Prevalence of Recurrent Aphthous Ulcers Among Dentistry Students’ in Kabul, Afghanistan: A Questionnaire-Based Study

Abstract

Introduction:
Recurrent aphthous stomatitis (RAS) is the mouth's most common and painful inflammatory ulcerative condition, also called aphthae or canker sores. Its prevalence is about 20% and predisposition factors involve genetics, environmental factors, and immune dysfunctions.

Objective:
Reviewing the literature and no study was found to show the prevalence and associated factors of recurrent aphthous ulceration in the context of Afghanistan. Therefore, this study aimed to determine the lifetime prevalence and associated factors of recurrent aphthous ulceration among dentistry students at Kabul University of Medical Sciences, Afghanistan.

Methods:
A cross-sectional questionnaire-based study was carried out among 223 dentistry students. A descriptive and inferential analysis was performed to find the association.

Results:
The prevalence of (RAS) in our sample group was 30%. (68.7%) of participants had one or more family members who experienced aphthous ulcers and the association was found to be significant (X 2 = 134.940; p < 0, 05). (81%) of participants experienced the condition to eating certain types of food (X 2 = 165.906; p < 0, 05) and (53.7%) of them reported the same about trauma (X 2 = 99.958; p < 0, 05). Regarding stress the difference was also statistically significant (X 2 = 56.830; p < 0, 05).

Conclusion:
We found that a considerable proportion of the study sample had experienced recurrent aphthous ulceration. Family history, stress, trauma, and dietary factors have an impact on the occurrence of RAS with no association with gender and smoking.

Full text

ORIGINAL RESEARCH
Prevalence of Recurrent Aphthous Ulcers Among
Dentistry Students’ in Kabul, Afghanistan:
A Questionnaire-Based Study
Mohammad Haris Taheri , Ali Maisam Eshraqi, Abdurrahman Anwari , Ahmad Milad Stanikzai
Faculty of Dentistry, Kabul University of Medical Sciences, Kabul, Afghanistan
Correspondence: Mohammad Haris Taheri, Jamal Mena, Ali Abad Teaching Hospital, Dentistry Teaching Clinic, Kabul, 3rd District, Kabul, Afghanistan,
Tel +93786234342, Email 01haris01@gmail.com
Introduction: Recurrent aphthous stomatitis (RAS) is the mouth’s most common and painful inammatory ulcerative condition, also
called aphthae or canker sores. Its prevalence is about 20% and predisposition factors involve genetics, environmental factors, and
immune dysfunctions.
Objective: Reviewing the literature and no study was found to show the prevalence and associated factors of recurrent aphthous
ulceration in the context of Afghanistan. Therefore, this study aimed to determine the lifetime prevalence and associated factors of
recurrent aphthous ulceration among dentistry students at Kabul University of Medical Sciences, Afghanistan.
Methods: A cross-sectional questionnaire-based study was carried out among 223 dentistry students. A descriptive and inferential
analysis was performed to nd the association.
Results: The prevalence of (RAS) in our sample group was 30%. (68.7%) of participants had one or more family members who
experienced aphthous ulcers and the association was found to be signicant (X
2
= 134.940; p < 0, 05). (81%) of participants
experienced the condition to eating certain types of food (X
2
= 165.906; p < 0, 05) and (53.7%) of them reported the same about
trauma (X
2
= 99.958; p < 0, 05). Regarding stress the difference was also statistically signicant (X
2
= 56.830; p < 0, 05).
Conclusion: We found that a considerable proportion of the study sample had experienced recurrent aphthous ulceration. Family
history, stress, trauma, and dietary factors have an impact on the occurrence of RAS with no association with gender and smoking.
Keywords: recurrent aphthous ulceration, prevalence, associated factors, Afghanistan
Introduction
Recurrent aphthous ulceration is an inammatory ulcerative condition of the oral mucosa, a shallow round ulcer with an
erythematous halo covered by a yellowish-gray slough.
1
It mainly occurs in the non-keratinized areas such as lips, tongue,
buccal mucosa, and soft palate.
2
Aphthous ulcers are classied into three groups based on their size; major, minor, and
herpetiform. Minor aphthous ulceration is small (less than one cm in diameter), well-dened, shallow, and heals within two
weeks without a scar. Major ulcers are bigger, and deeper and take up to six weeks to heal with scars. Herpetiform ulcers are
also small (3–6mm), shallow, multiple ulcers and take weeks to heal.
3
Aphthous ulceration is usually painful and interferes
with eating, speaking, and swallowing.
4
Oral ulcers have a negative impact on individuals’ oral health, routines, and daily
lives; hence, it has the potential to increase morbidity and decrease the quality of life signicantly.
5
The etiology of recurrent aphthous ulcers is unclear; however, many factors are associated with stress, trauma,
infection, allergy, genetic predisposition, or nutritional deciencies.
6,7
Nevertheless, it is reported as the most common
oral mucosal disorder worldwide.
1
The prevalence of recurrent aphthous ulceration was reported to vary from 5 to 66%
in different countries.
8,9
In the United States of America (USA), Shulman’s study revealed the prevalence of recurrent
aphthous ulcers to be 40% in a sample of children.
10
It frequently occurs among women more than men
11
and increases
with increasing age. Besides, minor aphthous ulcers are responsible for more than 80% of cases.
12
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Open Access Full Text Article
Received: 25 June 2022
Accepted: 6 September 2022
Published: 14 September 2022

