Association between psychological disorders and the presence
of Oral lichen planus, Burning mouth syndrome and Recurrent aphthous Stomatitis

SOTO-ARAYA M, ROJAS-ALCAYAGA G, ESGUEP A. ASSOCIATION BETWEEN PSYCHOLOGICAL DISORDERS AND THE PRESENCE OF ORAL LICHEN PLANUS, BURNING MOUTH SYNDROME AND RECURRENT APHTHOUS STOMATITIS. MED ORAL 2004; 9:1-7

ABSTRACT

OBJECTIVE: The aim of this study was to determine the existing relation between the Oral Lichen Planus (OLP), Recurrent Aphthous Stomatitis (RAS), Burning Mouth Syndrome (BMS) and psychological alterations of the patient, such as stress, anxiety and depression.
DESIGN OF THE STUDY: 18 patients with RAS, 9 patients with OLP and 7 patients with BMS, that presented the condition at the moment of the examination, were studied, as well as a control group of 20 healthy patients. Both groups were extracted of hospitals and universitary centers, where the clinical diagnosis was made by a team of oral pathologists. Two measuring instruments were applied to them about their psychological condition: the Test of Recent Experience, to measure the stress level and scale H.A.D., to determine the level of anxiety and depression; the score given by them were statistically analyzed through T-test and the Anova Tukey test.
RESULTS: Our results suggested a statistically significant association between these psychological disorders and the diseases of the oral mucosa in study. It was observed that the stress level is greater in patients with RAS and OLP, depression is particularly high in patients with BMS, and levels of anxiety are rised in the three groups, in comparison with the group control.
CONCLUSIONS: A positive relationship can be established between psychological alterations and RAS, OLP and BMS. The RAS and the OLP stress and anxiety levels were considered as high, whereas the BMS was more related to important levels of anxiety and depression. According to these findings it is possible to assume that psychological factors should be taking into account when oral health wants to be maintain as normal.

Key words: Recurrent aphthous stomatitis, oral lichen planus, burning mouth syndrome, stress, anxiety, depression.

INTRODUCTION

The oral cavity is location for different conditions of local and sistemic origin ; many of them with controverted and or multifactorial etiology, where the psychogenic factors constitute an important variable to be considered (1-3). It has been postulated that the oral lichen planus, the recurrent aphthous stomatitis and the burning mouth syndrome would constitute entities that deserve to be investigated as psychosomatic diseases.

The recurrent aphthous stomatitis, are primary ulcerations of white-yellowish color, surrounded by a erythematous areas. Single or manifold, constitute a cyclical and painful group of lesions and that usually appear in nonkeratinized buccal mucosa, although not in exclusive form (4-7). They are classified in; Minor Aphthous Ulcerations, Major Aphthous Ulcerations and Herpetiform Aphthous Ulcerations (7-10).

The lichen planus is a chronic mucous and skin disease characterized by different clinical patterns in the oral mucosa. It can be seen as reticular, papular, erosive, atrofic or bullous (11,12). Nevertheless other authors simplify the classification and recognize two main forms: reticular and erosive (6). It tends to be painless, except in the ulcerative and erosive forms, more frequently localized on cheeks, tongue, lips, gingiva, palate and floor of mouth (6,13).

Burning mouth syndrome (BMS), also known as stomatodynia, stomatopyrosis, oral dysesthesia and glossodynia, when affects only the tongue is a clinical condition characterized by pain and burning sensation in the mouth, that gradually increases in severity and frequency with negative laboratory and clinical findings, except for inflamation or atrophy of filiform papillae in some cases. More usually seen in women from fourth decade on (6,14,15).

