Abstract
The aim of this study was to investigate the psychological profiles of patients with recurrent aphthous ulcers (RAUs). 50 patients (27 men and 23 women, mean age 31.44 ± 9.95 years) with diagnosed RAUs participated in this study. 50 controls who matched the patients in age and gender were also recruited. The participants’ personality and psychological profiles were assessed using the Hospital Anxiety and Depression Scale (HAD) and the Neuroticism-Extraversion-Openness Five Factor Inventory (NEO-FFI). Data analysis showed that females had higher HAD anxiety scores than males in both patients and controls. Patients’ age, intensity of pain and number, position, duration, and frequency of ulcers had no relation to HAD and NEO-FFI scores. Patients reported higher levels of anxiety in comparison to controls, but both reported comparable depression scores. Patients’ NEO-FFI scores were not different from those reported by controls and the psychological profiles of patients and controls were similar. In conclusion; stressful situations and conditions (i.e. anxiety) rather than personality profiles and stable psychological traits were related to the occurrence of recurrent aphthous ulcers.
Recurrent aphthous stomatitis is a common oral mucosal disorder. It is clinically diagnosed by painful, recurrent, yellowish white or grey, single or multiple, and round or oval ulcers with erythematous margins mainly confined to non-keratinized oral mucosa. Its pathogenesis remains uncertain but is probably multifactorial.
The need for consideration of psychological factors in the pathogenesis of oral disease has been increasingly acknowledged over the last decades and many studies have highlighted the psycho-social impact of oral conditions. Oral health and status impacts on people’s daily living, quality of life and overall well-being, therefore, the clinical status, psychological factors, dental needs and patients’ perceptions should be assessed.
Acute psychological disorders (e.g. stress and anxiety) were found to be associated with the development of recurrent aphthous ulcers. Stressful situations are thought to cause transitory increase of salivary cortisol and/or provoke immunoregulatory activity by increasing the number of leukocytes at sites of inflammation. These changes are frequently detected at some stage during the pathogenesis of recurrent aphthous ulcers. Gallo et al. found high levels of psychological stress in recurrent ulcer patients; they concluded that stress might be a triggering or modifying factor rather than a causative factor for recurrent ulcers. Some studies found no association between psychological life stress and recurrent aphthous ulcers. Even though the present literature could not confirm beyond doubt that stress plays an important role in the pathogenesis of recurrent aphthous ulcers, many still think that stress may play a role in the aetiology of recurrent aphthous ulcers.
The literature lacks valid and reliable studies on the distinctive and vague relationship between psychological profiles and the occurrence of recurrent aphthous ulcers. Further evaluation and careful scientific based evidence are required to explore whether the assessment of certain patients’ psychological traits can predict their susceptibility to recurrent oral ulcers.
This study investigates the psychological traits in patients with recurrent aphthous ulcers and their potential role in the occurrence of recurrent aphthous ulcers using a valid, reliable and comprehensive psychological measure. The study hypothesis would be that psychological profiles have no relationship with recurrent aphthous ulcers.
Materials and methods
50 consecutive patients who were diagnosed with recurrent aphthous ulcers and were seeking treatment at Dental Health Teaching Center, Jordan University of Science and Technology, Irbid, Jordan were recruited into this study. The clinical procedures in this study were approved by the Deanship of Research, Jordan University of Science and Technology.
To be included in the study, recruited patients had to be 17 years of age or older in order to understand and score the questionnaires, and have no medical disease (including mental problems and psychological disorders) that might affect their ability to understand and/or to score the questionnaires. Patients had to have an existing diagnosis of recurrent aphthous ulcers from a consultant in oral medicine according to the previous literature.
The patients were exposed to an extensive full medical assessment including detailed history, full examination and laboratory tests (haematological and genetic analysis); and were only recruited to the study if they met the inclusion criteria of having recurrent aphthous stomatitis and no other systemic disease.
Ulcers were considered as recurrent aphthous ulcers when they were yellowish white or grey in colour, enclosed by an erythematous area, recurrent, painful, and not associated with systemic disease (including haematinic deficiencies, hormonal and metabolic conditions), allergic condition, and drug intake (e.g. corticosteroids and oral contraceptives). The ulcers had to be present at the moment of clinical examination. Ulceration that did not follow the above criteria was excluded.
