations are thought to cause a transitory increase in salivary cortisol and/or provoke immunoregulatory activity in cases of inflammation by raising the number and the activity of leukocytes [2,15,17].
There is a lack of valid and reliable studies in literature on both the distinctive and ambiguous relationship between the psychological profile and the occurrence of recurrent aphthous ulcers in the individual. This study investigates and compares the psychological traits of patients with recurrent aphthous ulcers with healthy controls and their potential role in the occurrence of recurrent aphthous ulcers using valid, reliable and comprehensive psychological measurement methods.
Materials and Methods
In accordance with the Helsinki II Declaration, prior to the beginning of this study all of the study subjects signed an informed consent form obtained from the Ethical Committee of the University of Kahramanmaras, Turkey.
In this study we included 50 sequential subjects suffering from both minor or major forms of RAU and 50 healthy volunteers. The study subjects were volunteers recruited from the Ear, Nose and Throat (ENT) Department of Kahramanmaras City State Hospital. Both the experimental and control groups were resident in the same geographical area, had the same socioeconomic status, and were matched for age and gender.
Non-smoker patients with a minimum two years history of minor, major and herpetiform RAU were included into the study. RAU was diagnosed based on clinical findings, and the patients were grouped depending on the severity of their RAU episodes and their ulcer types. All patients in the study were aged 18 or above, ensuring that they could understand and score the questionnaires correctly. Patients with medical conditions that would negatively affect their ability to understand or complete the study questionnaires (such as psychological disorders and mental problems) were not included into the study. The control group comprised persons with no RAU history who had been referred to our clinic for ENT treatment; in all other respects, these controls shared the same characteristics as the study group (or RAU) patients.
Patients who were less than 18 years of age; pregnant patients; patients with relatives taking part in the study; patients who received systemic steroids in the one month preceding the study; patients with a history of gastric bypass surgery or gastrectomy; patients who mistook their perioral lesions for RAU; and patients unwilling or unable to give informed consent were excluded from the study (Patients mistaking their perioral lesions for RAU were excluded to avoid the overrepresentation of herpetic lesions among the controls). Patients with the following systemic diseases were also excluded.Behçet’s syndrome, celiac disease, cyclic neutropenia, periodic fever, mouth and genital ulcers with inflamed cartilage syndrome, pharyngitis and adenitis syndrome, aphthous stomatitis, low white blood cell counts, Sweet’s syndrome, inflammatory bowel disease, Reiter’s disease, HIV/AIDS, Systemic lupus Erythematosus and severe immunodeficiency.
Each patient was assessed, and a record made of the number, position, duration and frequency of their ulcers. The assessment also asked for dental and medical histories and disorders, and personal information regarding age, gender, education, occupation, address and marital status. Moreover, an assessment was made of the pain experienced by the patient when the ulcers came into contact with oral structures or food. The patients were exposed to an extensive medical assessment, including a detailed history, a full examination and laboratory checks, including hematological and tuberculin skin tests.
The fifty control participants included in the study had all referred to the ENT clinic for routine examinations, but had never experienced recurrent aphthous ulcers. To be included in the study, the controls had to be free of systemic diseases, allergic conditions or unfavorable habits related to tobacco and drug abuse. Complete physical examination and laboratory assessments (including hematological assessments) were performed for all study subjects.
Anxiety levels were measured using Spielberger’s STAI (1983) which evaluates both trait anxiety as a general aspect of personality (STAI-T) and state anxiety as a response to a specific situation (STAI-S). The sensitivity of the STAI-S and STAI-T scale to general stress has been shown consistently in researches of emotional reactions. STAI-T is unique in its measurement of anxiety independently of depression, and includes 40 questions for the assessment of both trait anxiety (20 questions) and state anxiety (20 questions). Each item is scored on a four-point scale, with response categories varying according to the nature of the question. For both levels, the range of values falls 20 and 80, with a high score indicating a higher level of anxiety. The questionnaire has been tested extensively for reliability and validity.
