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IJCRR - 6(10), May, 2014

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ETIOLOGY AND PATHOPHYSIOLOGY OF RECURRENT APHTHOUS STOMATITIS: A REVIEW

Author: Arun Kumar M., Vasanthi Ananthakrishnan, Jaisri Goturu

Category: Healthcare

Abstract:Recurrent aphthous stomatitis is the most common oral mucosal ulcer disease. It causes severe pain and occurs repeatedly, causing discomfort in daily routine activities. The description of etiology is varied and none of the explanations given so far are satisfactory. Clinically this condition presents itself in three forms: major, minor and herpetiform ulcers. Causes for the ulcers could be related to host and / or environment. Host factors include genetic, nutritional deficiency, immune dysregulation and stress which can again be multifactorial. Environmental factors include trauma (both physical and chemical) and infections. There are several clinical syndromes which are associated with RAS like Behcet's syndrome. There are several causes acting together in initiating formation of ulcer unlike a single etiological factor as was thought previously. This means combination of host and environmental factors are essential not only for triggering the ulcer but also for an increase in size. The severity of etiological factors to which an individual is exposed would decide the type of ulcer. Identification of the trigger for a particular individual seems to be important in management of the disease. Hence understanding etiopathogenesis for recurrent aphthous stomatitis would be helpful in formulation of individualized treatment modalities. This review is intended to understand the cause and pathogenesis of recurrent aphthous stomatitis.

Keywords: Recurrent Aphthous Stomatitis, Oral Ulcers, RAS syndromes

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INTRODUCTION

Recurrent aphthous stomatitis (RAS)) is a disease of the oral mucosa which appears typically as ulcers in the mouth and causes severe pain. Repeated occurrence of ulcers is very debilitating. The prevalence, clinical presentation, etiology and pathogenesis of recurrent aphthous stomatitis will be discussed in this review.

Prevalence of RAS (Recurrent aphthous stomatitis)

RAS is a common oral mucosal condition and has been reported as affecting 20% of the general population at any given time. It reaches a peak of50% in selected populations such as university students1 . RAS usually appears first during childhood, with a tendency for ulcers to diminish in frequency and severity with age2 . In about 80 percent of patients with RAS, the condition develops before 30 years of age3 .

Clinical Presentation

The ulcers are typically seen on the buccal mucosa, the labial mucosa, the floor of the mouth or the tongue. A prodrome of localized burning or pain for 24 to 48 hours usually precedes the ulcers. The lesions are painful, with well defined margins and shallow necrotic center. All ulcers have yellow-grayish membrane at the base and are surrounded by raised margins and erythematous haloes. The pain is severe and gets aggravated on eating, swallowing and speaking. The pain usually persists for three to four days3 .

Three clinical presentations of RAS are:

Minor aphthous stomatitis (Minor or Mikulicz’saphthea or mild aphthous ulcers), Major aphthous stomatitis (MjRAS or periadenitis mucosanecrotica recurrence or Sutton’s disease) and Herpetiform ulcers.

Minor RAS: This is the commonest type of RAS and 75-85% of RAS are of this type. They typically measure 5-10 mm in size, last for 10-14 days and heal without scarring. Followingthe healing of the ulcers, there is a variable ulcer free intervalof about 3–4 weeks. Major RAS: They typically measure more than 10 mm in size, last for more than two weeks to months and generally heal by scarring. 10-15% of RAS are of this type. MjRAS may produce lesions

throughout the entire oral cavity, including the soft palate, tonsillar areas, and oropharynx. The longer duration simulates the malignant ulcer. Herpetiformulcers: They typically occur as crops of multiple ulcers measuring less than 5mm which may coalesce to form larger confluent areas of ulceration, usually with marked erythema. They last for 10-14 days but severity of pain is more than other forms. 5-10% of RAS are of this type. They resemble ulcers of primary Herpes simplex virus (HSV) infection. The recurrence period may be variable1,2 .

Etiology ofRecurrent aphthous stomatitis:

There are many hypotheses that are put forth for the etiology of RAS. There is no conclusive evidence regarding the etiopathogenesis of RAS.

