Probable Diagnosis Recurrent Apthous Ulcer

1. Case by Sarang SH, 10/06/2015
Final year BDS Student at Bibi Aseefa Dental College, Larkana
A 2o year old male presented in our OPD with chief complaint of;
 Small ulcers in lower lip since 15 days with pain & burning sensation.
History
Patient stated that these ulcers developed spontaneously, there was no any history of trauma to face,
he also stated that since childhood he develops similar small ulcers in his mouth every month which
disappears and then reappears after 15 or 20 days. These ulcers were associated with itching of mucosa,
pain, difficulty in eating, difficulty in speech. His sleep is disturbed for many times because burning
sensation in his mouth.
Patient also stated about his past medical history that he got Fever about 9 months ago which remained
for approx. 3 months.
About 3 years back he became severely ill and was admitted to hospital where he was told by doctors
that his Liver is unable to form blood in normal amount and was told to have deficiency of blood for
which he is taking medicines for long time but stopped since 1 year.
Drug history was elicited, he stated that he is using Somogel Tube and Tab Septran DS whenever ulcers
appear and provide relief to his associated complaints but this time the condition was not relieved
which made him to visit to Dentist by his Local General Practitioner.
Examination
On Examination extra orally patient looked little bit weak, pale. Eye Examination revealed paleness of
conjunctive and no other significant sign was elicited. There were no any ulcers extra orally on skin.
On intraoral examination, Paleness of oral mucosa small ulcers were present in mucosa of lower lip,
ventral surface of tongue, floor of mouth, buccal mucosa and small portion of hard palate.
Quantity of small ulcers were more on ventral surface of tongue and floor of mouth, less number was on
hard palate and approx. equal number on buccal mucosa and lower lip.
Ulcers had red periphery and pale raised center.
Other oral examination showed deposition of calculus and no other significant tooth related problem
was found.
Probable Diagnosis was established as “RECURRENT MINOR APTHOUS ULCERS”
Following treatment was provided for 1 week and follow up after a week to check the response.
Enziclor gel
Nitiles drops & Vitamin C Tab