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An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists


 
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Year : 2021  |  Volume : 25  |  Issue : 3  |  Page : 553-554
 

Association of bedtime with recurrent aphthous stomatitis: A cross-sectional study among health.care professional students


1 Department of Oral Pathology and Microbiology, Bharati Vidyapeeth (Deemed to be University) Dental College and Hospital, Sangli, Maharashtra, India
2 Department of Public Health Dentistry, ESIC Dental College and Hospital, Gulbarga, Karnataka, India
3 Department of Oral Pathology and Microbiology, Rajarajeshwari Dental College and Hospital, Bengaluru, Karnataka, India

Date of Submission29-Sep-2020
Date of Acceptance27-Apr-2021
Date of Web Publication11-Jan-2022

Correspondence Address:
Mamata Kamat
Department of Oral Pathology and Microbiology, Bharati Vidyapeeth (Deemed to be University) Dental College and Hospital, Sangli - 416 416. Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomfp.jomfp_401_20

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   Abstract 


Background: Although recurrent aphthous stomatitis (RAS) is the most common oral mucosal disease, the etiology remains poorly understood till date. In addition, RAS lacks definitive therapeutic options, and hence, it becomes even more important to know the etiological factor so as to relieve the symptoms and render treatment effectively. Recently, late bedtime has been shown to be associated with RAS. Due to prolonged duty hours along with lengthy learning and training periods, late bedtime is a frequent observation among health-care professional students. However, this is a less explored field in the previous studies on RAS.
Aims: This study aimed to evaluate the role of bedtime in the causation of RAS among health-care professional students.
Methods: This present cross-sectional survey was carried out among medical, dental and nursing students studying in our medical campus, using an anonymous, self-administered questionnaire consisting of 18 items. The collected data was statistically analyzed and interpreted. Descriptive analysis and Chi-square tests were employed to assess the association of RAS with various variables.
Results: Among a total of 1111 students who participated in the study, 39.8% (n = 442) experienced RAS. Factors such as history of digestive tract disease, family history and stress showed a positive correlation with RAS. Interestingly, both during examination and nonexamination period, RAS was more prevalent among students with bedtime >11pm than in students with bedtime <11 pm.
Conclusion: The study indicates that late bedtime is an independent risk factor for RAS and thus clinicians should focus on recommending a healthy lifestyle with adequate sleep to patients with RAS. This would benefit patients with RAS, especially health-care professional students, and could probably contribute to long-term remission in RAS.


Keywords: Aphthous, association, sleep, stomatitis


How to cite this article:
Kamat M, Datar U, Wadgave U, Varsha V K. Association of bedtime with recurrent aphthous stomatitis: A cross-sectional study among health.care professional students. J Oral Maxillofac Pathol 2021;25:553-4

How to cite this URL:
Kamat M, Datar U, Wadgave U, Varsha V K. Association of bedtime with recurrent aphthous stomatitis: A cross-sectional study among health.care professional students. J Oral Maxillofac Pathol [serial online] 2021 [cited 2022 May 20];25:553-4. Available from: https://www.jomfp.in/text.asp?2021/25/3/553/335537





   Introduction Top


Majority of the oral lesions result from the interaction among the host, lifestyle and environmental factors.[1] Recurrent aphthous stomatitis (RAS) or canker sore is one such common condition, which is characterized by recurrent, painful, multiple, small, round or ovoid ulcers with circumscribed margins, erythematous haloes and yellow or gray floors.[1],[2],[3],[4],[5]

RAS chiefly occurs in childhood or adolescence; with a peak incidence in the third decade.[4] RAS is generally seen on the unattached oral mucosa of the lips, cheeks and tongue.[2],[6] A multifactorial etiology has been proposed that includes microbial, nutritional, hormonal, mechanical injuries, immune dysregulation, genetic factors and stress.[7],[8],[9],[10],[11] However, a definitive cause of RAS remains largely unknown till date.

The average incidence varies between 5% and 25% in the general population.[8] Literature reports a high prevalence of RAS among the student population.[9],[12],[13] This has been attributed to the demanding academic activities, especially in professional students. Furthermore, with the increasing use of modern gadgets and technologies, late bedtime is frequently observed in students. Sleep disorders are known to cause immune dysregulation, which can render an individual susceptible to RAS.[4] However, literature shows few studies linking the association of RAS and bedtime, especially among health-care professional students.[4]

Hence, considering the above-mentioned facts, the present questionnaire survey intended to determine the prevalence of RAS and various factors associated with RAS with emphasis on the role of bedtime among the health-care professional students of Bharati Vidyapeeth Medical Campus, Sangli, India.


   Methods Top


After obtaining clearance from the Institutional Ethical Committee, the present cross-sectional survey was conducted among the students who fulfilled the following inclusion and exclusion criteria.

Inclusion criteria

  • Subjects who give written informed consent to participate in the study
  • Students studying in medical, dental and nursing colleges of Bharati Vidyapeeth Medical Campus, Sangli, Maharashtra.


Exclusion criteria

  • Subjects with habit of tobacco smoking
  • Subjects suffering from psychological disturbances, sleep disorders, inflammatory and allergic conditions
  • Subjects with a history of syndromes where RAS is one of its symptoms.