Genetic Factors:

Field and Allan in 2003 described that there is a genetic predisposition for RAS and more than 40% of affected individuals have first degree relatives with RAS2 . Scully et al 2004 found that the likelihood of RAS is 90% when both parents are affected, but only 20 % when neither parent has RAS. A family history of recurrent aphthous ulcers is evident in some patients. A familial connection includes a young age of onset and symptoms of increased severity. Recurrent aphthous ulcers are highly correlated in identical twins4 . HLA subtypes like HLA B-515 , HLA-B52, HLA-B446 , HLA-DRW10 and DQW17 antigens were found to be closely associated with RAS. 2.

Nutrition: Foods such as chocolate, coffee, peanuts, cereals, almonds, strawberries, cheese, tomatoes (even the skin of the tomatoes) and wheat flour (containing gluten) may be implicated in some patients. In one study of patients with RAS who previously were diagnosed in patch tests as reactive to agents such as benzoic acid, 50% showed clinical improvement when certain foods were excluded from the diet8 .

3. Vitamin Deficiency:

Hematinic (iron, folic acid, vitamins B-6 and B-12) deficiencies were twice as common in patients with RAS9 . As many as 20% patients with RAS had a hematinic deficiency. Lower dietary intake of folate and vitamin B-12 is more common among persons with aphthous ulcers and treatment with 1000 mcg/d has shown benefit in individuals regardless of serum vitamin B12 levels10. A small group of adolescents were shown to have reduced incidence and pain from RAS when given 2000 mg/d of ascorbic acid11 .

4. Immune Dysregulations:

Immune dysregulations may play a significant role but no conclusive evidence has been noted.Cytotoxic action of lymphocytes and monocytes on the oral epithelium seems to cause the ulceration, but the trigger remains unclear. Upon histologic analysis, RAS consists of mucosal ulcerations with mixed inflammatory cell infiltrates. T-helper cells predominate in the pre-ulcerative and healing phases, whereas T-suppressor cells predominate in the ulcerative phase12 . There is reduced response of patients' lymphocytes to mitogens. There may be alterations in the activity of natural killer cells in various stages of disease13. Increased adherence of neutrophils and reduced quantities and functionality of regulatory T cells in tissue with lesions and release of tumor necrosis factor-alpha (TNF-alpha) is seen14 . There is significant involvement of mast cells in the pathogenesis of RAS. Reduced cellular expression of heat shock protein 27 and interleukin 10is seen15 in aphthous lesions16 . There is an increase in the Toll-like receptor activity in RAS17 . Oxidative stress markers (glutathione and malondialdehyde) show altered levels and impaired balance18. Serum IgE levels were found to be increased in RAS patients by several investigators. Scully et al reported that increased IgE concentrations might be related to cell-mediated phenomena in the immunopathogenesis of RAS. The expression of protein C, protein S and Ddimer were increased, while t-PA (tissue plasminogen activator) was reduced in patients with RAS and Behcet‘s disease. Remarkably, the expression of PAI-1(Platelet activator inhibitor-1) was significantly elevated in both Behcet’s Disease and RAS patients compared with that in healthy controls19. The results suggest the abnormal fibrinolytic activity is due to increased inhibition of tissue plasminogen activator20 . 5. Trauma: Local trauma may play a role in initiating the mucosal injury which leads to ulcers in patients with RAS. This study was

initiated to determine whether standardized mechanical injury would lead to ulcers in patients prone to aphthous stomatitis when compared with normal controls. In this study experimental biopsies failed to disclose any histological differences between mechanically induced and spontaneous ulcers21 .

6. Physical or Psychological stress: Psychological stress may play a role in the manifestation of recurrent aphthous stomatitis as a trigger or a modifying factor22. No studies have conclusively proved stress as a causative or precipitating factor for RAS.

