| Abstract|| |
Aims: The aim of the present study was to examine clinical types and microbiological flora isolated from angular chelitis. Materials and Methods: An eroded and/or erythematous, with or without fissure formation, nonvesicular lesion radiating from the angle of the mouth was considered to be angular chelitis. A sample of the present study comprised of 40 patients having unilateral or bilateral angular chelitis and 20 healthy individuals without any lip lesions. Clinical examination was done. In both test and control groups, the sample for microbial analysis was obtained from angle of the mouth. Results: Clinically, four types of angular cheilitis lesions were found, Type I, II, III, and IV. The most common type of lesion found was Type I lesion. Microorganisms isolated from the lesion were Staphylococcus aureus, Candida or Streptococci in 33 (82.5%) cases either in pure culture or mixed culture. Among these 33 patients, S. aureus was found in 25 (75.5%) cases, Candida in 16 (48.4%) cases, and Streptococci in 5 (13.5%) cases, respectively. Out of 16 cases positive for Candida, in 13 cases further isolation of Candida was possible. Candida albicans was found in 6 cases and Candida stellastodia in 7 cases. In majority of the dentulous and edentulous patients, S. aureus showed profuse growth. Conclusions: There are microorganisms associated with angular cheilitis.
Keywords: Angular cheilitis, Candida, Candida albicans, Candida stellatodia, Staphylococcus aureus
|How to cite this article:|
Oza N, Doshi JJ. Angular cheilitis: A clinical and microbial study. Indian J Dent Res 2017;28:661-5
| Introduction|| |
Inflammation at the corner of the mouth is known by several names as angular chelitis, angular chelosis, angular stomatitis, commissural chelitis, and perleche. “Cheil” is a Greek word for lip and suffix “itis” indicates inflammation. Angular chelitis is a clinical diagnosis of the lesion affecting the angle of the mouth where both skin and mucosa may be affected and is characterized by maceration, erythema, and crust formation. Lemaistre , in 1886 gave name to this clinical picture as perléche, (pourlécher in Limousin dialect means to lick), it having been observed that persons having this disorder frequently moistened the affected areas with the tongue.
Etiological factors reported in relation to angular chelitis are infection, low vertical dimension and lack of lip support, old age, denture stomatitis, excessive carbohydrate consumption, deficiency of vitamins, iron deficiency, sensitivity to denture materials, prolonged use of antibiotics, etc., Lemaistre , and Finnerud , considered infection as direct etiological factor. Lemaistre , demonstrated what he termed as streptococcus plicatilis. Finnerud , observed its appearance in several members of the same family in mild epidemic form and its apparent infectious nature and tendency to heal in one place and break down in another. He isolated monilia chiefly. Microorganisms isolated from the angular cheilitis are Candida particularly, Candida albicans,,, Staphylococcus aureus + C. albicans,, and β-haemolytic streptococci along with these two organisms. In the present study, we tried to examine clinical types and microbiological flora isolated from angular chelitis.
| Materials and Methods|| |
An eroded and/or erythematous, with or without fissure formation, nonvesicular lesion radiating from the angle of the mouth was considered as angular chelitis. Patients were referred from the Department of Oral Diagnosis, of Government Dental College and Hospital, Ahmedabad, India. 40 patients having unilateral or bilateral angular chelitis and 20 healthy individuals without lip lesions matching the test group with regard to age, gender, and dental conditions were studied microbiologically as control group.
A detailed clinical examination of the lesion at the angle of the mouth was done in artificial light. Lesions were categorized into four types as described by Ohman et al.
- Type I: Small rhagades limited to the corner of the mouth, adjacent skin slightly involved
- Type II: Lesion with ragged border more extensive in length and depth than Type I lesion
- Type III: Lesion consisting of several rhagades radiating from the corner of the mouth into the adjacent skin
- Type IV: Lesion presenting no rhagades, but erythema of skin contagious to the vermilion border.
In both test and control groups, sample for microbial analysis was obtained from angle of the mouth. Sterile swabs were rubbed and rotated vigorously over these regions with as much pressure as possible to pick up deep-seated organisms. Bacteriological swabs were immediately inoculated in nutrient broth. After 30 min, material from nutrient broth was picked up through sterile swab. Saturated swab was streaked uniformly over the nutrient agar and Sabouraud media and incubated aerobically at 37°C. Within 1–3 days, easily identifiable colonies were observed.
Colonies appeared on the simple and Sabouraud agars were examined with naked eye. Their characteristics, according to size, shape, color, border, elevation, outline, translucency, and edges were noted. Smears were stained with gram stain and were examined under oil immersion lens in the light microscope. In test group, Gram-positive cocci in cluster and chain as well as Gram-positive budding yeast cells with sometimes hyphae formation were found. Further isolation of these organisms was carried out. Criteria for isolation and identification of Gram-positive cocci according to their morphology, staining characteristics and culture characteristics on nutrient agar and Gram-positive yeast on Sabouraud agar were followed as described by Cruickson. According to these criteria, the organisms were found S. aureus, Streptococci and Candida. The test for coagulase production was carried out for Staphylococcus. Hemolysis pattern of streptococci could not be carried out because of heavy contamination of Suptilis.
