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Copyright (c) 2025 Eshag Hassan Hamoud Alkallas, Suliman Ali Almojam, Yahya Mohammed Hassan Abiri, Reem Abdul Raheem Aljehani, Maryam Awad Nafi Al-Rashidi, Naifah Saleh Alrashidi, Saad Ghalib Alharbi, Abdullah Ali Abdu Hejry, Osama Mohammed Jaber Sulayyi, GHALLAH MEATG MAZEY AL RASHIDI, NOURAH MUSHABAB ALAHMARI, FAHAD ABDULLAH HUSSAIN QADIRI
This work is licensed under a Creative Commons Attribution 4.0 International License.
Angular Cheilitis: A Multidisciplinary Approach to Clinical Diagnosis, Nutritional Assessment, Laboratory Evaluation, and Pharmacological Management-An Updated Review
Corresponding Author(s) : Eshag Hassan Hamoud Alkallas
Saudi Journal of Medicine and Public Health, Vol. 2 No. 2 (2025)
Abstract
Background: Angular cheilitis is a common inflammatory disorder affecting the labial commissures and results from interacting infectious, mechanical, nutritional, inflammatory, and systemic factors. Persistent saliva-induced maceration compromises the epithelial barrier and facilitates colonization by organisms such as Candida albicans and Staphylococcus aureus. The condition is particularly relevant in older adults, denture users, individuals with nutritional deficiencies, immunocompromised patients, and those with systemic diseases.
Aim: This review aims to provide a comprehensive overview of the etiology, epidemiology, pathophysiology, clinical manifestations, diagnostic evaluation, and multidisciplinary management of angular cheilitis, with emphasis on nutritional, laboratory, dental, and pharmacological considerations.
Methods: A narrative review of relevant clinical and biomedical literature was undertaken to synthesize evidence concerning the causes, risk factors, epidemiological characteristics, pathophysiological mechanisms, clinical assessment, diagnostic investigations, and therapeutic approaches for angular cheilitis.
Results: Angular cheilitis commonly develops through persistent commissural maceration associated with saliva exposure, anatomical changes, denture use, xerostomia, mechanical irritation, and impaired epithelial integrity. Infectious involvement, particularly Candida and Staphylococcus, is frequent. Nutritional deficiencies involving iron, vitamin B12, folate, riboflavin, and zinc may contribute to persistent or recurrent disease. Systemic disorders, including diabetes, Sjögren syndrome, inflammatory bowel disease, and immunodeficiency, may increase susceptibility. Diagnosis is primarily clinical, with microbiological, nutritional, metabolic, immunological, patch-testing, or histopathological investigations selected according to presentation. Management includes barrier protection, antimicrobial therapy, correction of nutritional deficiencies, dental intervention, behavioral modification, and control of underlying systemic disease.
Conclusion: Effective management requires identification and correction of both local and systemic predisposing factors. A multidisciplinary approach can improve treatment response and reduce recurrence.
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- 1. Mahdani FY, Jati GD, Febrine ET, Cahyaningrum KW, Radithia D, Wicaksono S. Knowledge of Xerostomia and Angular Cheilitis in Geriatric Population among Clinical Dental Students: An Institutional Cross-Sectional Study. J Int Soc Prev Community Dent. 2023 Nov-Dec;13(6):443-449.
- 2. Scully C, van Bruggen W, Diz Dios P, Casal B, Porter S, Davison MF. Down syndrome: lip lesions (angular stomatitis and fissures) and Candida albicans. Br J Dermatol. 2002 Jul;147(1):37-40.
- 3. Blagec T, Glavina A, Špiljak B, Bešlić I, Bulat V, Lugović-Mihić L. Cheilitis: A cross-sectional study-multiple factors involved in the aetiology and clinical features. Oral Dis. 2023 Nov;29(8):3360-3371.
- 4. Cross D, Eide ML, Kotinas A. The clinical features of angular cheilitis occurring during orthodontic treatment: a multi-centre observational study. J Orthod. 2010 Jun;37(2):80-6.
- 5. Yesudian PD, Memon A. Nickel-induced angular cheilitis due to orthodontic braces. Contact Dermatitis. 2003 May;48(5):287-8.
- 6. Kounis NG, Mplani V, Ceasovschih A. A Multidirectional Interrelationship: Iron Deficiency Anemia Begets Angular Cheilitis and Atrial Fibrillation, Atrial Fibrillation Begets Heart Failure and Heart Failure Begets Atrial Fibrillation and Anemia. Balkan Med J. 2025 Mar 03;42(2):172-173.
- 7. Freitas J, Bliven P, Case R. Combined zinc and vitamin B6 deficiency in a patient with diffuse red rash and angular cheilitis 6 years after Roux-en-Y gastric bypass. BMJ Case Rep. 2019 Aug 02;12(8)
- 8. Rose JA. Folic-acid deficiency as a cause of angular cheilosis. Lancet. 1971 Aug 28;2(7722):453-4.
- 9. Serrano J, Lopez-Pintor RM, Gonzalez-Serrano J, Fernandez-Castro M, Casanas E, Hernandez G. Oral lesions in Sjogren's syndrome: A systematic review. Med Oral Patol Oral Cir Bucal. 2018 Jul 01;23(4):e391-e400.
- 10. MacFarlane TW, Helnarska SJ. The microbiology of angular cheilitis. Br Dent J. 1976 Jun 15;140(12):403-6.
