ANGULAR CHEILITIS: CASE REPORTS AND LITERATURE REVIEW

MAHREEN SHAHZAD, BDS, MSc (Oral Medicine)

2
RAHEELA FARAZ, BDS
3
ANAM SATTAR, BDS

ABSTRACT

Angular chelitis is inflammation typically seen at the both commissures (angles) of the lips. Angular chelitis is most often chronic, seen in the older, and due to infective and/or mechanical causes.
It is diagnosed clinically and treated with topical antifungals and antibacterial. The goals of this case
report and literature review is to describe angular cheilitis (soft-tissue disorders) in the oral cavity
that is commonly observed in diabetes and to discuss the clinical presentation, associated causative
factors and management strategies of angular chelitis.
Key Word: Angular Chelitis, fungal infections, Vit B complex deficiencies.
INTRODUCTION
Angular cheilitis is inflammation of one, or more
commonly both of the corners of the mouth. Initially, the corners of the mouth develope a gray-white
thickening and adjacent erythema (redness). Later,
the usual appearance is a roughly triangular area of
erythema, edema (swelling) and maceration at either
corner of the mouth. Typically the lesions give symptoms of soreness, pain, pruritus (itching) or burning or
a raw feeling in the later stage. Angular cheilitis often
represents an opportunistic infection of fungi and/or
bacteria, with multiple local and systemic predisposing
factors involved in the initiation and persistence of the
lesion. Such factors include nutritional deficiencies,
over closure of the mouth, dry mouth, a lip-licking
habit, drooling, and immunosuppression.5 Treatment
for angular cheilitis is based on the exact causes of the
condition in each case, but often an antifungal cream
is used among other measures.
CASE REPORTS
CASE 1
In July 2014, a 52 years old male attended Oral
Diagnosis and Medicine Department of Sir Syed Dental
Assistant Professor and Head Oral Diagnosis & Medicine Department, Sir Syed Dental Hospital, Karachi, Pakistan.
Correspondence: Dr. Mahreen Shahzad, DHA, Phase 7, Near
KPT Interchange, Korangi Road, Karachi. Residential address:
House No. 41, 1st Street Khayaban-e-Rahat, Phase-6, DHA,
Karachi. E-mail: mahreen_dimz@yahoo.com,
Contact: 35383241-35383978, ext- 820
2
Demonstrator, Oral Diagnosis & Medicine Department, Sir Syed
Dental Hospital
3
Demonstrator, Orthodontics Department, Sir Syed Dental Hospital
Received for Publication:
September 30, 2014
Revision Received:
October 30, 2014
Revision Accepted:
November 2, 2014
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Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)

Hospital. His chief complaint was pain in upper right

side of teeth, particularly in third molar since 25 days.
Pain was severe and intermittent in nature, radiated
towards head, aggravated on eating food and relieved
by analgesic. During intra oral examination upper
right third molar was found grossly carious. Working
diagnosis was reversible pulpitis and an OPG x-ray was
taken. He was advised to have extraction of this tooth
because it was grossly carious. During further facial
and oral examination angular cheilitis was detected
but the patient was not aware of it. He had a history
of diabetes mellitus type 2 and high blood pressure
since 15 years. The patient stated that he measured
his diabetes with glucose meter at house and random
blood sugar this morning was 250mg/dl. While taking
history related to angular cheilitis, he described this
condition is asymptomatic .On examination the lesions
was symmetrically present on both sides of the mouth.
The corners of the mouth developed a gray-white
thickening and adjacent erythema (redness), which
means that it was an initial stage (Fig 1). In the later
stage, erythema, edema (swelling) and maceration
at either corner of the mouth can give symptoms of
soreness, pain, pruritus (itching) or burning or a raw
feeling. Hence, patient was fully informed about the
condition that angular chelitis is a fungal infection
which is caused by his uncontrolled diabetes, poor oral
health and other oral complications. The chances of the
oral complications will be mini-mized if the disease is
well-controlled. Additionally, he was asked for regular
visit to the dentist (which is very important in diabetic
patients for timely prevention and management of oral
complications) and was prescribed miconazole gel 25mg/
ml QDS for 14 days. On second visit there was marked
improvement in his condition.

