European Journal of Cardiovascular Medicine

Recurrent aphthous stomatitis (RAS) is the most common ulcerative disease of the oral mucosa. It is characterized by recurring painful ulcers of the mouth that are round or ovoid covered by grayish white fibrin pseudo-membrane and surrounded by inflammatory halos.1,2 The term aphthous is derived from a Greek word ‘aphtha’ meaning ulceration.2,3. It is one of the least understood oral diseases and is among the most challenging problems faced by the affected persons and clinicians alike.4 The precise etiology of RAS remains unknown. The incidence of this disease ranges from 5% to 50% of general populations.1,5. The potential trigger factors considered are local factors such as trauma in individual who are genetically susceptible to RAS, microbial factors, nutritional factors, such as deficiency of folate and B- complex vitamins, immunologic factors, psychological stress, and allergy to dietary constituents. Extensive research has focused predominantly on immunologic factors, but a definitive etiology is not known.6 Local immune factors play a role in protection against oral disease which may be related to immunoglobulin A (IgA). IgA is the major class of immunoglobulin found in mucous secretion. Antibodies existing in mucous secretion especially IgA, are attached to micro-organism and reduce their mobility and adhesive properties and are considered as the first line of defense in oral cavity. Salivary IgA is an excellent indicator of oral mucosa immune status.7

Total protein is a vital component of saliva and is responsible for most of its functions like lubrication, physical protection, cleansing, buffering, maintenance of tooth integrity and antibacterial activity. Their level in the oral cavity is subjected to constant fluctuation which is depend on numerous factors.8 Secretory immunoglobulin A (IgA-s) is an important parameter to assess the auto immune status of the mucosa, with the advantage of being measurable by non-invasive methods and without patient discomfort. This is the major class of immunoglobulin found in mucous secretions, and is responsible for a barrier against a number of infectious, environmental allergens and carcinogenic substances and it also aids in many inborn protection mechanisms. IgA represent the second most abundant immunoglobulin in the human serum and prevails in the saliva in its dimeric form which better resist proteolysis in environments such as the mouth. If immunity has some regulating effect on the development of recurrent ulcers, it is expected that IgA-s be the immunoglobulin that provides protection, considering its role in other body parts. By considering that the salivary immune system is actively involved in the pathogenesis of recurrent aphthous ulcers, measuring IgA-s changes might have a valuable role in prediction of the onset and management of the disease. So far there is sparse literature regarding the relationship between total protein and recurrent aphthous ulcer. Hence the present study is designed to estimate the salivary immunoglobulin A levels and the total salivary proteins in recurrent aphthous ulcers and in healthy control group.

Aims and Objectives

To estimation the levels of salivary IgA and total salivary proteins in minor recurrent aphthous ulcer patients and compare with healthy volunteers (control group).

A cross sectional study consists of 100 patients aged between 18 to 50 years, divided into two group, group A (Study group) consist 50 patients diagnosed with clinically recurrent apthous ulcer and other group B (Control group) consist 50 healthy volunteers visiting the Department of Dentistry with the collaboration of Department of Pathology in the Saraswati Medical College, Unnao.

The whole study process was explained to the patients before and informed consent was obtained. The ethical clearance was obtained from institutional ethical board. Patients from outpatient department were selected and grouped as healthy individuals, clinically diagnosed as minor recurrent aphthous ulcers. The whole study process was described to the patient and an informed consent was taken before the saliva collection procedure and un-stimulated whole saliva measuring 1ml was collected by spit method in the calibrated measuring cup. The samples were centrifuged at 3000 rpm for 15 minutes and supernatants are collected and stored at - 20oC before transferring for lab analysis. Care was taken to see that patient’s does not consume food, smoke or chew gum at least one hour before the saliva collection procedure. The samples were then analyzed for salivary immunoglobulin A by immune Turbidimetric method and total salivary proteins by Biuret method. A salivary IgA and total salivary protein level in both the groups was tabulated and data were statistically analyzed by using independent student t test.

In the study of 100 individuals, the mean age of study group was 31.58 years where as in control group it was 30.16 years with a range of 20-50 years in study group and 19-50 years in the control group with a p value of 0.03 that’s significant. Out of 50 participants 36 (72%) were males and 14 (28%) were females in the study group where as in control group 38 (76%) were males and 12 (24%) were females. The comparison done on the basis of IgA and salivary protein between group A and group B as present in table 1 and table 2.

Table 1: COMPARE BETWEEN GROUP A AND GROUP B ON THE BASIS OF SALIVARY

Table 1 shows mean value of group A is 26.12and group 2 mean values Is 45.44, standard deviation of group A is 1.4797 and of group B is 2.2602. P value is highly significant.

