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Orthodontic Treatment and Angular Cheilitis
A Twin Center Study Between
Singapore and Glasgow
Elective Study 2005
Glasgow Dental Hospital and School
Dr Tay and Partners Singapore
July 19 – August 28
0004392
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Contents
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Abstract
Angular cheilitis is a clinical disease that has no true definition, but manifests itself as
erythematous fissuring of one or both angles of the mouth. In this study, the
relationship between angular cheilitis and orthodontic treatment was investigated at
two different centers of study: Glasgow Dental Hospital and School, and Dr Tay and
Partners Dental Practice Singapore. Clinical examinations of consecutive patients
receiving orthodontic treatment were done at both centers, and the presence or
absence of angular cheilitis was noted. Angular cheilitis lesions were graded
according to their severity using a scale adapted from Öhman et al. (1986). At the
Singapore center of study, no patients were recorded as having clinical signs of
angular cheilitis. At the Glasgow Dental Hospital and School, 10 of 204 patients (5%)
displayed signs of angular cheilitis. From the 10 patients, microbiological samples
were obtained using swabs of the angles of the mouth, and of the nares. An oral rinse
of PBS solution was also obtained from each patient. The samples were plated for
presence of Candida albicans and Staphylococcus aurues.
Key words: Angular cheilitis, orthodontic treatment, microbiological samples.
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Introduction
Angular cheilitis is a clinical condition that may be described as an eroded and
erythematous non-vesicular lesion radiating from the angle of the mouth23, and may
be unilateral or bilateral in presentation. Although angular cheilitis has been
associated with various microbiological species, including Candida, streptococci and
staphylococci, it is most commonly classified in the dental literature as a
manifestation of oral candidiasis14, 18, 20. Oral candidiasis (or candidosis) is an
inflammatory reaction usually caused by overgrowth of the commensal yeast Candida
albicans, but other fungal organisms may be involved18. Angular cheilitis has also
been linked in the dental literature to the elderly7, immunocompromised individuals12,
25
, and atopic individuals43.
No studies have been reported in the dental literature regarding the incidence of
angular cheilitis in patients undergoing orthodontic treatment. The elective study was
undertaken to investigate this at two centers of study (Glasgow and Singapore), and to
also discuss factors that may be involved in the aetiology of angular cheilitis.
Dr. Tay and Partners is a private practice dental clinic in Singapore that has been
established for several decades. It is one of the largest practices in the country, with
in-house specialists of nearly all facets of dentistry. Clinical experience at the practice
involved shadowing 2 orthodontic specialists in the Orthodontic department for a
period of 2 weeks. During this period of time, the elective project was also carried out
at the department. After 2 weeks at the practice, the elective project was continued at
the Glasgow Dental Hospital and School, Scotland, for a period of 4 weeks.
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
At both these centers, patients undergoing orthodontic treatment were examined for
signs of angular cheilitis, and the lesions were graded according to severity.
Ortho-what?
Orthodontics is the ‘ branch of dentistry concerned with development of the dentition
and occlusion, and with the diagnosis, interception and treatment of occlusal
anomalies’26 (Mitchell, 2001). In both Scotland and Singapore, orthodontic treatment
may be privately or state funded, and its popularity and acceptance by the general
public is increasing. Treatment durations largely depend on the presenting problems
of the patient, but usually range from 6 to 18 months, with an extra 12 months
necessary for post-treatment retention. Currently, approximately 22,500 cases of
orthodontic treatment are being provided under the National Health Service (NHS) in
Scotland.
Wires and Things
Several appliances are available for orthodontic treatment of teeth and may be broadly
classified into the following:
Fixed appliances
Fixed appliance therapy involves the bonding of ceramic or stainless steel brackets
onto the labial or lingual surfaces of teeth in a predetermined position. This type of
appliance is chosen to bodily move teeth. There are various bracket systems available,
and are used according to the discretion of the orthodontist. The brackets possess slots
that allow for an archwire to link the brackets in each dental arch. The archwire is
held into position using plastic ligatures.
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Removable appliances
A removable appliance is able to tip a tooth around a center of rotation located within
the root of the tooth. It is an appliance that is constructed by embedding stainless steel
or cobalt-chromium wires into acrylic. The metal wires are used as active
components, for retention or in providing anchorage to the movement of teeth.
