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Table of Contents
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 61-65

Anxiety and clenching as contributing factors of recurrent aphthous stomatitis

Department of Oral Medicine, Faculty of Dentistry, Universitas Indonesia, Jakarta, Indonesia

Date of Web Publication18-Jun-2019

Correspondence Address:
Dr Febrina Rahmayanti
Department of Oral Medicine, Faculty of Dentistry, Universitas Indonesia, Jakarta
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_5_19

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Background: Recurrent aphthous stomatitis (RAS) is a common oral mucosa disease. Anxiety plays a role in the development of RAS, as it can lead to parafunctional oral habits such as bruxism (teeth grinding or jaw clenching) that may injure the mucosa, and this physical trauma can trigger ulceration in susceptible individuals with RAS. This case report describes the parafunctional oral habits caused by anxiety as the contributing factors of RAS. Case Report: A 17-year-old female came to the Dental Hospital, Faculty of Dentistry, Universitas Indonesia, with the complaints of ulcers at the lateral aspect of the tongue for 4 days since the tongue was bitten while she was sleeping. From the patient history, clinical evaluation, and investigation of the questionnaire, we detected a bruxism habit. We assumed that clenching was a contributing factor for the ulcers in this case. Intra-oral examination revealed two irregular ulcers of about 3 mm and 0.5 mm that were surrounded by erythematous halos and were yellow at the floors of the 46 and 36 teeth. The patient completed the Hospital Anxiety and Depression Scale and the Hamilton Rating Scale for Anxiety; the results of both were moderate anxiety. The management we suggested to the patient to control the anxiety was referral to a psychologist and an orthodontist; we gave chlorhexidine 0.2% to compress the lesions three times a day. Conclusion: Anxiety can produce a parafunctional oral habit that is a contributing factor of RAS. Coping with anxiety is needed to improve the clenching activity and RAS.

Keywords: Anxiety, bruxism, clenching, recurrent aphthous stomatitis

How to cite this article:
Mayanti W, Rahmayanti F, Pradono SA. Anxiety and clenching as contributing factors of recurrent aphthous stomatitis. Sci Dent J 2019;3:61-5

How to cite this URL:
Mayanti W, Rahmayanti F, Pradono SA. Anxiety and clenching as contributing factors of recurrent aphthous stomatitis. Sci Dent J [serial online] 2019 [cited 2023 Jun 5];3:61-5. Available from: https://www.scidentj.com/text.asp?2019/3/2/61/260559

  Background Top

Recurrent aphthous stomatitis (RAS) is an oral mucosal disease found in about 20% of the general population.[1] RAS is characterized by recurrent, shallow, round or oval, and painful ulcers at intervals of several days to 2–3 months. The ulcer comes with an erythematous halo and a yellowish color. RAS usually begins in childhood or adolescence with a tendency to decrease in severity and frequency with age.[1]

Factors considered important in the development of RAS include nutrition, drugs, food hypersensitivity, hormones, infections, trauma, tobacco, and psychological stress. Anxiety and stress were significantly associated with RAS because they are considered to lead to an increase in salivary cortisol that will provoke immunoregulatory activity.[2] In addition, emotional and psychological factors, such as stress and anxiety, can interfere with various hormonal, vascular, and muscular functions, all of which can produce peripheral changes that include pain, impaired jaw movement, xerostomia, and ulceration.[3] Bruxism is a repetitive activity of the jaw muscle characterized by clenching or teeth grinding and/or by bracing or mandibular gnashing. Some investigators have speculated that anxiety can lead to parafunctional oral habits such as clenching, lip, and cheek biting, and that those physical traumas may initiate the ulcerative process in susceptible individuals.[4] In individuals predisposed to RAS, mild physical injury to the oral mucosa may lead to RAS. Local trauma predisposes to RAS by producing edema and early cellular inflammation associated with increased viscosity of the oral submucosal extracellular matrix.[4],[5] Clenching is one of the emotional factor responses of anxiety, fear, and frustration associated with muscle hyperactivity.[6] It is an occlusal parafunctional activity that may be done consciously or unconsciously.[7] However, clenching at night is done unconsciously and mostly comes with sound production.[8]

This article provides an overview of the effects of anxiety as a trigger factor that modifies RAS through an oral parafunctional clenching habit that initiates ulceration.

