What is the cause of recurrent stomatitis in an elderly male patient?

Recurrent Stomatitis in Elderly Male Patients: Causes and Diagnostic Approach

The most likely causes of recurrent stomatitis in an elderly male patient are nutritional deficiencies (particularly vitamin B12, iron, folate, and riboflavin), followed by autoimmune conditions, medication-related effects, and systemic diseases that are more prevalent in this age group.

Primary Nutritional Deficiencies to Evaluate

The cornerstone of evaluation should focus on hematinic deficiencies, which are common and treatable causes:

• Vitamin B12 deficiency is significantly associated with recurrent aphthous stomatitis (RAS), with levels found to be significantly lower in RAS patients compared to controls 1
• Iron deficiency occurs in approximately 20.1% of RAS patients and is associated with angular cheilitis and recurrent oral ulceration 2
• Folate deficiency is present in 2.6% of RAS patients and produces angular stomatitis, oral ulcers, and glossitis 2, 3
• Riboflavin deficiency classically presents with angular cheilitis, glossitis, photophobia, and corneal vascularization 3

Critical Laboratory Workup

Order the following tests before initiating any treatment:

• Complete blood count to assess for anemia (present in 20.9% of RAS patients) 2
• Serum iron, ferritin, vitamin B12, and folic acid levels 2
• Serum autoantibodies: gastric parietal cell antibody (present in 13.0% of RAS patients), thyroglobulin antibody (19.4%), and thyroid microsomal antibody (19.7%) 2
• Serum homocysteine levels (elevated in 7.7% of RAS patients) 2

Age-Specific Considerations in Elderly Males

Elderly patients require special consideration due to higher comorbidity burden:

• Medication review is essential as corticosteroids, anticonvulsants, and other drugs can interfere with vitamin B6 metabolism and contribute to oral lesions 4
• Assess for inflammatory bowel disease (IBD), which can present with recurrent oral ulceration and occurs in up to 15% of new diagnoses in individuals older than 60 years 5
• Rule out malignancy, as elderly patients with oral lesions have higher risk of colorectal cancer, hematologic malignancies (leukemia, lymphoma), and other neoplasms 5, 6
• Consider immunosuppression-related causes if the patient is on biologics or immunomodulators, as elderly patients face up to 20-fold increased infection risk with these therapies 7

Differential Diagnosis Beyond Nutritional Causes

Do not assume all recurrent stomatitis is purely nutritional or infectious:

• Autoimmune conditions including Behçet's disease, connective tissue diseases, and immune-mediated disorders (agranulocytosis, cyclic neutropenia) must be considered 5, 6
• Medication-induced stomatitis from NSAIDs, chemotherapy agents, or other drugs 5
• Infectious causes including herpes simplex virus, Candida (especially in immunocompromised), and bacterial infections 6, 8
• Systemic diseases such as chronic kidney disease (which alters vitamin metabolism), IBD, and hematologic disorders 5, 2

Critical Pitfalls to Avoid

• Lesions persisting beyond 2 weeks despite appropriate treatment warrant biopsy to exclude dysplasia or malignancy 3
• Do not assume angular cheilitis is purely nutritional—it most commonly has a mixed infectious etiology requiring combination antifungal and corticosteroid therapy 3
• In patients with macrocytic anemia, always measure both folate and B12 simultaneously to avoid masking B12 deficiency with folate supplementation alone 3
• Consider bilateral presentation with glossitis or other oral mucosal changes as a strong indicator of nutritional deficiency rather than isolated infectious cause 3

Risk Factors Specific to Elderly Population

Evaluate for these predisposing factors in elderly males:

• Poor dietary intake, malabsorption syndromes, alcoholism 3
• Chronic kidney disease (alters vitamin metabolism and increases homocysteine) 5, 3
• Polypharmacy and drug-drug interactions (29% of elderly use ≥5 prescription drugs) 5
• Recent antibiotic exposure, particularly fluoroquinolones, cephalosporins, and clindamycin 5
• Proton pump inhibitor use (associated with vitamin B12 malabsorption) 5
• Comorbid cardiac disease, IBD, or immunosuppressive conditions 5

Treatment Algorithm Based on Findings

For confirmed nutritional deficiency:

• Oral supplementation with the deficient vitamin: riboflavin, pyridoxine 50-100 mg daily for 1-2 weeks, vitamin B12, or folate as indicated 3
• Recheck levels 3-6 months after starting supplementation, then annually once normalized 4

For immunologically-mediated RAS without deficiency:

• Topical corticosteroids (triamcinolone acetonide) as first-line 9, 8
• Topical anti-inflammatory drugs (amlexanox) or antiseptics (lidocaine) for symptom control 9
• Systemic corticosteroids (prednisone) or immunomodulatory drugs (thalidomide) for severe cases 9

For elderly patients requiring immunosuppression:

• Prefer budesonide over systemic corticosteroids due to lower systemic bioavailability and reduced adverse effects 7
• Avoid anti-TNF agents when possible due to significantly higher infection risk in elderly patients 7
• Consider vedolizumab or ustekinumab if biologic therapy is needed, as they have lower infection and malignancy risk profiles 7