Patients affected by any systemic disease including metabolic conditions, haematinic deficiencies, hormonal conditions, hypertension, diabetes, cardiovascular, renal, gastrointestinal, and liver disease were excluded. Patients with any other mucosal or skin disease that might be associated with oral lesions were excluded from the study. Patients with habits of tobacco chewing, Narghile and cigarette smoking were also excluded from the study. Narghile is a type of smoking using a special device that contains a water reservoir through which the smoke passes before it is inhaled. Although it was first known in Turkey and the Arab world, it is used worldwide and is also known as hubble bubble.
An invitation to participate in the study was extended to the patients. Each participant was given a brief explanation of the study and informed consent was obtained from each participant before they were recruited into the study.
Each patient was assessed to record number, position, duration and frequency of ulcers. The assessment also included patients’ dental and medical histories, complaints, and personal information regarding age, gender, education, occupation, address and marital status. Pain due to contact by oral structures or food was evaluated. Patients reported the intensity of pain due to ulcers using a visual analogue scale (VAS), scored from 0 (no pain) to 10 (maximum pain possible). Patients had to have stable periodontal health with no prosthetic rehabilitation or missing teeth as this might have affected the results. Details of the dental condition are beyond the scope of this study.
50 control participants who attended the dental clinics seeking routine dental care and had never experienced recurrent aphthous ulcers were recruited into the study. They matched the patients for age and gender. To be included, controls had to have no systemic disease, allergic condition, undesirable habits related to tobacco and smoking, or to be taking drugs. Detailed medical histories and an extensive review of the controls’ medical records were used for this purpose.
To be included, the controls had to have attended for routine dental care (check ups, simple scaling and polishing, and fluoride application). The reason for their dental visit had to exclude pain or prosthetic/restorative drives to eliminate any psychological effects of pain or having lost teeth.
One investigator (Dr. Karasneh) conducted all clinical examinations in the Oral Diagnosis Clinic, Dental Health Teaching Center, Jordan University of Science and Technology. Intra examiner reliability was tested on five duplicate clinical examinations using Kappa statistics. Kappa was 1.00 indicating substantial agreement as the examination criteria were very clear and simple.
Psychological and personality assessments
On the same day as the examination, each participant completed the Hospital Anxiety and Depression Scale (HAD) and the Neuroticism-Extraversion-Openness Five Factor Inventory (NEO-FFI).
The HAD scale was developed at St. James University Hospital, Leeds, UK. It quickly spots mood disorders in non-psychiatric hospital clinics, separates depression from anxiety, assesses the change of patient emotional state and the degrees of anxiety and depression, and excludes symptoms caused by physical illness so they do not affect the scores. It is short and easy to answer. Although it is not comprehensive for personality evaluation it gives an idea about mild levels of mood disorders.
The HAD scale consists of 14 items and it is divided into two subscales: anxiety and depression. Each item has 4 responses to choose from and each response has a score. Scores added in each subscale to give a maximum score of 21 are categorized as: 0–7 normal; 8–10 about to be pathological; and 11–21 clinically morbid.
Each participant completed the NEO-FFI test to assess their personality profiles. The test consisted of 60 questions analysing the five major personality dimensions: neuroticism, extraversion, openness, agreeableness and conscientiousness. Each dimension was assessed using 12 questions. This test is a comprehensive method to measure five dimensions of personality, has good reliability and validity, is simple, requires a short time to answer, and its scores are easy to analyse statistically. This questionnaire was validated for a Jordanian population in previous studies and was found valid and reliable.
Each participant was provided with a full explanation of the dimensions and the methods of scoring each questionnaire, and the process of completing the questionnaires was supervised by the investigator.
10 subjects answered the questionnaires twice with a 1 week interval. Reliability tests were carried out on all questions using correlation coefficients. The correlation coefficients were high and ranged from 0.8 to 0.94.
Statistical analysis
The data were analysed using the Statistical Package for the Social Sciences 16 (SPSS 16, SPSS Inc., Chicago, IL, USA). The association between the variables was analysed using the Pearson correlation test. ANOVA test was used to compare patient and control groups. For all statistical analysis, the significance level was set at P ≤ 0.05. The sample size was set to be ≥50 participants in order to conduct this study to obtain 80% power and an odds ratio of 2.5 at 5% significance level.
Results
The study sample consisted of 50 participants with recurrent ulcers (27 (54%) men and 23 (46%) women) aged between 17 and 66 years (mean age 31.44 years, SD = ±9.95 years).
