/home/opencode/cpanel/stomaeduj_hacked/uploads/2019/12/Article_6_4_3-Obradovic.pdf ORAL MEDICINE SMOKING AND RECURRENT APHTHOUS STOMATITIS Original Articles Radmila Radisa Obradović1a* , Marija LJ Igic2a, Aleksandar D Mitic3a , Ana S Pejcic1a , Kosta M Todorovic4b , Zana Popovic5c 1 Department of Periodontology and Oral Medicine, Faculty of Medicine, Niš University, Serbia 2 Department of Children and Preventive Dentistry, Faculty of Medicine, Niš University, Serbia 3 Department of Dental Pathology and Endodontics, Faculty of Medicine, Niš University, Serbia 4 Department of Oral Surgery, Faculty of Medicine, Niš University, Serbia 5 Department of Dentistry, Faculty of Medical Sciences, Kragujevac University, Serbia a DDS, PhD, Professor b DDS, Assistant c DDS, Postdoctoral Student ABSTRACT DOI: https://doi.org/10.25241/stomaeduj.2019.6(4).art.3 OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license. Introduction: Recurrent aphthous stomatitis (RAS) is one of the most usual inflammatory diseases of the oral mucosa. The clinical characteristics of RAS are Peer-Reviewed Article well defined, but the exact etiology and pathogenesis of the disease are not. Citation: Obradović RR, Igic M, Mitic A, Pejcic A, Todorovic K, Popovic Z. Smoking and recurrent Several investigations have noticed cigarette smoking to have a protective effect aphthous stomatitis. Stoma Edu J. 2019;6(4):237-240 on RAS. The aim of the study is to investigate the association between cigarette Received: July 08, 2019 smoking and RAS in order to improve the current knowledge on this issue. Revised: October 25, 2019 Accepted: October 28, 2019 Methodology: 68 patients with RAS participated in the study. A full mouth Published: December 16, 2019 clinical examination was performed and an anamnesis was taken for each patient. *Corresponding author: The statistical analysis was performed using Student t-test. Professor Radmila Radisa Obradović, DDS, PhD Department of Periodontology and Oral Medicine, Results: While 6 (8.9%) of patients with RAS were smokers, a significantly higher Faculty of Medicine, Niš University 81, Dr Zoran Djindjic percentage (24.9%) among the subjects with RAS were not smokers (group II) (χ2 Blvd, 18000 Niš, Serbia Tel: +381-64-235-9595, =70.4; d.f. = 2, P < 0.001). Fax: +381-18-42-38-770, e-mail: dr.rada@yahoo.com Conclusion: The negative association between smoking and RAS indicated by Copyright: © 2019 this investigation is not meant to encourage people to smoke nor to spare them the Editorial Council for the Stomatology Edu Journal. from the intention to quit their habit. These conclusions should be used to clear up the cause and pathogenesis of the RAS and to identify better prevention and treatment. Keywords: Oral medicine; Aphthae; Mouth; Smoking; Oral health, Recurrent Aphthous Stomatitis, Smoking. 1. Introduction are produced [3]. Inheritance of HLA-B51 antigen, Recurrent aphthous stomatitis (RAS) is a very common vitamin B12 deficiency, recurrent herpes labialis, disease of the oral mucosa. It is called minor aphthous Helicobacter pylori, hepatitis C and hypersensitivity ulcers, herpetiform ulcers, aphthosis and many other to nickel are involved in the development of names. Aphthous ulcers can occur alone or as part of RAS [4,5]. It is necessary to better understand a syndrome [1]. RAS occurs only in non-keratinized the pathogenesis and primary cause of RAS [2]. mucosa as painful, shallow round ulcers with an Previously, it is thought that approximately 0.89% erythematous halo covered by a membranous layer. of the adults over 17 years of age have at least one The clinical ulcerative period for minor aphthous aphthous lesion and that males (1.13%) have almost ulcers may last for 2 weeks and lesions usually heal twice the RAS than females (0.67%). It is noticed without a scar [2]. The clinical characteristics of RAS that reported prevalence of RAS varies according are well known, but the exact etiology and patho- to patient selection, presence of lesions at the time genesis of the disease are not complete. The etiology of investigation or during a specified period and of RAS includes stress, microorganisms, food hyper- newer literature data show that the RAS prevalence sensitivity, immune dysregulation, hormonal fac- is between 5 and 60%, depending on the population tors and a genetic predisposition, usage of the group studied [2]. toothpaste with SLS [1,2]. Current investigations It is estimated that tobacco use is the major cause of have focused on a possible immunopathogenesis of more than 5 million deaths every year [6]. Smoking RAS [2,3]. The epithelial cell death and the creation is a common risk factor in a number of chronic of ulceration probably results from the activation of diseases like lung diseases, cancer, cardiovascular a cell-mediated immune response in which Tumor