[Bacterial lip abscess in an immunocompetent patient]

Lip abscesses are a potentially serious condition rarely reported in the medical literature. This disease requires prompt diagnosis and treatment with hospitalization, intravenous antibiotics, and urgent surgical drainage. Clinical knowledge of this condition is essential to guide the differential diagnosis and correctly adapt the etiological treatment. The presence of necrotic and cavitated lesions requires ruling out immunosupression or methicillin-resistant agent. We report a necrotic and cavitated bacterial lip abscess caused by methicillin-sensitive Staphylococcus aureus in an immunocompetent male.

Angular cheilitis, part 1: local etiologies

Angular cheilitis (AC) is a common condition characterized by erythema, moist maceration, ulceration, and crusting at the corners of the mouth. This article focuses on the common local factors that act alone and in combination to produce AC. These factors are categorized as irritant, allergic, and infectious causes. Identifying the underlying etiology of AC is a critical step in developing an effective treatment plan for this condition.

The Oral HIV/AIDS Research Alliance: updated case definitions of oral disease endpoints

The Oral HIV/AIDS Research Alliance (OHARA) is part of the AIDS Clinical Trials Group (ACTG), the largest HIV clinical trials organization in the world. Its main objective is to investigate oral complications associated with HIV/AIDS as the epidemic is evolving, in particular, the effects of antiretrovirals on oral mucosal lesion development and associated fungal and viral pathogens. The OHARA infrastructure comprises: the Epidemiologic Research Unit (at the University of California San Francisco), the Medical Mycology Unit (at Case Western Reserve University) and the Virology/Specimen Banking Unit (at the University of North Carolina). The team includes dentists, physicians, virologists, mycologists, immunologists, epidemiologists and statisticians. Observational studies and clinical trials are being implemented at ACTG-affiliated sites in the US and resource-poor countries. Many studies have shared end-points, which include oral diseases known to be associated with HIV/AIDS measured by trained and calibrated ACTG study nurses. In preparation for future protocols, we have updated existing diagnostic criteria of the oral manifestations of HIV published in 1992 and 1993. The proposed case definitions are designed to be used in large-scale epidemiologic studies and clinical trials, in both US and resource-poor settings, where diagnoses may be made by non-dental healthcare providers. The objective of this article is to present updated case definitions for HIV-related oral diseases that will be used to measure standardized clinical end-points in OHARA studies, and that can be used by any investigator outside of OHARA/ACTG conducting clinical research that pertains to these end-points.

Managing complications of radiation therapy in head and neck cancer patients: Part VI. Management of opportunistic infections

Head and neck cancer is becoming a more recognizable pathology to the general population and dentists. The modes of treatment include surgery and/or radiation therapy. Where possible, pretreatment dental assessment shall be provided for these patients before they undergo radiation therapy. There are occasions, however, whereby head and neck cancer patients are not prepared optimally for radiation therapy. Because of this, they succumb to complicated oral adverse effects after radiation therapy. The last part of this series reviews the opportunistic infections that can occur to the perioral structure. Their management is briefly discussed.

Cheilitis as a variation of Candida-associated lesions

OBJECTIVE

Occasionally, the clinical diagnosis of Candida-associated lesion is difficult because of a variety of its clinical manifestations. There have been a few reports on Candida-associated lip lesion except angular cheilitis. In this paper, we investigate the relation of Candida in persistent lesions of the lip.

SUBJECTS AND METHODS

The present study includes consecutive nine patients with persistent erosive lip lesion. For each patient the age at presentation, gender, duration of the disease, other symptoms or signs, complete medical history and prior treatment or medications for the symptom were obtained. Then, mycological examination and the direct cytologic examination were performed.

RESULTS

The reported average duration of the disease was 7 months. Six of nine patients had received prior treatments with topical steroids at the other clinic, which failed to resolve their symptoms. Six of nine patients had a predisposing factor for candidiasis. In the culture examination, Candida albicans were isolated in seven patients (77.8%). Five of nine patients received the direct cytologic examination, and four of them revealed pseudohyphae of fungi. The anti-fungal treatment was miconazol gel 25 mg four times per day, and average duration of the treatment was 2 weeks. The outcome was as follows: complete remission in five, remarkable response in two and no response in two.