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Angular Cheilitis: Case Reports And Literature Review

CASE 2

Fig 1: A 52 years old male with angular chelitis

In September 2014, a 33 years old female attended
Oral Diagnosis and Medicine Department of Sir Syed
Dental Hospital. Her chief complaint was pain in upper
right side of teeth since 3 days. Pain was severe and
continuous in nature, non-radiating, aggravated on
eating food and was not relieved by taking medicine.
During intra oral examination her upper right second
pre molar had broken down root. Diagnosis of infected
BDR was made because periapical radiolucency was
noticeable on x-ray. Therefore, she was advised to get
the infected roots removed. During facial and oral examination unilateral angular cheilitis and geographic
tongue was also noticed (Fig 2) and patient had mild
discomfort at the angle of the mouth and the tongue.
Her conjunctivae were pale and nails were brittle.
Hence, advised for CBC (laboratory test) but she refused
because that was not her chief complaint. Accordingly,
we only prescribed her miconazole gel QDS for 2 weeks
for angular chelitis and benzydamine hydrochloride
mouth wash 12 % BD for the relief of geographic tongue
discomfort.
CASE 3

Fig 2: Angular chelitis on right side of angle of mouth

and geographic tongue

In July, a 25 years old female came in OPD of oral
diagnosis and medicine department of Sir Syed Dental
Hospital with the complaint of pain in lower left side
of teeth since 3 days. Pain was sharp continuous and
radiating in nature. It usually aggravated while lying
horizontally and was relieved on taking medicine. A
diagnosis of reversible pulpitis was made and she was
advised to have a confirmatory periapical radiograph.
After that she was referred to endodontics department
for RCT followed by crown. On extra and intra oral examination she was also diagnosed with angular cheiltis
unilaterally on right side of the angle of mouth (Fig
3).While taking further history she said that she had
filling of upper right first molar last week by some other
dentist, since then she have erythema and discomfort
on right side. Her medical history was unremarkable
and the diagnosis of angular chelitis was made due to
long treatment procedure of filling. She was prescribed
miconazole gel QDS for 2 weeks and on her next follow
up after a week time angular chelitis was completely
resolved.
DISCUSSION

Fig 3: Angular Chelitis on right side of the angle of

mouth
Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)

Angular chelitis is a relatively common condition,
accounting for between 0.7-3.8% of oral mucosal lesions
in adults and between 0.2-15.1% in children, though
overall it occurs most commonly in adults in the third
to sixth decades of life. It occurs worldwide, and both
males and females are affected. Angular cheilitis is
the most common presentation of fungal and bacterial infections of the lips.5 Angular cheilitis appears
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Angular Cheilitis: Case Reports And Literature Review

as redness or as fissures at the corners of the mouth

involving the junction of the mucosa and may also
represent a form of candidiasis.7 The lesions are more
commonly symmetrically present on both sides of the
mouth but sometimes only one side may be affected. In
some cases, the lesion may be confined to the mucosa of
the lips, and in other cases the lesion may extend past
the vermilion border (the edge where the lining on the
lips becomes the skin on the face) onto the facial skin.
Angular chelitis occur significantly more frequently in
diabetic than in non-diabetic patients.8 Other causes
of angular cheilitis that should be included in a differential diagnosis include vitamin deficiencies, anemia,
staphylococcal infections, and decrease in face height
caused by mouth over closure from loss of teeth.7 In
people with angular cheilitis who wear dentures, often
there may be erythematous mucosa underneath the
denture (normally the upper denture), an appearance
consistent with denture-related stomatitis. On the
basis of clinical finding, an erythematous fissure at the
angles of the mouth, a diagnosis of angular cheilitis is
determined.9 The skin lesions should also be swabbed.
Microbial cultures and a haematological workup (blood
picture, and assays of levels of serum iron/ferritin,
serum vitamin B12 and corrected red blood cell folate)
are indicated when systemic involvement is suspected.
Diagnosis is often supported by investigations, especially if there are associated lesions such as ulceration
and /or glossitis. The treatment of angular cheilitis
is highly dependent on the cause, so the underlying
disease should be treated. If Candida is implicated, an
antifungal ointment like ketoconazole should be prescribed, the use of miconazole nitrate 2% gel applied
topically four times a day for 2 weeks is very effective
treatment option.10 These substances should be applied
to the affected area. When Staphyloccocus aureus is

Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)

implicated, topical treatment with a combination of

mupirocin or fusidic acid and 1% hydrocortisone cream
(to counter inflammation) works effectively. This can
be applied to the angles of the mouth.
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