recurrent+aphthous+stomatitis+investigation+of+possible+etiologic+factors

8/6/2019 Recurrent+Aphthous+Stomatitis+Investigation+of+Possible+Etiologic+Factors

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Recurrent aphthous stomatitis: investigation of possible etiologic factors

Serap Koybasi, MDa,4, Ali Haydar Parlak, MD b, Erdinc Serin, MDc,Fahrettin Yilmaz, MDa , Didem Serin, MDd

a Department of Otolaryngology, Abant Izzet Baysal University, Izzet Baysal Faculty of Medicine, Bolu, Turkey b Department of Dermatology, Abant Izzet Baysal University, Izzet Baysal Faculty of Medicine, Bolu, Turkeyc Department of Biochemistry, Abant Izzet Baysal University, Izzet Baysal Faculty of Medicine, Bolu, Turkey

d Department of Ophthalmology, Abant Izzet Baysal University, Izzet Baysal Faculty of Medicine, Bolu, Turkey

Received 17 August 2005

Abstract Objective: To investigate the association of serum vitamin B12, folic acid, iron, calcium, magnesium,

and phosphorus levels as well as family history and cigarette smoking with recurrent aphthousstomatitis (RAS).

Methods: Thirty-four patients with RAS and 32 control subjects were included in this controlled

prospective screening study. Both groups received a questionnaire, and serum screening tests were

performed. The collected data were analyzed using v2 test and binary logistic regression analysis.

Results: Family history was found to be the most significant predisposing factor for RAS among the

investigated ones. Regarding the serum tests, only vitamin B12 was found to have significant

correlation with RAS. Patients with vitamin B12 deficiency, positive family history, and nonsmoking

status have been found to have the highest risk for having RAS.

Conclusions: RAS is a multifactorial disease. Positive family history, vitamin B12 deficiency, and

nonsmoking status are among the important predisposing factors.

D 2006 Elsevier Inc. All rights reserved.

1. Introduction

Recurrent aphthous stomatitis (RAS) is one of the most

common oral diseases worldwide. The pr evalence ranges

from 2% to 66% in different populations [1,2]. RAS is a

disease characterized by recurring ulcers in the oral mucosa

without any sign of other diseases. Aphthous ulcers are

painful and shallow ulcers, usually covered with a grayish

white pseudomembrane that is surrounded by an erythem-

atous margin. Recurrent aphthous ulcers arise on nonkerati-

nized oral mucosa such as lateral margins of the tongue and

buccal and labial mucosa.

RAS is classified according to clinical characteristics

of the ulcers as minor ulcers, major ulcers, and herpeti-

form ulcers. The most common type is RAS with minor

ulcers and comprises approximately 80% of the cases. In

this type, the ulcers are less than 1 cm in diameter,

round, clearly defined, and painful ulcers and heal within

10 to 14 days without scarring. In major RAS (Sutton

disease), painful lesions are more than 1 cm in diameter,

may last for weeks, and usually heal with scar formation.

The herpetiform aphthous stomatitis, the least common

type, presents itself as multiple clusters of pinpoint lesions

that may give rise to large irregular ulcers lasting 7 to

10 days [3].

Although there are many factors accused in the etiology

of RAS, we still need to seek for more accurate and strong

statements regarding the etiology because of the contradic-tory literature and for patients’ benefit.

In this prospective study, we aimed to investigate

possible roles of predisposing factors for RAS. These

included family history, cigarette smoking, and serum tests.

Serum tests included vitamin B12, folic acid, iron (Fe++),

Fe++ saturation levels, total iron-binding capacity (TIBC),

ferritin, calcium (Ca++), magnesium (Mg++), and phospho-

rus (P) levels. Complete blood count with hemoglobin and

hematocrit levels was also performed.

0196-0709/$ – see front matter D 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.amjoto.2005.09.022

4 Corresponding author. Department of Otolaryngology, Abant Izzet

Baysal University, Izzet Baysal Faculty of Medicine, Bolu 14280, Turkey.

Tel.: +90 374 253 4656; fax: +90 374 253 4615.

E-mail address: [email protected] (S. Koybasi).

American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 229– 232

www.elsevier.com/locate/amjoto



2. Materials and methods

Thirty-four patients with a diagnosis of RAS with

recurrent minor ulcers were included in this study.