CONCLUSION

Our results suggested that one form of the varieties of Candida-associated lesions might be considered in the case of lip lesion with unknown origin that was persistent and ineffective to the topical steroids treatment.

Multiple suppurative cystic lesions of the lips and buccal mucosa: A case of suppurative stomatitis glandularis

Cheilitis glandularis (CG) is a rare inflammatory salivary gland disease that usually affects the lips. Although the etiology of CG is still unknown, it is believed to be a hereditary disease with an autosomal dominant pattern of inheritance. Three clinical presentations of CG are described in the literature: simple, superficial suppurative, and deep suppurative. A case of deep suppurative CG that extended to the buccal mucosa has been previously reported as suppurative stomatitis glandularis (SSG). Here we report a case of SSG in a 64-year-old white female with a history of bilateral renal transplants for adult polycystic kidney disease, who presented with painful swollen lips and bilateral buccal mucosal lesions. The diagnosis and management of the case is discussed. To the best of our knowledge, this is the second report of SSG, a rare condition affecting the minor salivary glands in the oral cavity.

Staphylococcus aureus in the oral cavity: a three-year retrospective analysis of clinical laboratory data

OBJECTIVE

A retrospective analysis of laboratory data to investigate the isolation of Staphylococcus aureus from the oral cavity and facial area in specimens submitted to a regional diagnostic oral microbiology laboratory.

METHODS

A hand search of laboratory records for a three-year period (1998-2000) was performed for specimens submitted to the regional diagnostic oral microbiology laboratory based at Glasgow Dental Hospital and School. Data were collected from forms where S. aureus was isolated. These data included demographics, referral source, specimen type, methicillin susceptibility and clinical details.

RESULTS

For the period 1998-2000, there were 5,005 specimens submitted to the laboratory. S. aureus was isolated from 1,017 specimens, of which 967 (95%) were sensitive to methicillin (MSSA) and 50 (5%) were resistant to methicillin (MRSA). The 1,017 specimens were provided from 615 patients. MRSA was isolated from 37 (6%) of patients. There was an increasing incidence of S. aureus with age, particularly in the >70 years age group. The most common specimen from which MSSA was isolated was an oral rinse (38%) whilst for MRSA isolates this was a tongue swab (28%). The clinical condition most commonly reported for MSSA isolates was angular cheilitis (22%). Erythema, swelling, pain or burning of the oral mucosa was the clinical condition most commonly reported for MRSA isolates (16%). Patients from whom the MSSA isolates were recovered were most commonly (55%) seen in the oral medicine clinic at the dental hospital, whilst patients with MRSA were more commonly seen in primary care settings such as nursing homes, hospices and general dental practice (51%).

CONCLUSION

In line with more recent surveys, this retrospective study suggests that S. aureus may be a more frequent isolate from the oral cavity than hitherto suspected. A small proportion of the S. aureus isolates were MRSA. There were insufficient data available to determine whether the S. aureus isolates were colonising or infecting the oral cavity. However, the role of S. aureus in several diseases of the oral mucosa merits further investigation.

Noma-like gangrenous cheilitis in a child with cyclic neutropenia associated with myeloperoxidase deficiency

An unusual case of cyclic neutropenia and hereditary myeloperoxidase deficiency complicated by noma-like gangrenous cheilitis is described. Klebsiella pneumoniae and Candida albicans were cultured from the involved area. We present this case to increase physician awareness of the possible association of both quantitative and qualitative defects of neutrophils and to stress the importance of the early and effective management of skin infections that can rapidly progress to severe sequelae when associated with profound neutropenia.

Down syndrome: lip lesions (angular stomatitis and fissures) and Candida albicans

BACKGROUND

The incidence of angular cheilitis (angular stomatitis, perleche, commissural fissures) appears to be increased in people with Down syndrome (DS). Lip fissures are also (in our clinical impression) a fairly regular feature, yet this is scarcely mentioned in the literature.

OBJECTIVES

To establish the incidence of angular cheilitis and lip fissures in a substantial group of patients with DS and to examine the relationship with Candida albicans.

PATIENTS AND METHODS

The prevalence of orofacial soft tissue lesions was investigated in a group of 77 DS patients. Swabs were taken from lip lesions, palate and tongue and inoculated on Sabouraud's agar discs for the isolation of C. albicans, identified with commercially available kits.