diseases; and a major risk factor in the prevalence of Necrosis Factor Alpha (TNFα) and other cytokines periodontal diseases [6-10]. Cigarette smoke contains Stomatology Edu Journal 237 SMOKING AND RECURRENT APHTHOUS STOMATITIS Table 1. Relationship between RAS and smoking. Original Articles RAS (no RAS or RAS history) Total Smoking (group I) 6 (8.9%) 68 (91.9%) 74 Nonsmoking (group II) 62 (24.9%) 202 (76.5%) 264 Total 68 (20.1%) 270 (79.9%) 338 approximately 4800 chemicals, with over 60 of them patients constituted group II (264 patients). known to have 3 damaging effects on human cells [11]. Cigarette smoking could camouflage signs of 4. Results periodontal disease like gingival bleeding or redness, There were 68 participants with RAS, out of which 31 by suppressing the immune response which could (46.92%) were men and 37 (53.1%) were women. The cause a problem in the diagnosis of the disease. average age was 29.7± 8.8 years. 66 (97.1%) had the Several studies have noticed cigarette smoking to minor type of the disease, 2 (2.9%) had both minor have a protective effect on RAS [12-15]. It is not clear and major RAS. how cigarette smoking can reduce RAS prevalence The relationship between RAS and smoking is but it is thought that immunological mechanisms shown in Table 1. While 6 (8.9%) of patients with RAS are involved and that the cytokine (TNF) plays an were active smokers (group I), a significantly higher important role in the pathogenesis. Nicotine has percentage (24.9%) among the subjects with RAS been shown to influence the immune response in were not smokers (group II) (χ2 =70.4; d. f. = 2, P < inflammatory conditions [16,17]. It acts through the 0.001). central nervous system inducing the production of glucocorticoids and activating the autonomic 5. Discussion nervous system and consequently reducing the level Smoking is a known risk factor in a number of chronic of inflammation [16]. diseases and major risk factor of periodontal disease Nicotine can activate the nicotinic acetylcholine [2-6]. Cigarette smoking suppresses the immune receptors on macrophages and reduce the host response, masks early signs of periodontal production of TNF1and interleukins [17]. disease and has as reported by some authors a beneficial protective effect on RAS. It has also been 2. The aim of the study noticed that the incidence of RAS is higher among The aim of the study is to investigate the association young individuals and that adults younger than 40 between cigarette smoking and RAS in order to years of age have more than twice higher RAS rate increase current knowledge on this issue. than those older than 40 years [12-15]. We noticed similar results in our study where the average age 3. Methodology of the patients with RAS was 29.7±8.8 years. It The study was conducted on 338 patients who could be suspected that stress could be an aphthae came at the Department of Oral Medicine and provoking factor. Previously, lifestyle could induce Periodontology of the Dental Clinic of Faculty of stress and social conditions and self-management Medicine, Niš University, for one year. The Ethics are important determinants of health. The effects Committee of the Faculty of Medicine Niš approved of living exposed to many stress factors may cause the study protocol (evidential number 01-2800-7). poorer health and more frequent occurrence of RAS After the medical history was taken, the patients [18,19]. Literature data reveal a significant reduction who had undergone antibiotic and corticosteroid of RAS in individuals who smoke. The prevalence therapy in the last three months, were not included and odds ratios for number of cigarettes smoked is in the study. A full mouth clinical examination was significant and suggest a dose response effect [14,15]. performed and the patients with active aphthous A reduction in RAS prevalence with higher blood lesions and who per medical history had suffered levels of nicotine is found to be significant [20]. from oral ulcers at least once within a period of 5 Our study noticed a similar situation. where 8.9% months were considered to suffer from RAS. The of patients with RAS were active smokers and a patients with other oral diseases who came at the significantly higher percentage (24.9%) among Dental Clinic of the Medical Faculty Niš for other the subjects with RAS were not smokers (group II) medical reasons were also included in this study. (χ2 =70.4; d. f. = 2, P < 0.001). Kalpana [13] noticed Out of all the examined patients, 68 patients had that significant differences exist in the prevalence RAS and 270 had no RAS or RAS history. Patients of RAS among cigarette smokers, which could be who smoked over 10 cigarettes per day (per medical related to the number of cigarettes smoked per day history) were considered to be “smokers” and they and duration of the habit. The “protective