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Angular Cheilitis

Perleche

Angular cheilitis is characterized by inflammatory lesions presenting in the corner(s) of the mouth. The causes include infection with Candida albicans or Staphylococcus aureus, wearing oral dentures or other devices, anemia, deficiencies in the B vitamins, etc. The diagnosis is achieved by findings on physical exam, a thorough history, and a workup of underlying etiologies.


Presentation

Angular cheilitis is defined as inflammation of the corner(s) of the mouth [1]. While the cause has not been completely elucidated [2], the most predominant etiology is infection with Candida albicans (commonly found on dentures) [2], Staphylococcus aureus (found on face masks), and beta-hemolytic streptococci [3] [4] [5]. Specifically, this condition may arise from poorly fitting oral dentures [1], occupational face masks, pacifier use in young children [3], contact irritation such as with nickel found in orthodontic braces [1] [6], excessive salivation [3] [7], and thumb sucking and lip licking [8]. Very importantly, angular cheilitis can develop secondary to anemia and deficiency in the B vitamins as well as immunosuppression [4]. It is also one of the oral manifestations in patients with Crohn's disease and may be observed in those with no gastrointestinal involvement [9] [10] [11].

This unpleasant condition is characterized by erythematous, scaly, and ulcerating fissures found on the angles of the mouth [5]. These lesions can bleed and cause pain and burning, especially when applying pressure on them [1]. Additionally, the lips are often dry. Successful therapy is essential to prevent further episodes of angular cheilitis [12].

The inspection yields findings such as cracking, mucosal atrophy, crusting, ulceration, and other signs suggestive of inflammation [4]. The patient may be wearing dentures or have manifestations of the gingival and dental disease [4].

Plethora
  • A plethora of antifungal treatments are available. The overall prognosis of oral candidiasis is good, and rarely is the condition life threatening with invasive or recalcitrant disease.[ncbi.nlm.nih.gov]
Cheilitis
  • Angular cheilitis is a type of cheilitis (inflammation of the lips).Angular cheilitis can be caused by infection, irritation, or allergies. Infections include by fungi such as Candida albicans and bacteria such as Staph. aureus.[en.wikipedia.org]
  • MAIN OUTCOME MEASURES: The presence and absence of angular cheilitis was recorded. A six-point clinical scale was used to describe the clinical features of angular cheilitis when present.[ncbi.nlm.nih.gov]
  • Showing it to your doctor, he would certainly tell you point blank – Angular Cheilitis! This would be followed by you asking, “What is Angular Cheilitis?” To learn specific details of angular cheilitis in an informative video, Click Here.[web.archive.org]
  • Abstract The purpose of this prospective study was to re-examine the relative importance of various factors in the pathogenesis of angular cheilitis. Sixty-four patients with cheilitis were examined clinically and microbiologically.[ncbi.nlm.nih.gov]
  • Abstract The incidence of recurrence of angular cheilitis following a successful antimicrobial treatment was studied in 48 patients.[ncbi.nlm.nih.gov]
Cracked Lips
  • The inflammation can cause pain in the lips, cracked lips, ulceration, reddened skin, and tenderness at the involved area. Typically, both sides of the mouth are involved, but the condition can occur on one side only.[rxlist.com]
  • This treatment not only heals cracked lips, but it also helps alleviate pain associated with the condition. Simply hold a cucumber slice to the affected area for a couple minutes a day, twice a day, everyday.[healthyfocus.org]
  • There is a characteristic other option to treating this agonizing skin condition and it can definitely enhance the presence of the skin around cracked lip corners treatment the mouth.[works.bepress.com]
Dry Eyes
  • Biotin (vitamin B7) deficiency has also been reported to cause AC, along with hair loss (alopecia) and dry eyes. Zinc deficiency is known to cause AC. Other symptoms may include diarrhea, alopecia and dermatitis.[en.wikipedia.org]
Eczema
  • Furthermore, after extensive research for angular cheilitis, I am now almost positive I had angular cheilitis instead of eczema.[healthywildandfree.com]
  • […] due to nutritional deficiency states: 5% due to xerostomia (dry mouth): immunosuppressant medications drugs: indinavir sorafenib substance abuse esp. cocaine, methamphetamines, heroin, and hallucinogens other causes: chronic mucocutaneous candidiasis eczema[ozemedicine.com]
  • Other causes include: Dry chapped lips Lip licking Atopic cheilitis (eczema) Oral retinoid therapy ( isotretinoin and acitretin ) Antiretroviral treatment Nutritional deficiency including riboflavin, iron, vitamin B12 and zinc A compromised immune system[dermcoll.edu.au]
  • Children wearing braces are also more likely to develop angular cheilitis Dribbling of saliva causes an irritant reaction Dry lips eg in atopic eczema, and as a result of medications such as retinoids (isotretinoin, acitretin), and anticholinergic drugs[pcds.org.uk]
  • Maintaining good oral hygiene Proper denture fit Commonly Associated Conditions Nutritional deficiencies Diabetes mellitus type 2 Immunodeficiency Irritant or allergic reactions to oral hygiene products Irritant or allergic reactions to denture products Eczema[unboundmedicine.com]
Koilonychia
  • Chronic iron deficiency may also cause koilonychia (spoon shaped deformity of the fingernails) and glossitis (inflammation of the tongue).[en.wikipedia.org]
Suggestibility
  • It has been suggested that in the future the role of the dental practitioner increasingly will be that of the oral physician.[ncbi.nlm.nih.gov]
  • Other etiological factors suggested for this disorder were found to be of subordinate importance.[ncbi.nlm.nih.gov]
  • These observations suggest that the cell-mediated arm of the immune system is involved in the inflammatory reaction of lesions infected by Candida albicans.[ncbi.nlm.nih.gov]
  • A new clinical grade of angular cheilitis is suggested that may help future research.[ncbi.nlm.nih.gov]
  • They suggest that common medicinal treatments to do not actually cure the condition, but rather alleviate some symptoms. Earth Clinic suggests taking on angular cheilitis using some simple DIY remedies: Yogurt.[epicraze.com]
Clumsiness
  • […] paresthesias anywhere in body - tingling, pins and needles, etc (my back, it's directly related to the gas in my intestines) paresthesias in both legs - burning sudden electric like shocks/pains shooting down arms, body, legs shooting down from neck movement clumsiness[forums.phoenixrising.me]

