Angular cheilitis (AC) is a common inflammatory disorder affecting one or both oral commissures. It is characterized by erythema, fissuring, crusting, and discomfort.
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✅ Introduction
Angular cheilitis, also known as perlèche or angular stomatitis, is a multifactorial lesion localized at the corners of the mouth. Although often considered a minor condition, it can significantly impair eating, speaking, and oral hygiene. Predisposing factors differ by age group but commonly include local irritation, infection, and immunologic or nutritional disturbances.
Dentists play a crucial role in identifying the underlying etiology and implementing effective treatment strategies.
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In Children
▪️ Frequent lip licking or thumb sucking
▪️ Excessive drooling
▪️ Malocclusion or open bite
▪️ Nutritional deficiencies (iron, folate, vitamin B12)
▪️ Atopic dermatitis
▪️ Immunosuppression
In Adults
▪️ Ill-fitting dentures
▪️ Reduced vertical dimension of occlusion
▪️ Xerostomia
▪️ Diabetes mellitus
▪️ Iron deficiency anemia
▪️ Vitamin B-complex deficiency
▪️ Smoking
▪️ Immunocompromised states, including HIV infection
Microbial Causes
▪️ Candida albicans
▪️ Staphylococcus aureus
▪️ Mixed bacterial-fungal infection
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Signs
▪️ Erythema at one or both oral commissures
▪️ Linear fissures or cracks
▪️ Crusting or ulceration
▪️ Maceration of adjacent skin
▪️ White pseudomembranes in candidal cases
Symptoms
▪️ Burning sensation
▪️ Pain during mouth opening
▪️ Itching
▪️ Tenderness
▪️ Difficulty eating spicy or acidic foods
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Diagnosis is usually clinical and based on history and examination. Recurrent or refractory cases may require:
▪️ Microbiological culture
▪️ Complete blood count
▪️ Serum ferritin
▪️ Vitamin B12 and folate levels
▪️ Blood glucose testing
✅ Differential Diagnosis
📊 Summary Table: Differential Diagnosis of Angular Cheilitis
| Condition | Key Clinical Features | Distinguishing Characteristics |
|---|---|---|
| Herpes Labialis | Grouped vesicles that ulcerate and crust | Usually preceded by tingling and affects the vermilion border |
| Atopic Dermatitis | Dry, erythematous, pruritic skin lesions | Associated with eczema on other body areas |
| Contact Dermatitis | Redness, scaling, and irritation | Linked to cosmetics, toothpaste, or allergens |
| Lichen Planus | White reticular lesions with erosive areas | Presence of Wickham striae in oral mucosa |
| Actinic Cheilitis | Chronic scaling and atrophy of the lip | Primarily affects the lower lip and is sun-related |
Topical Antifungal Therapy
▪️ Clotrimazole 1% cream
▪️ Miconazole 2% cream
▪️ Nystatin ointment
Topical Antibiotics
▪️ Mupirocin for confirmed or suspected bacterial infection
Barrier Protection
▪️ Petroleum jelly or zinc oxide ointment to reduce saliva irritation
Correction of Predisposing Factors
▪️ Adjust or replace ill-fitting dentures
▪️ Restore lost vertical dimension
▪️ Treat xerostomia
▪️ Improve oral hygiene
▪️ Address lip licking habits
Nutritional Supplementation
▪️ Iron
▪️ Vitamin B12
▪️ Folate
▪️ Riboflavin
Systemic Treatment
Systemic antifungals may be indicated in severe or recurrent candidal infections.
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Angular cheilitis is a multifactorial disease, and successful management requires treatment of both the lesion and its underlying cause. In children, habitual behaviors and drooling are predominant factors, whereas in adults, denture-related issues and systemic diseases are more common. Failure to investigate nutritional deficiencies or metabolic disorders often leads to recurrence.
Mixed infections involving Candida albicans and Staphylococcus aureus are particularly frequent, supporting the use of combination therapy when clinically indicated.
🎯 Clinical Recommendations
▪️ Evaluate for local and systemic contributing factors.
▪️ Assess denture fit and occlusal vertical dimension in adults.
▪️ Investigate iron and vitamin deficiencies in recurrent cases.
▪️ Encourage habit control in pediatric patients.
▪️ Use barrier ointments to protect the oral commissures.
▪️ Reassess lesions that persist beyond 2–3 weeks.
✍️ Conclusion
Angular cheilitis is a common but often recurrent condition affecting both children and adults. Effective treatment depends on identifying infectious, nutritional, mechanical, and systemic etiologies. With appropriate diagnosis and targeted therapy, most patients experience rapid symptom resolution and long-term prevention of recurrence.
📚 References
✔ Park, K. K., & Brodell, R. T. (2011). Angular cheilitis, part 1: Local etiologies. Cutis, 87(6), 289–295.
✔ Brodell, R. T., & Park, K. K. (2011). Angular cheilitis, part 2: Nutritional, systemic, and drug-related causes and treatment. Cutis, 88(1), 27–32.
✔ Gonsalves, W. C., Chi, A. C., & Neville, B. W. (2007). Common oral lesions: Part I. Superficial mucosal lesions. American Family Physician, 75(4), 501–507.
✔ Lalla, R. V., Patton, L. L., & Dongari-Bagtzoglou, A. (2013). Oral candidiasis: Pathogenesis, clinical presentation, diagnosis and treatment strategies. Journal of the California Dental Association, 41(4), 263–268.
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