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How Do I Manage a Patient with Angular Cheilitis?

Eric T. Stoopler, DMD, FDS RCSEd; Christine Nadeau, DMD; Thomas P. Sollecito, DMD, FDS RCSEd

Posted on May 09, 2013

Tags: diagnosis oral health oral medicine treatment


Cite this as: J Can Dent Assoc 2013;79:d68


Angular Cheilitis

  • Inflammation of the angles of the mouth, characterized by fissures, scaling, erythema and crusting (fig. 1).
  • Cause is usually multifactorial, due to a primary infection and/or non-infectious causes, such as mechanical irritation, nutritional deficiency or other dermatologic condition.

Fig 1. Typical presentation of angular cheilitis with erythema, crusting and mild fissuring of the angles of the mouth bilaterally.

Presentation

Population

  • Individuals with increased folding or wrinkling of skin at the corners of the mouth
  • Individuals wearing dentures with decreased vertical dimension of occlusion
    • Saliva pools in the fissures, creating a chronic moist environment for infection with Candida albicans, Staphylococcus aureus and/or Streptococcus (rare)
    • Individuals with underlying systemic conditions including endocrine disorders (e.g., diabetes), immunological disorders (e.g., HIV infection), nutritional deficiencies, hematologic malignancies or solid organ malignancies

Signs

  • Red, scaly fissured lesions at the angles of the mouth, usually bilateral

Symptoms

  • Pain severity: can range from asymptomatic to severe discomfort
  • Burning
  • Irritation
  • Pruritis

Investigation

  1. If the patient wears dentures: Are the dentures stable and comfortable? Is the vertical dimension of occlusion appropriate?(Poorly fitting dentures could cause the wrinkling that creates a favorable environment for the condition to manifest.)

  2. Does the patient have a tendency to lick their lips/corners of mouth?

  3. Have there been any recent changes to saliva quality or quantity?

  4. Does the patient report oral burning or taste alterations, which may be indicative of a generalized oral fungal infection? If present, it could be a source of re-infection.

  5. Ask the patient about any recently prescribed medications (including antibiotics) that may cause this condition.

  6. Obtain a thorough dental and medical history.
    • Recognize responses to review of systems that raise suspicion for underlying systemic disorders.
    • Determine the stability of current medical conditions.
    • Tobacco use may predispose to the development of this condition.

  7. If a more thorough investigation is warranted, refer for cytology culture or laboratory assessment to rule out local or systemic predisposing factors.

Diagnosis

Based on clinical finding of erythematous fissures at the angles of the mouth, a diagnosis of angular cheilitis is determined.

Differential Diagnosis

  • Contact dermatitis
  • Actinic cheilitis

Treatment

Common Initial Treatments

  1. Initial evaluation of predisposing local factors:
    • Evaluation of prostheses
    • Maintenance of oral hygiene
    • Maintenance of prosthesis hygiene
    • Local salivary gland issues
    • Intraoral fungal infection

  2. Prescribe a topical ointment or cream:
    • Usually a combination of topical antifungal and antibacterial (e.g., nystatin and mupirocin); consider the use of combination antifungal/antibacterial/glucocorticosteroid ointment (e.g., Viaderm-K.C.® ointment) as an alternative.
    • Apply a thin layer to the angles of the mouth 2–3 x daily for 2 weeks.

  3. Patients should use a new toothbrush when management is started as their toothbrush may be contaminated.

  4. If an intraoral fungal infection is present, appropriate therapy should be initiated.

Follow Up

Follow up recommended at 2 weeks:

  • If the condition is resolved: continue monitoring.
  • If the condition is not resolved: consider prescribing an appropriate systemic antifungal.
  • If systemic issues are suspected as a cause: the patient should be referred to their primary care physician for additional evaluation and/or management.

THE AUTHORS

 

Dr. Stoopler is an associate professor of oral medicine and director, postdoctoral oral medicine program, department of oral medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania.

 

Dr. Nadeau is a resident in oral medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania.

 

Dr. Sollecito is chair and professor of oral medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania.

Correspondence to: Dr. Eric T. Stoopler, University of Pennsylvania School of Dental Medicine, 240 South 40th St., Philadelphia, PA 19104, USA. Email: ets@dental.upenn.edu

The author has no declared financial interests.

This article has been peer reviewed.

Suggested Resources

  1. Neville BW, Damm DD, Allen CM, Bouquot JE. Erythematous candiasis. In: Oral and Maxillofacial Pathology. 3rd ed.  St. Louis: Saunders Elsevier; 2009. p. 214, 216–17.
  2. Farah CS, Lynch N, McCullough MJ. Oral fungal infections: an update for the general practitioner. Aust Dent J. 2010;55(Suppl 1):48–54.
  3. Giannini PJ, Shetty KV. Diagnosis and management of oral candidiasis. Otolaryngol Clin N Am. 2011;44(1):231–40.
  4. Park KK, Brodell RT, Helms SE. Angular cheilitis, part 1: local etiologies. Cutis. 2011;87(6):289–95.
  5. Park KK, Brodell RT, Helms SE. Angular cheilitis, part 2: nutritional, systemic and drug-related causes and treatment. Cutis. 2011;88(1):27–32.
  6. Sharon V, Fazel N. Oral candidiasis and angular cheilitis. Dermatol Ther. 2010;23(3):230–42.


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