Abstract
Recurrent aphthous ulceration (RAU) is a common oral mucosal disease. The etiological involves in genetics, vitamin deficiencies, trauma, immune dysfunction and stress. This study was to explore the related risk factors of recurrent aphthous ulceration (RAU) among college students, and provide basis for further research. We conducted a questionnaire survey among students from three colleges in Wuhu by stratified cluster sampling. The information collected includes general demographic characteristics, dietary habits and so on. The overall prevalence of RAU is 23.30% among college students (23.23% in male and 23.39% in female). There are statistical significance in prevalence of RAU between subjects with RAU and without RAU (P<0.05) the prevalence of RAU in different grade, age, adequate brushing time, good brushing habits, wear dentures or braces, other oral disease, eat barbecue, adequate exercise time is statistic difference. According to the result of multinomial logistic regression analysis, the risk of recurrent aphthous ulceration factors including grade, inadequate brushing time. Tempering was a protective factor of RAU. Some measure should be taken to control dental ulcer, which consist of promoting a correct way of living habits, paying attention to the health conscious diet, strengthen physical exercise, self-decompression and keeping good mentality.
Keywords: Recurrent aphthous ulceration, college students, influence factor
Introduction
Recurrent aphthous stomatitis (RAS) is character of chronic, inflammatory, ulcerative diseases of the oral mucosa [1,2]. The prevalence of oral ulcers in worldwide is about 4%, with aphthous ulcers being the most common, affecting about 25% of the population worldwide [3]. Based on the clinical features, recurrent aphthous ulceration divide into three type: minor aphthae (Mikulicz’s aphthae; MiRAS), major aphthae (Sutton’s aphthae; MaRAS) and herpetiform aphthae (HeRAS) [4]. A common oral mucosal disorder is characterized by multiple, recurrent, small, round, or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or grey floors that present first in childhood or adolescence [5]. RAS is capable of causing severely painful and may interfere with eating, speaking, and swallowing. Predilection sites include the ventral surface of the tongue, floor of the mouth, and buccal, labial, soft palatal, and or pharyngeal mucosa [1,6]. Thus, RAS can result in significant morbidity and quality of life [7,8]. Although RAS is the most common disease affecting the oral mucosa, the etiology and pathogenesis of RAS remain unknown. previous study found that some factors of RAU, such as local, trauma, microbial, systemic, nutritional, immunological, and genetic factors [6,9,10].
Therefore, the aim of the study is to explore the risk factors of RAU among college students.
Subjects and methods
Subjects
This cross section study is conducted among college students from Wuhu (China) in November, 2013. A questionnaire was conducted among students from three college by cluster sampling method. Before the survey, the investigator must determine whether the object description meet the criteria of RAU.
Include criteria
Based on clinical examination, students with suspected malignant ulcers were excluded from the study, which follow the WHO guidelines [11]. We divide the subjects into two groups: RAU group and non-RAU group. Recurrent oral ulcers questionnaire includes general demographic characteristics (age, gender, nationality, height, weight, etc.), behavior and dietary habits (smoking, drinking, genetics, diet, oral hygiene, types of fruits and vegetables intake and psychological factors).
Methods
In order to make students well understand the aim of the study, we introduce the purpose of the survey, requirements and considerations, as well as described the survey voluntary and confidential before the investigation. The questionnaires also are checked when we collect the data.
Quality control
Quality controller are arranged to answer investigators’ questions on-site and responsible for collecting, reviewing the questionnaire. The questionnaires need to be returned to the investigators until the omissions and logic errors filling out completely or modifying correctly. Following the investigations, quality controller would sort out and unify all the questionnaires to data custodian.
Data collection and analysis
Establish a database for data entry by Epidata 3.0 software. Import the data to SPSS16 for data analysis. We describe the characteristics of study population. Relationships between general information and dependent variable RAU were assessed using multivariate logistic regression. Adjusted odds ratios (OR) and their 95% confidence intervals (CI) were calculated. A value of P<0.05 was considered statistically significant.
Ethical approval
This study is approved by local Ethical Committee. A written informed consent was obtained from the respondents.
Results
General demographic characteristics
This study enrolled 1858 subjects, including 1033 males and 825 females, their age was ranged from 16 to 26 years. The characteristics of study population are showed in Table 1.
Table 1.