Functional appliances
Also known as myofunctional appliances, these appliances utilize forces generated by
the orofacial soft tissues in order to move teeth19. There are currently at least 6 types
of commonly used functional appliances, which include the Bionator and Clark Twin
Block appliances. Patient selection, as well as patient compliance towards treatment,
in the prescribing of functional appliances is critical in ensuring successful treatment.
Retainers
This group of appliances may be broadly classified into fixed or removable retainers.
Fixed retainers are often small sections of arch wire bonded onto the labial or lingual
surfaces of teeth. These ensure that teeth that have been moved orthodontically do not
relapse into their pre-treatment positions. Removal retainers are also used for the
retention of teeth post-treatment, but may be removed by the patient for cleaning. A
Hawley retainer is similar to an acrylic removable appliance, but does not possess
active components in its design. An Essix retainer is a vacuum-formed retainer that
covers the crown of teeth within the dental arch. It is similar to a mouth guard, but
constructed using very thin plastic material.
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Methods of Detection
The human oral cavity is home to more than 500 bacterial species, of which only 50%
are cultivable4. With the introduction of molecular techniques such as the polymerase
chain reaction (PCR), the identity of previously unknown microbes can now be
realized. However, such techniques have yet to fully replace the age-old process of
culturing samples taken from the oral cavity. In this study, microbiological samples
were cultivated in the Glasgow Dental Hospital and School microbiology laboratories.
2 pathogens were specifically cultivated for: Staphylococcus aureus and Candida
albicans.
S. aureus is a Gram-positive, coagulase-positive coccus. It is a major human pathogen
found on the surfaces of skin, and possesses several virulence factors that allow it to
cause disease in a susceptible host. Candida species comprise of small round yeasts,
of which C.albicans is the commonest. C.albicans is found in the normal flora of the
oropharynx, gut and vagina, but is not found on normal skin38. About 60% of the
population carry C.albicans as part the oral flora, without having evidence of
candidiasis30. Candidiasis is often seen as ‘a disease of the diseased’ as its prevalence
increases with immunocompromised individuals30. Oral candidiasis may manifest
itself in several forms, such as thrush, denture stomatitis and angular cheilitis, and its
degree of severity varies between individuals.
As S.aureus and C.albicans are microorganisms that have often been linked in the
scientific literature to angular cheilitis, these were the pathogens chosen for
identification in this study.
However, as mentioned previously, angular cheilitis is not always caused by
infectious aetiology. In the dental literature, angular cheilitis has been linked to
vitamin B12 deficiency, Folic acid deficiency and Fe2+ deficiency. In these situations,
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
provision of topical antifungals or antibacterials would not be the solution. Instead,
the underlying causes of angular cheilitis in these cases have to be investigated by use
of haematological tests. An association of angular cheilitis and nickel allergy has also
been reported43, and patients suspected of such atopy would be required to undergo
patch testing.
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Materials and Methods
Clinical Procedures
Selection of patients
Consecutive patients undergoing orthodontic treatment with the orthodontists at the
clinics were examined. For patients to qualify for the study, they had to be undergoing
treatment, and possess any of the orthodontic appliances described in the Introduction.
Patients were categorized into having either of the following appliances: fixed
appliances (‘Fixed’), removable appliances (‘URA’), functional appliances (‘Func.’)
or other appliances (‘Others’). ‘Others’ appliances include retainers, transpalatal arch
wires, and maxillary protraction appliances.
Patients and/or their accompanying parents were informed of the nature of the study,
as well as the need for clinical samples to be obtained should angular cheilitis be
detected on one or both corners of the mouth. Verbal informed consent was obtained
before clinical examinations were carried out on any orthodontic patient.
Ethical approval was not required for this study as each component of the study
reflected best clinical practice, and should ideally be carried out in all patients where
angular cheilitis is detected.
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Examination and Data Collection
A single examiner (ME) was responsible for examining all patients undergoing
orthodontic treatment for signs of angular cheilitis. The clinician responsible for the
patient’s orthodontic treatment was asked to confirm these findings.