Candida species were determined according to methods advocated by Cruickshank  and Russell and Melville. Biochemical tests were carried out using agar media containing glucose, maltose, sucrose, and lactose. A germ tube formation test was carried out by method described by MacKenzie. They used serum for the test. Instead of serum, we used plasma separated from the discarded blood in the blood bank. Chlamydospore production was observed by inoculating isolated Candida on Cornmeal agar.
Semiquantitation of microorganisms
Semiquantitation of microorganisms was carried out according to criteria described by Turrell, i.e., <5 number of colonies– sparse growth, between 5 and 20 colonies– moderate growth and >20 colonies-profuse growth.
| Results|| |
Out of 40 patients, 24 (60%) were female and 16 (40%) were male. The youngest patient in the test group was of 5 years and the eldest 70 years [Table 1]. All patients having angular chelitis complained of pain or discomfort during opening of the mouth. Bilateral lesions were more frequently found, 31 (77.5%). Essentially four types of lesions were identified among 40 patients examined. Lesions of Type I were most frequent, 34 (85%). Among edentulous patients, no one was wearing complete denture; hence, no denture stomatitis was found. Leukoplakia at the commissure was observed in 4 cases. They all were heavy smokers. Drooling of the saliva was observed in seven patients [Table 1]. Six of them were children and one was mentally retarded. Majority of Type I and Type II lesions were of short duration.
|Table 1: Clinical findings related to different types and duration of angular cheilitis|
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Microbial results in patients with angular cheilitis
Out of 40 patients having angular chelitis, S. aureus, Candida or Streptococci were isolated in 33 (82.5%) cases. Among these 33 patients, S. aureus was found in 25 (75.5%) cases, Candida in 16 (48.4%) cases and Streptococci in 5 (13.5%) cases, respectively [Table 2]. In none of the lip samples obtained from 20 control patients, S. aureus, Candida or Streptococci were isolated. In the control cases, Sarcina, Gram-positive rods, S. aureus or discrete cocci were found. Three cases showed no growth of the organisms.
S. aureus showed profuse growth in majority of the positive cases. Co-relating type of angular chelitis and isolated micro-organisms, majority of Type I, II, and III lesions showed profuse growth of S. aureus. In majority of the dentulous and edentulous patients, S. aureus showed profuse growth [Table 3].
|Table 3: Type and semiquantitation of micro-organisms in relation with number of cases, relationship between clinical types of angular cheilitis and their dentate status|
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Out of 40 cases, Candida was isolated in 16 cases. In 13 cases, further isolation was done by germ tube formation in plasma, chlamydospore formation on cornmeal agar and sugar fermentation [Table 4].
| Discussion|| |
Angular cheilitis is a fissuring inflammation at the angle of the mouth. Angular cheilitis was seen slightly more frequently in women than men in our study; female patients were 24 (60.0%) and male patients 16 (40.0%) [Table 1]. These findings agree with those of Cawson, Ritchie and Fletcher  and Rose  showing female predilection 71.0%, 63.0%, and 62.0%, respectively. Female predominance was mentioned in studies by Mäkilä and MacFarlane and Helnarska  Although almost equal incidence of angular cheilitis among both the genders was observed by Ohman et al. i.e., 51.0%. The occurrence of angular chelitis was not observed more in male patients in any of the studies maybe because of greater hormonal variations such as menstruation, pregnancy, menopause, and anemia.
Angular cheilitis occurs in both young and adults. Patients studied by Fox and Ainsworth, Macfarlane and Helnarska  and Ohman et al. were from the second to eighth decade, whereas Lemaistre  and Finneurd  studied perleche in children. In our study, the age distribution of the patients reveals that lesions were seen from the first to seventh decade.
Clinical examination of 40 patients included in the present study revealed that angular chelitis appear in various forms. Variations seen in the clinical appearance of angular chelitis in our study agree with Cawson, Ritchie and Fletcher  and Ohman et al. Cawson examined group of 35 patients wearing complete dentures and identified two different types of lesions, those with and those without deep folds at the corner of the mouth. Ritchie and Fletcher  graded inflammation at the angle of the mouth as angular chelitis (inflammation occurring at the corner of the mouth) and angular cheilosis (severe inflammation, maceration, and fissuring of the external tissues of the mouth). The study completely agrees with Ohman et al., as all four types of lesions described by them were observed [Table 1]. In the present study, Type I lesions were common than Type II, III, and IV lesions. Whereas Ohman et al., observed Type II lesions more common than Type I, III, and IV lesions.
