recurrent aphthous stomatitis ( ras ) is one of the most frequently encountered oral mucosal disorders . despite extensive amount of research , the etiology of ras remains unclear . the aim of the study was to assess the levels of anxiety and salivary cortisol levels in patients with ras and also to determine the association and relationship of salivary cortisol levels to variations of stress . a total of 30 patients suffering with ras , along with the same number of age and sex matched healthy controls were included in the study . saliva was collected from all the subjects at 9.00 am to avoid diurnal variations of cortisol levels . student 's t - test was used to compare the anxiety and salivary cortisol levels between both groups . the mean salivary cortisol level of the ras group showed a very highly significant difference ( p = 0.000 ) from the controls . the mean anxiety scores of the ras group showed a very highly significant difference ( p = 0.000 ) from the controls . the values of pearson correlation coefficient between anxiety and salivary cortisol was 0.980 and one with a p value of 0.000 showing that there is a highly positive correlation between anxiety and salivary cortisol . thus besides traditional treatment of ras patients , our findings suggest that psychological support is also needed . recurrent aphthous stomatitis ( ras ) is the most common type of ulcerative disease of the oral mucosa , and it affects approximately 20% of the general population with a range from 5% to 66% . highest prevalence of 66% was found by ship et al . on dental and medical students . minor ras , which makes up more than 80% of all ras cases , is a small ( up to 1 cm in diameter ) , shallow , painful , well - circumscribed , and round - shaped ulceration that is covered with a yellow - grayish pseudo membrane and surrounded by an erythematous halo . major ras is characterized by ulcers that are typically larger and deeper than minor ras . herpetiform ulcers manifest as multiple recurrent clusters of small ulcers ( less than 4 mm in diameter ) that are scattered throughout the oral mucosa . previous studies have suggested that psychological disturbances such as stress and anxiety could play a role in the onset and recurrence of ras lesions . the worldwide distribution , high frequency and decreased quality - of - life generated by ras have resulted in a great deal of research into the etiology and efficient therapy of this disease . however , the etiology of ras still remains unclear , and the currently available therapy remains inadequate . several studies have reported a relationship between ras and various causes , but the results are conflicting . it is suggested that stress with its presumed effects on the immune system , constitutes one of the major causative agents of ras . an insight into a patient 's psychological status can be estimated from both serum free and salivary cortisol levels . cortisol , also called as a stress hormone , has been used as an indicator in the stress evaluation studies . salivary cortisol may actually provide a better measure than serum cortisol of the stress response as it more accurately measures the amount of unbound cortisol compared to serum measures . salivary cortisol exhibits a clear diurnal variation and circadian rhythmicity with a time course closely parallel to that of plasma cortisol . various scales were used in the psychological assessment of patients in previous studies , some were self - reported and others assessed by a psychiatrist . though stress and anxiety have been mentioned as possible factors related to the development of ras ; this association somewhat remains controversial . the aim of this cross sectional study was to conduct an investigation in assessing the relationship between anxiety and salivary cortisol in patients with ras by using both psychological testing instrument ( hamilton 's anxiety scale [ has ] ) and physiological testing instrument ( salivary cortisol ) . the study was conducted in the department of oral medicine and radiology , kamineni institute of dental sciences , india , after approval by institutional ethics committee . thirty patients suffering from ras ( 17 females 57% , 13 males 43% ) were taken for the study after an informed consent . the inclusion criteria for patients were as follows : minor form of ras , non - smokers , and a minimum of 2 years of ras history to rule out from other types of acute recurrent ulcers like recurrent herpes . patients suffering from systemic diseases including endocrine and metabolic diseases , hematinic deficiencies , patients using steroids / oral contraceptive pills , pregnant patients , smokers were excluded from the study . saliva samples were obtained from the study group when aphthous stomatitis was absent after healing . control and study group samples were collected between 9 and 9:15 am , before a meal without stimulation by passive drooling directly into a sterile glass tube until 5 ml is collected . the collected salivary samples were centrifuged for 15 min at 3000 rpm and frozen at -20c until shortly before assay . during assay , salivary cortisol was measured by competitive enzyme linked immunosorbent assay method , by using cortisol eia ( diametra kit , korea ) . the normal cortisol concentrations that were given as a guide line according to the kit are in the ranges from 8.2 to 27.59 nmol / l ( 0.3 - 1 g / dl ) at morning time and 1.65 - 6.89 nmol / l ( 0.06 - 0.25 g / dl ) at evening collected samples . after saliva collection anxiety levels were measured by using  has  that provides the measures of overall anxiety , psychic anxiety ( mental agitation and psychological distress ) and somatic anxiety ( physical complaints related to anxiety ) . this scale consists of 14 questions , among which seven address the psychic and the remaining seven addresses the somatic anxiety . the individuals are rated on a five point scale for each of the 14 items ranging from 0 to 4 . the total anxiety score ranges from 0 to 56 , where < 17 indicates mild severity , 18 - 24 mild to moderate severity and 25 - 30 moderate to severe . t - test was used to compare the anxiety and salivary cortisol levels between patients with ras and the control group as the base line data was normally distributed . pearson 's correlation analysis was used to study the correlation among anxiety and salivary cortisol levels in patients with ras . logistic regression analysis was used for calculation of each variable 's independent contribution to dependent variable . ras was a dependent variable , and salivary cortisol and anxiety levels were independent variables in this model . for this trail 60 patients