The control group was composed of 32 healthy volunteers

without oral aphthae history and undergoing preoperative

blood tests for septoplasty operation with a diagnosis of

nasal septal deviation. After obtaining an informed consent (according to principles outlined in the Declaration of

Helsinki), both groups were given a questionnaire about

the disease. Questionnaire included age, sex, smoking status,

family history, and systemic disorders. Both groups were

acknowledged about the disease and asked if any of

their family members had the symptoms. In addition, the

patient group was asked about the frequency and dura-

tion of the disease and the ulcers. Family history was

accepted positive in case of the presence of the disease in at

least one first-degree relative. Patients who smoked more

than 1 cigarette on regular daily basis were accepted as

active smokers.

In addition to otolaryngological examination, dermato-

logic and ophthalmologic examinations were made for

exclusion purposes. Pathergy test and antinuclear antibody

tests were performed to rule out possible coexisting sys-

temic disease; patients with Behcet disease or gastrointes-

tinal symptoms were not included in the study.

Complete blood count and the levels of vitamin B12, folic

acid, Ca++, Mg++, P, Fe++, Fe++ saturation level, TIBC, and

ferritin were investigated. The tests were performed in

serum collected after an overnight fast.

The results were evaluated using v2 test and binary

logistic regression analysis.

3. Results

Patient group was composed of 34 patients with 17 men

and 17 women, and the control group was composed of

32 individuals with 13 men and 19 women. Age ranged

between 10 and 66 years with a mean of 36.7 years in the

patient group and between 11 and 74 years in the control

group with a mean of 34.3 years. We did not show any

significant influence of age or sex on RAS (binary logistic

regression analysis, P N .05).

The most striking result was the influence of family

history on RAS. The rates of positive family history in

patient and control group were 54.2% and 9%, respectively.

In the presence of family history, we found a statistically

significant risk for having RAS (v2 = 16.8, P b .001).

According to our laboratory’s normal range (200-

835 pg/mL), we found 12 (35.2%) of 34 patients to be

deficient in vitamin B12, whereas in the control group, none

of the patients had vitamin B12 deficiency. Binary logistic

regression analysis revealed a significant relationship

between vitamin B12 and RAS probability ( P = .028).

As far as smoking was considered, 8 (20%) of 34 patients

were smokers in the patient group compared with 14 smokers

(43.7%) in the control group; v2 test revealed a borderline

significance level (v2 = 3.73, P = .052) concerning RAS and

smoking status.When considered together, the influence of family

history, vitamin B12 deficiency, and cigarette smoking on

RAS probability was calculated to be statistically sig-

nificant using binary logistic regression analysis ( P b

.001). This finding was summarized in Fig. 1. The non-

smoking patients with positive family history and vitamin

B12 deficiency were found to have the grater risk for

having RAS.

Folic acid, Ca++, Mg++, P, Fe++, Fe++ saturation level,

TIBC, ferritin, hemoglobin, and hematocrit levels were

found to have some degree of correlation with RAS, which

Fig. 1. Summary of the effect of studied predisposing factors for RAS in

relation with vitamin B12. As clearly seen, patients with low vitamin B12

level, positive family history, and nonsmoking status had the highest risk

for having RAS.

Table 1

Among the serum tests performed, only vitamin B12 was found to have a

statistically significant correlation with RAS ( P = .028).

Serum tests Group Mean SD P

Vitamin B12 Disease 245.5 97.9 .028

Control 294.0 80.0

Folic acid Disease 8.756 4.422 .916

Control 8.658 3.172Fe++ Disease 67.82 33.41 .675

Control 71.16 31.98

Fe++ saturation Disease 21.97 10.50 .757

Control 22.88 13.53

TIBC Disease 359.21 50.18 .074

Control 333.6 66.0

Ferritin Disease 68.5 61 .267

Control 53.51 49.48

Hemoglobin Disease 13.532 2.046 .797

Control 13.419 1.543

Hematocrit Disease 40.06 6.36 .303

Control 38.37 7.31

Ca++ Disease 9.4412 0.3775 .122

Control 9.6031 0.4748

Mg++

Disease 2.1765 0.2090 .074Control 2.0844 0.2142

P Disease 3.203 0.696 .654

Control 3.2719 0.5607

S. Koybasi et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 27 (2006) 229–232230



were not statistically significant (binary logistic regression

analysis, P N .05). Results of these evaluations were

summarized in Table 1.

We studied the frequency and duration of the aphthous

lesions and whether they were related to family history,

vitamin B12 deficiency, or cigarette smoking. We could not

show any significant relation between these parameters and

RAS (binary logistic regression analysis P N .05).

4. Discussion

Morbidity is quite high in RAS; quality of life of RAS

patients is affected in that the recurrent and painful intraoral

mucosal lesions and increased salivation give discomfort

while eating, drinking, and speaking. Because the exact

etiology of RAS is still unknown, most patients with RAS are

usually given some medications to relieve their pain only,

instead of an etiologic screening and curative treatment.

