Association Between Exam Related Stress and Frequency of Recurrent Aphthous Stomatitis Among University Students at LUMHS

Abstract

Background: Recurrent aphthous stomatitis (RAS) is a common inflammatory condition of the oral mucosa characterized by recurrent painful ulcers that may interfere with eating, speaking, and overall quality of life. Psychological stress has been proposed as an important precipitating factor for ulcer development, particularly among university students who frequently experience heightened academic pressure during examination periods. Objective: To assess the association between examination-related stress and the occurrence of recurrent aphthous ulcers among university students at Liaquat University of Medical and Health Sciences (LUMHS), and to evaluate the role of selected behavioral and familial risk factors. Methods: A cross-sectional observational study was conducted among 105 university students at LUMHS between November 2025 and February 2026. Data were collected through a structured online questionnaire assessing demographic characteristics, history of recurrent aphthous ulcers, examination-related stress scores, sleep duration during exams, smoking status, meal-skipping behavior, family history of ulcers, and medical conditions. Descriptive statistics were used to summarize participant characteristics. Differences in mean stress scores between students with and without ulcers were analyzed using the independent samples t-test, while associations between categorical variables were assessed using the chi-square test. Results: Recurrent aphthous ulcers were reported by 58 students (55.2%) during the previous 12 months. The mean examination stress score was significantly higher among students with ulcers (17.74 ± 5.50) compared with those without ulcers (14.06 ± 5.67), with a mean difference of 3.68 (95% CI: 1.34–6.02; p = 0.002). Significant associations were observed between ulcer occurrence and smoking (OR = 2.21; 95% CI: 1.02–4.89; p = 0.042), sleep duration less than five hours during examinations (OR = 3.86; 95% CI: 1.56–9.57; p < 0.001), and positive family history (OR = 3.02; 95% CI: 1.30–7.03; p = 0.010), whereas systemic medical conditions showed no significant association (p = 0.444). Conclusion: Examination-related psychological stress is significantly associated with recurrent aphthous ulcer occurrence among university students. Behavioral factors such as sleep deprivation and smoking, along with familial predisposition, may further increase susceptibility to ulcer episodes. Implementation of stress management strategies and promotion of healthy lifestyle practices within university health programs may help reduce the burden of recurrent aphthous stomatitis in student populations.