Table 2: COMPARE BETWEEN GROUP A AND GROUP B ON THE BASIS OF SALIVARY PROTEIN

Table 2 shows mean value of group A is 0.0455 while group B is 0.019. Standard deviation of group A is 0.0607 while of group B is 0.0118. P value is significant.

Recurrent aphthous ulceration also known as canker sores represents the second most common type of oral ulcerations after traumatic ulceration. The classic presentation of RAS is recurrent, self-limiting ulcers that mainly affect non-keratinized oral mucosa.9 They are classified into three clinical variation namely minor, major and herpetiform, Minor aphthous accounts approximately 70- 90% of RAS patients presenting the most common form of aphthous ulcerations. Secretory immunoglobulin A (IgA-s) is an important parameter to assess the auto immune status of the mucosa, with the advantage of being measurable by non-invasive methods and without patient discomfort. This is the major group of immunoglobulin found in mucous secretions, and is responsible for a barrier against a number of infectious, environmental allergies and carcinogenic substances and it also aids in many in born protection mechanism.7 Considering the fact that immunity has some regulatory effects on the development of recurrent ulcers, salivary IgA provides protection , considering its role in other body parts like in gastro intestinal tract, intestines and respiratory tract.12 IgA represents the second most abundant immunoglobulin in the human serum and prevails in the saliva in its dimeric form which better resist proteolysis in environment such as mouth. IgA is the major class of immunoglobulin found in mucosal secretions. Antibodies existing in mucosal secretions, especially IgA are attached to microorganism and reduces their mobility and adhesive properties and are considered as the first line of defense in oral cavity.11

In our study, male predominance was noted in the study group which account for 72% (36). This is in accordance with Martinez et al and Rajmane et al study where majority of the patients were females, that’s no correlate with our study10,42 apart from our study, Females are more prone to stress and emotional situation which can affect their immune response. They seek medical examination more frequently than males but as present our current study now days males are more affected. Maximum number of patients belongs to 21-30 years of age group which is correlated with the study conducted by Kareem et al in which about 80% patients developed the condition before 30 years of age. The highest incidence is among young people however the severity and frequency of ulcers decrease with age that’s results shows to similar to our study.43. A high prevalence and severity of the disease has been found in student with a high socioeconomic background. This is because of psychological stress which acts as a triggering factor for RAS and is typically observed during stressful situations such as academic load in professional students and also in any other significant changes in life. This in accordance with Abdullah et al study, where majority of the patients were student.15

In our study there was significant relationship between the age and gender of the patients with the levels of salivary IgA . But it is not so in case of total salivary proteins. In Mortinez et al (2007 ) study where they assessed secretory IgA level total proteins and the salivary flow in 20 aphthous ulcer patients where they found no significant relationship between age and gender with salivary IgA and total proteins.13 The present study, the level of salivary IgA in study group was significantly higher than the control group which is in accordance with Pakfetrat et al, Martinez et al, Mohammed et al. This could reflect an important role for salivary IgA in pathogenesis of RAS. Four mechanisms could be proposed: Firstly, the presence of a threshold level of salivary IgA above which direct destruction of keratinocytes may commence.

Secondly indirect destruction through IgA immune complex- mediated mechanism, although this type of uncontrolled immune response occurs in the circulation; Thirdly, these IgA antibodies are auto antibodies against oral mucosal cell antigens, or they may be produced against a foreign antigen that is immunologically cross-reactive with a component of oral self-tissues and Fourthly, these elevated levels might be a normal local immune response( innate or adaptive) to neutralize the etiological factors that have already caused epithelial destruction. The principal mechanism of protective immunity against antigens in mucosal lumen is antibody- mediated neutralization which is dominated by IgA.11

In our study the level of salivary total protein for study group was significantly lower than the control group and it was contradictory with the results by Martinez et al where the total protein concentrations did not vary when the patients were compared with and without lesions. The results of this study suggest that there is a strong correlation between IgA-s and the pathogenesis of recurrent aphthous ulcer and a weak correlation of salivary total proteins with the lesion. IgA-s is implicated in recurrent aphthous ulcer and may play an important role in their defense mechanisms and it also helps in the pathogenesis of RAS. But the exact protective role of this immunoglobulin is still not clearly defined.

After that we concluded, in our study RAS showed a male predominance with maximum number of patients in the age group of 20-50 years. The salivary immunoglobulin A levels was significantly higher in minor RAS group than the healthy control group. The total salivary proteins level was also significantly lower in minor RAS group than the healthy control group. However, studies on longer series of patients for a longer duration may be required to determine the exact pathogenesis of minor RAS and the role of salivary IgA and total salivary protein in the disease mechanism.