RAS may be associated with several diseases such as

Behcet disease, gluten-sensitive enteropathy, perniciousanemia, cyclic neutropenia, inflammatory bowel disease,

and FAPA (periodic fever, aphthous stomatitis, pharyngitis,

and adenitis). Despite extensive investigations, studies have

failed to find the exact etiology and pathophysiology of

RAS. Heredity, hemanitic deficiencies, immune dysregula-

tion, some foods, drugs, stress, local trauma, hormonal

disturbances, infections, smoking habits, and poor oral

hygiene are proposed factors [4-8].

A high incidence of aphthous stomatitis was reported by

Miller et al [8] in identical twins compared with noniden-

tical twins (90% vs b60%). Miller et al [9], in their study,

indicated an increased susceptibility to RAS among children

of RAS-positive parents. Shohat-Zabarski [10] reported that

more than 42% of RAS patients had first-degree relatives

with RAS. In our series, we found positive family history

in 54.2% of the patients. Whether this high degree of

association is because of a direct genetic influence or similar

social status, traditions, or habits of the family members is

not known yet. Among the predisposing factors we could

study, we found family history to have the strongest

correlation with RAS ( P b .001).

Serum vitamin status is another proposed predisposing

factor for RAS, and it has been shown that up to 20% of RAS

patients may have at least one hemanitic deficiency [5,11-13].

In our study, we found 12 (35.2%) of 34 patients to bedeficient in vitamin B12 according to our laboratory’s normal

range comparing with none in the control group ( P b .05).

Palopoli and Waxman [12] proposed that the diseases

commonly associated with RAS do this through diminishing

intestinal absorption of vitamin B12, resulting in vitamin B12

deficiency. The question is how vitamin B12 deficiency

causes RAS. So far, this issue remained unclear, but the

dramatic response to vitamin B12 replacement therapy and

higher incidence of RAS in cases that have vitamin B12

deficiency suggest a direct role of this vitamin on the

pathogenesis of RAS [6,11,14,15].

Cigarette smoking is known to have a protective effect

on RAS. This protective effect of smoking may be related to

the increased keratinization of the oral mucosa in smokers.

Keratin layer may possibly act as a mechanical and chemical

barrier of the oral mucosa against minor traumas or

microbial agents [16]. Recurrent ulcerations wer e pr evented

with the use of 8-mg 7-day Nicorette tablets [17]. In our

study, we found 20% active smokers (7 patients) in the RAS

group versus 43.7% (14 patients) in the control group

( P = .052). This finding, although not statistically

significant enough, is concurrent with the literature

[16,18]. The data about the protective effect of tobacco

are limited and need further studies.

Iron deficiency is anot her proposed predisposing factor

for RAS [5]. Porter et al [19], in their study, have shown a

significantly lower serum ferritin level (11.6%) in RAS

patients com pared with control group (4.9%). However,

Wray et al [15] reported Fe++ deficiency to be very rare

among patients with recurrent ulcerations. They also

claimed that RAS patients with Fe++

deficiency respond ina longer period to replacement therapy with Fe++, compared

with replacement with vitamin B12 and folic acid which they

attributed to the difficulty in reconstituting body stores of

Fe++. Others failed to demonstrate an association of Fe++

deficiency with RAS [6,20]. Results of our study did not

show a direct association of the disease neither with serum

Fe++, Fe++ saturation level, ferritin, nor hemoglobin and

hematocrit levels, but with TIBC, although statistically not

significant ( P = .074).

The association of RAS with the predisposing factors

found to be significant was summarized in Fig. 1. The

highest occurrence of RAS was found to be in nonsmoking

patients with a positive family history and vitamin B12

deficiency. Obviously, among these 3 factors, only vitamin

B12 deficiency might be overcome by replacement therapy

as we could not change the family history or encourage

patients to smoke.

Previous studies proposed possible etiologic roles of folic

acid and minerals [5,15]. However, there are studies that

deny such a relationship between RAS and folic acid [20].

Our attempts to find such an association between serum

folic acid, Ca++, Mg++, or P levels with RAS have failed.

This may be attributed to regional differences of our

patients, but we think that this issue should be studied

further with a larger multicenter series.Taking all these findings into consideration, we can

clearly state that RAS is a multifactorial disease, and we can

conclude that positive family history, vitamin B12 deficien-

cy, and smoking status are among the studied possible

etiologic factors.

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