The data was collected with a help of anonymous self-administered questionnaire. Before starting the study, all the participants were explained the purpose of the study and were given information about RAS. The questionnaire consisted of a total of 18 items; including demographic and RAS-related information (size, number, duration of RAS and related factors such as bedtime, stress and family history).

The obtained data was entered into Microsoft Excel and statistically analyzed. Statistical analysis was performed using SPSS software version 16. Descriptive analysis of all variables was done. Chi-square test was employed to assess the association of RAS with various variables.


   Results Top


A total of 1111 students consisting of medical, dental and nursing colleges participated in the survey. The mean age was 20.3 years. The descriptive data is depicted in [Table 1]. It was found that 39.8% (n = 442) of students experienced RAS, while 60.2% (n = 669) did not [Table 2]. Among the students with RAS, 61 subjects (13.8%) experienced prodromal symptoms, while 381 (86.2%) did not. Lip mucosa was the most commonly affected site (40.7%) followed by buccal mucosa (32.6%) and other locations. Maximum number of students (81.7%) experienced 1–2 ulcers during each attack of RAS. The majority of RAS positive students had ulcers <1 mm (57.5%) and the maximum number of students (93.9%) reported that the usual time taken to heal was 1–2 weeks.
Table 1: Descriptive data of study population

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Table 2: Prevalence of recurrent aphthous stomatitis among study population

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The correlation between RAS and parameters such as history of digestive tract disease, history of allergy, family history and stress is depicted in [Table 3]. The results showed a positive correlation of RAS with history of digestive tract diseases, family history and stress. However, the history of allergy (P = 0.75) and frequency of catching cold (P = 0.337) did not show any association with RAS.
Table 3: Correlation between RAS and various parameters

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Both during examination and nonexamination period, RAS was more prevalent among students with bedtime >11pm than in students with bedtime <11pm, P = 0.022 and 0.04, respectively [Table 4] and [Table 5].
Table 4: Association of bedtime and recurrent aphthous stomatitis during nonexamination period

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Table 5: Association of bedtime and recurrent aphthous stomatitis during examination period

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   Discussion Top


RAS is the most common oral mucosal disease, which affects the quality of life.[3] Due to the high prevalence and associated pain, RAS is considered as one of the public health concerns.[3] The present cross-sectional survey was undertaken to establish the prevalence of RAS among the health-care professional students of Bharati Vidyapeeth Medical Campus, Sangli, India, and to assess various factors related to the occurrence of RAS.

Literature reports a prevalence of 5%–25% in the general population and about 50%–60% in the professional population,[8] that has been linked to pressure from academic activities.[9] A prevalence of 56% in Danish dental students,[13] 23.3% in college students[9] and 53.2% in the student population[4] has been reported in the literature. Recently, a study on RAS among the student population by Ma et al. reported a prevalence of 53.2% among the student population.[4] In the present study, the prevalence of RAS was 39.8%. The variation in the prevalence rate can be attributed to differences in the study design and methodology, sample size and study population.

Literature reports that RAS is frequently seen in females (n = 5) which was also observed in the present study. RAS has a predilection to occur on the nonkeratinized mucosa such as buccal mucosa, labial mucosa, floor of the mouth, ventral surface of the tongue and soft palate.[9] The same was observed in the present study where labial mucosa (30.7%) was the most frequently affected site.

Various predisposing factors have been suggested for RAS. These include local and systemic factors such as trauma, genetics, vitamin deficiencies, immune dysfunction, stress and digestive tract disorders.[2],[5],[6],[14] Recently, association of late bedtime and RAS has also been reported.[4]

In the present study, more number of students with RAS (54.4%) had a history of digestive tract disease than those without RAS and the difference was statistically significant (P = 0.003). Similar findings have been reported in the literature.[5],[6] This has been attributed to food and microelement deficiencies in patients with gastrointestinal disturbances.[6]

Our results showed a positive correlation between family history and RAS (statistically significant P = 0.001). This association between RAS and positive family history is linked to alteration in the metabolism of interleukins, interferon-γ, tumor necrosis factor-alpha and selected human leukocyte antigen allele.[6]

Similarly, a positive correlation was found between stress and RAS (significant P = 0.001). It is suggested that stress induces immunoregulatory activity, alters immune functioning and leads to increased salivary cortisol concentrations.[6],[10] It is also postulated that stress may lead to parafunctional oral habits which initiate ulcerations in susceptible individuals.[10] Stress due to academic activities could be linked as the stress-inducing factor in the current study population.