  Case Report Top

A 17-year-old woman came to the Dental Hospital, Faculty of Dentistry, Universitas Indonesia. Informed consent has been obtained from the patient. The patient had complaints of ulceration on both lateral aspects of the tongue for 4 days since being bitten while asleep. The patient admitted that ulcers had frequently occurred for 3 years usually as a result of trauma. Ulcers usually appear on the tongue, buccal mucosa, and labial mucosa. She claimed to have developed a habit of clenching during sleep 3 years ago. Her medical and family history was noncontributory. She rarely consumed fruits and vegetables. She had treated ulcers with triamcinolone ointment and there was an improvement. Since clenching was apparent, investigations were performed with Shetty et al.'s questionnaire for detecting bruxer.[7]

In the extra-oral examination, there was clicking on the right temporomandibular joint, and there were erosive areas on the lower lip 33, 31, and 41 regions, edema of the lips, and no lymphadenopathy. The intraoral examination revealed two ulcers with irregular borders, 3 mm and 5 mm on the lateral tongue 36 and 46 regions with a white base, well circumscribed and with an erythematous border [Figure 1]. Almost all the mandibular teeth and posterior maxillary teeth were malpositioned [Figure 2].
Figure 1: Ovoid ulcer, irregular borders, 3 mm and 0.5 mm on the lateral tongue 36 and 46 regions, white base, well circumscribed, and erythematous border

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Figure 2: Malposition of maxillary and mandibular teeth

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She was asked to fill out the Hospital Anxiety and Depression Scale (HADS) questionnaire and obtained an anxiety score of 13, which indicated moderate anxiety, and a depression score of 4, which is normal. After a few minutes, the patient filled out the second questionnaire, the Hamilton Rating Scale for Anxiety (HRSA), and obtained a score of 23, indicating moderate anxiety. In the subjective examination, it was discovered that the patient always felt anxious about her studies. Based on the patient history, clinical and subjective examination, minor RAS and cheilitis were diagnosed. The patient was advised to control her anxiety and referred to a psychologist. In addition, the patient was asked to undergo complete hematological examinations and immunoglobulin E (IgE) titers. She was instructed to apply 0.2% chlorhexidine gluconate three times daily at the ulcers' area and Vaseline® ointment with 0.5 g amoxicillin, 0.25 g chlorpheniramine maleate, and 25 g lanolin on the lip four times daily.

At the second visit, 3 weeks after the first visit, the patient felt an improvement. The old ulcers had healed, but there was new ulceration about 1 week previously because of being bitten while sleeping on the right of the tongue. Chlorhexidine gluconate 0.2% was applied regularly three times a day, but the lip ointment was only used twice a day. She refused a consultation with a psychologist because she thought she could control the anxiety by herself. The adjunctive examination showed that the total IgE and hematologic examination results all had values within the normal limits.

The patient was asked to complete the HADS questionnaire again, and she obtained a score of 10, indicating mild anxiety. The HRSA questionnaire was also completed, and a score of 20 was obtained, which also indicates mild anxiety. In the extraoral examination, erythema was found in the lower lip 33, 31, and 41 regions, and in the intraoral examination, there was an ulcer of 2 mm, well circumscribed with an irregular border, an erythematous area around the ulcer, and a grayish-white base on the lateral tongue of 45 [Figure 3]. Based on the subjective and clinical examinations, minor RAS and cheilosis were diagnosed, and the patient was required to continue therapy of 0.2% chlorhexidine gluconate and Vaseline® ointment that had previously been given, and she was advised to try to control her anxiety.
Figure 3: Round ulcer 2 mm with an irregular border, an erythematous area around the ulcer, and a grayish-white base on the lateral tongue of 45

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  Discussion Top

RAS is one of the most common oral mucosa disorders.[9] It has the characteristics of recurrent ulcerations that are self-limiting and commonly found in the nonkeratinized oral mucosa such as the labial and buccal mucosa, the maxillary and mandibular sulci, the unattached gingiva, the soft palate, the throat, tonsillar fauces, the mouth floor, the ventral and the inferior lateral surfaces of the tongue.[4],[10] In this case, the ulcer was located in the lateral tongue adjacent to the lingual surface of the teeth 45, 46, and 36.

There are three main types of RAS as follows: minor, major, and herpetiform.[11] Minor RAS occurs in >80% of all RAS cases. It has characteristics of superficial ulceration with a diameter <10 mm. It is well-defined, round or oval, and covered with a grayish-yellow pseudomembrane, and it is surrounded with an erythematous halo. Patients usually complaint of pain, but the ulcer generally resolves without scarring after 10–14 days.[4] In this case, the diagnosis of minor RAS was made based on a subjective and clinical examination. In the subjective examination, it was found that the patient frequently had recurrent ulcerations, especially on the lateral tongue, and that the ulcers resolved within 1–2 weeks without scarring. In the clinical examination, the ulcers were 10 mm in diameter with an erythematous halo.