- 11. Dorocka-Bobkowska B, Zozulinska-Ziolkiewicz D, Wierusz-Wysocka B, Hedzelek W, Szumala-Kakol A, Budtz-Jörgensen E. Candida-associated denture stomatitis in type 2 diabetes mellitus. Diabetes Res Clin Pract. 2010 Oct;90(1):81-6.
- 12. Kahana M, Yahalom R, Schewach-Millet M. Recurrent angular cheilitis caused by dental flossing. J Am Acad Dermatol. 1986 Jul;15(1):113-4.
- 13. Sonis AL. The prevalence of oral mucosal lesions in United States adults: data from the Third National Health and Nutrition Examination Survey, 1988-1994. J Evid Based Dent Pract. 2005 Sep;5(3):166-7.
- 14. Sharon V, Fazel N. Oral candidiasis and angular cheilitis. Dermatol Ther. 2010 May-Jun;23(3):230-42.
- 15. Peltola P, Vehkalahti MM, Wuolijoki-Saaristo K. Oral health and treatment needs of the long-term hospitalised elderly. Gerodontology. 2004 Jun;21(2):93-9.
- 16. Devani A, Barankin B. Dermacase. Angular cheilitis. Can Fam Physician. 2007 Jun;53(6):1011, 1022-3.
- 17. Ohman SC, Jontell M, Dahlen G. Recurrence of angular cheilitis. Scand J Dent Res. 1988 Aug;96(4):360-5.
References
1. Mahdani FY, Jati GD, Febrine ET, Cahyaningrum KW, Radithia D, Wicaksono S. Knowledge of Xerostomia and Angular Cheilitis in Geriatric Population among Clinical Dental Students: An Institutional Cross-Sectional Study. J Int Soc Prev Community Dent. 2023 Nov-Dec;13(6):443-449.
2. Scully C, van Bruggen W, Diz Dios P, Casal B, Porter S, Davison MF. Down syndrome: lip lesions (angular stomatitis and fissures) and Candida albicans. Br J Dermatol. 2002 Jul;147(1):37-40.
3. Blagec T, Glavina A, Špiljak B, Bešlić I, Bulat V, Lugović-Mihić L. Cheilitis: A cross-sectional study-multiple factors involved in the aetiology and clinical features. Oral Dis. 2023 Nov;29(8):3360-3371.
4. Cross D, Eide ML, Kotinas A. The clinical features of angular cheilitis occurring during orthodontic treatment: a multi-centre observational study. J Orthod. 2010 Jun;37(2):80-6.
5. Yesudian PD, Memon A. Nickel-induced angular cheilitis due to orthodontic braces. Contact Dermatitis. 2003 May;48(5):287-8.
6. Kounis NG, Mplani V, Ceasovschih A. A Multidirectional Interrelationship: Iron Deficiency Anemia Begets Angular Cheilitis and Atrial Fibrillation, Atrial Fibrillation Begets Heart Failure and Heart Failure Begets Atrial Fibrillation and Anemia. Balkan Med J. 2025 Mar 03;42(2):172-173.
7. Freitas J, Bliven P, Case R. Combined zinc and vitamin B6 deficiency in a patient with diffuse red rash and angular cheilitis 6 years after Roux-en-Y gastric bypass. BMJ Case Rep. 2019 Aug 02;12(8)
8. Rose JA. Folic-acid deficiency as a cause of angular cheilosis. Lancet. 1971 Aug 28;2(7722):453-4.
9. Serrano J, Lopez-Pintor RM, Gonzalez-Serrano J, Fernandez-Castro M, Casanas E, Hernandez G. Oral lesions in Sjogren's syndrome: A systematic review. Med Oral Patol Oral Cir Bucal. 2018 Jul 01;23(4):e391-e400.
10. MacFarlane TW, Helnarska SJ. The microbiology of angular cheilitis. Br Dent J. 1976 Jun 15;140(12):403-6.
11. Dorocka-Bobkowska B, Zozulinska-Ziolkiewicz D, Wierusz-Wysocka B, Hedzelek W, Szumala-Kakol A, Budtz-Jörgensen E. Candida-associated denture stomatitis in type 2 diabetes mellitus. Diabetes Res Clin Pract. 2010 Oct;90(1):81-6.
12. Kahana M, Yahalom R, Schewach-Millet M. Recurrent angular cheilitis caused by dental flossing. J Am Acad Dermatol. 1986 Jul;15(1):113-4.
13. Sonis AL. The prevalence of oral mucosal lesions in United States adults: data from the Third National Health and Nutrition Examination Survey, 1988-1994. J Evid Based Dent Pract. 2005 Sep;5(3):166-7.
14. Sharon V, Fazel N. Oral candidiasis and angular cheilitis. Dermatol Ther. 2010 May-Jun;23(3):230-42.
15. Peltola P, Vehkalahti MM, Wuolijoki-Saaristo K. Oral health and treatment needs of the long-term hospitalised elderly. Gerodontology. 2004 Jun;21(2):93-9.
16. Devani A, Barankin B. Dermacase. Angular cheilitis. Can Fam Physician. 2007 Jun;53(6):1011, 1022-3.
17. Ohman SC, Jontell M, Dahlen G. Recurrence of angular cheilitis. Scand J Dent Res. 1988 Aug;96(4):360-5.