Interestingly, in the present study, both during examination and nonexamination periods, it was found that subjects with late bedtime (>11pm) had more risk of RAS than those who slept early (statistically significant P = 0.022 and 0.04, respectively). This finding is in accordance with a similar study by Ma et al.[4] Similarly, a total of 44.7% of subjects reported the association of lack of sleep to RAS in a study by Baccaglini et al.[15] This indicates that late bedtime is an independent risk factor for RAS. However, as these studies included a mixed population of students from various courses, we exclusively focused on the health-care professional students. The associated mechanism linking late bedtime and RAS is summarized in [Figure 1]. However, there is less research on this relationship. Moreover, such studies are not done in the Indian student population. Hence, an attempt has been made in the present study to understand this association. Nevertheless, factors such as recall bias, social desirability bias and the subject's sincerity toward the completion of the questionnaire should be taken into consideration while considering the results of the study.
Figure 1: Mechanism of association between recurrent aphthous stomatitis and bedtime. ACTH; Adenocorticotropic Hormone, GH; Growth Hormone

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Overall, this paper broadens the knowledge on the unexplored information regarding the relationship between bedtime and RAS. In addition, the outcomes of this study highlight the importance of adequate sleep on reducing the risk of RAS among health-care professional students including dental professionals. Hence, further research in this subject may shed light on the etiopathogenic mechanism of RAS and aid in the development of preventive measures for RAS.


   Conclusion Top


In the present study, the prevalence of RAS was found to be 39.8% among health-care professional students. It was found that late bedtime has a significant effect on the incidence of RAS. However, future research needs to be undertaken with larger sample size and varied population to further strengthen the association between bedtime and RAS. Furthermore, early and adequate bedtime habits can be recommended to reduce the incidence and recurrence of RAS.

Acknowledgments

The authors would like to thank all the students who participated in the study. The authors would also like to thank Dr. Anand Shigli, Ex-Dean of Bharati Vidyapeeth (Deemed to be University) Dental College and Hospital, Sangli; Dr. R.B.Kulkarni, Ex-Dean of Bharati Vidyapeeth (Deemed to be University) Medical College and Hospital, Sangli and Dr. Nilima Bhore, Dean of Bharati Vidyapeeth Nursing College, Sangli, for helping in data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gavic L, Cigic L, Biocina Lukenda D, Gruden V, Gruden Pokupec JS. The role of anxiety, depression, and psychological stress on the clinical status of recurrent aphthous stomatitis and oral lichen planus. J Oral Pathol Med 2014;43:410-7.  Back to cited text no. 1
    
2.
Scully C, Porter S. Oral mucosal disease: Recurrent aphthous stomatitis. Br J Oral Maxillofac Surg 2008;46:198-206.  Back to cited text no. 2
    
3.
Huling LB, Baccaglini L, Choquette L, Feinn RS, Lalla RV. Effect of stressful life events on the onset and duration of recurrent aphthous stomatitis. J Oral Pathol Med 2012;41:149-52.  Back to cited text no. 3
    
4.
Ma R, Chen H, Zhou T, Chen X, Wang C, Chen Y, et al. Effect of bedtime on recurrent aphthous stomatitis in college students. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:196-201.  Back to cited text no. 4
    
5.
Jurge S, Kuffer R, Scully C, Porter SR. Mucosal disease series. Number VI. Recurrent aphthous stomatitis. Oral Dis 2006;12:1-21.  Back to cited text no. 5
    
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Slebioda Z, Szponar E, Kowalska A. Etiopathogenesis of recurrent aphthous stomatitis and the role of immunologic aspects: Literature review. Arch Immunol Ther Exp (Warsz) 2014;62:205-15.  Back to cited text no. 6
    
7.
Chattopadhyay A, Chatterjee S. Risk indicators for recurrent aphthous ulcers among adults in the US. Community Dent Oral Epidemiol 2007;35:152-9.  Back to cited text no. 7
    
8.
Ship JA. Recurrent aphthous stomatitis. An update. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:141-7.  Back to cited text no. 8
    
9.
Shi L, Wan K, Tan M, Yin G, Ge M, Rao X, et al. Risk factors of recurrent aphthous ulceration among university students. Int J Clin Exp Med 2015;8:6218-23.  Back to cited text no. 9
    
10.
Eguia-del Valle A, Martínez-Conde-Llamosas R, López-Vicente J, Uribarri-Etxebarria A, Aguirre-Urizar JM. Salivary cortisol determination in patients from the Basque Country with recurrent aphthous stomatitis. A pilot study. Med Oral Patol Oral Cir Bucal 2013;18:e207-11.  Back to cited text no. 10
    
11.
Gomes CC, Gomez RS, Zina LG, Amaral FR. Recurrent aphthous stomatitis and Helicobacter pylori. Med Oral Patol Oral Cir Bucal 2016;21:e187-91.  Back to cited text no. 11
    
12.
Safadi RA. Prevalence of recurrent aphthous ulceration in Jordanian dental patients. BMC Oral Health 2009;9:31.  Back to cited text no. 12
    
13.
Donatsky O. Epidemiologic study on recurrent aphthous ulcerations among 512 Danish dental students. Community Dent Oral Epidemiol 1973;1:37-40.  Back to cited text no. 13
    
14.
Ge L. Healthy lifestyle habits benefit remission of recurrent aphthous stomatitis and RAS type ulceration. Br Dent J 2018;224:70-1.  Back to cited text no. 14
    
15.
Baccaglini L, Theriaque DW, Brantly ML, Shuster JJ. Environmental triggers in recurrent aphthous stomatitis. Oral Surg Oral Med Oral Pathol Oral Radiol 2008:106:E8.  Back to cited text no. 15
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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