were enrolled . the ras group comprised of 13 males and 17 females and the mean age was 29.2 years ( range 18 - 60 years ) . the control group comprised of the same number of age and sex matched individuals ( mean age 29.2 years ) . the mean salivary cortisol levels were 47.73  8.80 nmol / l ( 1.73  0.319 g / dl ) in ras patients and 13.905  3.55 nmol / l ( 0.504  0.129 g / dl ) in controls with a p value of 0.000 . the mean anxiety levels in ras group were 27  4.76 and 10.2  3.27 in the control group ( p = 0.000 ) as indicated in table 1 . comparison of salivary cortisol levels and anxiety scores ( meansd ) of patients we found that salivary cortisol and anxiety levels were significantly higher in ras group as compared to control group . there was a highly significant positive correlation ( p = 0.000 ) between salivary cortisol levels and anxiety . a logistic regression model in which the ras was taken as dependent variable and salivary cortisol and anxiety levels were taken as independent variables were performed . salivary cortisol levels and anxiety scores were found significantly related with ras [ table 2 ] . logistic regression analysis , in which the group membership ( ras or control ) was dependent variable the impact of oral disorders on quality of life has been increasingly recognized as an important outcome measure for clinical trials , especially since oral disorders frequently have detrimental effects on speech , nutrition , physical appearance , self - esteem and social interaction . ras frequently affects patient quality of life as a result of long lasting and recurrent episodes of burning pain . the etiopathogenesis of ras appears to be complex ; interactions with genetic , nutritional and hematological factors are reported . much has now been clarified about the mechanisms involved , interesting new associations such as the involvement of t - cell mediated immunologic reaction have emerged . several reviews have , however , reported little objective evidence to support such an association . there is good evidence that stress and anxiety are related to increased resting levels of cortisol . the present study was undertaken in an attempt to gain a better understanding of the role that has been attributed to stress , anxiety and salivary cortisol in the development of ras and also to assess the relationship of salivary cortisol levels with stress and anxiety in patients with ras . a previous study mccartan et al . investigated the possible association between anxiety , measured by hospital anxiety and depression scale , and salivary cortisol in patients with ras ; and concluded that stress may play a role in the etiology of ras . albanidou - farmaki et al . conducted a case control study and compared the association between state and trait anxiety , measured by spielberger 's state - trait anxiety inventory ; and serum and salivary cortisol levels in patients with ras ; concluding that stress may be involved in the pathogenesis of ras . conducted a case control study to assess the influence of psychological stress on manifestations of ras ; by means of a questionnaire developed by the psychology institute of sao paulo university ( symptoms of stress list ; vas visual analog scale questionnaire ) and concluded that stress may play a role in the manifestation of ras . present study results also showed statistically significant increase in salivary cortisol and anxiety levels in ras patients during inactive stage compared to control group . our study in contrast to previous studies ( 2 and 5 ) used has , which provides the measures of overall anxiety , psychic anxiety ( mental agitation and psychological distress ) and somatic anxiety ( physical complaints related to anxiety ) . stress and anxiety may play a significant role in the onset and recurrence of ras lesions . ras is typically observed during stressful situations such as school exam periods , dental treatments and periods of significant changes in life . stress alters the regulation of both the sympathetic and parasympathetic branches of the nervous system , with consequential alterations in hpa - hypothalamic - pituitary - adrenal axis . autonomic activation and elevation of hormones , including those produced by hpa axis play pivotal roles in regulating immune surveillance mechanisms . this immune regulatory activity with an increased number of leukocytes at the sites of inflammation induced by psychological stress is characteristic , often observed during the pathogenesis of ras . in conclusion , the present study showed a positive association between salivary cortisol levels and anxiety in ras patients during inactive stage . therefore , measurement of the salivary cortisol and anxiety which reflect response to stress seems a promising parameter in the investigation of ras . in conclusion , we suggest that stress management interventions may be beneficial along with conventional treatment methods in ras patients .
background and objectives : recurrent aphthous stomatitis ( ras ) is one of the most frequently encountered oral mucosal disorders . despite extensive amount of research , the etiology of ras remains unclear . 
 psychological - emotional factors were considered as one of the major predisposing factors . the aim of the study was to assess the levels of anxiety and salivary cortisol levels in patients with ras and also to determine the association and relationship of salivary cortisol levels to variations of stress.materials and methods : a total of 30 patients suffering with ras , along with the same number of age and sex matched healthy controls were included in the study . 
 saliva was collected from all the subjects at 9.00 am to avoid diurnal variations of cortisol levels . 
 salivary cortisol levels were measured by competitive enzyme linked immunosorbent assay . 
 anxiety levels of both groups were measured by using hamilton 's anxiety scale . 
 student 's t - test was used to compare the anxiety and salivary cortisol levels between both groups.results:the mean salivary cortisol level of the ras group showed a very highly significant difference ( p = 0.000 ) from the controls . 
 the mean anxiety scores of the ras group showed a very highly significant difference ( p = 0.000 ) from the controls . 
 the values of pearson correlation coefficient between anxiety and salivary cortisol was 0.980 and one with a p value of 0.000 showing that there is a highly positive correlation between anxiety and salivary cortisol.conclusion:results suggest that anxiety may be involved in the pathogenesis of ras . 
 thus besides traditional treatment of ras patients , our findings suggest that psychological support is also needed .