7. Infections: The possible immunopathological destruction of oral mucosa by viridian streptococci was under consideration until 1986 but was disproved23 .Streptococcus sanguisor its L-form has been implicated, as has autoimmunity to the oral mucosal homogenate. A common or cross-reactive antigen between streptococci and oral epithelium has been suggested and demonstrated between the streptococcal 60–65 kD heat shock protein (HSP) and oral mucosal tissue. Significant increase in serum antibodies to HSP has been detected in patients with RAS24 . Helicobacter pylori has been detected in lesional tissue of oral ulcers, but the frequency of serum immunoglobulin G antibodies to H pylori is not increased in recurrent aphthous ulcers, and the organisms have never proven causative25,26 . 8. Tobacco smoking: Patients suffering from RAS usually are nonsmokers, and there is a lower prevalence and severity of RAS among heavy smokers as opposed to moderate smokers. Some patients report an onset of RAS after smoking cessation, while others report control on re-initiation of smoking. The use of smokeless tobacco is associated with a significantly lower prevalence of RAS. Nicotine-containing tablets also appear to control the frequency of RAS27 .

Recurrent aphthous stomatitis Associated Syndromes

i. Behcet’s disease (BD)is a multisystemic, chronic, relapsing vasculitis that affects nearly all organs and systems. It is associated with multiple oral, genital ulcers, arthritis, hematemesis, melena, and epigastric pain as predominant manifestations. Seung-Ho Rhee et al 2005 in their study described that RAS and BD had similar presenting symptoms like oral lesions and abdominal pain. There was no clinical, endoscopical, histopathologicalor serological difference between patients with intestinal BD, RAS and healthy volunteers in Anti-Neutrophil Cytoplasmic Antibodies (pANCA) 28 . ii. RAS is a part of

PFAPA syndrome which includes the Periodic Fever, Aphthous stomatitis, Pharyngitis and cervical Adenitis. PFAPA syndrome is regarded as a nonhereditary disease of unknown etiology although the clinical observation is that, in a small proportion of cases, one of the parents or a more distant relative had similar symptoms in childhood29 .

MAGIC syndrome: Mouth And Genital ulcers with Inflamed Cartilage syndrome (also known as "MAGIC syndrome") is a cutaneous condition2 .

iv. Imerslund-Grasbeck syndrome (IGS) is characterized by Juvenile megaloblastic anemia due to vitamin B12 deficiency and proteinuria. All the three cases of ImerslundGrasbeck syndrome described in the study ArnonBroides et al 2006 were associated with RAS. Though it was described that defective neutrophil phagocytosis and neutropenia caused by the Vitamin B12 deficiency may be the possible mechanism for the causation of stomatitis, none of the patients had neutropenia. The cause of RAS in IGS was inconclusive30 .

v. Sweet’s syndrome, also known as acute febrile neutrophilicdermatosis, is characterizedby fever, neutrophil leukocytosis, erythematous skin plaques or nodules and, often, classical RAS. It may occur in conjunction with malignant conditions, such as leukemia2

vi. Celiac disease (CD) is caused by gluten sensitivity of the small intestines. According to study by SelimAydemir et al 2004 the CD prevalence (40%) in patients with RAS is higher than in the normal population. It is also described that RAS may be the presenting sign of the disease and may be used as a marker for the CD31 .

vii. Crohn’s disease: The intraoral involvement in Crohn’s disease (CD) is observed in approximately 9% of cases and oral inflammation precedes intestinal symptoms in about 60% of these patients. Hence it is important to consider the differential diagnosis of Crohn’s disease in subjects with intestinal symptoms and RAS32 .

Pathophysiology of Recurrent aphthous stomatitis:

The complex interactions of various etiological factors together can trigger ulcer formation. Etiological factors can be classified into predisposing factors and precipitating / triggering factors. The factors like HLA associations, immune dysregulation, nutritional deficiency, personality type A are the predisposing factors. Microtrauma, infections, stress could be the initiating or triggering factor for ulcer formation. Those individuals who are susceptible when exposed to the triggering factors for certain duration tend to develop ulcers. Based on the intensity and duration of the triggering factors, ulcer starts growing till the factors are removed. Pain suffered by the patients is directly proportional to the size of the ulcer and severity of the triggering factors. For example the serum cortisol level: which is a biomarker of the stress was increased in thesubjects with RAS and the increase was directly proportional to the ulcer size33 .

