Reference Determination Content
Suggested draft · fictitious patient
Mouth Ulcers
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 February 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 February 2025;
- A pre-deployment dental and medical examination by the dental officer and medical officer, dated 20 January 2011;
- A deployed health record and stool microscopy by the medical officer, Afghanistan, dated 4 April 2011;
- A deployed health record by the medical officer, Afghanistan, dated 10 May 2011;
- A psychology consultation by the psychologist, Afghanistan, dated 30 May 2011;
- A deployed health record and pathology by the medical officer, Afghanistan, dated 20 June 2011;
- An oral medicine consultation by the oral medicine specialist, dated 14 November 2011;
- A deployed health record and pathology by the medical officer, Iraq, dated 12 October 2015;
- An oral medicine review by the oral medicine specialist, dated 2 February 2016.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
9 July 2008 and 2 December 2019
Mouth Ulcers
You have stated that your condition was caused by:
- experiencing a category 1A or 1B stressor, or severe psychological stress, within the 1 month before the clinical onset of recurrent aphthous stomatitis
- having iron, vitamin B12 or folate deficiency at the time of the clinical onset of recurrent aphthous stomatitis
- in a person with a prior history of regular smoking, ceasing to smoke within the 6 months before the clinical onset of recurrent aphthous stomatitis
- having trauma to the oral mucosa at the site of ulceration within the 7 days before the clinical onset of recurrent aphthous stomatitis
- taking a non-steroidal anti-inflammatory drug, nicorandil, a beta-blocker or another drug associated with oral ulceration for at least the 2 weeks before the clinical onset of recurrent aphthous stomatitis
- having sleep deprivation, with an average of less than 5 hours of sleep per night, for at least the 4 weeks before the clinical onset of recurrent aphthous stomatitis
- having a gastrointestinal infection or disorder causing malabsorption, including giardiasis or coeliac disease, within the 3 months before the clinical onset of recurrent aphthous stomatitis
Diagnosis: Mouth Ulcers
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 26 February 2025, and is supported by an oral medicine consultation by the oral medicine specialist, dated 14 November 2011.
I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:
Reasonable Hypothesis - no Statement of Principles determined for this condition
which requires the evidence to connect the condition with service.
I am satisfied that the evidence establishes the following link to your service:
- experiencing a category 1A or 1B stressor, or severe psychological stress, within the 1 month before the clinical onset of recurrent aphthous stomatitis
- having iron, vitamin B12 or folate deficiency at the time of the clinical onset of recurrent aphthous stomatitis
- in a person with a prior history of regular smoking, ceasing to smoke within the 6 months before the clinical onset of recurrent aphthous stomatitis
- having trauma to the oral mucosa at the site of ulceration within the 7 days before the clinical onset of recurrent aphthous stomatitis
- taking a non-steroidal anti-inflammatory drug, nicorandil, a beta-blocker or another drug associated with oral ulceration for at least the 2 weeks before the clinical onset of recurrent aphthous stomatitis
- having sleep deprivation, with an average of less than 5 hours of sleep per night, for at least the 4 weeks before the clinical onset of recurrent aphthous stomatitis
- having a gastrointestinal infection or disorder causing malabsorption, including giardiasis or coeliac disease, within the 3 months before the clinical onset of recurrent aphthous stomatitis
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with multiple painful shallow ulcers of the inside of the cheeks, lips and tongue, with burning pain on eating, drinking and speaking, recurring in crops every four to six weeks, each lasting about ten days.Since the 2015 worsening you have had larger, deeper ulcers lasting three to six weeks that heal with scarring, with almost continuous ulceration, difficulty eating, weight loss and pain on speaking on 20 June 2011.
The diagnosis was made clinically by an oral medicine specialist on 14 November 2011, after four documented crops of ulcers from June 2011. The ulcers were shallow, round, 3 to 6 mm, with grey-yellow bases and erythematous haloes, confined to non-keratinised mucosa and healing within two weeks without scarring, typical of minor aphthae. Coeliac serology, HIV and herpes simplex testing were negative, and there were no features of Behcet disease or inflammatory bowel disease. Iron and folate deficiency were documented on 20 June 2011.
This has then led to further investigations and the diagnosis of your condition of Mouth Ulcers. I have accepted your condition of Mouth Ulcers.
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that this condition is related to your wartime service.
I have therefore accepted that this condition is related to your service with effect from 12 June 2011.