RESULTS

Lip fissures were seen in at least one-quarter of DS patients. Angular cheilitis was also found in a similar percentage.

CONCLUSIONS

C. albicans was isolated from a substantial proportion of lesions tested, and was present more frequently than in those without lip lesions, but it is uncertain whether this represents cause or effect.

Oral candidosis

Oral candidosis is the most common opportunistic fungal infection encountered in dentistry. Normally a benign inhabitant of mucous membranes, the fungal organism, Candida albicans, may present serious, even life-threatening infection in specific patient populations. As an opportunistic organism, Candida albicans is extremely responsive to any process resulting in immunosuppression. The clinical manifestations of oral candidosis are variable, occasionally complicating the clinical diagnosis and management. Treatment is often initially rendered based on a provisional clinical diagnosis and supplemented with adjunctive laboratory tests. Specific therapeutic intervention should be tailored to the individual patient, based on the current health status of the patient and the clinical presentation and severity of the infection.

Candidiasis: pathogenesis, clinical characteristics, and treatment

Candida organisms live on the skin and mucous membranes of up to 75 percent of the population. They can live commensally without causing harm or can change to an aggressive form and invade tissue, causing both acute and chronic disease in the host. Oropharyngeal candidiasis manifests clinically as acute pseudomembranous, acute atrophic, chronic atrophic, chronic hypertrophic/hyperplastic, and angular cheilitis. Systemic infection leading to candidemia can be devastating and cause up to a 60 percent mortality rate in medical or post-surgical intensive care wards. Oral nystatin, clotrimazole, and fluconazole usually provide appropriate therapy; although resistance to medications is increasing, particularly in immunocompromised hosts.

Antimycotic agents in oral candidosis: an overview: 1. Clinical variants

The advent of the human immunodeficiency virus and the increasing prevalence of immunocompromised individuals in the community have resulted in a resurgence of opportunistic infections, including oral candidoses. Despite the availability of a number of effective antimycotics for the management of oral candidoses, therapeutic failure is not uncommon. Further, the presence of many clinical variants of oral candidosis, both new and old, may confound the unwary clinician and complicate its management. These problems have been partly circumvented by the introduction of the triazole group of antimycotics, which initially appeared to be highly effective. However, an alarming increase in organisms resistant to triazoles has been reported recently. In this paper we provide an overview of clinical variants of oral candidosis. A second paper will discuss recent advances in the usage of antimycotics in the management of this condition.

Diseases of the lips

The vermilion of the lips was conceptualized by Jean Darier as the semi-mucosa. The anatomy of the lips is transitional from skin to mucous membrane. This article emphasizes inflammatory diseases of the lips known as cheilitis. Angular cheilitis is a reactive process with several possible causes, including infections, mechanical, nutritional deficiency, and various dermatoses. Contact cheilitis may be caused by a primary irritant or a delayed hypersensitivity allergic reaction to contactants. Plasma cell cheilitis is a reactive periorificial mucositis. Exfoliative cheilitis is also a reactive process, probably secondary to factitious activity of the patient. Cheilitis glandularis is a chronic inflammatory disorder of the labial salivary glands and their ducts. There are three forms: simple, superficial suppurative, and deep suppurative. A premalignant potential is present in cheilitis glandularis. Cheilitis granulomatosa is one manifestation of orofacial granulomatosis. The granulomatous conditions of Melkersson-Rosenthal syndrome, sarcoidosis, and Crohn's disease may be associated with cheilitis granulomatosa or it may stand alone as Miescher's cheilitis. Actinic cheilitis is another premalignant form of cheilitis that is amenable to a variety of therapeutic modalities.

Exfoliative cheilitis (EC) in AIDS: association with Candida infection

Forty-seven of 165 patients with AIDS (28.5%) showed exfoliative cheilitis (EC), predominantly of the lower lip (n = 37). Histologically, hyphae were revealed in 23 of 47 cases (49%). In 14 of 23 specimens the histological and microbiological findings were in accordance. Smears of the vermilion border revealed Candida albicans in half of the cases (51%); however, combinations with C. krusei, C. tropicalis and C. glabrata were also seen. Twenty of 35 patients given fluconazole either prophylactically or therapeutically showed clinical signs of oral candidiasis. Frequent moistening of the lips may result in infection of the vermilion border with Candida species; consequent desiccation of the lips will lead to scale formation and exfoliation. Smears of the vermilion border of the lower lip of 20 controls with AIDS were positive in four cases. Twenty HIV-negative controls without EC showed negative microbiological results for Candida species. Exfoliative cheilitis may be associated with Candida infection in some cases and may be considered another variant of candidiasis in AIDS patients.