CONCLUSION

Recurrent aphthous stomatitis or aphthous ulcers are more common in younger adults. There are several causes that have been explained for ulcer formation but no single cause is definitive. The cause is still nonspecific. There are multiple factors which may be acting together in a complex manner in initiating the formation of ulcer unlike a single etiological factor as was thought previously. This means a combination of host and environmental factors are essential not only for triggering the ulcer but also for an increase in size. The severity of etiological factors to which an individual is exposed would decide the type of ulcer. Underlying mechanisms relating to pathogenesis need to be explored inorder to establish the treatment protocol.

ACKNOWLEDGEMENT

Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

References:

REFERENCES

1. Ship JA, Chavez EM, Doerr PA, Henson BS, Sarmadi M. Recurrent aphthous stomatitis. Quintessence Int. 2000; 31(2):95-112.

2. E. A. Field and R. B. Allan. Oral ulceration – aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic. Aliment PharmacolTher 2003; 18: 949–962.

3. Scully C, Gorsky M, Lozada. The diagnosis and management of recurrent aphthous stomatitis: A consensus approach. J Am Dent Assoc 2004; 134: 200–207.

4. Miller MF, Garfunkel AA, Ram C, Ship II. Inheritance patterns in recurrent aphthous ulcers: twin and pedigree data. Oral Surg Med Oral Pathol. Jun 1977;43(6):886-91.

5. Mustafa Özdemir1, HasanAcar et al. HLAB51 in Patients with Recurrent Aphthous Stomatitis. ActaDermato-Venereologica. 2008: 203-203.

6. LutfiJaber, Abraham Weinberger, Tirza Klein, Isaac Yaniv, Mukamel. Close Association of HLA-B52 and HLA-B44 Antigens in Israeli Arab Adolescents with Recurrent Aphthous Stomatitis. Arch Otolaryngol Head Neck Surg. 2001; 127(2):184-187.

7. Wilhelmsen NS, Weber R, Monteiro F, Kalil J, Miziara ID. Correlation between histocompatibility antigens and recurrent aphthous stomatitis in the Brazilian population. Braz J Otorhinolaryngol. MayJun 2009;75(3):426-31.

8. Zuzanna ?lebioda1, El?bieta Szponar1, Anna Kowalska. Recurrent aphthous stomatitis: genetic aspects of etiology. Post?pyDermatologii i Alergologii XXX 2013;2 :96-102

9. Kozlak ST, Walsh SJ, Lalla RV. Reduced dietary intake of vitamin B12 and folate in patients with recurrent aphthous stomatitis. J Oral Pathol Med. Feb 7 2010;

10. Carrozzo M. Vitamin B12 for the treatment of recurrent aphthous stomatitis. Evid Based Dent. 2009;10(4):114-115.

11. Yasui K, Kurata T, Yashiro M, Tsuge M, Ohtsuki S, Morishima T. The effect of ascorbate on minor recurrent aphthous stomatitis. ActaPaediatr. 2009; 99 (3): 442- 445.

12. Rogers III RS. Recurrent aphthous stomatitis: Clinical characteristics and evidence for an immunopathogenesis. J Invest Dermatol. 1977; 69: 499-509.

13. Sun A, Chu CT, Wu YC, Yuan JH. Mechanisms of depressed natural killer cell activity in recurrent aphthous ulcers. ClinImmunolImmunopathol. Jul 1991; 60(1):83-92.

14. Taylor LJ, Bagg J, Walker DM, Peters TJ. Increased production of tumour necrosis factor by peripheral blood leukocytes in patients with recurrent oral aphthous ulceration. J Oral Pathol Med. Jan 1992; 21(1):21-5.

