Angular Cheilitis

Question 1

What are the other terms for angular cheilitis

Answer 1

Perleche
Cheilosis
Angular stomatitis
Commmisural fissures

Question 2

What is angular Cheilitis

Answer 2

A condition frequently encountered in clinical practice

An inflammation of one or both corners of themouth.Often the corners areredwith skin breakdown and crusting. It can also be itchy or painful.

Question 3

What is the sequence of tx for angular Cheilitis

Answer 3

Clinical examination
Case history
Differential diagnosis 
Investigation
Diagnosis
Tx

Question 4

Does angular Cheilitis require liason with medical practitioner

Answer 4

Yes, helpful for undertaking haematological investigations
Identifying potential aetiological factors
Orofacial condition may have other systemic signs and symptoms
Empirical tx of angular Cheilitis without adequate investigation will almost certainly result in recurrence of symptoms due to failure to eliminate all predisposing factors including the presence of underlying systemic disease

Question 5

What do microbiological investigations of angular Cheilitis show? What species cause angular Cheilitis

Answer 5

Candida - opportunistic yeast
1/3 cases have staph species
1/3 cases have a mmix of candida and staph
Occasionally 1/3 show strep

Question 6

What factors in the social history may give a clue to the source and nature of the microbial component in angular Cheilitis?

Answer 6

The oral flora of a pt who wears a prosthesis (denture or orthodontic appliance) is likely to contain high levels of candida which spread to the angles which contrasts to a dentare individual who is likely to have infection involving staph that have originated from colonisation within the nose. This division is not obsolute esp with those with xerostomia and immunocompromised pts

Question 7

Is the oral flora different in patients with appliances? (orthodontic and prosthodontic). How do?

Answer 7

The oral flora of a pt who wears a prosthesis (denture or orthodontic appliance) is likely to contain high levels of candida which spread to the angles which contrasts to a dentare individual who is likely to have infection involving staph that have originated from colonisation within the nose

Question 8

If a dentate pt presents with angular Cheilitis what microbiological species are more likely to be the cause? Staph, strep or candida? Why?

Answer 8

Staph. they have originated from colonisation of the nose

Question 9

What area does angular cheilitis affect

Answer 9

Angular Cheilitis can affect One or both angles of the mouth

Question 10

What are the differential clinical diagnosis of the inflammatory changes:
Redness soreness and ulceration at the angle of the mouth

Answer 10

Recurrent herpes labialis

Lichen planus

Question 11

What is involved in clinical exam and case history?

Answer 11

Complaint
Duration
Previous tx
Wearing of any prosthesis
Full medical and drug history

Question 12

What percentage of patients with orofacial grandulomatosis suffer from angular Cheilitis

Answer 12

20%

Question 13

What is the reason for the association between orofacial grandulomatosis and angular Cheilitis?

Answer 13

It is unclear but maybe that the physical enlargement and splitting of the lips, due to lymphoedema, provide a suitable environment for the development of opportunistic infection

Question 14

How does angular cheilitis arise? Pathophysiology

Answer 14

Angular Cheilitis involves endogenous micro organisms that originate from a chronic reservoir of infection. In the face of infection involving staph species the reservoir is usually the anterior region of the nostrils since 40% of the general population have nasal commensal carriage of this bacterial species especially staph aureus

Question 15

What % of the general population have nasal commensal carriage of staphylococcus species?

Answer 15

40%

Most commonly staph aureus

Question 16

What other species have been found associated with angular Cheilitis?

Answer 16

MRSA

Question 17

When candidal species are found in angular Cheilitis is it always candida albicans? What other candida is present

Answer 17

C tropicalis
C glabrata
C dublineinsis

Question 18

What is the level of oral carriage of candida in the mouth?

Answer 18

Ranges from 7 - 40%

Question 19

What is chronic erythematous candidosis?

Answer 19

The most frequently occurring form of oral candidosis

Associated with the wearing of an upper appliance

Question 20

Chronic erythematous candidosis presentarion

Answer 20

Redness (erythema) in the palatal mucosa confined to those areas covered by a partial or full acrylic appliance

Question 21

What is pseudo membranous candidosis?

Answer 21

Removable superficial extensive white patches

Question 22

Where is pseudo membranous candidosis seen

Answer 22

In the soft palate most commonly associated with steroid inhaler use

Question 23

What is chronic hyperplastic candidosis

Answer 23

Rarer form of oral candidosis

Seen almost exclusively in smokers

Question 24

What is median rhomboid glossitis

Answer 24

Rarer form of oral candidosis
Maybe a source of candida
An erythematous ‘kissing lesion’ is sometimes seen in the mid lines of the hard palate of pts with median rhomboid glossotis due to direct inoculation of the palatal tissue with candida from the dorsum of the tongue

Question 25

What is angular Cheilitis'association with immunosuppression

Answer 25

Hiv infection has been implicated in a range of intra oral candidal infections and as such it is not surprising that angular Cheilitis is a recognised opportunistic feature of this and other forms of immune deficiency.

