Aphhthous Ulcer Stomatitis: Clinical Presentation, Diagnostic Evaluation, Management, And Outcomes – A Case Report

Abstract

Recurrent aphthous stomatitis (RAS), commonly referred to as aphthous ulcer stomatitis, is a prevalent chronic inflammatory condition of the oral mucosa characterized by recurrent, painful ulcerations. Although benign and self-limiting, the condition significantly affects oral intake, speech, and quality of life. The etiology is multifactorial, involving immune dysregulation, nutritional deficiencies, genetic predisposition, and local triggers.

We report the case of a 32-year-old female presenting with recurrent painful oral ulcers for 6 months, affecting eating and daily activities. Clinical examination revealed multiple shallow ulcers with erythematous halos on the buccal mucosa and tongue. Laboratory investigations indicated iron deficiency and low vitamin B12 levels. The patient was managed with topical corticosteroids, oral supplements, and supportive care, resulting in symptomatic relief and reduced recurrence frequency.

This case emphasizes the importance of identifying underlying systemic factors, implementing targeted therapy, and adopting a holistic management approach in recurrent aphthous stomatitis.

Introduction

Recurrent aphthous stomatitis (RAS) is one of the most common disorders affecting the oral mucosa, with a prevalence ranging from 5% to 25% in the general population. It is characterized by recurrent episodes of painful, round or oval ulcers with a yellowish base and erythematous margins, typically affecting non-keratinized mucosal surfaces such as the buccal mucosa, labial mucosa, and tongue.

RAS is broadly classified into three types: minor, major, and herpetiform ulcers. Minor aphthae are the most common, accounting for approximately 80–85% of cases. The condition usually begins in childhood or adolescence and tends to decrease in frequency with age.

The exact pathogenesis remains unclear but is believed to involve a T-cell-mediated immune response leading to mucosal destruction. Contributing factors include nutritional deficiencies (iron, vitamin B12, folate), stress, hormonal changes, food sensitivities, and systemic conditions such as celiac disease and inflammatory bowel disease.

Despite its benign nature, RAS can significantly impair quality of life due to pain and recurrent episodes. Early recognition and identification of underlying causes are essential for effective management and prevention of recurrence.

Case Report

Patient History

A 32-year-old female presented to the outpatient department with:

• Recurrent painful oral ulcers for 6 months
• Difficulty in eating and speaking during episodes
• Burning sensation in the oral cavity
• Ulcers recurring every 3–4 weeks

There was no history of fever, weight loss, or systemic illness. The patient reported increased stress levels due to occupational factors.

Medical history revealed no chronic diseases. There was no history of similar lesions in childhood.

Dietary history suggested inadequate intake of green leafy vegetables and animal protein. There was no history of tobacco or alcohol use.

Family history was non-contributory.

Clinical Examination

General Examination

• Patient conscious and oriented
• Vitals stable
• Mild pallor noted

Oral Examination

• Multiple round to oval ulcers measuring 3–5 mm
• Location: buccal mucosa, lateral border of tongue, and inner lip

• Ulcers with yellowish base and erythematous halo
• Tender on palpation
• No induration or bleeding
• No vesicles or crusting

Systemic Examination

• No significant abnormalities detected

Clinical Evaluation

Differential Diagnosis

Based on clinical presentation, the following were considered:

• Recurrent aphthous stomatitis (most likely)
• Herpetic stomatitis
• Oral candidiasis
• Lichen planus
• Traumatic ulcers

The absence of vesicles, fungal plaques, and systemic symptoms favored a diagnosis of aphthous ulcers.

Investigations

Laboratory Tests

• Complete blood count: Mild anemia

• Serum iron: Reduced
• Vitamin B12: Low
• Serum folate: Borderline low
• Blood glucose: Normal
• ESR: Mildly elevated

Other Tests

• No biopsy required (typical presentation)

Diagnosis

A diagnosis of recurrent aphthous stomatitis (minor type) associated with nutritional deficiency was established based on clinical features and laboratory findings.

Management and Outcome

Management Strategy

The treatment plan focused on:

• Pain relief
• Reduction of ulcer duration
• Prevention of recurrence
• Correction of nutritional deficiencies

Medical Management

• Topical corticosteroids (triamcinolone acetonide oral paste)
• Topical anesthetic gel (lidocaine) for pain relief
• Antiseptic mouthwash (chlorhexidine)
• Oral iron supplementation
• Vitamin B12 and folic acid supplements

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Supportive Measures

• Avoidance of spicy and acidic foods
• Maintenance of oral hygiene
• Stress management techniques
• Adequate hydration
• Dietary counseling

Clinical Course

During treatment:

• Pain reduced within 3–5 days
• Ulcers healed within 10–14 days
• Frequency of recurrence decreased over time

Follow-Up

At 1 Month

• Reduced severity of ulcers
• Improved oral intake

At 3 Months

• Fewer episodes reported
• Nutritional parameters improving

At 6 Months

• Significant reduction in recurrence frequency
• Occasional mild ulcers only

Discussion

Pathophysiology

RAS is considered an immune-mediated condition involving T-cell activation and cytokine release, leading to epithelial damage.

Key mechanisms include:

• Immune dysregulation
• Increased TNF-alpha levels
• Mucosal barrier breakdown
• Nutritional deficiencies affecting epithelial integrity

Etiology

Contributing factors include:

• Nutritional deficiencies (iron, vitamin B12, folate)
• Stress and psychological factors
• Hormonal changes
• Food hypersensitivity
• Genetic predisposition

In this case, nutritional deficiency and stress were significant contributors.

Epidemiology

• Prevalence: 5–25% globally
• More common in females
• Peak incidence in young adults
• Decreases with age

Clinical Manifestations

Minor Aphthae

• Small ulcers (<1 cm)
• Heal without scarring

Major Aphthae

• Larger, deeper ulcers
• May scar

Herpetiform Ulcers

• Multiple small ulcers
• May coalesce

Diagnostic Considerations

Diagnosis is primarily clinical and includes:

1. Detailed history
2. Oral examination
3. Nutritional assessment
4. Laboratory tests (if recurrent or severe)

Biopsy is reserved for atypical or non-healing ulcers.

Treatment Considerations

Topical Therapy

• First-line treatment
• Includes corticosteroids and anesthetics

Systemic Therapy

• For severe or refractory cases
• Includes corticosteroids, colchicine, or immunomodulators

Nutritional Therapy

• Essential in deficiency states
• Improves outcomes

Emerging Therapies

• Biologic agents targeting TNF-alpha
• Laser therapy
• Probiotics

Complications

Although benign, RAS can lead to:

• Nutritional compromise due to pain
• Psychological distress
• Reduced quality of life

Prognosis

The prognosis is generally good, with most cases resolving spontaneously. However, recurrence is common.

Factors influencing prognosis:

• Frequency of episodes
• Underlying deficiencies
• Patient compliance
• Stress levels

Conclusion

Recurrent aphthous stomatitis is a common yet often distressing oral condition with multifactorial etiology. This case highlights the importance of a comprehensive approach, including identification of underlying nutritional deficiencies and appropriate therapeutic intervention.

Topical therapy combined with nutritional supplementation and lifestyle modification can significantly reduce symptom severity and recurrence. Patient education and regular follow-up are crucial for long-term management.

With ongoing research into immunological pathways and targeted therapies, future treatment strategies may offer more definitive control of this recurrent condition.

References

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3. Bergqvist C, Ezzedine K. Vitiligo: A review. Dermatology. https://pubmed.ncbi.nlm.nih.gov/30235393/
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