15. Hasan A, Childerstone A, Pervin K, et al. Recognition of a unique peptide epitope of the mycobacterial and human heat shock protein 65-60 antigen by T cells of patients with recurrent oral ulcers. ClinExpImmunol. Mar 1995;99(3):392-7. 16. Miyamoto NT Jr, Borra RC, Abreu M, Weckx LL, Franco M. Immune-expression of HSP27 and IL-10 in recurrent aphthous ulceration. J Oral Pathol Med. Sep 2008;37(8):462-7. 17. Borra RC, de Mesquita Barros F, de Andrade Lotufo M, Villanova FE, Andrade PM. Toll-like receptor activity in recurrent aphthous ulceration. J Oral Pathol Med. Mar 2009;38(3):289-98. 18. Arikan S, Durusoy C, Akalin N, Haberal A, Seckin D. Oxidant/antioxidant status in recurrent aphthous stomatitis. Oral Dis. Oct 2009; 15(7):512-5. 19. Seung-Ho Rhee, Young-Bae Kim, Eun-So Lee. Comparison of Behcet’s Disease and Recurrent Aphthous Ulcer according to Characteristics of Gastrointestinal Symptoms. J Korean Med Sci 2005; 20: 971-6. 20. Hong Shang, Jingjing Ye, Min Ji. Anticoagulant and Fibrinolytic Disorders in Patients with Behçet’s Disease and Recurrent Aphthous Ulcer. Chinese Journal of Physiology 2011; 54:1-6. 21. David Wray, Edward A Graykowski, Abner Louis Notkins. Role of mucosal injury in initiating recurrent aphthous stomatitis. British Medical Journal 1981; 283: 1569- 1570. 22. Camila de Barros Gallo, Maria Angela Martins Mimura, Norberto Nobuo Sugaya. Psychological stress and recurrent aphthous stomatitis. Clinics 2009; 64(6):645-648. 23. Hoover, J. A. Olson, J. S. Greenspan. Humoral Responses and Cross-reactivity to Viridans Streptococci in Recurrent Aphthous Ulceration. J Dent Res 1986; 65(8):1101-1104. 24. A Hasan, A Childerstone, K Pervin, et al. Recognition of a unique peptide epitope of the mycobacterial and human heat shock protein 65-60 antigen by T cells of patients with recurrent oral ulcers. ClinExpImmunol. 1995; 99(3): 392–397. 25. Birek C, Grandhi R, McNeill K, Singe;r D, Ficarra G, Bowden G. Detection of Helicobacter pylori in oral aphthous ulcers. J Oral Pathol Med. May 1999;28(5):197- 203. 26. 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(9): 804-808. 27. KamileMarako?luand RecepErolSezeret al. Recurrentaphthous stomatitis frequency in the smoking cessation people: Clin Oral Invest 2007; 11:149–153. 28. Seung-Ho Rhee, Young-Bae Kim, Eun-So Lee. Comparison of Behcet’s Disease and Recurrent Aphthous Ulcer according to Characteristics of Gastrointestinal Symptoms. J Korean Med Sci 2005; 20: 971-6. 29. Kelly L Brown1, Per Wekell et al., Profile of blood cells and inflammatory mediators in periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome: BMC Pediatrics 2010, 10:65.30. ArnonBroides, Baruch Yerushalmi, Rachel Levy et al. Imerslund-Grasbeck Syndrome Associated With Recurrent Aphthous Stomatitis and Defective Neutrophil Function. J PediatrHematolOncol 2006: 28(11); 715-720. 31. SelimAydemir, NilgünSolakTekin, ErolAktunç et al. Celiac disease in patients having recurrent aphthous Stomatitis. Turk J Gastroenterol 2004; 15 (3): 192-195. 32. Roy S. Rogers III.Recurrent aphthous stomatitis: Clinical characteristics and associated systemic disorders. Seminars in Cutaneous Medicine and Surgery 1997; 16 (4): 278-283. 33. Arunkumar M, VasanthiAnanthakrishnan, JaisriGoturu. Role of Serum Cortisol in Recurrent Aphthous Stomatitis. Biomedicine 2012, 32(3), 331-336.

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A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02

A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01

A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24

A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23

A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22

A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21

A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20

A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19

A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18

A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17

A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16

A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15

A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020

A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"

A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13

A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for Vol 12 issue 12

A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for Vol 12 issue 11

A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for Vol 12 issue 10

A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for Vol 12 issue 09

A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for Vol 12 issue 08

A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for Vol 12 issue 07

A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20

A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR

A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13

A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR

A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR.

A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award

A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award

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ETIOLOGY AND PATHOPHYSIOLOGY OF RECURRENT APHTHOUS STOMATITIS: A REVIEW

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