Pain and Pain-Related Interference Associated with Recurrent Aphthous Ulcers

Aims: (1) To use psychometrically sound measures to characterize the pain levels and pain-related interference associated with recurrent aphthous ulcers (RAU); (2) to determine whether subjects with RAU report clinically significant psychologic symptoms; and (3) to examine the relationships between physical characteristics and self-reported psychologic symptoms, pain, and pain-related interference. Methods: Forty-seven subjects with RAU and an active ulcer completed the Graded Chronic Pain Scale and the Symptom Checklist-90R (SCL-90R). Ulcers were photographed for measurement, and subjects rated pain levels on a 0-to-10 scale before and after swabbing of the ulcer with a saturated solution of sodium chloride and distilled water. Results: Mean characteristic pain intensity was 4.76, with a pain-related interference score of 1.21. None of the average SCL-90R subscale scores were considered elevated. In the model predicting pain intensity after swabbing, pain intensity before swabbing explained 43.6% of the variance (P = .000). Neither the addition of physical characteristics (R2 change = .04; P = .28) nor psychologic characteristics (R2 change = .09; P = .83) contributed significantly to the model. In contrast, only psychologic characteristics contributed to the variance explained in the model predicting pain-related interference (R2 change = .505; P = .007). Conclusions: RAU is a moderately painful condition causing some impairment in functioning. Self-reported pain intensity of a sore does not appear to be influenced by psychologic characteristics. However, pain-related interference appears to be related to psychologic and not physical characteristics.

pain; psychology; recurrent aphthous ulcers

1. Scully C, Gorsky M, Lozada-Nur F. The diagnosis and management of recurrent aphthous stomatitis. J Am Dent Assoc 2003;134:200–207.

2. Langlais RP, Miller CS. Color Atlas of Common Oral Diseases, ed 2. Philadelphia: Lippincott Williams & Wilkins, 1998.

3. Shulman JD, Beach MM, Rivera-Hidalgo F. The prevalence of oral mucosal lesions in US adults: Data from the Third National Health and Nutrition Examination Survey, 1988–1994. J Am Dent Assoc 2004;135:1279–1286.

4. Axell T. A prevalence study of oral mucosal lesions in an adult Swedish population. Odont Rev 1976;27:1–103.

5. Shulman JD. An exploration of paint, annual, and lifetime prevalence in characterizing recurrent aphthous stomatitis in USA children and youths. J Oral Pathol Med 2004; 33:558–566.

6. Shohat-Zabarski R, Kalderon S, Klein T, Weinberger A. Close association of HLA-B51 in persons with recurrent aphthous stomatitis. Oral Surg Oral Med Oral Pathol 1992;74:455–458.

7. Ship II. Inheritance of aphthous ulcers of the mouth. J Dent Res 1965;44:837–844.

8. Ship II. Epidemiologic aspects of recurrent aphthous ulcerations. Oral Surg Oral Med Oral Pathol 1972;33: 400–406.

9. Elsheikh MN, Mahfouz ME. Prevalence of helicobacter pylori DNA in recurrent aphthous ulcerations in mucosa-associated lymphoid tissues of the pharynx. Arch Otolaryngol Head Neck Surg 2005;131:804–808.

10. Pederson A. Psychologic stress and recurrent aphthous ulceration. J Oral Pathol Med 1989;18:119–122.

11. Nolan A, Lamey PJ, Milligan KA, Forsyth A. Recurrent aphthous ulceration and food sensitivity. J Oral Pathol Med 1991;20:473–475.

12. Harris M. Psychosomatic disorder of the mouth and face. Practitioner 1975;214:372–379.

13. Larato DC. Stress and aphthous ulcers. J Acad Gen Dent 1972;20:25–26.

14. Minneman MA, Cobb C, Soriano F, Burns S, Schuchman

L. Relationships of personality traits and stress to gingival status or soft-tissue oral pathology: An exploratory study. J Public Health Dent 1995;55:22–27.

15. 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.

16. Tang L, Ma L, Liu N. Effects of psychosocial factors on recurrent aphthous ulcer. [abstract]. Hua Xi Kou Qiang Yi Xue Za Zhi 2001;19:102–103.

17. Chiappelli F, Cajulis OS. Psychobiologic views on stress related oral ulcers. Quintessence Int 2004;35:223–227.

18. McCartan BE, Lamey PJ, Wallace AM. Salivary cortisol and anxiety in recurrent aphthous stomatitis. J Oral Pathol Med 1996;25:357–359.

19. Von Korff M, Dworkin SF, LeResche L. Graded chronic pain status: An epidemiologic evaluation. Pain 1990;40: 279–291.

20. Arikan OK, Birol A, Tuncez F, Erkek E, Koc C. A prospective randomized controlled trial to determine if cryotherapy can reduce the pain of patients with minor form of recurrent aphthous stomatitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e1–e5.

21. Alidaee MR, Taheri A, Mansoori P, Ghodsi SZ. Silver nitrate cautery in aphthous stomatitis: A randomized controlled trial. Br J Dermatol 2005;153:521–525.

22. Von Korff M, Ormell J, Keefe F, Dworkin SF. Grading the severity of chronic pain. Pain 1992;50:133–149.

23. Derogatis LR. Symptom Checklist 90-R. Minneapolis, MN: National Computer Systems, 1991.

24. Dworkin SF, Sherman JJ, Mancl L, Ohrbach R, LeResche L, Truelove E. Reliability, validity, and clinical utility of the research diagnostic criteria for Temporomandibular Disorders Axis II scales: Depression, non-specific physical symptoms, and graded chronic pain. J Orofac Pain 2002;16:207–220.

25. Myers JL, Well AD. Research Design and Statistical Analysis. New York: HarperCollins, 1991.

26. Von Korff M. Epidemiological and survey methods: Assessment of chronic pain. In Turk DC, Melzack R (eds). Handbook of Pain Assessment. New York: The Guilford Press, 2001:603–618.

27. Kahneman D, Tversky A. On the psychology of prediction. Psychol Rev 1973;80:237–251.

28. Kahneman D, Tversky A. The psychology of preferences. Sci Am 1982;246:160–173.

29. Schulz-Kinderman F, Hennings U, Ramm G, Zander AR, Hasenbring M. The role for biomedical and psychosocial factors for the prediction of pain and distress in patients undergoing high-dose therapy and BMT/PBSCT. Bone Marrow Transplant 2002;29:341–351.

30. Syrjala KL, Chapko ME. Evidence for a biopsychosocial model of cancer treatment-related pain. Pain 1995;61: 69–79.

31. Putzke JD, Richards JS, Hicken BL, DeVivo MJ. Interference due to pain following spinal cord injury: Important predictors and impact on quality of life. Pain 2002;100:231–242.

32. Brown FF, Robinson ME, Riley JL, Gremillion HA. Pain severity, negative affect, and microstressers as predictors of life interference in TMD patients. Cranio 1996;14: 63–70.

33. Turner JA, Dworkin SF, Mancl L, Huggins KH, Truelove EL. The roles of beliefs, catastrophizing, and coping in the functioning of patients with temporomandibular disorders. Pain 2001;92:41–51.

34. List T, Paulin G, Lundstrom I, Ohrbach R. Orofacial disorder diagnosis: Relationship to the jaw limitation scale. J Dent Res (Special Issue A)2002;81:1024.