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Case Report

Anxiety and Clenching as Contributing Factors of Recurrent Aphthous

Stomatitis
Wiwik Mayanti, Febrina Rahmayanti1, Siti Aliyah Pradono1

Department of Oral Background: Recurrent aphthous stomatitis (RAS) is a common oral mucosa disease.

Abstract
Medicine, Oral Medicine
Residency Program, Faculty
of Dentistry, Universitas
Indonesia, 1Department
of Oral Medicine, Faculty
of Dentistry, Universitas
Indonesia, Jakarta, Indonesia
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

Background various hormonal, vascular, and muscular functions, all of

R ecurrent 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
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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
Address for correspondence: Dr. Febrina Rahmayanti,
Department of Oral Medicine, Faculty of Dentistry, Universitas
Indonesia, Jakarta, Indonesia.
E‑mail: febrina_r@ui.ac.id
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For reprints contact: reprints@medknow.com

How to cite this article: Mayanti W, Rahmayanti F, Pradono SA. Anxiety

DOI: 10.4103/SDJ.SDJ_5_19 and clenching as contributing factors of recurrent aphthous stomatitis.
Sci Dent J 2019;3:61-5.

© 2019 Scientific Dental Journal | Published by Wolters Kluwer - Medknow 61

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Mayanti, et al.: Anxiety and clenching as contributing factors of RAS
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
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].
She was asked to fill out the Hospital Anxiety and
Depression Scale (HADS) questionnaire and obtained an
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
62 Scientific Dental Journal ¦ Volume 3 ¦ Issue 2 ¦ May-August 2019
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 2: Malposition of maxillary and mandibular teeth
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Mayanti, et al.: Anxiety and clenching as contributing factors of RAS
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
Discussion
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
Scientific Dental Journal ¦ Volume 3 ¦ Issue 2 ¦ May-August 2019
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
63
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Mayanti, et al.: Anxiety and clenching as contributing factors of RAS
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
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
64 Scientific Dental Journal ¦ Volume 3 ¦ Issue 2 ¦ May-August 2019
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.
Acknowledgments
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
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Field EA, Allan RB. Review article: Oral
ulceration – Aetiopathogenesis, clinical diagnosis and
management in the gastrointestinal clinic. Aliment Pharmacol
Ther 2003;18:949‑62.
2. Bilal N, Fatih Karakus M, Varkal MD, Boztepe OF, Bilal B,
Sarica S. An assessment of the levels of anxiety and depression
in patients with recurrent aphthous stomatitis. Arch Otolaryngol
Rhinol 2016;2:1‑5.
3. Kandagal VS, Shenai P, Chatra L, Ronad YAA, Kumar M. Effect
of stress on oral mucosa. Biol Biomed Rep 2014;1:13‑6.
4. Gallo Cde B, Mimura MA, Sugaya NN. Psychological stress and
recurrent aphthous stomatitis. Clinics (Sao Paulo) 2009;64:645‑8.
5. Chavan M, Jain H, Diwan N, Khedkar S, Shete A, Durkar S,
et al. Recurrent aphthous stomatitis: A review. J Oral Pathol Med
2012;41:577‑83.
6. Hartono SW, Rusminah N, Adenan A. Bruksisma. Dentofasial
2011;10:184‑9.
7. Shetty S, Pitti V, Satish Babu CL, Surendra Kumar GP,
Deepthi BC. Bruxism: A literature review. J Indian Prosthodont
Soc 2010;10:141‑8.
8. Shahraki N, Yassaei S, Moghadam MG. Abnormal oral habits:
A review. J Dent Oral Hyg 2012;4:12‑5.
9. Tada H, Fujiwara N, Tsunematsu T, Tada Y, Arakaki R, Tamaki N,
et al. Preventive effects of mouthguard use while sleeping on
recurrent aphthous stomatitis: Preliminary interventional study.
Clin Exp Dent Res 2017;3:198‑203.
10. Scully C, Shotts R. ABC of oral health. Mouth ulcers and other
causes of orofacial soreness and pain. BMJ 2000;321:162‑5.
11. Gavic L, Cigic L, Biocina Lukenda D, Gruden V,
Gruden Pokupec JS. The role of anxiety, depression, and
psychological stress on the clinical status of recurrent
aphthous stomatitis and oral lichen planus. J Oral Pathol Med
2014;43:410‑7.
12. McCartan BE, Lamey PJ, Wallace AM, Salivary WA, Mccartan P.
Salivary cortisol and anxiety in recurrent aphthous stomatitis. J
[Downloaded free from http://www.scidentj.com on Wednesday, February 17, 2021, IP: 10.232.74.27]

Mayanti, et al.: Anxiety and clenching as contributing factors of RAS

Oral Pathol Med 1996;25:357-59.
13. De Luca Canto G, Singh V, Conti P, Dick BD, Gozal D,
Major PW, et al. Association between sleep bruxism and
psychosocial factors in children and adolescents: A systematic
review. Clin Pediatr (Phila) 2015;54:469‑78.
14. Lavigne GJ, Khoury S, Abe S, Yamaguchi T, Raphael K.
Bruxism physiology and pathology: An overview for clinicians.
J Oral Rehabil 2008;35:476‑94.
15. Wieckiewicz M, Paradowska‑stolarz A, Wieckiewicz W.
Psychosocial Aspects of bruxism: The most paramount factor
influencing teeth grinding. BioMed Res Int 2014;2014:1‑7.
16. Lobbezoo F, Ahlberg J, Glaros AG, Kato T, Koyano K,
Lavigne GJ, et al. Bruxism defined and graded: An international
consensus. J Oral Rehabil 2013;40:2‑4.
17. Harish YR, Puranik M. Psychosocial factors and bruxism – A
review. Int J Heal Sci Res 2017;6:435‑42.
18. Nadendla LK, Meduri V, Paramkusam G, Pachava KR.
Relationship of salivary cortisol and anxiety in
recurrent aphthous stomatitis. Indian J Endocrinol Metab
2015;19:56‑9.
19. Pozzi G, Frustaci A, Tedeschi D, Solaroli S, Grandinetti P,
Di Nicola M, et al. Coping strategies in a sample of
anxiety patients: Factorial analysis and associations with
psychopathology. Brain Behav 2015;5:e00351.

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