Using a VAS score from 0 to 10; all patients reported intense pain (8–10 score) due to ulcers. Regarding the position of ulcers, 7 patients had recurrent ulcers on the floor of the mouth, 15 had them on tongue mucosa, 20 had buccal ulcers, and 45 were affected by labial ulcers. In 37 patients the ulcers were recurrent on an irregular basis, whilst 13 patients had ulcers frequently on a regular basis. Ulcer duration of <7 days was reported by 13 patients, whilst 36 patients had ulcer duration of 7–14 days and 1 patient reported that ulcers persisted for more than 14 days. 26 patients had solitary ulcers and 24 had multiple ulcers.
The patients’ HAD scores for depression ranged from 0 to 18 (mean score 6.46 ± 4.09), whilst for anxiety the scores ranged from 3 to 18 (mean score 9.74 ± 3.39). Amongst controls, the HAD scores for depression ranged from 0 to 15 (mean score 5.62 ± 3.52), whilst for anxiety the scores ranged from 1 to 18 (mean score 7.58 ± 3.48).
For patients’, the mean NEO-FFI dimension scores were 22.26 for neuroticism, 29.08 for extraversion, 21.94 for openness, 28.52 for agreeableness, and 34.92 for conscientiousness. Amongst controls, the mean NEO-FFI dimension scores were 20.62 for neuroticism, 29.44 for extraversion, 21.12 for openness, 27.76 for agreeableness, and 35.90 for conscientiousness. Table 1 summarizes the mean, standard deviation, maximum and minimum values for NEO-FFI dimension scores in patients and controls.
| NEO-FFI dimension | Mean score | Standard deviation | Maximum score | Minimum score | ||||
|---|---|---|---|---|---|---|---|---|
| Patients | Controls | Patients | Controls | Patients | Controls | Patients | Controls | |
| Neuroticism | 22.26 | 20.62 | 5.53 | 6.21 | 37 | 34 | 12 | 4 |
| Extraversion | 29.08 | 29.44 | 4.54 | 3.84 | 38 | 40 | 18 | 22 |
| Openness | 21.94 | 21.12 | 4.38 | 4.34 | 33 | 32 | 13 | 11 |
| Agreeableness | 28.52 | 27.76 | 3.29 | 4.79 | 37 | 40 | 22 | 18 |
| Conscientiousness | 34.92 | 35.90 | 5.60 | 5.61 | 45 | 48 | 20 | 16 |
Age, gender, intensity of pain as well as number, position, duration and frequency of ulcers were correlated to patients’ HAD and NEO-FFI scores. No significant relations were detected except that females had higher HAD anxiety scores ( P = 0.008) and higher extraversion scores than males ( P = 0.015) ( Table 2 ).
| Age | Gender | Ulcer position | Ulcer number | Ulcer frequency | Ulcer duration | |
|---|---|---|---|---|---|---|
| HAD depression scores | ||||||
| R | 0.193 | −0.065 | 0.038 | 0.178 | 0.176 | 0.121 |
| P (2-tailed) | 0.179 | 0.652 | 0.796 | 0.217 | 0.227 | 0.404 |
| HAD anxiety scores | ||||||
| R | 0.159 | 0.371 | 0.033 | 0.086 | 0.049 | 0.036 |
| P (2-tailed) | 0.269 | 0.008 * | 0.821 | 0.551 | 0.738 | 0.802 |
| Extraversion NEO-FFI scores | ||||||
| R | −0.193 | 0.341 | −0.014 | 0.036 | 0.047 | 0.056 |
| P (2-tailed) | 0.180 | 0.015 * | 0.925 | 0.802 | 0.747 | 0.698 |
| Other NEO-FFI scores | ||||||
| R | NS | NS | NS | NS | NS | NS |
| P (2-tailed) | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 |
Amongst controls, no relationships were detected between age and gender, and HAD and NEO-FFI scores ( P > 0.05), except that females had higher HAD anxiety scores than males ( P = 0.046) and younger participants had higher neuroticism ( P = 0.036) and lower agreeableness scores ( P = 0.022) than older ones ( Table 3 ).
| Age | Gender | |
|---|---|---|
| HAD depression scores | ||
| R | −0.039 | −0.015 |
| P (2-tailed) | 0.787 | 0.920 |
| HAD anxiety scores | ||
| R | −0.082 | −0.283 |
| P (2-tailed) | 0.571 | 0.046 * |
| Neuroticism NEO-FFI scores | ||
| R | −0.297 | −0.243 |
| P (2-tailed) | 0.036 * | 0.089 |
| Agreeableness NEO-FFI scores | ||
| R | 0.324 | −0.089 |
| P (2-tailed) | 0.022 * | 0.540 |
| Other NEO-FFI scores | ||
| R | NS | NS |
| P (2-tailed) | >0.05 | >0.05 |
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