effect” on constituted group I (74 patients). The nonsmoking RAS was noticed only when the persons were heavy 238 Stoma Edu J. 2019;6(4): 237-240 www.stomaeduj.com SMOKING AND RECURRENT APHTHOUS STOMATITIS smokers or had smoked for longer periods of time. by a bias of selection of the sample. Other researchers Original Articles Cigarette non-smokers have far greater odds of RAS have found a lower incidence of RAS in smokers on than individuals who smoked >1 pack per day. It the basis of the disease history but not by direct could was concluded that the associations of RAS detection of present lesions by a practitioner [12-14]. with cigarette smoking and with cotinine levels A similar negative correlation between smoking and were significant. Our study noticed similar results, RAS was noticed in our study. The treatment and, namely that a higher number of individuals with many times, the diagnosis of RAS are a challenge RAS were nonsmokers (24.9%). RAS is characterized in the daily life of the clinician. Dental professionals by recurrences of short-lived lesions. The lesions and otorhinolaryngologists are usually responsible are not always noticed at the time of examination for the first contact with the patients who have RAS. and the diagnosis is often based on the patient’s These professionals should be alert to the clinical clinical history. The statistical evaluation of RAS is aspects of this condition since each patient will hampered because lesions cannot be evaluated by be treated in an individualized manner, because the investigator at any time and is usually based on treatment is usually palliative and not curative. a self-reported history of RAS. Such a diagnosis is less reliable that one based upon the observation of 6. Conclusion present lesions by a practitioner. It is to be noticed On the basis of the aim of the study, its applied that many of the studies which found a negative methodology and the results obtained it can be correlation between RAS and smoking were based concluded that the incidence of RAS is higher on a self-reported history of RAS [21]. Information among young individuals and among subjects who should be carefully interpreted, especially where do not smoke. The negative association between there is some basis to suspect response bias. The smoking and RAS in our study is not indeed meant to findings in this study were based on anamnesis encourage people to smoke nor to sway them in the and clinical examination conducted by an decision to quit their habit. Smoking cessation is the experienced practitioner and provide data on the main option to remove the harmful tobacco effects general prevalence of RAS in smokers. There is a on oral tissues and to improve the quality of life. small number of studies in which patients were diagnosed by direct detection of present lesions Author Contributions by a practitioner. Queiroz et al [22] evaluated 4895 All authors (RO, MI, AM, AP, KT, and ZP) contributed in cases of recurrent aphthous ulcerations with a focus data collection and analysis, and manuscript writing. on treatment, diagnosis and etiology. Data such All authors agree to be accountable for the content as sex, age, race, location, smoking habits, types of the work. of treatment, relapsing episodes, laboratory test results and clinical characteristics were collected. Acknowledgment Regarding smoking habits, in the majority of This research was supported by a grant from the patients, 59 (77.6%) smoking was not recorded. 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She is also a member of the Niš Dental Clinic’s Ethical Committee, Serbian Medical Society, Serbian Anthropological Society and Serbian Oral Laser Society (SOLAS). She participates in national projects, and delivers many dental courses and conferences as a lecturer. She has many scientific publications in international and Serbian medical and dental journals. Questions 1. Recurrent aphthous stomatitis (RAS) is very common disease of the oral mucosa. It is called: qa. Minor aphthous ulcers; qb. Herpetiform ulcers; qc. Simple aphthosis; qd. All of the above answers are correct 2. Cigarette smoking could influence signs of periodontal disease like: qa. Provoking bleeding; qb. Provoking gingival redness; qc. Camouflage gingival bleeding or redness; qd. Provoking gingival swelling. 3. The etiology of RAS includes: qa. Stress and immune dysregulation; qb. Microorganisms and food hypersensitivity; qc. Hormonal factors and a genetic predisposition; qd. All of the above answers are correct. 4. The patients were divided into: qa. Two groups: smokers and nonsmoking patients; qb. Three groups: smokers, nonsmoking patients and patients with RAS; qc. Two groups: smokers and patients with RAS; qd. Two groups: nonsmoking patients and patients with RAS. 240 Stoma Edu J. 2019;6(4): 237-240 www.stomaeduj.com