Angular Cheilitis Flashcards
Clinical exam and tx
What are the other terms for angular cheilitis
Perleche
Cheilosis
Angular stomatitis
Commmisural fissures
What is angular Cheilitis
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.
What is the sequence of tx for angular Cheilitis
Clinical examination Case history Differential diagnosis Investigation Diagnosis Tx
Does angular Cheilitis require liason with medical practitioner
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
What do microbiological investigations of angular Cheilitis show? What species cause angular Cheilitis
Candida - opportunistic yeast
1/3 cases have staph species
1/3 cases have a mmix of candida and staph
Occasionally 1/3 show strep
What factors in the social history may give a clue to the source and nature of the microbial component in angular Cheilitis?
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
Is the oral flora different in patients with appliances? (orthodontic and prosthodontic). How do?
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
If a dentate pt presents with angular Cheilitis what microbiological species are more likely to be the cause? Staph, strep or candida? Why?
Staph. they have originated from colonisation of the nose
What area does angular cheilitis affect
Angular Cheilitis can affect One or both angles of the mouth
What are the differential clinical diagnosis of the inflammatory changes:
Redness soreness and ulceration at the angle of the mouth
Recurrent herpes labialis
Lichen planus
What is involved in clinical exam and case history?
Complaint Duration Previous tx Wearing of any prosthesis Full medical and drug history
What percentage of patients with orofacial grandulomatosis suffer from angular Cheilitis
20%
What is the reason for the association between orofacial grandulomatosis and angular Cheilitis?
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
How does angular cheilitis arise? Pathophysiology
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
What % of the general population have nasal commensal carriage of staphylococcus species?
40%
Most commonly staph aureus
What other species have been found associated with angular Cheilitis?
MRSA
When candidal species are found in angular Cheilitis is it always candida albicans? What other candida is present
C tropicalis
C glabrata
C dublineinsis
What is the level of oral carriage of candida in the mouth?
Ranges from 7 - 40%
What is chronic erythematous candidosis?
The most frequently occurring form of oral candidosis
Associated with the wearing of an upper appliance
Chronic erythematous candidosis presentarion
Redness (erythema) in the palatal mucosa confined to those areas covered by a partial or full acrylic appliance
What is pseudo membranous candidosis?
Removable superficial extensive white patches
Where is pseudo membranous candidosis seen
In the soft palate most commonly associated with steroid inhaler use
What is chronic hyperplastic candidosis
Rarer form of oral candidosis
Seen almost exclusively in smokers
What is median rhomboid glossitis
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
What is angular Cheilitis’association with immunosuppression
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.
What microbiological investigations may be completed
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
How should microbiplogical samples be handled
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
What haematological investigations maybe completed for diagnosis of angular cheilitis
FBC corrected whole blood folate Vitamin B12 Ferritin Fasting venous Plasma glucose
What should be done in the initial visit in general practice to manage angular Cheilitis
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)
What should be completed at the review stage to manage angular cheilitis?
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
What percentage of patients with angular Cheilitis have been found to have haematological abnormalities? What are these abnormalities
50%
Low levels of iron or vitamin B12 of raised venous glucose
What is plummer vinson syndrome
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
If staphylococal infection is suspected then what should be the tx for the angular Cheilitis
Sodium fusidate ointment 2% applied to angles 4 times daily for 10 days
If the angular Cheilitis is found to be a staph infection what should the pt be given
Two 15g tubes of sodium fusidate ointment 2% one for the andlew and one for the anterior aspects of the nose
How does staph aureus spread between the angles and nose
The route is unclear
Maybe prolonged contact of the nose and mouth with fingers, prolonged wearing if face masks or urti
What other ointment maybe effective against staph infection apart from sodium fusidate?
Mupirocin cream 2% three times daily
If the infection is found to be candidal what is the tx?
Miconazole 2% cream 20g tube applied twice daily for up to 10 days after lesions have cleared up
What is the benefit of miconazole
If the infection is mixed
Miconazole has activity not only against candida species but also gram positive bacteria, including staph species
What should the clinician bear in mind when prescribing metformin
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
What is an alternative to the Miconazole 2% tx?
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
What other antifungal medications maybe prescribed apart from
Miconazole 2%
and Miconazole with hydrocortisone 1%
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
What is the standard tx for oral candidosis
Fluconazole 50mg capsule once daily for 144 days
What should be used to tx oropharyngeal candidosis in hiv positive pts and otherwise healthy pts
Itraconazole
Systemic Itraconazole 100mg capsule where fluconazole resistance has developed
If there is erythematous candidosis associated with a denture what should the pt be instructed to do?
Apply sugar free Miconazole oromucosal gel 24mg/ml to the fitting surface or the denture 4times daily
Prescribe 80mg tube