[Malignant angular cheilitis]

A case of chronic angular cheilitis is reported. Candida albicans was isolated repeatedly and the process developed into epitheliomatous carcinoma. The etiopathogenic role of Candida albicans and possible mechanism of action are discussed.

In-vitro proteinase production by oral Candida albicans isolates from individuals with and without HIV infection and its attenuation by antimycotic agents

In-vitro proteinase production by oral Candida albicans isolates from patients with and without HIV infection (18 isolates from each group) was assessed by image analysis of a plate assay, with bovine serum albumin (BSA) as a substrate. The effect of sub-minimal inhibitory concentrations (sub-MICs) of nystatin, amphotericin B, clotrimazole and miconazole on in-vitro proteinase production by these yeast isolates was also investigated. Proteinase production by C. albicans isolates from patients with HIV infection was significantly greater than production by those from individuals without infection. All 18 isolates from HIV-infected individuals produced proteinase, in comparison to 56% of isolates from uninfected individuals. Pre-exposure of C. albicans isolates (seven proteinase producers from each group) to 1/4 and 1/16 MICs of nystatin, amphotericin B, clotrimazole and miconazole resulted in decreased proteinase production in all isolates tested. However, after exposure to the four antimycotic agents, proteinase production was decreased to a significantly greater extent in isolates from uninfected individuals than in those with HIV disease. Furthermore, when the relative concentration effect of antimycotic agents on proteinase production was compared, C. albicans isolates from the HIV-free group demonstrated a salient dose-response relationship compared with the HIV-infected group. These results indicate that C. albicans from patients with HIV infection are significantly more proteolytic than those from individuals without the infection, and that polyenes and imidazoles curtail the proteolytic activity of all C. albicans isolates, albeit to a lesser extent in those from HIV-infected patients. It appears that HIV disease favours oral colonisation by more proteolytic C. albicans isolates, with resilient proteolytic activity.

Clinical, microbiological and ultrastructural features of angular cheilitis lesions in Southern Chinese

OBJECTIVE

To obtain baseline data on angular cheilitis in Southern Chinese.

DESIGN

A cross-sectional investigation of the clinical, microbiological and ultrastructural features of the condition.

SUBJECTS AND METHOD

Thirty six Chinese adults with angular cheilitis; 28 controls matched for age and sex, with no inflammation. Clinical examination, swabs of lesions for microbiology, impressions of lesions for ultrastructure, using replica technique.

MAIN OUTCOME MEASURES

Severity of lesions, associated signs and symptoms, incidence and type of microorganisms, ultrastructural features.

RESULTS

Of a total 68 lesions 32 were bilateral and four unilateral. Forty four (65%) were mild (Type I) and the remaining 24 (35%) moderate (Type II). Infective agents were isolated from 37 (54%) lesions; pure growth of Candida spp and Staph. aureus was noted in nine lesions each; a mixed growth of the two in II, beta-haemolytic streptococci in three and a mixed flora including coliforms in the other five. Candida spp were present in one control, beta-haemolytic streptococci in two and coliforms in four others. Scanning electron microscopy revealed natural topography of the angular skin with sparse colonisation by bacteria and yeasts.

CONCLUSIONS

Angular cheilitis in Southern Chinese seems to be characterised by a milder clinical presentation and classic infective agents of the disease: Candida spp and Staph. aureus.