At Dr. Tay and Partners dental clinic (Singapore), only visual examination of the
patient was carried out, without the need for microbiological sampling should the
patient present with angular cheilitis. The corners of patients’ mouths were examined
for erythematous fissuring, and the dental practitioner confirmed the observations.
At the Glasgow Dental Hospital and School, patients who exhibited clinical signs of
angular cheilitis were informed of the findings and the need for samples to be
obtained. A flow chart of the steps taken for the examination of patients for clinical
signs of angular cheilitis may be found in Appendix 1.
The angular cheilitis lesions, if present, were graded using a scale adapted from
Öhman et al.(1986)28:
Type 0
Healthy vermilion border
Type 0/1
Minor nicks or cuts in vermilion border at angle of mouth.
Type 1
Lesion limited to corner of mouth. Adjacent skin involved
slightly.
Type 2
Lesion with one rhagad, more extensive in length and depth
than Type 1 lesions.
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Orthodontic Treatment and Angular Cheilitis
Type 3
2005 Elective Study Report
Lesion consisting of several rhagads radiating from the corner
of mouth into adjacent skin.
Type 4
Lesion presenting no rhagads, but erythema of skin contiguous
to the vermilion border.
Patients who presented with unilateral or bilateral angular cheilitis lesions were
identified as ‘AC-positive’ (Angular Cheilitis- positive), and the grading type was
recorded. Patients who did not present with angular cheilitis were graded as ‘0’
accordingly, and were identified as AC- negative (Angular Cheilitis- negative).
At both centers, data regarding patients’ sex, oral hygiene status, and appliance types
were recorded (Appendix 2). Any relevant medical or dental history was also
recorded. Oral hygiene of each patient was graded as poor, fair and good. Both the
dentist and ME determined the status of oral hygiene for each patient.
All examinations and microbiological sampling was carried out before the dentist
began treating their patients to prevent any contamination of the angles of the mouth
prior to microbiological sampling.
Acquisition of Clinical Samples
Clinical procedures were adapted from those described by Lamey et al (1989)21. On
the event that an angular cheilits lesion was detected on one or both corners of the
mouth, it was explained to the patient and/or accompanying parent that samples were
required for the identification of bacterial or fungal sources of infection. The patient
and/or accompanying parent was also informed of the need to return to the Glasgow
Dental Hospital and School for a review appointment 2 weeks later to obtain the
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
results of the microbiological tests. Verbal informed consent was obtained before
samples were taken.
Sterile swabs (Medical Wire & Equipment Co. (Bath) Ltd.) were moistened with
sterile phosphate-buffered solution (PBS). Separate swabs were taken of the following
sites by the observer:
•
Swab of left corner of mouth
•
Swab of right corner of mouth
•
Swab of left anterior nares
•
Swab of right anterior nares
In addition to the swabs, an oral rinse sample is obtained from the patient. 9ml of
phosphate-buffered solution (pH 7.4) was held in the mouth for 60 seconds, and then
expectorated back into the PBS bottle.
Oral microbiology laboratory request forms (Appendix 3) were filled out and signed
by the examining dentist. The samples were then cultured in the microbiology
laboratory at the Glasgow Dental Hospital and School.
Cultural Analysis
Clinical swabs and oral rinses were cultured for the presence of 2 known
microbiological causes of angular cheilitis: Candida albicans and Staphylococcus
aureus. Both microorganisms may be present in the oral cavities of healthy
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
individuals, without any clinical signs of disease. Sabouraud’s agar was used for the
detection of C.albicans. Columbia blood agar (supplemented with 5 or 7.5% horse
blood) was used for the detection of S.aureus. The plates were incubated overnight at
37°C, and the amount of microbial growth classified into light, moderate or heavy
growth. A microbiologist at the Glasgow Dental Hospital and School confirmed the
results of the microbial sampling.
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Results
Gender distribution:
Table I shows the gender distribution of orthodontic patients seen at Glasgow Dental
Hospital and School, and Dr Tay and Partners Singapore respectively. The results
demonstrate that there are more female than male patients currently undergoing
orthodontic treatment at both centers.
Table I: Gender distribution of orthodontic patients at Glasgow and Singapore centers.
