Angular Cheilitis is actually a physical appearance of a lesion characterised by red inflammation to the angles of the mouth. It is not an actual diagnosis but a clinical sign.
It is most commonly seen in the older person with dentures.
There is a primary infection TOGETHER with other multifactorial conditions which predispose the patient to the primary infection.
An imbalance of the normal microbiological flora occurs at the corners of the mouth and secondary factors increase the likelihood of this microbiological imbalance occurring.
Symptoms that occur.
1. Irritation of the skin at the corners of the mouth occurs and this Irritation can be asymptomatic but it can also cause severe discomfort for the patient with stinging and burning.
As mentioned above, secondary factors increase this occurring. It is more common in elderly patients who have wrinkling of the skin at the corners of the mouth.
These individuals may also have an underlying systemic condition which includes endocrine disorders such as diabetes, immunological lowering disorders such as HIV infection, common nutritional deficiencies, and malignancies.
Saliva in these patients, drools into the fissures at the corners of the mouth and this creates a chronic moist environment for certain microorganisms that are implicated in angular cheilitis. The main microorganisms are candida albicans and staphylococcus aureus. These are already present in the normal flora but increase to create an unbalanced microbiological environment.
Another common factor is that patients will often have dentures with a decreased vertical dimension of occlusion. When there is a decreased vertical dimension of occlusion, the skin at the corners of the mouth will be more wrinkled and hence creating a niche for bacteria/fungus in order to flourish.
It is also noticed that patients wear poorly fitting dentures with poor denture hygiene wearing at night will often also have denture stomatitis on the palatal surface and we know that candida albicans is implicated in denture stomatitis.
Therefore when investigating a patient some of the things that a clinician should look out for are:
1. To check if dentures have reduced vertical dimension.
2. Is there denture stomatitis?
3. Does the patient have a tendency to lick their lips and corners of the mouth. Children who have angular cheilitis often have this habit. (Licking and saliva creates a moist environment which cause implicated organisms to take over.)
4. Is there any alteration in taste or burning mouth as this could be an oral fungal infection which will become a chronic source of infection at the corners of the mouth.
5. Checking Medical history which may indicate that underlying systemic condition such as undiagnosed/uncontrolled diabetes including recent use of antibiotics.
6. Do the dentures have a good fit?
Treatment depends on the underlying condition but also involves treating the primary infection.
Initially the treatment is localised but if it does not resolve, you should consider prescribing an appropriate systemic antifungal agent.
1. Treatment will include correcting the denture or in most cases a remake.
2. To maintain hygiene of the denture including not wearing them at night-time. If there is denture stomatitis present than this needs to be resolved.
3. There are three combinations of antifungals that are commonly used.
(a) To use topical antifungal cream such as miconazole or nystatin.
(b) To use combination of topical antifungal and antibacterial cream as an alternative.
(c) Another combination is the use of an antifungal,antibacterial and a glucocorticosteroid ointment.
If there is no improvement then the patient can be referred for blood tests to assess for an underlying undetected system condition or uncontrolled diabetes.