Recurrent painful oral ulcers in a young adult

§Chief complaint

Mouth ulcers every few weeks for 3 years

§Medical & dental history

• 01Vegetarian diet
• 02Menstrual irregularity; no gastrointestinal symptoms
• 03No sharp teeth or appliances

§Clinical examination

• 01Three round shallow ulcers 4-6 mm with yellow-grey floors and erythematous haloes on non-keratinised mucosa
• 02No ulcers on the hard palate or attached gingiva
• 03No genital ulcers, no ocular symptoms, no skin lesions
• 04No lymphadenopathy or fever

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§Differential diagnosis

§Final diagnosis

Minor recurrent aphthous stomatitis with iron deficiency

Confinement to non-keratinised mucosa, small size, recurrence and healing without scarring define minor aphthae. Absence of genital and ocular involvement excludes Behcet disease. Haematinic deficiency is the commonest correctable cause.

§Investigations

• 01Full blood count, ferritin, vitamin B12, folate — ferritin 6 ng/mL
• 02Coeliac serology (tTG-IgA) — negative
• 03No biopsy needed for typical aphthae

§Treatment plan

• 01Iron replacement and dietary advice
• 02Topical: chlorhexidine mouthwash, benzydamine, topical corticosteroid at prodrome
• 03Avoid SLS-containing toothpaste and known dietary triggers
• 04Systemic therapy only for severe, disabling disease

§Follow-up & outcome

• 01Ulcer frequency fell from fortnightly to twice yearly after 3 months of iron therapy
• 02Ferritin normalised at 6 months

§Clinical pearls / learning points

• 01Aphthae never occur on keratinised mucosa — an ulcer on the hard palate or attached gingiva is something else.
• 02Screen for haematinic deficiency and coeliac disease in every adult with recurrent aphthae.
• 03Any single ulcer lasting more than 3 weeks must be biopsied.

§Related diseases

§Similar cases