Gender distribution of orthodontic patients
(Glasgow and Singapore)
160
140
120
Number of 100
80
patients
60
40
20
0
144
60
Males
(Glasgow)
60
32
Males
(Singapore)
Females
(Glasgow)
Females
(Singapore)
Gender of patient
Appliance type distribution:
Tables II and III demonstrate the distribution of appliance types of orthodontic
patients at the Glasgow and Singapore centers respectively. At both centers, more
than 50% of orthodontic patients were undergoing fixed appliance therapy. At the
Glasgow center, 17 of 204 appliances (12%) were removable appliances (URA). At
the Singapore center, 13 of 93 appliances (14%) were removable appliances (URA).
At the Glasgow and Singapore centers respectively, appliances classified as ‘Others’
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
amounted to 48 of 204 appliances (30%) and 17 of 93 appliances (19%). Of the
‘Others’ appliances, retainers were the most common for both centers. The number of
patients undergoing functional appliance therapy (Func.) was the least at both centers
of the elective study: 8 of 204 appliances (5%) and 8 of 93 appliances (9%) were
functional appliances at the Glasgow and Singapore centers respectively.
Table II. Distribution of appliance types in orthodontic patients at
Glasgow Dental Hospital and School
Appliance Types (Glasgow)
30%
Fixed
URA
53%
5%
Func.
Others
12%
Table III. Distribution of appliance types in orthodontic patients at
Dr Tay and Partners Singapore
Appliance Types (Singapore)
19%
Fixed
9%
URA
Func.
58%
14%
Others
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Oral hygiene status distribution:
(Tables IV and V) Majority of patients at both the Glasgow and Singapore centers had
good oral hygiene (56% and 83% respectively). 83 of 204 patients (41%) receiving
orthodontic treatment at the Glasgow center, and 13 of 92 patients (14%) at the
Singapore Center had fair oral hygiene. The least numbers of patients presented with
poor oral hygiene in either the Glasgow or Singapore centers of study: 6 of 204
patients (3%) at the Glasgow center, and 3 of 92 patients (3%) at the Singapore center
of study.
Table IV: Distribution of oral hygiene status of orthodontic patients at
Glasgow Dental Hospital and School
Oral Hygiene Status (Glasgow)
115
120
100
Number of
patients
83
80
60
40
20
0
6
Poor
Fair
Good
Oral Hygiene Status
Table V: Distribution of oral hygiene status of orthodontic patients at
Dr Tay and Partners Singapore
Oral Hygiene Status (Singapore)
80
70
60
50
Number of
40
Patients
30
20
10
0
76
13
3
Poor
Fair
Good
Oral Hygiene Status
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
AC-positive versus AC-negative patients:
At Glasgow Dental Hospital and School, 11 of 204 patients (5%) were identified as
ACC-positive (Angular Cheilitis- positive). The remaining 193 patients were ACnegative (Angular Cheilitis- negative). At Dr Tay and Partners Singapore, all 92
patients examined were identified as AC-negative (Table VI). In comparison, patients
at the Glasgow Dental Hospital and School were more likely to develop angular
cheilitis than patients at Dr Tay and Partners Singapore.
Table VI. Number of patients with and without angular cheilitis
at the Glasgow and Singapore centers of study.
ACC-positive versus ACC-negative patients
(Glasgow and Singapore)
AC Status
AC-negative
(Glasgow)
193
AC-positive
(Glasgow)
11
AC-negative
(Singapore)
92
AC-positive 0
(Singapore)
0
50
100
150
200
Number of patients
AC-positive patients (Glasgow):
Ten patients (9 female; 1 male) at Glasgow Dental Hospital and School were found to
demonstrate clinical signs of angular cheilitis. The AC-positive patients were aged
between 13 and 33 years (mean age 17.5 years). Information regarding relevant
medical history, oral hygiene status, and appliance type are presented for each patient
in Table VII. The AC grading for each patient is also recorded. From Table VII, it can
15
Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
be seen that 5 of the 10 AC-positive patients presented with bilateral lesions of
angular cheilitis. The remaining 5 patients were found to have unilateral angular
cheilitis lesions. All patients received angular cheilitis gradings of 0, 0/1, or 1, with
grade 1 being the most severe.
No patients were found to demonstrate gradings 2 or 3.
