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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 W Woorrdd CCoouunntt == 55664433 Contents A Abbssttrraacctt… …… …… …… …… …… …… …… …… …… …… …… …… …… …… …… …11 IInnttrroodduuccttiioonn… …… …… …… …… …… …… …… …… …… …… …… …… ….... 22 -- 66 M Maatteerriiaallss aanndd M Meetthhooddss… …… …… …… …… …… …… …… …… ….. 77 -- 1111 RReessuullttss… …… …… …… …… …… …… …… …… …… …… …… …… …… ….... 1122 -- 1199 D Diissccuussssiioonn… …… …… …… …… …… …… …… …… …… …… …… …… ….... 2200 --2255 A Acckknnoow wlleeddggeem meennttss… …… …… …… …… …… …… …… …… …… …… …...... 2266 A Appppeennddiixx 11:: E Exxaam miinnaattiioonn FFlloow w CChhaarrtt… …… …… …… …… … 2277 A Appppeennddiixx 22:: A Anngguullaarr CChheeiilliittiiss PPaattiieennttss LLiisstt… …… …… … 2288 A Appppeennddiixx 33:: M Miiccrroobbiioollooggyy RReeqquueesstt FFoorrm m… …… …… …… ….. 2299 RReeffeerreenncceess… …… …… …… …… …… …… …… …… …… …… …… …… ….. 3300 -- 3322 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. 1 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. 2 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. 3 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. 4 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, 5 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. 6 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. 7 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. 8 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 9 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 10 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. 11 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’ 12 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 13 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 14 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 16 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 17 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 19 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. 20 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 22 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. 25 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 26 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. 30 Orthodontic Treatment and Angular Cheilitis 2005 Elective Study Report Appendix 2 Angular Cheilitis Patients List No. Name Hosp. 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