History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include age over 75 years, male gender, presence of dentures, immune deficiency, Down's syndrome, xerostomia, diabetes, and chronic inflammatory skin disease.
oral candidiasis
Suggests Candida albicans as the aetiology.[2]
Other diagnostic factors
common
pruritus
If severe, indicates allergic contact dermatitis.
painful red fissures
Appear at corner of mouth as either a single fissure, a single deeper and longer fissure following a skin fold, several fissures radiating from the corners of the mouth, or erythema of the skin adjacent to the corners of the mouth without fissures.
eczematous dermatitis of lower face
Suggests a staphylococcal infection as the aetiology.
May also be medicine reaction.
uncommon
specific medicines
Some medicines may induce xerostomia or angular cheilitis.
Sorafenib (multikinase inhibitor) has been reported to produce angular cheilitis.[6]
history of inflammatory bowel disease
GI symptoms may occur, such as diarrhoea, constipation, or bloody stool.
history of acid reflux
There may be a history of acid reflux.
history of total parenteral nutrition
May be associated with malnutrition.
history of eating disorders
With dental caries, an eating disorder is a possible aetiology.
alopecia
Fissures with alopecia, diarrhoea, and oral ulcerations suggest a zinc deficiency.[2]
diarrhoea/constipation
May occur secondary to inflammatory bowel disease or zinc deficiency.[2]
Fissures with alopecia, diarrhoea, and oral ulcerations suggest a zinc deficiency.
bloody stool
May occur secondary to inflammatory bowel disease.
aphthous ulcers
Indicates iron deficiency with or without anaemia.
Fissures with alopecia, diarrhoea, and oral ulcerations suggest a zinc deficiency.
pale, de-papillated atrophic tongue
Suggestive of iron deficiency.[2]
red, glossy, de-papillated tongue
Suggestive of folate or niacin deficiency.[2]
red atrophic tongue
Suggestive of vitamin B12 deficiency.[2]
reddish-purple de-papillated tongue
Suggestive of riboflavin deficiency.[2]
smooth, shiny red lips
Suggestive of riboflavin deficiency.[2]
dental caries
An eating disorder is a possible aetiology if dental caries are seen on examination.
palatal erosions
Abnormal mucosal changes such as palatal erosions may be seen on examination.
Risk factors
strong
age over 75 years
More common in older people.[5]
male sex
There is a 2-fold increase in men.[5]
dentures
The odds increase 3-fold in denture users.[5]
Poor denture hygiene may cause mucosal injury or infection via dentures.
immune deficiency
Frequently present in patients with HIV; 10% may have localised candidiasis.[8]
Immunosuppressive medicine (e.g., chemotherapy) also increases risk.
Down's syndrome
Seen in 25% of patients with trisomy 21.[15]
xerostomia
Either as isolated xerostomia or as part of Sjogren's syndrome.[11]
chronic inflammatory skin disease
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