The distribution of the various gradings of angular cheilitis lesions identified in the
AC-positive patients can be seen from Table VIII:
Table VIII: Distribution of gradings of AC lesions in patients
at Glasgow Dental Hospital and School.
Number of AC lesions
Grading of Angular Cheilitis lesions in AC-positive
patients (Glasgow)
9
10
8
6
6
5
4
2
0
0
0
0
Grading of Angular Cheilitis
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Table VII: AC-positive patients at Glasgow Dental Hospital and School.
Unit Number
Gender
Age
Medical History
Oral Hygiene
Appliance Type
(Years)
534468
F
567936
F
16
13
Clear
Clear
Uses inhalers during
sports; tonsils removed
AC Grading
R /
L
0
Fair
Fixed (U&L)
1 /
Fair
Fixed (U&L)
1 / 1
Good
Fixed (U&L)
0
/
1
0
595595
F
13
573089
F
33
Clear
Good
Fixed (U&L)
1 /
418449
F
16
Asthmatic
Good
Essix retainers
0/1 / 0/1
518058
F
15
Clear
Fair
Fixed (U&L)
1
578304
F
20
Good
Fixed (U&L)
0/1 / 0
482312
M
18
Fair
Fixed (U&L)
0/1 / 1
514255
F
14
Asthma; uses Ventolin inhaler;
allergic to penicillin antibiotics.
Fair
Fixed (U&L)
0/1 / 1
398517
F
17
Asthma; uses inhaler; allergic
to nuts.
Fair
Fixed (U)
1
On fluoxetine medication;
‘allergy’ to cheese.
Clear
/ 0
/ 1
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Microbiological results from AC-positive patients (Glasgow):
The microbiological samples of the 10 AC-positive patients were compared with
respect to the type of microorganism (C.albicans vs. S.aureus) and the clinical site
(angles of mouth, nares and oral cavity/saliva) (Table IX).
Table IX: Microbiological results of AC-positive patients at Glasgow center.
Unit
Number
Microbiology
Oral Rinse
Nares
Angle
R
L
R
L
534468
C.albicans
S.aureus
0
0
0
0
0
0
0
0
1
0
567936
C.albicans
S. aureus
1
0
1
0
0
0
0
0
2
0
595595
C.albicans
S.aureus
0
0
0
0
0
3
0
3
1
0
573089
C.albicans
S.aureus
1
0
1
0
0
0
0
0
2
0
418449
C.albicans
S.aureus
0
3
0
3
0
3
0
3
1
1
581508
C.albicans
S.aureus
1
0
1
0
0
0
0
0
2
0
578304
C.albicans
S.aureus
0
0
1
0
0
2
0
2
3
0
482312
C.albicans
S.aureus
1
0
1
0
0
0
0
0
1
0
514255
C.albicans
S.aureus
0
0
0
0
0
0
0
0
2
0
398517
C.albicans
S.aureus
0
0
1
3
0
0
0
0
2
0
Where 1 = Light growth of microorganism
2 = Medium growth of microorganism, and
3 = Heavy growth of microorganisms
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Overall, C.albicans was most commonly detected at the angles of the mouth and in
the oral rinses. 10 of 40 (25%) clinical swab samples demonstrated that C.albicans
was present at the angles of the mouth, and 10 of 10 (100%) oral rinse samples
demonstrated the presence of C.albicans in the oral cavity. When present, either light
or moderate growth was detected. S.aureus was detected in the nares of 3 patients
(33%), and at the angles of the mouths of 2 patients (20%). It was also detected as a
light growth of microorganisms in one oral rinse sample. However, unlike C.albicans,
its presence appears to be related with moderate or heavy growth of the
microorganism.
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Orthodontic Treatment and Angular Cheilitis
Elective Study 2005
Discussion
Although no studies have been done to-date regarding the incidence of angular
cheilitis in patients undergoing orthodontic treatment, there has been a substantial
amount published in the scientific literature regarding the condition, angular cheilitis.