The second test, the Beck Depression Inventory (BDI) is commonly used as a self-report scale to assess the severity of depression. The BDI was developed to determine the type and the degree of depression based on symptoms , and takes the form of a questionnaire containing 21 items rating emotional, cognitive, motivational and physiological symptoms, among others. Each item consists of four expressions on a scale of 0 to 3 rating the intensity of depression as a reflection of the participants’ feelings over the previous week. Possible scores range from 0 to 63, with a higher score indicating a more severe depression. The Turkish version of the BDI was standardized, and has been found to be reliable and valid.
The statistical analyses were performed using the Statistical Package for Social Sciences Statistical Software, release 21 (SPSS Windows Version 21, SPSS, Inc., Chicago, IL, USA), while a t-test was used to determine the average of the basic data. For the purpose of the study, p<0.05 was considered statistically significant.
The present study consisted of 50 participants with recurrent ulcers and 50 healthy controls (participants without recurrent ulcers). The study group was 54% (27) female and 46% (23) male, aged between 18 and 65 years (mean 36.9±13.2). The control group was matched with the study group with respect to the number of patients and the ratio of males and females. The age average in the control group was 36.7±12.7, while the age range was between 18 and 63 (Table 1).
We determined that 56% (28) of the patients had good dental hygiene while 44% (22) had lower/reduced dental hygiene. Aphthous ulcers were determined to be minor in 88% (44) of the patients, major in 8% (4) and herpetiform in 4% (2). Food allergies, determined by patient histories, were present in 14% (7) of the patients. In a determination of the increasing rate of Ig in patients, elevations of IgE, IgA, and IgG levels were evaluated as 14% (8), 10% (5) and 8% (4), respectively. C3 levels were assessed as positive at the rate of 4% (2), while none of the patients had increased C4 levels. In the control group, the increase in IgE, IgA and IgG levels was determined as 12% (6), 10% (5) and 4% (2), respectively. In addition, C3 and C4 levels were positive in 2% (1) and 2% (1) of the control group patients, respectively (Table 2).
A comparison of the aphthous ulcer group with the control group revealed no significant difference between the two in terms of the STAI-S psychiatric score (State-Trait Anxiety Inventory-State form) (p>0.05), with an average score of 43 in the patient group and 40.8 in the control group (Table 2).
In contrast, a significant difference was identified between the two groups in terms of the STAI-T scores (p<0.05), which were 49.9 in the patient group and 46.5 in the control group. No significant difference was determined between the male patients and the control group (p>0.05), while there was a statistically significant difference between the women (p<0.05) (Table 3).
The results of the Beck Depression Inventory revealed no significant difference between the two groups (Figure 1).
- Ship JA (1996) Recurrent aphthous stomatitis. An update. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 81: 141-147 .
- Albanidou-Farmaki E, Poulopoulos AK, Epivatianos A, Farmakis K, Karamouzis M, et al. (2008) Increased anxiety level and high salivary and serum cortisol concentrations in patients with recurrent aphthous stomatitis. Tohoku J Exp Med 214: 291-296 .
- Embil JA, Stephens RG, Manuel FR (1975) Prevalence of recurrent herpes labialis and aphthous ulcers among young adults on six continents. Can Med Assoc J 113: 627-630 .
- Shulman JD (2004) An exploration of point, annual and lifetime prevalence in characterizing recurrent aphthous stomatitis in USA children and youths. J Oral Pathol Med 33: 558-566.
- Chattopathyay A, Chatterjee S (2007) Risk indicators for recurrent aphthous ulcers among adults in the US. Common Dent Oral Epidemiol 35: 152-159 .
- Messadi DV, Younai F (2010) Aphthous ulcers. Dermatol Ther 23: 281-290.
- Scully C (2006) Clinical practice. Aphthous ulceration. N Eng J Med 355: 165-172 .
- Scully C, Porter S (2008) Oral mucosal disease: recurrent aphthous stomatitis. Br J Oral Maxillofac Surg 46: 198-206 .