However, to tackle the problem, it is essential to know the prevalence and risk factors of recurrent aphthous in
Afghanistan. We reviewed the literature and found no study to show the prevalence of recurrent aphthous ulceration in
the context of Afghanistan. Therefore, we design this study, given the limited resources, to determine the prevalence of
recurrent aphthous ulceration in a sample of dentistry students at Kabul University of Medical Sciences, Kabul,
Afghanistan.
Method
A descriptive cross-sectional study was carried out among a consensus sample of 223 dentistry students at Kabul
University of Medical Sciences, Kabul, Afghanistan. The participants of the present study were dental students who have
passed the courses regarding recurrent aphthous. The study was approved by the ethics committee of Kabul University of
Medical Sciences and the signed consent of all participants was obtained before handing over the questionnaire. We
conrm that this study complies with the declaration of Helsinki.
A questionnaire was developed by researchers after an extensive literature review. The questionnaire contains 2
sections. The rst section contains questions on the demographic characteristics of the participants such as age, gender,
and class. The second section contains questions divided into 5 parts with a total of 23 questions related to the occurrence
history of recurrent aphthous ulceration, family history, diet, stress, and trauma.
Statistical Analysis
The data were analyzed by using SPSS version 16.0. The frequency distribution of recurrent aphthous ulceration was
calculated. A frequency table was utilized to determine the lifetime prevalence of recurrent aphthous ulcers and a chi-
square test was applied to nd the association of factors with recurrent aphthous ulceration. The level of signicance was
xed at p < 0.05 for all comparisons.
Result
Totally, 223 students participated in the study. About half of the respondents were female (50.2%) and male (49.8%).
Their age ranged from 22–28 years. Among 223 respondents, 117 (52.46%) were in the fth grade and 106 (47.54%)
were last year’s students of dentistry faculty (Table 1).
Nearly, all of the respondents (99.6%) were non-smokers. The lifetime prevalence of recurrent aphthous was found to
be 30% (n=67) and nearly, two-thirds of them (n = 46; 68.7%) have one or more family members who experienced oral
aphthous ulcers. Most of the respondents (n = 54; 81%) who have experienced the situation claimed that eating certain
types of food was the cause of the ulcer. Besides, the majority of the experienced group (n = 36; 53.7%) reported trauma
as a triggering factor for the occurrence of their oral ulcers while two-thirds of them (n = 22; 32.8%) mentioned that
stress was the reason for their ulcers. The frequency distribution of all related risk factors in participants with RAS is
shown below in Table 2.
The result of the chi-square test showed that gender and smoking did not have a signicant association with recurrent
aphthous ulcers (p> 0.05). However, certain types of food (X
2
= 165.9; p<0.05), family history of recurrent aphthous
Table 1 Characteristics of the Study Population
Variable Male Female Total
N % N %
Age group
22–25 99 44.39 96 43.04 195
26–28 12 5.38 16 7.17 28
Grade
5th year 61 27.35 56 25.11 117
House Job (last year) 50 22.42 56 25.11 106
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ulceration (X
2
= 134.9; p<0.05), trauma (X
2
= 99.9; p<0.05) and stress (X
2
= 56.8; p< 0.05) had statistically signicant
association with recurrent aphthous ulcers (Table 3).
Discussion
Recurrent aphthous ulcer is a common oral disorder that causes suffering and pain. Besides, it interferes with routine activities
by affecting eating and wallowing. Therefore, having evidence on the prevalence and associated factors of recurrent aphthous
ulceration gives policymakers insight into the proportion of communities who suffer from the condition in addition to related
factors. However, the rate of this condition in different regions of the world had considerable variation.
5
Hence, the present
study illustrates the situation of the condition in the context of Afghanistan.
The result of this study reects the rate of recurrent aphthous ulcers only in dental students of Kabul University of Medical
Sciences. However, there is no reason to believe that this group of students is different from other students in Afghanistan. The
subjects of this study were dentistry students who have passed the courses related to recurrent aphthous in their curriculum. Thus,
they had enough knowledge of the signs and symptoms of the condition. Due to that, they were the right subjects for this study.
However, our study showed that the prevalence of recurrent aphthous ulcers was 30% among dentistry students at
Kabul University of Medical Sciences. Comparison of the present nding with those from previous studies should be
undertaken with caution because of differences in the study design, sample size, and geographical location. The result of
this study was higher than that study by Muhammad Ajmal et al in Saudi Arabia conducted among dentistry students