Characteristics of study population
| Variable | Male | Female | Total | ||
|---|---|---|---|---|---|
|
|
|||||
| N | % | N | % | ||
| Grade | |||||
| Freshman class | 312 | 61.18 | 198 | 38.82 | 510 |
| Sophomore | 232 | 61.21 | 147 | 38.79 | 399 |
| Junior | 203 | 51.00 | 195 | 40.00 | 398 |
| Senior | 286 | 50.09 | 285 | 49.91 | 571 |
| Age | |||||
| <20 | 342 | 55.25 | 277 | 44.75 | 619 |
| 20-22 | 574 | 55.14 | 467 | 44.86 | 1041 |
| >22 | 117 | 59.09 | 81 | 40.91 | 198 |
| RAU | |||||
| Yes | 240 | 55.43 | 193 | 44.57 | 433 |
| No | 793 | 55.65 | 632 | 44.35 | 1425 |
Related factors
Of 1858 respondents, the overall prevalence of RAU is 23.30% (23.23% in male and 23.39% in female); the risk factors which may affect recurrent aphthous ulcers as following: grade, age, adequate brushing time, good brushing habits, wear dentures or braces, other oral diseases, eating barbecue, adequate exercise time, parental illness, physical symptoms, etc. The difference was statistically significant (P<0.001). Factors associated with recurrent aphthous ulcers analysis are showed in Table 2.
Table 2.
The related factors of recurrent aphthous ulceration
| Variable | Non-RAU Object | RAU Object | χ2 | P | ||
|---|---|---|---|---|---|---|
|
|
||||||
| n | % | n | % | |||
| Grade | 20.007 | <0.001 | ||||
| Freshman class | 421 | 82.55 | 89 | 17.45 | ||
| Sophomore | 289 | 76.25 | 90 | 23.75 | ||
| Junior | 309 | 77.64 | 89 | 22.36 | ||
| Senior | 406 | 71.10 | 165 | 28.90 | ||
| Age | 6.770 | 0.034 | ||||
| <20 | 497 | 80.29 | 122 | 19.71 | ||
| 20~22 | 781 | 75.02 | 260 | 24.98 | ||
| >22 | 147 | 74.24 | 51 | 25.76 | ||
| Adequate brushing time | 8.034 | 0.005 | ||||
| No | 524 | 73.18 | 192 | 26.82 | ||
| Yes | 901 | 78.90 | 241 | 21.10 | ||
| Good brushing habits | 4.245 | 0.039 | ||||
| On | 719 | 78.75 | 194 | 21.25 | ||
| Yes | 706 | 74.71 | 239 | 25.29 | ||
| Wear dentures or braces | 4.109 | 0.043 | ||||
| On | 1353 | 77.18 | 400 | 22.82 | ||
| Yes | 72 | 68.57 | 33 | 31.43 | ||
| Other oral disease | 5.849 | 0.016 | ||||
| On | 1018 | 78.25 | 283 | 21.75 | ||
| Yes | 407 | 73.07 | 150 | 26.93 | ||
| Eat barbecue | 3.959 | 0.047 | ||||
| On | 1347 | 77.19 | 398 | 22.81 | ||
| Yes | 78 | 69.03 | 35 | 30.97 | ||
| Adequate exercise time | 7.652 | 0.006 | ||||
| No | 1092 | 75.26 | 359 | 24.74 | ||
| Yes | 333 | 81.82 | 74 | 18.18 | ||
| The prevalence of Parents | 85.785 | <0.001 | ||||
| All | 30 | 53.57 | 26 | 46.43 | ||
| One party | 225 | 61.14 | 143 | 38.86 | ||
| All no | 1170 | 81.59 | 264 | 18.41 | ||
| Physical symptoms | 7.649 | 0.022 | ||||
| The heavier | 18 | 75.00 | 6 | 25.00 | ||
| General | 284 | 71.54 | 113 | 28.46 | ||
| Normal | 1123 | 78.15 | 314 | 21.85 | ||
Multivariate logistic regression analysis
All relevant variables into multinomial logistic regression models are showed in Table 3. the results reveals that un-adequate brushing time and un-adequate exercise time students are more likely to suffer from RAU, OR (95% CI) values were 1.334 and 1.438, respectively; students whose parent with RAU have higher prevalence of recurrent aphthous ulceration than those of students whose both parents without RAU (OR=3.945; 95% CI=2.252, 6.908; OR=2.783; 95% CI=2.143, 3.615); Grade is a risk factor of RAU, the students from freshman year and third-year suffering lower recurrent aphthous ulceration than that of the four-year (OR=0.572; 95% CI=0.419, 0.782; OR=0.638; 95% CI=0.465, 0.875). After adjusted the gender and age, a statistically significant association also was observed.
Table 3.