Workup

The diagnosis is based on clinical findings and assessment of risk factors. Furthermore, the workup consists of the patient's history, physical exam, and investigation of the etiology.

Very importantly, the clinician must inquire about the onset, duration, previous episodes, and past treatments [1]. In an effort to determine the predisposing factors and underlying cause, the clinician should elicit the patient's dental history, use and fit of dentures or other prostheses, dental hygiene, and other pertinent information [2] [3]. Additional details regarding any medication use, tobacco smoking/chewing, and alcohol use should be obtained [2] [4]. Moreover, the patient's medical history should be evaluated for anemia, nutritional deficiencies, immunosuppression, allergic cutaneous conditions, and so forth [2] [4].

Swabs of the angles of the mouth and nose are helpful with determining the offending organism. Additionally, samples of the dentures are useful for microbial assessment [1].

If primary therapy is ineffective, the patient should undergo a thorough workup for anemia and nutritional deficiencies with a complete blood count (CBC), iron studies as well as measurements of vitamins B2, B6, B12, and folate [1] [4]. Correction of iron deficiency anemia and any vitamin insufficiency will successfully treat the angular cheilitis [1] [13].

Treatment

  • Clinical assessments including a microbial examination were carried out 8 months and 5 yr after termination of treatment.[ncbi.nlm.nih.gov]
  • Ninety-six per cent of the patients who participated in the open trial had no sign of infection after 42 days of treatment.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To report the prevalence and clinical features of angular cheilitis occurring in patients undergoing orthodontic treatment. DESIGN: Cross-sectional, observational study.[ncbi.nlm.nih.gov]
  • The purpose of this paper is to increase the awareness among clinicians of angular cheilitis occurring during orthodontic treatment. It also proposes a treatment regime which may be used.[ncbi.nlm.nih.gov]
  • To report conservative treatment based on the use of dermal fillers for a case of recurrent angular cheilitis. An 80-year-old patient with a history of recurrent angular cheilitis that was not resolved with a conventional approach sought treatment.[ncbi.nlm.nih.gov]

Prognosis

  • The overall prognosis of oral candidiasis is good, and rarely is the condition life threatening with invasive or recalcitrant disease.[ncbi.nlm.nih.gov]