Microorganisms are often considered to be associated with angular chelitis. Macfarlane and Helnarsk  isolated S. aureus, Candida and/or β haemolytic streptococci from 68% of angular chelitis. In our study, out of 40 patients with angular chelitis, S. aureus, Candida and/or streptococci were isolated in 33 (82.5%) cases [Table 2].
Combining both pure and mixed form, total number of isolates of S. aureus were in 25 (75.7%), Candida in 16 (48.4%), and streptococci in 5 (13.5%) cases out of 33 cases [Table 2]. These findings agree with MacFarlane and Helnarska. They isolated S. aureus in 75%, Candida in 44%, and Streptococci in 15% of cases. In both these studies, the number of isolates of S. aureus are almost double than those of Candida. This finding does not support the common belief that Candida and angular chelitis are closely associated. MacFarlane et al. explained this on the basis that previous workers had used Sabouraud medium alone to culture organisms. This culture medium selectively encourages the growth of yeasts and farley supports the growth of S. aureus and β haemolytic Streptococci. Hence, it is not surprising that Candida species have become recognised as the common infective cause of angular chelitis and that other potential pathogens have been missed. Dahlen's  study observed the isolates of S. aureus more in dentate patients and of Candida in edentulous patients with denture stomatitis.
The aim for semiquantitation was to see the relative severity of the infection, to estimate the relationship between the various microorganisms in the sample and to determine whether or not the flora could be considered normal in the septicate case and location. In our study, S. aureus showed profuse growth predominantly which agrees with the findings of Dahlen et al. and Ohman et al. Candida showed sparse, moderate and profuse growth in almost equal number of cases where in Ohman et al.'s  study the occurrence of C. albicans was often sparse. They said that as usually heavy growth of S. aureus and a sparse growth of C. albicans was obtained in their study, it seems that yeasts would be less significant than S. aureus. On the other hand, when antifungal measures were taken against angular chelitis, lesions healed rapidly as quoted by Cawson  and Shuttleworth and Gibbs. This could imply that Candida species do not have to be present in large numbers to sustain a clinical lesion.
In correlating the type of angular chelitis and isolated micro-organisms, in ours and Ohman et al.'s  study, Type I, II, and III lesions showed sparse to profuse growth of S. aureus, Candida and streptococci. Type IV lesions showed growth of Candida.
Out of 16 cases positive for Candida, in 13 cases further isolation of Candida was possible. C. albicans was found in 6 cases and Candida stellastodia in 7 cases. Germ tube was positive in all C. albicans species and was negative only in one C. stellastodia case. C. albicans showed negative chlamydospores in 2 cases and C. stellastodia showed positive chlamydospore formation in 4 cases. Martin et al. said that there are strains of C. albicans that are poor chlamydospore producers and there are strains of C. stellastodia that form germ tubes as well as chlamydospores.
In our study and Ohman et al.'s  study, none of the lip samples obtained in the control patients, Candida, S. aureus or streptococci were isolated. However, MacFarlane and Helnarska , out of 45 individuals in control group, observed S. aureus in 3 (7%) cases (all scanty growth), Candida in 10 (22%) (scanty to moderate growth) and Streptococci in none of the case. The fact that S. aureus and/or C. albicans were recovered in very few number of cases in MacFarlane and Helnarska's  study and were not recovered in ours' and Ohman's  study in the lip samples of healthy control patients further support the view that angular chelitis is an infectious disorder.
| Conclusions|| |
Angular cheilitis may appear in various forms; small rhagades limited to the corner of the mouth to extensive rhagades radiating from the corner of the mouth into the adjacent skin. It can also appear as erythema of the skin contiguous with vermilion border. It can appear as unilateral or bilateral lesions.
The fact that micro-organisms, particularly S. aureus, Candida and Streptococci could be found from the lesions does not necessarily imply that these organisms initiated the lesion by invading the tissues at the corner of the mouth. It could be that they were there because of conditions that favoured their multiplication. These conditions are called predisposing factors. The predisposing factor may be hypovitaminosis, iron deficiency, age-related because of sagging of tissue of corner of the mouth, reduced vertical dimension of occlusion, denture related, etc., However, the very fact that these micro-organisms were isolated from the lesions showed profuse growth in the majority of cases and were not isolated from lip samples of healthy individual suggest that their presence cannot be denied. They may be secondary invaders, aggravating the process. Thus, topical chemotherapy may not produce a permanent cure if the predisposing conditions are not cured or removed,,,,, but the application of antibacterial preparation on lesions with rhagades formation and antifungal preparation on lesions with only erythema without rhagades may control the infection and help in the healing of lesions.
The author is greatly thankful to Dr. Miss KF Billomoria for her constant guidance and support and Mr. Jayantilal Patel, senior technician in microbiology, for his technical guidance and helping me throughout my study. Without their support it was impossible to complete my work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Nirima Oza
Dispensary, Sri Aurobindo Ashram, Puducherry - 605 002
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]