Mouth Ulcers (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 February 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 26 February 2025;
- A pre-deployment dental and medical examination by the dental officer and medical officer, dated 20 January 2011;
- A deployed health record and stool microscopy by the medical officer, Afghanistan, dated 4 April 2011;
- A deployed health record by the medical officer, Afghanistan, dated 10 May 2011;
- A psychology consultation by the psychologist, Afghanistan, dated 30 May 2011;
- A deployed health record and pathology by the medical officer, Afghanistan, dated 20 June 2011;
- An oral medicine consultation by the oral medicine specialist, dated 14 November 2011;
- A deployed health record and pathology by the medical officer, Iraq, dated 12 October 2015;
- An oral medicine review by the oral medicine specialist, dated 2 February 2016.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
9 July 2008 and 2 December 2019
Mouth Ulcers (Worsening)
You have stated that the worsening of your condition was caused by:
- experiencing a category 1A or 1B stressor, or severe psychological stress, within the 1 month before the clinical worsening of recurrent aphthous stomatitis
- having iron, vitamin B12 or folate deficiency at the time of the clinical worsening of recurrent aphthous stomatitis
- taking a non-steroidal anti-inflammatory drug, nicorandil, a beta-blocker or another drug associated with oral ulceration for at least the 2 weeks before the clinical worsening of recurrent aphthous stomatitis
- having sleep deprivation, with an average of less than 5 hours of sleep per night, for at least the 4 weeks before the clinical worsening of recurrent aphthous stomatitis
- inability to obtain appropriate clinical management for recurrent aphthous stomatitis
Diagnosis: Mouth Ulcers (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 26 February 2025, and is supported by an oral medicine consultation by the oral medicine specialist, dated 14 November 2011.
I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:
Reasonable Hypothesis - no Statement of Principles determined for this condition
which requires the evidence to connect the condition with service.
I am satisfied that the evidence establishes the following link to your service:
- experiencing a category 1A or 1B stressor, or severe psychological stress, within the 1 month before the clinical worsening of recurrent aphthous stomatitis
- having iron, vitamin B12 or folate deficiency at the time of the clinical worsening of recurrent aphthous stomatitis
- taking a non-steroidal anti-inflammatory drug, nicorandil, a beta-blocker or another drug associated with oral ulceration for at least the 2 weeks before the clinical worsening of recurrent aphthous stomatitis
- having sleep deprivation, with an average of less than 5 hours of sleep per night, for at least the 4 weeks before the clinical worsening of recurrent aphthous stomatitis
- inability to obtain appropriate clinical management for recurrent aphthous stomatitis
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with multiple painful shallow ulcers of the inside of the cheeks, lips and tongue, with burning pain on eating, drinking and speaking, recurring in crops every four to six weeks, each lasting about ten days.Since the 2015 worsening you have had larger, deeper ulcers lasting three to six weeks that heal with scarring, with almost continuous ulceration, difficulty eating, weight loss and pain on speaking on 20 June 2011.
The diagnosis was made clinically by an oral medicine specialist on 14 November 2011, after four documented crops of ulcers from June 2011. The ulcers were shallow, round, 3 to 6 mm, with grey-yellow bases and erythematous haloes, confined to non-keratinised mucosa and healing within two weeks without scarring, typical of minor aphthae. Coeliac serology, HIV and herpes simplex testing were negative, and there were no features of Behcet disease or inflammatory bowel disease. Iron and folate deficiency were documented on 20 June 2011.
After the condition arose, it was worsened during your service. On 20 September 2015, on warlike service in Iraq, a rocket landed about 50 metres from your accommodation during an indirect fire attack, a life-threatening event, within the 1 month before the worsening, from 12 September 2015 to 12 October 2015. Blood tests on 12 October 2015 showed a ferritin of 11 microgram/L. You took ibuprofen 400 mg three times daily from 18 August 2015 for a back strain sustained carrying radio equipment on warlike service, and continued it throughout the 2 weeks before the worsening, from 28 September 2015 to 12 October 2015. From August to October 2015 you worked night radio watches in Iraq and slept less than five hours a day in shared, noisy daytime accommodation, throughout the 4 weeks before the worsening, from 14 September 2015 to 12 October 2015, on warlike service. On deployment in Iraq your prescribed iron supplements and topical corticosteroid could not be resupplied, no oral medicine specialist was available, and systemic therapy could not be started in theatre.
This has then led to further investigations and the diagnosis of your condition of Mouth Ulcers (Worsening). I have accepted your condition of Mouth Ulcers (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that the worsening of this condition is related to your wartime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 12 October 2015.
