A series of 328 consecutive out-patients with recurrent aphthae were screened for deficiencies of iron, folic acid and vitamin B12, by examination of the peripheral blood, by assays of serum vitamin B12 and corrected whole blood folate, and estimation of the serum iron and total iron binding capacity; deficiencies were demonstrated in 45 patients (13·7%). Of these, 31 were deficient in iron, 15 in folic acid and 11 in vitamin B12; 11 patients had combined deficiencies.
Of the 45 aphthae patients with deficiencies, 29 had anaemia or demonstrable abnormalities in the red cell indices or stained blood film, and the essay results were confirmatory. In the remaining 16 patients, no red cell changes were present, and diagnosis depended entirely on reduced levels of serum vitamin B12, whole blood folate or iron saturation of transferrin; such latent deficiencies occurred only with iron and folic acid, whereas all patients with vitamin B12 deficiency even without anaemia had morphological changes in the blood.
Individual patients with a deficiency could not be distinguished from those without a deficiency on the basis of clinical examination of the mouth ulcers. However, aphthae patients who also had glossitis or angular cheilitis were more likely to suffer from such deficiencies.
Thirty-nine of the deficient aphthae patients available for follow-up were assessed at least 6 months after appropriate replacement therapy; 23 showed a complete remission of ulcers, 11 were improved and 5 were not helped.
It is suggested that the considerable incidence of deficiencies found in this series and the clinical and haematological response to replacement therapy confirms the need for full screening of patients with re-recurrent aphthae. Since 16 out of 45 of these patients had no anaemia or morphological abnormalities in the peripheral blood, their deficiencies would have been missed on routine haematological examination alone; for this reason it is recommended that screening should also include estimation of the serum iron and total iron-binding capacity, whole blood folate and, possibly vitamin B12.
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