Angular cheilitis, also known as angular stomatitis or angular cheilosis, is a clinical
condition that has no true definition21, but can be described as erythematous fissuring
at one or both corners of the mouth. It is a multifactorial disease37, most commonly
associated with microbiological species such as candida5, streptococci and
staphylococci. Angular cheilitis has also been observed in the elderly,
immunocompromised individuals, and atopic individuals. Other etiological reasons
include mechanical trauma to the angles of the mouth, caused by denture wearing,
tonsillectomy11, and mustache grooming13. Although not usually seen as a lifethreatening condition (there is only one reported case of malignant angular cheilitis35),
angular cheilitis in a patient should alert the dental practitioner to the underlying cause
of such lesions, and prompt further investigation27.
Oral Hygiene – Keeping things clean
Orthodontic therapy, whatever the choice of appliance, requires the introduction of
foreign objects and materials into the oral cavity. Even before orthodontic treatment
commences, the patient’s oral hygiene has to ideally be of a good standard. The
microflora of the mouth is highly diverse, and its composition, metabolic activity and
pathogenicity are affected by several factors, intrinsic and extrinsic32. It has been
shown in the dental literature that orthodontic appliances do have effects on the oral
microbiota1, 8, 15, 16, 29, 31, 33, 36, 39, 40, although the authors may not be in agreement
Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
regarding the exact ways in which the appliances do so. Atack et al (1996)3 reported
in their study that fixed orthodontic appliances inhibit oral hygiene to a great extent,
and also create new surfaces for plaque and debris to accumulate. This in turn
predisposes to a greater risk of infection and carriage of oral microbes.
Before the elective study was done, it was thought that should patients have angular
cheilitis, their oral hygiene status would be poor or fair. However, the results from the
study demonstrated otherwise. At the Singapore center, 16 of 92 patients (17%) had
poor/fair oral hygiene, but there were zero cases of angular cheilitis. At the Glasgow
center, a greater percentage (44%) of patients had poor/fair oral hygiene, but of these,
only 6 patients had signs of angular cheilitis. 5 of 115 patients at the Glasgow center
of study demonstrated signs of angular cheilitis even though they had good oral
hygiene. These results suggest that oral hygiene alone cannot be seen as a defining
factor for the onset of angular cheilitis.
A City of Microbes41
The investigation deeper into the formation of biofilm by microorganisms began early
in the twentieth century with the work of researchers such as Zobell44, Henrici17 and
Lloyd22 whose studies focused on aquatic bacterial populations. Since that time, there
has been an abundance of research carried out on the formation of biofilm, as well as
the impact of biofilm on nature. As in the case of angular cheilitis, there is no true
definition for what biofilm is. However, all proposed definitions share three basic
ingredients: microbes, glycocalyx and surface10. Watnick P and Kolter R (2002)41
present one of the most intriguing descriptions of a biofilm in their review of biofilms.
In their paper, the biofilm is analogous to a bustling city: complex, highly differential
and multicultural. In nature, the biofilm is also almost invariably a multispecies
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
microbial community harbouring bacteria that have distinct roles to play within their
developed niches.
The quality of the biofilm formed at the angles of the mouth may have influence on
the development of angular cheilitis in a susceptible patient. In a study by Wikström
et al (1983)42, it was demonstrated that microorganisms isolated from patients with
angular cheilitis were responsible for the production of enzymes capable of degrading
fibrinogen as well as fibrin. In Wikström’s study, S. aureus was one of several
bacteria capable of concurrent fibrinogenolytic and fibrinolytic activity, and was
detected in 7 of 9 patients (78%) with angular cheilitis. S.aureus was found in the
microbiologcal samples of 3 AC-positive patients in our elective study.
During the course of the elective, patients found to demonstrate clinical signs of
angular cheilitis were asked to return to the Glasgow Dental Hospital for a review
appointment. The review appointment was scheduled for 2 to 3 weeks after the
clinical samples were obtained. This time period ensured that the samples could be
cultured and the results interpreted by a microbiologist before the patient was seen.
This allowed the clinician in charge of the review appointments to make a decision as
to whether any medication was necessary for the patient on an individual basis.
At the review appointments for the first 5 patients identified as AC-positive, it was
surprising to find that all 5 patients demonstrated signs and symptoms of healing of
the angular cheilitis lesions, without having been prescribed with anti-fungal or antibacterial medication.