The prevalence of Staphylococcus aureus, Enterobacteriaceae species, and Candida species and their relation to oral mucosal lesions in a group of 79-year-olds in Göteborg

A subject sample comprising 100 persons (47 men and 53 women) 79 years of age and selected on a statistical basis (representing all persons of that age living in Göteborg) was the object of a general medical, clinical, and microbiologic study of the prevalence of microorganisms in the oral cavity known to cause opportunistic infections. A high prevalence of diseases and frequent medications were recorded among the participants. Staphylococcus aureus was present in five patients and Enterobacteriaceae species in only one individual. Candida albicans was not found in any samples from the palatal mucosa of the 25 individuals without dentures. Of 36 healthy denture wearers C. albicans was found in 9 (25%). In 39 persons with denture stomatitis C. albicans was obtained in 11 (28%) of the samples from the mucosa, 29 (74%) from the dentures, and 10 (26%) from the angulus oris. The prevalence of S. aureus, enteric rods, and C. albicans was low in the elderly population and, when present, correlated with the presence of dentures. No association with the patients' general health or drug use was obtained.

Angular cheilitis in a group of Sri Lankan adults: a clinical and microbiologic study

The relative importance of various factors in the pathogenesis of angular cheilitis in a population of Sri Lankan adults was studied. Forty-nine patients with cheilitis were examined clinically and microbiologically. Only 5 of 49 patients were full denture wearers. The clinical presentation of the lesions could be categorized as mild (Type I), moderate (Type II) or severe (Type III) and the duration of the lesions ranged from 1 month to more than 4 yr. Hematologic investigations revealed 18 patients with low hemoglobin 8 of whom had hypochromic, microcytic anaemia. Pathogenic organisms were isolated from 59% of the lesions; Candida spp. in 24 patients and Staph. aureus in 11 patients. A significant positive relationship between commissural leukoplakia and an infective etiology of angles was noted. This study confirms the multifactorial etiology of angular cheilitis while highlighting the varied clinical presentation of the lesions in an Asian population.

Oral candidosis in the elderly in long term hospital care

A total of 137 patients in long term hospital care were interviewed and examined to determine the prevalence, nature and most important causes of oral candidosis in the hospitalized elderly. Oral candidal infection as determined by the imprint culture technique was present in 47% of patients with a further 31% being carriers of Candida. The prevalence of chronic atrophic candidosis in denture wearers was 38%, while 26% of all patients had angular cheilitis, 67% of which had an infective etiology. Microbiologic examination strongly indicated the upper denture as the major source of infection in those with dentures despite the existence of a ward policy which should have encouraged good oral and denture hygiene.

Effect of cannabis use on oral candidal carriage

The effects of cigarette smoking on oral candidal carriage and candidosis have been well documented but few similar studies on cannabis smoking have appeared, therefore it was felt that such a study needed to be undertaken. In this investigation, the effect of cannabis smoking combined with methaqualone and tobacco on candidal prevalence, density and candidosis was examined in 55 users. Age and sex matched tobacco-smoking (n = 58) and non-smoking controls (n = 50) were examined similarly. The imprint culture technique was used for harvesting Candida. Results showed an increased prevalence and density of C. albicans in cannabis users while there was no apparent difference in the prevalence of candidiasis. However, two subjects presented with oral multifocal candidiasis.

Oral medicine in practice: angular cheilitis

In a series of twelve articles the authors aim to cover the more common oral medicine problems likely to be encountered in dental practice. Whenever possible, clinical photographs have been used to illustrate important points, and the text is deliberately succinct and without references. In the first article, the pathogenesis, investigation and management of angular cheilitis is reviewed.

Treatment of angular cheilitis. The significance of microbial analysis, antimicrobial treatment, and interfering factors

This prospective study evaluated the significance of microbial analysis and antimicrobial treatment for the cure of angular cheilitis. Furthermore, various etiologic factors were investigated for their relative effect on the healing process. The study included 1) an open trial with 50 patients infected by Candida albicans and/or Staphylococcus aureus, and 2) an intraindividual comparison of eight patients with bilateral lesions infected by Candida albicans as the only detected pathogen. After a base-line examination the patients received ointments containing nystatin and/or fusidic acid, on the basis of the outcome of an initial microbial analysis. The patients were evaluated clinically, photographed, and examined for microorganisms at different time intervals. Ninety-six per cent of the patients who participated in the open trial had no sign of infection after 42 days of treatment. Lesions in the double-blind study, treated with nystatin, were healed after 28 days, whereas lesions that received placebo persisted throughout the treatment period. Increasing age, dry skin, and extended skinfolds at the corner of the mouth were factors closely related to the length of the healing process.