Etiology

  • The diagnosis is achieved by findings on physical exam, a thorough history, and a workup of underlying etiologies. Angular cheilitis is defined as inflammation of the corner(s) of the mouth.[symptoma.com]
  • A significant positive relationship between commissural leukoplakia and an infective etiology of angles was noted.[ncbi.nlm.nih.gov]
  • Identifying the underlying etiology of AC is a critical step in developing an effective treatment plan for this condition.[ncbi.nlm.nih.gov]
  • Other etiological factors suggested for this disorder were found to be of subordinate importance.[ncbi.nlm.nih.gov]
  • Furthermore, various etiologic factors were investigated for their relative effect on the healing process.[ncbi.nlm.nih.gov]

Epidemiology

  • Patient Population: Prevalence and Epidemiology Knee // Shoulder & Elbow // Hip // Spine // Foot & Ankle // Hand & Wrist Fragility Fractures: Diagnosis and Treatment Shoulder & Elbow The Characteristics of Surgeons Performing Total Shoulder Arthroplasty[mdedge.com]
  • […] below -- Basics Description Erythema, moist maceration, ulceration, and crusting at the corners of the mouth Three main types: irritant, allergic, and infectious Also known as perlèche, angular cheilosis, commissural cheilitis, and angular stomatitis Epidemiology[unboundmedicine.com]
Sex distribution
Age distribution

Pathophysiology

  • […] stomatitis Epidemiology Incidence Most common in 3rd, 5th, and 6th decades of life ( 1 ) Present in up to 25% of Down syndrome patients ( 1 ) Prevalence 0.7–3.8% of oral lesions in adults ( 1 ) 0.2–15.1% of oral lesions in children ( 1 ) Etiology and Pathophysiology[unboundmedicine.com]

Prevention

  • In edentulous and immunosuppressed patients, candidiasis may recur very quickly, and preventive therapy consisting of an application of a barrier ointment such as petrolatum, zinc oxide, or use of an imidazole cream q.d. may be necessary to prevent recurrences[derm101.com]
  • The fact is, with the right kind of food, you can prevent angular cheilitis from coming back.[healthydietbase.com]
  • Dentures that do not fit properly should be adjusted to prevent lip irritation via friction and to allow the mouth to properly close. This will prevent saliva build-up on the corners of the mouth.[healthy-skincare.com]
  • All these information can serve as your starting ground—at least when it comes to the prevention of Angular Cheilitis.[dentureadhesiveguide.com]

References

Article

  1. Devani A, Barankin B. Answer: Can you identify this condition? Can Fam Physician. 2007;53(6):1022-1023.
  2. Ohman SC, Dahlen G, Moller A, Ohman A. Angular cheilitis: a clinical and microbial study. J Oral Pathol. 1986;15(4):213–217.
  3. Lamey PJ, Lewis MA. Oral medicine in practice: angular cheilitis. Br Dent J. 1989;167(1):15–18.
  4. Warnakulasuriya KA, Samaranayake LP, Peiris JS. Angular cheilitis in a group of Sri Lankan adults: a clinical and microbiologic study. J Oral Pathol Med. 1991;20(4):172–175.
  5. Gonsalves WC, Wrightson AS, Henry RG. Common oral conditions in older persons. Am Fam Physician. 2008;78(7):845-852.
  6. Yesudian PD, Memon A. Nickel-induced angular cheilitis due to orthodontic braces. Contact Dermatitis. 2003;48(5):287–238.
  7. Neville BW. Oral Maxillofacial Pathology. 2nd ed. Philadelphia, Pa.: W.B. Saunders; 2002.
  8. Kahana M, Yahalom R, Schewach-Millet M. Recurrent angular cheilitis caused by dental flossing. J Am Acad Dermatol. 1986;15(1):113–114.
  9. Kalmar JR. Crohn′s disease: Orofacial considerations and disease pathogenesis. Periodontol 2000. 1994;6:101–115.
  10. Field EA, Tyldesley WR. Oral Crohn′s disease revisited-a 10-year-review. Br J Oral Maxillofac Surg. 1989;27(2):114–123.
  11. Harikishan G, Reddy NR, Prasad H, Anitha S. Oral Crohn’s disease without intestinal manifestations. J Pharm Bioallied Sci. 2012;4(Suppl 2): S431-S434.
  12. Ohman SC, Jontell M, Dahlen G. Recurrence of angular cheilitis. Scand J Dent Res. 1988;96(4):360–365.
  13. Rose JA. Folic-acid deficiency as a cause of angular cheilosis. Lancet. 1971;2(7722):453–454.

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Last updated: 2019-06-28 11:45