This observation supports findings that angular cheilitis is a multifactorial disease,
and may have a non-infectious etiology. It also highlights the importance of biofilm
on the development of angular cheilitis. In the future, other methods of sampling that
23
Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
allow for better collection of biofilm should be employed to study its microbiological
makeup. This study was designed to identify only 2 microorganisms: Candida
albicans and Staphylococcuse aureus. However, if biofilm formation is to be
investigated as a factor in the development of angular cheilitis, a greater variety of
microbial agents will have to be identified.
A Question of Materials?
Acrylic denture wearers are often at an increased risk of candida carriage due to the
large surface area of the denture. Biofilm with candida albicans forms on the fitting
surface of the denture, and causes the palate of the patient to become erythematous.
This is known as denture stomatitis, and is easily treated by improving the patient’s
oral hygiene and denture care. Removable and functional appliances are also
constructed using acrylic. One hypothesis before the elective study was carried out
was that acrylic appliances would increase the risk of AC. However, the results
showed that 9 of 10 AC-positive patients (90%) were undergoing fixed appliance
therapy.
Anhoury et al. (2002)2 carried out a study to compare the microbial profile between
metallic and ceramic bracket materials. The aim of the study was to clarify which of
the 2 bracket materials possessed a higher plaque retaining capacity, and to determine
the levels of caries-inducing bacteria (Streptococcus mutans and Lactobacillus spp.)
of the 2 types of brackets. It was found that although the quantity of plaque did not
differ between the 2 materials, the quality of the plaque did. The mean counts of
caries-inducing species did not differ between the metallic and ceramic brackets.
Instead, there were a greater number of periodontal species found on the metallic
24
Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
brackets as compared to the ceramic brackets. This may suggest a role of periodontal
pathogens, or pathogens other than C.albicans, S.mutans and S.aureus, in the etiology
of angular cheilitis. Periodontal pathogens such as Treponema denticola and
Porphyromonas gingivalis are proteolytic Gram-negative bacteria. Both appear to play
significant roles in periodontal disease7, 34. The release of proteolytic enzymes by
pathogens such as these may not be strictly limited to periodontal pockets, and
perhaps identification of periodontal pathogens should be an area of investigation
regarding angular cheilitis.
A Battle of the Races
In the study done by Dias and Samaranayake (1995)9 investigating angular cheilitis in
Southern Chinese patients in Hong Kong, it was found that the 68 angular cheilitis
lesions identified on 36 Chinese Adults fell onto the ‘Mild’ and ‘Moderate’
categories, with 65% of the lesions being of the former category. It was therefore
suggested in this study that angular cheilitis presents milder clinically in patients of
Chinese origin. Of the 92 patients seen at Dr Tay and Partners Singapore, the majority
of patients were of Asian origin. The number of patients found with angular cheilitis
at that center was zero. The findings from the elective study, although limited, appear
to support the results from the study carried out by Dias and Samaranayake.
To date, no studies have been done to investigate the occurrence of angular cheilitis in
patients undergoing orthodontic treatment. One aim of the elective study was to
compare the occurrence of angular cheilitis in orthodontic patients of 2 different
centers: Singapore and Glasgow. It was observed in the studied sample populations
that patients in Glasgow are infinitely more likely to develop angular cheilitis than
those in Singapore.
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
In Conclusion…
Despite the amount of dental literature concerned with the etiology of angular
cheilitis, one question still remains unanswered -- which occurred first: the fissuring
of the mucosa followed by colonization of the underlying exposed tissues, or the
colonization of these areas by microorganisms leading to fissuring at the corners of
the mouth? The limited conclusions from this study do suggest that further
investigations should be carried out on patients undergoing orthodontic treatment to
obtain a better understanding of why and how some patients are susceptible to the
development of angular cheilitis.
The initial hypothesis of the elective study was that angular cheilitis would be
increased in patients with poor oral hygiene, and in patients wearing removable
appliances. However, it was found in this elective study that this was not the case.
Five of 10 patients (50%) found with signs of angular cheilitis had good oral hygiene,
whereas there were no signs of angular cheilitis found in any of the 16 patients with
poor or fair oral hygiene at the Singapore center of study. In the 10 patients with
angular cheilitis, nine patients (90%) wear receiving fixed appliance therapy, with 1
patient using vacuum-formed (essix) retainers. These results suggest that the quality
of microorganisms found attached as biofilm to either the orthodontic appliance or
oral tissues of the patients has a more important role to play in the etiology of angular
cheilitis than factors such as appliance type and oral hygiene status.