Recurrence of angular cheilitis

The incidence of recurrence of angular cheilitis following a successful antimicrobial treatment was studied in 48 patients. Clinical assessments including a microbial examination were carried out 8 months and 5 yr after termination of treatment. Eighty percent of the patients reported recurrence of their angular cheilitis on one or more occasions during the observation period. Patients with cutaneous disorders associated with dry skin or intraoral leukoplakia had an increased incidence of recrudescence. Neither the presence of denture stomatitis nor the type of microorganisms isolated from the original lesions of angular cheilitis, i.e. Candida albicans and/or Staphylococcus aureus, were associated with the number of recurrences. The present observations indicate that treatment of the majority of patients with angular cheilitis should be considered in a longer perspective than previously supposed, due to the short lasting therapeutic effects of the antimicrobial therapy.

Angular cheilitis: a clinical and microbial study

The purpose of this prospective study was to re-examine the relative importance of various factors in the pathogenesis of angular cheilitis. Sixty-four patients with cheilitis were examined clinically and microbiologically. In addition, a subsample of 23 patients was examined for serum iron and transferrin. The clinical appearance of the lip lesions fell into 4 categories. A ground rhagad at the corner of the mouth involving adjacent skin, was the most frequent type among dentate patients, whereas among denture wearers a deep lesion following the labial marginal sulcus was frequently observed. Dentate patients and denture wearers with cheilitis often had atopic constitution or cutaneous diseases. Pathogenic microorganisms were cultured from the lesions in all 64 patients; Staphylococcus aureus in 40 patients and Candida albicans in 45. The results of this study indicate a correlation between angular cheilitis and pathogenic microorganisms. Furthermore, among dentate patients, a correlation exists between cutaneous discomfort and angular cheilitis. Other etiological factors suggested for this disorder were found to be of subordinate importance.

Antibiotic sensitivity and phage typing of Staphylococcus aureus isolated from non-hospitalized patients with angular cheilitis

Strains of Staphylococcus aureus were isolated from 360 patients with angular cheilitis. Of these 24 per cent were sensitive to penicillin G, 74 per cent to tetracycline, 93 per cent to fusidic acid and 96 per cent to erythromycin. Twenty per cent belonged to bacteriophage Group I, 9 per cent to Group II, 13 per cent to Group III, 39 percent miscellaneous and 19 per cent were untypable. A number of phage typing patterns which have been reported for strains associated with specific forms of staphylococcal disease were present in the 360 isolates. In investigations involving cross infection of Staph. aureus, both patients and staff should be examined for evidence of infection at the angles of the mouth.

Fibrinogenolytic and fibrinolytic activity in oral microorganisms

Samples were taken from blood accumulated in dental alveoli after surgical removal of mandibular third molars, from subgingival plaque of teeth with advanced periodontal destructions, from teeth with infected necrotic pulps, and from subjects suffering from angular cheilitis. Of the microorganisms subcultured from these samples, 116 strains were assayed for enzymes degrading fibrinogen and fibrin. Enzymes degrading fibrinogen were assayed with the thin-layer enzyme assay cultivation technique. This assay involves the cultivation of microorganisms on culture agars applied over fibrinogen-coated polystyrene surfaces. Enzymes degrading fibrin were assayed with both a plate assay and a tube assay, in which fibrin was mixed with a microbial culture medium. Microorganisms degrading fibrinogen or fibrin or both were isolated from all sampling sites. Activity was mainly detected in strains of Actinomyces, Bacteroides, Fusobacterium, Peptococcus, Propionibacterium, and Staphylococcus aureus. Most Fusobacterium strains degraded fibrinogen only. Enzymes degrading fibrinogen as well as enzymes degrading fibrin via activation of plasminogen were revealed in strains of Clostridium, S. aureus, and Streptococcus pyogenes. It was generally found that fibrinogen was degraded by more strains than was fibrin, which indicates that different proteases may be involved.

Nystatin and amphotericin B in the treatment of denture-related candidiasis

A double-blind trial of nystatin, amphotericin B, and a placebo was carried out in fifty-two cases of denture-related candidiasis and/or angular cheilitis. The drugs effected a significant clinical cure, but recurrence of the signs was common after withdrawal of the drugs. Concurrent bacteriologic examination showed few cures and continued presence of Candida albicans during the trial. A specimen from a red palate was examined histologically.