A direct relationship between these lesions and the psychological factors involved ( RAS 4,5,10, LPO 16-24, and SBU 25-37) has been postulated. Numerous investigations have been carried out trying to identify and quantify the stress, anxiety and depression levels of these alterations in patients, by means of diverse questionnaires, such as the HAD Scale (20,25,38), Catell 16 PF (24,32), Hamilton Anxiety Scale (23,24), Recent Life Changes questionnaire (39), General Health Questionnaire-28(28), Beck Depression Inventory (14,40) and the Spielberger State-Trait Anxiety Inventory (24,40). Results obtained have been varied and contradictory. Our objective is to determine the existing relationship between the OLP, RAS, BMS and psychological alterations of patients.

MATERIALS AND METHODS

The sample was constituted by 34 adult patients who presented RAS, OLP or BMS at the moment of the clinical examination and were free of sistemic disease of immunological connotation (see table 1). This sample was selected between people who consulted spontaneously in a period of 4 months, at the Diagnosis Centre of the Faculty of Odontolgy of the University of Chile and to the Maxillofacial Department of the San Juan de Dios, Barros Luco and Sótero del Rio Hospitals. 18 out of the 34 were RAS carriers (15 with minor ulcerations, 1 with major ulceration and 2 with herpetiform aphthous ulcerations), 9 were diagnosed as LPO (4 reticular OLP, 3 erosive OLP and 2 atrophic OLP) and 7 suffered of BMS. The control group, on the other hand, was integrated by 20 healthy adult patients, of age and sex similar to the experimental group with no history of them; these were selected in the same dental centers. The patients of both groups participated voluntarily, signing a written consent form.

Inclusion and exclusion criteria: Primary ulceration of the oral mucosa was considered like RAS when presented yellowish white color, surrounded by a erythematous area, recurrent and painful. The injury had to be present at the moment of the clinical examination, independently of its number and size. Ulcerations that did not fulfill the criteria indicated were excluded. The clinical diagnosis of the OLP was established when the presence of papules and white striae were seen with or without atrophy and erosions of the oral mucosa, or on apparently normal mucosa. The injury had to be present at the moment of the clinical examination. Cases related to local etiologic factors were excluded. BMS was recognized when chronic, unconstant burn and pain symptoms, specially in the tongue and lips, were diagnosed in an otherwise normal oral mucosa at the moment of clinical examination. Patients with xerostomia or under treatment with psychoactive drugs (antidepressing, sedative, narcotics) were excluded.

Clinical examination and the diagnosis were confirmed by an oral pathologist present in each one of these centers. Then, measuring instruments of psychological state were applied to patients. One of these was the Test of Recent Experience (T.R.E.) or Florenzano´s test, which allowed to know the degree of stress that each subject was put under, by means of 42 oriented items to search the changes or recent experiences in the last undergone 6 months. Points were assigned to each item according to the importance of the vital event. A final score of 0 to 300 points was considered as a low amount of vital events, from 301 to 600 points, was considered as a high amount of changes or in stress (40). The second used questionnaire was the Anxiety Hospital and Depression Scale (HAD) of Dr Snaith´s, designed to determine the levels of anxiety and depression in nonpsychiatric populations. Scale HAD consists of a total of 14 items and it is divided in two subscales, one for anxiety and the other for depression; each item consists of a question and 4 answers to choose, each one with a previously assigned score. Points added in each subscale can reach a maximum value of 21 subclassified as: 0-7 normal; 8-10 about to be pathological and 11-21 clinically morbid (26). The results according to the score obtained in the tests were statistically analyzed using: the T-test, for the comparison between the group of cases (complete) and control group, and the Anova-Tukey Test for the evaluation of the four sub-groups: LPO, URO, SBU and control. The distribution by frequencies was analyzed on the basis of the statistical test of Chi-square.