The etiology of minor RAS is not fully understood, but the mechanism of cellular immune response is thought to play a role in the immunopathogenesis. Several factors such as genetics, food allergens, local trauma, endocrine changes (menstrual cycle), psychological (stress and anxiety), smoking cessation, certain drugs, nutritional deficiencies, and microbial agents are thought to affect the occurrence of minor RAS. Although there is no specific diagnostic test for minor RAS, the patient was referred for hematologic and IgE examinations to look for possible predisposing factors and eliminate possible systemic causes.[10]

Stress and anxiety can affect the body's immune system, and hence they are regarded as one of the major predisposing factors of minor RAS.[9] Anxiety is an unpleasant emotional state characterized by unwanted concerns and fears about the events of daily life.[3] Anxiety comes from an unconscious internal or external conflict in life such as a traumatic experience, stress, or loss.[12] Anxiety is a normal response to stressors, but if the response to stressors is considered excessive, it continues even when the stressor has been removed; this is so-called anxiety disorder.[3] Several mechanisms show associations between anxiety and minor RAS. Anxiety can lead to parafunctional oral habits such as bruxism (grinding and clenching) and biting on the lips and cheeks. This physical trauma can trigger ulceration in susceptible individuals with minor RAS.[13]

Bruxism is a repetitive activity of the jaw muscle characterized by clenching or teeth grinding and/or by bracing or mandibular gnashing.[8] Bruxism can occur during sleep (sleep bruxism) or during wakefulness (awake bruxism).[13] In this case report, anxiety was considered to contribute to clenching activities. Clenching as a parafunctional habit is diagnosed by subjective examination, clinical evaluation, and by the investigation questionnaire for detecting bruxer of Shetty et al.[7] Some researchers have found that atypical movements of the teeth may not be present during a dental examination. Therefore, the clinician cannot use the presence of clinical findings (tooth wear) as a direct indication of active sleep clenching. Some researchers have suggested the use of home video recordings to confirm the clenching.[14]

Parafunctional oral habits are considered to have multifactorial etiology. Sleep bruxism or clenching have been associated with peripheral factors such as tooth interference in dental occlusion and psychosocial influences such as stress or anxiety. Clenching is included in the compulsive oral habits of the individual when emotional stress cannot be tolerated.[15] In this case, according to the patient history, we suggest that the etiology of clenching was anxiety. We used two simple and reliable methods for measuring anxiety, the HADS, and the HRSA. The patient was asked to complete a questionnaire with regard to how they had been feeling for the previous 7 days.

There are three ways to establish the occurrence of bruxism or clenching: “possible” sleep or awake bruxism should be based on self-report by means of questionnaires and/or the anamnestic part of a clinical examination. “Probable” sleep or awake bruxism should be based on self-report plus the inspection part of a clinical examination. “Definite” sleep bruxism should be based on self-report, a clinical examination, and a polysomnographic recording, preferably along with audio/video recordings.[16]

Pathological emotional experiences can lead to the development of muscle parafunctional activity. Chronic stress and reactions to stressors that trigger functional impairment of nerve-muscle systems are a major etiologic factor for psychological clenching. The limbic system is a part of the brain that controls emotions and reactions, and it is located in the middle of the encephalon. The limbic and hypothalamus systems are parts of the brain that contributes to the occurrence of clenching.[17] Pathological chronic stress and emotional disorders result from functional disturbances of the limbic system,[15] whereas the hypothalamus is the part of the brain that is the center of coordination of the autonomic nervous system.[18] All information from the external environment such as stressors is processed in the brain. The central nervous system is responsible for responding to stressors.[17]

The recommended anxiety management of this patient was intended to improve the clenching and RAS. Nevertheless, the patient refused to consult with a psychologist and tried to control the anxiety by herself. Nine coping styles have been reported: (1) searching for support (to get emotional support, help, and advice from others); (2) acceptance (to accept reality); (3) changing perspective (to see from a different perspective to seem more positive); (4) problem-solving (to take action and make the situation better); (5) avoidance (to refuse to believe the reality); (6) self-blame (to criticize oneself); (7) unfinalized activity (to turn to work or other activities to distract); (8) religion (to pray or meditate); and (9) substance use (to use alcohol/drugs to feel better).[19] Coping management of anxiety is tailored for each individual according to their life events.[19] Although the methods were not explained to the patient, she automatically used emotion-focused coping, which is religion to control her anxiety.

  Conclusion Top

RAS is an oral mucosal disease that can be affected by psychological factors. Anxiety is a psychological factor that can act as a trigger and/or factor that modifies the occurrence of RAS through oral parafunctional habits such as clenching. Within the limitation of this case report, coping methods can be considered as part of RAS management. However, the method needs further study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


We would like to express our appreciation to all those who provided us with the possibility to complete this case report.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3]


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