Question 26

What microbiological investigations may be completed

Answer 26

``` Swab or smear of each angle of the mouth Swab of each anterior nares Swab or imprint of the palate Swab of imprint of the fitting surface of the upper appliance if worn Oral rinse if no appliance worn ```

Question 27

How should microbiplogical samples be handled

Answer 27

All microbiological specimens should be promptly delivered to the lab for culture or staining if rapid transport of the sample is not possible then overnight storage in a refrigerator is acceptable but it is likely that such delay will reduce the reliability and levels of any subsequent culture

Question 28

What haematological investigations maybe completed for diagnosis of angular cheilitis

Answer 28

``` FBC corrected whole blood folate Vitamin B12 Ferritin Fasting venous Plasma glucose ```

Question 29

What should be done in the initial visit in general practice to manage angular Cheilitis

Answer 29

Provide topical antimicrobial agent to lesional tissues and source of infection (nose or mouth as appropriate) Minimise possible local predisposing factors (improve denture hygiene reduce sugar intake correct use of inhaled steroids)

Question 30

What should be completed at the review stage to manage angular cheilitis?

Answer 30

Review after 4 weeks If symptoms have resolved then reinforce prevention. If no improvement has occurred Undertake microbiological investigations liaise with medical practitioners Undertake haematological investigations liaise with medical practicioners Or Refer to specialist

Question 31

What percentage of patients with angular Cheilitis have been found to have haematological abnormalities? What are these abnormalities

Answer 31

50% | Low levels of iron or vitamin B12 of raised venous glucose

Question 32

What is plummer vinson syndrome

Answer 32

Also called Patterson brown kelly syndrome Or sideropenic dysphagia It's a triad of iron deficiency anaemia, difficulty swallowing due to oesophageal and glossotis that includes angular Cheilitis as a presenting feature

Question 33

If staphylococal infection is suspected then what should be the tx for the angular Cheilitis

Answer 33

Sodium fusidate ointment 2% applied to angles 4 times daily for 10 days

Question 34

If the angular Cheilitis is found to be a staph infection what should the pt be given

Answer 34

Two 15g tubes of sodium fusidate ointment 2% one for the andlew and one for the anterior aspects of the nose

Question 35

How does staph aureus spread between the angles and nose

Answer 35

The route is unclear | Maybe prolonged contact of the nose and mouth with fingers, prolonged wearing if face masks or urti

Question 36

What other ointment maybe effective against staph infection apart from sodium fusidate?

Answer 36

Mupirocin cream 2% three times daily

Question 37

If the infection is found to be candidal what is the tx?

Answer 37

Miconazole 2% cream 20g tube applied twice daily for up to 10 days after lesions have cleared up

Question 38

What is the benefit of miconazole

Answer 38

If the infection is mixed | Miconazole has activity not only against candida species but also gram positive bacteria, including staph species

Question 39

What should the clinician bear in mind when prescribing metformin

Answer 39

Miconazole even in topical format must not be given to a pt who is taking warfarin or a station due to the potential for a significant drug interaction

Question 40

What is an alternative to the Miconazole 2% tx?

Answer 40

Miconazole 2% with hydrocortisone 1% 30g tube for 7 days Whilst including a steroid in the prep may appear illogical when treating an infective process in reality the presence of anti inflammatory produces a food clinical response In additional to txing the tissues at the angles themselves the reservoir of chronic infection in the oral cavity is also eliminated

Question 41

What other antifungal medications maybe prescribed apart from Miconazole 2% and Miconazole with hydrocortisone 1%

Answer 41

Amphotericin or nystatin (but it has now been suggested that these two polyene antifungal agents have minimal benefit when used topically in the mouth) Newer generations of triazole antifungal which can be given systemically in contrast to the polyene or imidazole which are limited to topical use only are the agents of choice

Question 42

What is the standard tx for oral candidosis

Answer 42

Fluconazole 50mg capsule once daily for 144 days

Question 43

What should be used to tx oropharyngeal candidosis in hiv positive pts and otherwise healthy pts

Answer 43

Itraconazole Systemic Itraconazole 100mg capsule where fluconazole resistance has developed

Question 44

If there is erythematous candidosis associated with a denture what should the pt be instructed to do?

Answer 44

Apply sugar free Miconazole oromucosal gel 24mg/ml to the fitting surface or the denture 4times daily Prescribe 80mg tube