From this elective study, it was found that 5% of orthodontic patients seen at Glasgow
Dental School and Hospital demonstrated clinical signs of angular cheilitis. In
Scotland, there are currently approximately 22,500 patients receiving orthodontic
treatment under the National Health Service. 5% of this number would mean that
1100 patients undergoing orthodontic treatment are suffering from angular cheilitis at
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
any one time. This number has to alert orthodontists and dental practitioners to the
prevalence of angular cheilitis in the population, and to encourage them to take
appropriate measures to help their patients. As a result of the elective study, a
suggested treatment regime has been formulated:
1. Clinical debridement or sampling
•
A clinical sample obtained for microbiological screening allows for
identification of the organisms present, and to detect antibiotic sensitivities
of any organism present.
•
Angular cheilitis lesions showed signs of healing in some patients upon
their return to the review appointment. This finding suggests that adequate
removal of biofilm at the angles of the mouth is helpful in encouraging
healing of angular cheilitis lesions.
2. Prescribing miconazole
•
Candida albicans was the most commonly detected microorganism in the
elective study. Although its role may be one of a secondary colonizer of
angular cheilitis lesions, the presence of Candida albicans on angular
cheilitis lesions may aggravate the existing condition, preventing healing.
•
Miconazole has anti-fungal and anti-bacterial properties, which makes it
the best choice for patients with angular cheilitis lesions that fail to heal
upon their return to the review appointment.
3. Haematology
•
Patients with angular cheilitis lesions that fail to heal after a course of
treatment with miconazole should be referred for haematological testing.
The role of haematinics such as vitamin B12 , iron and folate has been well
documented in the dental literature. Patients with haematinic deficiencies
27
Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
may demonstrate signs of angular cheilitis, and the orthodontist who sees a
patient on a regular basis may be the first healthcare professional to spot a
problem with the patient.
4. Patch testing
•
In patients with angular cheilitis that cannot be attributed to any of the
above causes, patch testing may be useful as it screens the patients’
response to a variety of allergens.
•
Patch testing would be the last in the series of tests taken for a patient with
angular cheilitis.
28
Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
owledgements
ckn
A
knnowledgements
Ack
I would like to thank the following:
Royal College of Physicians and Surgeons of Edinburgh
For their generous Elective Study Scholarship.
Glasgow Dental Hospital and School
Dr David Cross for his patience and guidance in helping me formulate the elective.
☺
The teaching staff of the Orthodontics Department for allowing totake up precious
time during their patients’ appointments!
☺
The nursing staff of the Orthodontic Department for enduring me for 4 weeks!
☺
The Microbiology Department, namely Margaret Jackson, Joyce Hope and
Maureen, for their time and assistance with clinical samples.
☺
Dr Andrew Smith for his time and assistance in providing the results of the
microbiological sampling.
☺
Patients who kindly consented to participating in the Elective Study.
Dr Tay and Partners Singapore
Dr Tay, for granting me permission to carry out my Elective Study at the practice.
☺
Dr Hwang Yee Cheau for being my overseas supervisor, and for teaching me more
about Orthodontics!
☺
All the Dental surgeons at the practive who made me feel welcomed.
☺
Patients who kindly consented to participating in the Elective Study.
29
Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Appendix 1
Examination of Orthodontic Patients for Signs of Angular Cheilitis
Orthodontic Patient
Fixed/ Functional/URA/
Other
↓
Does the patient have
No
Record patient’s details:
clinical signs of AC?
→
Number/ Gender/ Appliance
Type/ OH/ RMH/ RDH
↓
Yes
Record patient’s details:
Number/ Gender/ Appliance
Type/ OH/ RMH/ RDH/
AC Grade
↓
Take 2 x angles swabs, 2 x nares
swabs, and 60 seconds PBS
oral rinse.
↓
Schedule review appointment in
2 weeks with Dr. David Cross.
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Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
Appendix 2
Angular Cheilitis Patients List
No.
Name
Hosp. No.
R angle
L angle
OH
Appliance
RMH
31
Orthodontic Treatment and Angular Cheilitis
2005 Elective Study Report
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