(14%).
13
In contrast, it is lower than that of Safadi RA in Jordan (78%).
14
This could be explained by differences that
exist in the populations in terms of genetic predisposition, stress, lifestyle, and other related factors. Nevertheless, our
result is also in line with studies of Du Qian et al in China (29.4%) carried out among college students
15
and studies by
Rabail Akbar et al conducted among students of Gulf Medical University (38.6%).
4
Table 2 The Frequency Distribution of All Possible
Related Risk Factors in Participants
Related Risk
Factors
Frequency
Yes No
Gender Male 31 (46.3%) 36 (53.7%)
Female 36 (53.7%) 31 (46.3%)
Dietary factors 54 (81%) 13 (19%)
Family history 46 (68.7%) 21 (31.3%)
Stress 22 (32.8%) 45 (67.2%)
Trauma 36 (53.7%) 31 (46.3%)
Smoking 1 (0.4%) 66 (99.6%)
Table 3 Factors Associated with Recurrent Aphthous Ulceration
Variables Recurrent Aphthous
Ulcers
X
2
P-value
Yes No
Gender Male 31 (46.3%) 36 (53.7%) 0.471 0.492
Female 36 (53.7%) 31 (46.3%)
Dietary factors 54 (81%) 13 (19%) 165.906 0.000
Family history 46 (68.7%) 21 (31.3%) 134.940 0.000
Stress 22 (32.8%) 45 (67.2%) 56.830 0.000
Trauma 36 (53.7%) 31 (46.3%) 99.958 0.000
Smoking 1 (0.4%) 66 (99.6%) 2.339 0.126
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Moreover, in this study dietary factors were claimed to be triggering recurrent aphthous ulceration, which is in line
with a study in China. Du Qian et al in their study pointed out that the prevalence of recurrent aphthous ulcers was higher
in those who consume sweet drinks, carbonated beverages, and fried foods, frequently.
15
While Patil et al reported that
foodstuff has less effect as a triggering factor for recurrent aphthous ulcers.
16
Besides, family history was another
important associated factor in our study, which is in line with others’ ndings.
17
Shi et al found a higher prevalence
among those whose parents had recurrent aphthous ulceration than those whose parents did not have the condition.
5
Respondents of this study claimed that stress was a triggering factor for the onset of recurrent aphthous ulcers, which is
similar to others.
18,19
A study by Sharma et al in India revealed that the rate of recurrent aphthous ulceration was higher
among those who have experienced a severe level of stress than those who did not.
20
The last nding of this study was
trauma as a risk factor for the onset of recurrent aphthous ulceration. This was in line with the ndings of a study in the
United States
21
but in contrast with another study in the United Arab Emirates.
4
This study is the rst to determine the prevalence and associated factors of recurrent aphthous ulceration in the
context of Afghanistan. No other publication was found to address the prevalence and associated factors of this condition
in Afghanistan.
Considering the various limitations of our study including the restricted study period and lack of a signicant budget,
led, not assess the inuence of systemic conditions on the prevalence of recurrent aphthous ulcers. The study was
conducted in a single institute and the data does not reect reporting of the community as a whole. Hereupon, further
observations are required with a large sample size.
Conclusion
We found that family history, stress, trauma, and dietary factors have an impact on the occurrence of RAS with no association
with gender and smoking. Also, a considerable proportion of the study sample had experienced recurrent aphthous ulceration.
Therefore, having evidence of the prevalence and associated factors among the Afghanistan population will help dental
professionals to address this condition in their daily practice by giving proper information to their clients.
Transparency Declaration
The correspondent author (the manuscript’s guarantor) afrms that the manuscript is an honest, accurate, and transparent
account of the study being reported; no important aspects of the study have been omitted, and any discrepancies from the
study as planned have been explained.
Details of Ethical Approval
This research was approved by the Research and Ethics committee of Kabul University of Medical Sciences. Participants
have agreed to take part in the survey and signed the consent form. We conrm that this study complies with the
declaration of Helsinki.
Acknowledgment
We thank all who in one way or another contributed to the completion of this paper especially KUMS’ Research and
Ethics Committee. First, we give thanks to Allah for protection and the ability to do work. We are so grateful to Professor
Dr. Emal Shekaib, head of the Oral and Maxillofacial surgery department; Professor Dr. Ahmad Farid Daanish, member
of the Pharmacology department; Dr. Ahmad Siyar Noormal, and the Faculty of Dentistry at the Kabul University of
Medical Sciences (KUMS) for making it possible for us to conduct a study here. I give deep thanks to the students of the
faculty for participating in this study.
Funding
No funding was received for carrying out this research.
Disclosure
The authors declare that there is no competing interest in this work.
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