RESULTS

In relation to the amount of vital events and stress, it was observed that the average value of the group of cases with pathology was high (374.53), whereas the control group appears with normal levels, that is to say, less than 300 (239.75), obtaining significant differences (p<0.05). In relation to the anxiety, the group of cases presented an average of 11.59, that defines them as morbid, whereas the control group got 7.25, valued normal (p<0.05). For depression, the group of cases reached 7.03 and the control group 3.95 , both classified as normal, nevertheless, their difference is statistically significant (p<0.05). Values and percentages in patients with RAS in relation with the variables of stress, anxiety and depression, are displayed in tables 2 and 3. In the two first variables there are statistically significant differences with respect to the group control, for depression both groups present similar percentage and average values. OLP group is shown in tables 2 and 3. Presents statistically significant differences for stress and anxiety in comparison with the control group, nevertheless, the average value for depression, does not show differences between both groups, being considered as normal.

Finally, the data referred to the group with B.M.S. can be observed in tables 2 and 3. Compared with the control group, the percentage of patients with this pathology affected by stress, anxiety and depression are clearly superior. However, averages values do not present differences for stress, but they do can be found for anxiety and depression.

DISCUSSION

The analysis of the results, point out an association between psychic alterations of patients and alterations of the oral mucosa exists, particularly in conditions like RAS., OLP and BMS. When our group of cases is evaluated, it is observed that the levels of stress, anxiety and depression present significant differences with the group control, specially for stress and anxiety. Although, in this work it was not possible to established the cause-effect relationship of the psychic aspects of the individual and the oral pathology, despite the fact that they are associate. Our results also established that RAS and OLP are associated to high levels of stress and anxiety whereas the B.M.S. was related to important degrees of anxiety and depression. Previous studies have demonstrated that each one of these conditions is related in its etiology to psychological being the BMS the one with more evidence sustained, whereas information about RAS and OLP, was less clear and contradictory. It was also observed in BMS that anxiety and depression scored considerable differences compared to the control group. The outstanding value reaches by depression in this group, unlike the other studied conditions, locates it in an unquestionable place within the causes of the disease.

To Gorsky, Lamb and col. (29,32), the psychological factors have been considered like the commonest and etiologic factor of the BMS. According to Van Der Ploeg, Hammaren, Feinmann and Jontell (26,31,41,42), the BMS would be tie to the neurotic anxiety, depression, tendencies and problems of long data, whereas for Lamey, Lamb and Main (25,32,33), the anxiety and soon the depression and cancerofobia would be the prevalentes causes, which agrees with our findings. Shoenberg (34) stresses that factors like psychological stress, in connection with losses due to death or separation are associate to the BMS and that besides the local treatment, therapy should be focused in the underlying depression.

When behavior of the group with RAS was analyzed separately, we could appreciate that stress and anxiety appear in most of the affected patients, obtaining significant differences with the controls, demonstrating with it the importance of these acute psychological disorders in the development of this condition and by the other hand the less importance of depression in its development. Cohen and Shafer (9,43) also find high incidence of RAS in individuals submitted to stress situations. Mc Cartan and cols. (44), distinguished RAS produced by known organic causes and RAS produced by stress situations, expressed with significant rates of anxiety which cause a transitory increase of salivary cortisol. These conclusions are similar to our findings where both type of RAS were found.

Results of the group with OLP, presented the same characteristic of RAS, even more marked; stress and anxiety appeared like morbids in most of the patients, obtaining important significant differences with the controls, whereas the score for depression were under morbid levels. This has been also established in several previous works (17-20,23)

Burkhart and col. (17) have also pointed out that more than half of his patients with OLP related high levels of stress in relation to work, relationship and losses, before or during the appearance of the condition, whereas Hampf and col. (18) determined an important degree of psychic disturbances and disconfort in their patients with OLP at the moment of clinical examination. Other investigations have tried to distinguish the importance of the psychological factors in relation to the different types of OLP, with no clear results: Mc Cartan (20) found a high level of anxiety in cases of nonerosive OLP, whereas Lowental and Pisanti (19) establish them for the erosive-bullous form. On the other hand Allen and cols. (16) and Macleod (21) reported that there were no relationship between the patients of this condition and stressing events or symptoms of anxiety experienced by them; they concluded that the psychological factors were not important in its etiology nor in the severity of the OLP. These differences can be explained by the different quality of the measuring instruments .

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