- Victoria JM, Correia-Silva Jde F, Pimenta FJ, Kalapothakis E, Gomez RS (2005) Serotonin transporter gene polymorphism (5- HTTLPR) in patients with recurrent aphthous stomatitis. J Oral Pathol Med 34: 494-497 .
- Porter SR, ScullyC, Pedersen A (1998) Recurrent aphthous stomatitis. Crit Rev Oral Biol Med 9: 306-321.
- Natah SS, Konttinen YT, Enattah NS, Ashammakhi N, Sharkey KA, et al. (2004) Recurrent aphthous ulcers today: a review of the growing knowledge. Int J Oral Maxillofac Surg 33: 221-224 .
- Picek P, Buljan D, Rogulj AA, Stipetić-Ovcarićek J, Catić A, et al. (2012) Psychological status and recurrent aphthous ulceration. Coll Antropol 36: 157-159.
- Buajeeb W, Laohapand P, Vongsavan N, Kraivaphan P (1990) Anxiety in recurrent aphthous stomatitis patients. J Dent Assos Thai 40: 253-258.
- Gallo CB, Mimura MAM, Sugaya NN (2009) Psychological stres and recurrent aphthous stomatitis. Clinics 64: 645-658.
- McCartan BE, Lamey P-J, Wallace AM (1996) Salivary cortisol and anxiety in recurrent aphthous stomatitis. J Oral Pathol Med 25: 357-359.
- Soto-Araya M, Rojas- Alcayaga G, Esguep A (2004) Association between psychological disorders and the presence of oral lichen planus, burning mouth syndrome and recurrent aphthous stomatitis. Med Oral 9:1-7.
- Redwine L, Snow S, Mills P, Irwin M (2003) Acute psychological stres: effects on chemotaxis and cellular adhesion molecule expression. Psychosom Med 65: 598-603.
- Kim HJ, Park EH (2010) Diagnostic efficiency of BDI in a clinical setting: comparison among depression, anxiety, psychosis and control group. Int J Innov Managd Technol 1: 502–506.
- Rogers RS (1997) Recurrent aphthous stomatitis: clinical characteristics and associated systemic disorders. Semin Cutan Med Surg 16: 278-283.
- Saral Y, Coskun BK, Ozturk P, Karatas F, Ayar A (2005) Assesment of salivary and serum antioxidant vitamins and lipid peroxidation in patients with recurrent aphthous ulceration. Tohoku J Exp Med 206: 305-312.
- Santos AM, Nobre EL, Garcia e Costa J, Nogueira PJ, Macedo A, et al. (2002) Grave’s disease and stres. Acta Med Port 15: 423- 427.
- Manolache L, Seceleanu-Petrescu D, Benea V (2008) Lichen planus patients and stresful events. J Eur Acad Dermatol Venereol 22: 437-441.
- Manolache L, Seceleanu-Petrescu D, Benea V (2010) Life events involvement in psoriasis oncet/recurrence. Int J Dermatol 49: 636-641.
- Cağlayan F, Miloglu O, Altun O, Erel O, Yilmaz AB (2008) Oxidative stres and myeloperoxidase levels in saliva of patients with recurrent aphthous stomatitis. Oral Diseases 14: 700-704.
- Paterson AJ, Lamb AB, Clifford TJ, Lamey PJ (1995) Burning mouth syndrome: the relationship between the HAD scale and paratunctional habits. J Oral Pathol Med 24: 289-292.
- Miller AH (1998) Neuroendocrine and immune system interactions in stres and depression. Psychiatr Clin North Am 21: 443-463.
- Pedersen A (1989) Psychologic stres and recurrent aphthous ulceration. J Oral Pathol Med 18: 119-122.
- AL-Omiri MK, Karasneh J, Lynch E (2012) Psychological profiles in patients with recurrent aphthous ulcers. Int J Oral Maxillofac Surg 41: 384-388.
- Cohen L (1978) Etiology, pathogenesis and classifications of aphthous stomatitis and Behcet’s syndrome. J Oral Pathol 7: 347-352.