Persistent Oral Ulcer: Diagnostic and Treatment Considerations

Case at a Glance

A 32-year-old male presents with a persistent oral ulcer of 10 days duration, clinically consistent with an aphthous ulcer, seeking guidance on treatment options and the need for further medical evaluation.

Patient's Story

The patient is a 32-year-old male with no significant medical history who developed what he believed to be a canker sore approximately 10 days prior to presentation. He reports this is his first occurrence in over 10 years. The lesion initially caused discomfort but has evolved into what he describes as 'a small pit' with minimal associated pain. He denies tobacco use, smokeless tobacco use, and reports only occasional alcohol consumption. He is not currently taking any medications and has no known medical conditions.

Initial Assessment

Physical examination reveals a small, well-demarcated oral ulcer consistent with an aphthous ulcer. The patient has attempted self-treatment with salt water rinses and baking soda paste without significant improvement. The lesion's persistence beyond the typical healing timeframe of minor aphthous ulcers (7-10 days) prompted the patient to seek medical advice.

The Diagnostic Journey

The clinical presentation and appearance are most consistent with an aphthous ulcer (canker sore). The patient's description of the lesion as a 'small pit' with decreased pain suggests the ulcer may be in the healing phase but progressing slowly. Differential considerations include minor aphthous stomatitis, traumatic ulceration, or less likely, other causes of oral ulceration given the patient's age and lack of risk factors.

Final Diagnosis

Aphthous ulcer (minor aphthous stomatitis)

Treatment Plan

Recommendation for topical corticosteroid therapy with high-potency preparation such as clobetasol gel for rapid resolution. Patient education provided regarding proper application technique and expected timeline for improvement. Instructions given to follow up if no improvement within one week of treatment initiation or if lesion worsens.

Outcome and Follow-up

Patient advised to monitor response to topical corticosteroid treatment. Follow-up recommended if lesion persists beyond 2 weeks total duration or if new concerning features develop. Patient counseled on when to seek immediate care for oral lesions in the future.