Related factors of recurrent aphthous ulceration
| Variable | Unadjusted OR (95% CI) | P | Adjusted OR# (95% CI) | P | ||
|---|---|---|---|---|---|---|
| Adequate brushing time | ||||||
| No | 1.334 | (1.060, 1.680) | 0.014 | 1.353 | (1.073, 1.705) | 0.011 |
| Yes | 1 | 1 | ||||
| Adequate exercise time | ||||||
| No | 1.438 | (1.072, 1.928) | 0.015 | 1.466 | (1.091, 1.970) | 0.011 |
| Yes | 1 | 1 | ||||
| Anxiety levels | ||||||
| The heavier | 0.419 | (0.172, 1.022) | 0.056 | 0.429 | (0.176, 1.048) | 0.063 |
| General | 0.892 | (0.638, 1.247) | 0.503 | 0.896 | (0.640, 1.253) | 0.520 |
| Normal | 1 | 1 | ||||
| The prevalence of Parents | ||||||
| All | 3.945 | (2.252, 6.908) | <0.001 | 3.922 | (2.280, 6.922) | <0.001 |
| One party | 2.783 | (2.143, 3.615) | <0.001 | 2.802 | (2.125, 3.641) | <0.001 |
| All no | 1 | 1 | ||||
| Grade | ||||||
| Freshman Class | 0.572 | (0.419, 0.782) | <0.001 | 0.526 | (0.346, 0.799) | 0.003 |
| Sophomore | 0.781 | (0.570, 1.070) | 0.124 | 0.732 | (0.509, 1.053) | 0.093 |
| Junior | 0.638 | (0.465, 0.875) | 0.005 | 0.625 | (0.451, 0.866) | 0.005 |
| Senior | 1 | 1 | ||||
Adjusted for gender, age.
Discussion
Recurrent aphthous ulcers represent a very common but poorly understood mucosal disorder, which occur in men and women of all ages, races and geographic regions [1].
Present study reveal that students whose parents suffer from RAU more more prone to RAU. Multivariate logistic regression analysis showed that genetic factors are risk factors of recurrent oral ulcers, which are similar to the findings of Koybasi et al. [12], family history was the most important factor for RAU among the investigated ones. Occur among sibling may be parents’ RAU status [13] with increased risk in children of two affected parents (67-90%), and correlation between the incidence of RAU and identical twins was found [14].
The brushing time is a protective factor of RAU. Several studies demonstrated that microorganisms’ including bacteria and viruses plays an important role in the development of RAU [15-17]. In addition, Helicobacter pylori has been detected in the dental plaque and saliva of healthy persons with gastric disease [18,19]. Oral cavity may be an alternative reservoir for the organism. Thus, the way to inhibit the growth of helicobacter pylori infection is brushing teeth in correct way.
The studies demonstrate that un-exercise students are 1.466 times compare to those who do exercise usually, doing exercise was a protective factor of RAU. Physical exercise could improve the body’s immune system, which has been recognized by the fact of the medical profession. Several studies show that the cytokines of human, including IL-2, IL-10, IL-12, IFN-γ, TNF-β, TGF-α, play an important role in the development of RAU [20-22]. The secretion of anti-inflammatory cytokines TGF-α IL-10 was significantly decreased in RAS patients compared to the healthy controls. Albanidou-Farmaki [23] found increasing of T lymphocytes can produce pro-inflammatory cytokines (IL-2, IL-12 and IFN-γ) and reduce IL-10-level in peripheral blood of the RAS patients in comparison to the healthy controls. Modern college students spend much time in the dormitory to play games and learn knowledge, and ignore the importance of exercise. Epidemiology study of sport find that the during time and frequent of the exercise failure to meet the reference of our national [24].
Meanwhile, the prevalence of RAU in grade one, grade three students is lower than that of the students from grade four. The possible reason is that with students from higher grade have more pressure for seeking job. An increasing number of studies suggest that anxiety, depression, and psychological stress are associated with symptoms of RAS [25-27]. Laura B, recorded 160 cases of patients with RAU daily stress of events through telephone follow-up [28], which find that stressful events may involved in initiation of new RAS episodes.
Conclusions
Genetic, brushing time, exercise, grades and other factors have an impact on the incidence of RAU. Thus, learn self-buck, maintain a good attitude, a positive and optimistic approach to life; focus on healthy eating, balanced diet nutrition; promote healthy living, good habits; long-term exercise can better reduce risk of RAU.
Acknowledgements
We grateful thank Yanjiao Fang and Zhengdong Dou from Centers for Disease Control and Prevention (Wuhu, China) for their help. This study was supported by Provincial Training Programs of Innovation and Entrepreneurship for Undergraduates (AH201310368116), Provincial Natural Science Research Project of Anhui Colleges (No. KJ2012B205).
Disclosure of conflict of interest
None.
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