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Bdj > Angular Cheilitis > Flashcards

Angular Cheilitis Flashcards

Clinical exam and tx

1
Q

What are the other terms for angular cheilitis

A

Perleche
Cheilosis
Angular stomatitis
Commmisural fissures

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2
Q

What is angular Cheilitis

A

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.

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3
Q

What is the sequence of tx for angular Cheilitis

A 
Clinical examination
Case history
Differential diagnosis 
Investigation
Diagnosis
Tx
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4
Q

Does angular Cheilitis require liason with medical practitioner

A

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

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5
Q

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

A

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

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6
Q

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

A

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

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7
Q

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

A

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

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8
Q

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

A

Staph. they have originated from colonisation of the nose

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9
Q

What area does angular cheilitis affect

A

Angular Cheilitis can affect One or both angles of the mouth

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10
Q

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

A

Recurrent herpes labialis

Lichen planus

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11
Q

What is involved in clinical exam and case history?

A 
Complaint
Duration
Previous tx
Wearing of any prosthesis
Full medical and drug history
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12
Q

What percentage of patients with orofacial grandulomatosis suffer from angular Cheilitis

A

20%

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13
Q

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

A

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

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14
Q

How does angular cheilitis arise? Pathophysiology

A

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

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15
Q

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

A

40%

Most commonly staph aureus

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16
Q

What other species have been found associated with angular Cheilitis?

A

MRSA

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17
Q

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

A

C tropicalis
C glabrata
C dublineinsis

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18
Q

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

A

Ranges from 7 - 40%

19
Q

What is chronic erythematous candidosis?

A

The most frequently occurring form of oral candidosis

Associated with the wearing of an upper appliance

20
Q

Chronic erythematous candidosis presentarion

A

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

21
Q

What is pseudo membranous candidosis?

A

Removable superficial extensive white patches

22
Q

Where is pseudo membranous candidosis seen

A

In the soft palate most commonly associated with steroid inhaler use

23
Q

What is chronic hyperplastic candidosis

A

Rarer form of oral candidosis

Seen almost exclusively in smokers

24
Q

What is median rhomboid glossitis

A

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

25
Q

What is angular Cheilitis’association with immunosuppression

A

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.

26
Q

What microbiological investigations may be completed

A 
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
27
Q

How should microbiplogical samples be handled

A

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

28
Q

What haematological investigations maybe completed for diagnosis of angular cheilitis

A 
FBC
corrected whole blood folate
Vitamin B12
Ferritin
Fasting venous Plasma glucose
29
Q

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

A

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)

30
Q

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

A

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

31
Q

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

A

50%

Low levels of iron or vitamin B12 of raised venous glucose

32
Q

What is plummer vinson syndrome

A

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

33
Q

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

A

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

34
Q

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

A

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

35
Q

How does staph aureus spread between the angles and nose

A

The route is unclear

Maybe prolonged contact of the nose and mouth with fingers, prolonged wearing if face masks or urti

36
Q

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

A

Mupirocin cream 2% three times daily

37
Q

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

A

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

38
Q

What is the benefit of miconazole

A

If the infection is mixed

Miconazole has activity not only against candida species but also gram positive bacteria, including staph species

39
Q

What should the clinician bear in mind when prescribing metformin

A

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

40
Q

What is an alternative to the Miconazole 2% tx?

A

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

41
Q

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

A

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

42
Q

What is the standard tx for oral candidosis

A

Fluconazole 50mg capsule once daily for 144 days

43
Q

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

A

Itraconazole

Systemic Itraconazole 100mg capsule where fluconazole resistance has developed

44
Q

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

A

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

Bdj (15 decks)

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