1. Lip disorders
Dr. Sameei Sdiq
M.Sc. Oral Medicine
College Of Dentistry/ Hawler Medical University
2. • The lips represent a transitional area between the oral mucous
membrane and the skin of the face and may, therefore, be involved in
pathological processes affecting both structures.
3. Swelling of the lips
• There is considerable individual and racial variation in the size of lips.
Abnormal swellings of the lips can either be diffuse or localized to a
particular area of the lip
5. Angular cheilitis
• Angular cheilitis is a condition characterized by erythema, fissures,
scaling, and/or crusting at the corners of the mouth. It may occur as an
isolated finding or as a component of chronic multifocal candidiasis.
Microbiologic studies suggest that the condition is caused by Candida
albicans and/or Staphylococcus aureus.
6. • Additional contributory factors may include loss of vertical dimension of
occlusion (which creates a favorable environment for microbial overgrowth
due to accentuation of the commissural folds with salivary pooling),
• Prosthodontic or orthodontic appliances (which may harbor fungal
organisms), ‘
• Nutritional deficiencies ( Iron or vitamin B complex deficiency),
• Local irritation (e.g., From chewing on objects, thumb sucking, lip licking
or picking, flossing),
• Medications (e.g., Isotretinoin, indinavir, sorafenib).
7. • Deficiency states, such as:
■ Iron deficiency
■ Hypovitaminoses (especially B)
■ Malabsorption states (e.g. Crohn disease) or eating disorders
■ Possibly zinc deficiency, but only rarely
■ Immune defects, such as in down syndrome, HIV Infection, Diabetes ,
cancer, immunosuppressed People.
8. • Clinically, angular cheilitis may affect one or both corners of the
mouth.
• The patient may complain of soreness, pain, burning, or pruritus. The
condition can last anywhere from a few days to several years, and
alternating periods of relapse and remission are common in chronic
cases.
11. • Angular cheilitis is a mixed infection. Candida is found in as many as 90% of
cases, but the proportion varies in different populations, being higher in
denture wearers. Staphylococci, streptococci or other pathogens are
frequently present and exactly which organisms are causative is unclear.
• Treatment is targeted at treating the intraoral reservoir of candidal
infection using local measures and antifungal drugs as appropriate.
12. • Miconazole gel is the ideal first-line treatment for the commissures as
it has additional activity against several Gram-positive bacterial
species including staphylococci and can be expected to successfully
treat almost all cases. Failure is more likely due to incomplete
treatment of the intraoral infection, but if this appears controlled,
changing to 2% fusidic acid cream for the angles on assumption of
staphylococcal or streptococcal infection is logical.
13. • There is a particularly high proportion of patients with anaemia as a predisposing
cause in angular cheilitis and iron, folate and B12 levels should be checked.
• In the edentulous and those with loss of lip support with prominent skin folds,
attempts to correct vertical dimension or thicken the labial flange cannot usually
remove these susceptible areas.
• Dermal fillers haven been tried but so far remain without a good evidence base.
14. Chronic Lip Fissure
• A chronic lip fissure represents a persistent linear ulcer in the sagittal
plane of the upper or lower lip vermilion. The condition affects
approximately 0.6% of the population, and the etiology is unclear.
• Some authors suggest that the lesions result from physiologic
weakness of tissues along embryologic planes of fusion; this theory
is supported by the observation that lower lip fissures tend to
occur at midline, whereas upper lip fissures often occur slightly
lateral to midline.
15. • Additional proposed contributory factors include cold weather, smoking,
bacterial or fungal infections, vitamin deficiency, mouth breathing,
misaligned anterior teeth (possibly combined with parafunctional
habits), and playing wind instruments.
• In addition, some investigators have noted an increased prevalence of
chronic lip fissures among patients with Down syndrome, Crohn disease, or
orofacial granulomatosis.
16. • The lesion may be present continuously or intermittently, and
symptoms often worsen during the winter months. Various topical
treatments reported include tacrolimus, corticosteroids,
hydrocortisone and iodoquinol, aureomycin, sulfonamides, and
moisturizers. However, refractory lesions may necessitate simple
excision or excision with Z-plasty. Alternative treatment methods
include cryotherapy and carbon dioxide laser therapy.
17.
18. Lip Fissure. A, Chronic fissure of the vermilion border of the upper lip. B, Same site
2 weeks later, after use of hydrocortisone and iodoquinol cream.
19. Exfoliative cheilitis
• Exfoliative cheilitis is a condition characterized by persistent scaling
and flaking of the lip vermilion. The process results from excessive
keratin production and subsequent desquamation. The etiology is
uncertain, although studies have noted associations with
factitial/parafunctional activities (e.g., lip licking, biting, picking,
sucking), stress, and psychiatric disorders (e.g., anxiety, depression,
obsessive-compulsive disorder)
20. • Clinical examination typically shows scaling or peeling of the lip
vermilion, at times accompanied by erythema, crusting, and/or bleeding.
Most cases involve both lips, although involvement of only one lip also is
possible. Lip dryness is a common complaint among affected patients;
infrequently, there may be pain or burning as well. Many patients try to
self-treat by applying lip balm, although a constantly moist environment
may favor the development of superimposed candidiasis. In many
examples, concurrent angular cheilitis may be evident, or secondary
candidiasis may develop diffusely on the lip vermilion
21. • Conditions that may be considered in the differential diagnosis for
exfoliative cheilitis include allergic contact cheilitis and atopic cheilitis.
With regard to management, the patient should be instructed to make a
conscious effort to avoid lip licking or other potential sources of irritation.
Some case reports have noted improvement with antifungal therapy,
antibacterial agents, corticosteroids, tacrolimus ointment, pimecrolimus
ointment, antidepressants, Calendula officinalis ointment, excimer laser
therapy, or cryotherapy. In our experience, antifungal therapy in
combination with the cessation of lip balm usage
22.
23. Exfoliative Cheilitis
Generalized peeling and dryness
of the lips.
Same patient from after treatment, which
consisted of topical 1% hydrocortisone/1%
iodoquinol applied to the lip vermilion plus
intraoral clotrimazole troches and cessation of
petrolatum-based lip balm.
24. Actinic cheilitis (solar keratosis)
• Actinic cheilosis is a common, premalignant lesion of the lower lip vermilion caused by
chronic ultraviolet light exposure. Similar lesions on the skin are called actinic
keratoses . Major risk factors for actinic cheilosis include increased age, male gender,
outdoor occupational/leisure activities, proximity to the equator, and light-
complexioned skin.
• In addition, patients with certain genetic disorders (e.g., xeroderma pigmentosum,
albinism) are at increased risk for developing actinic cheilosis and skin cancer. Cofactors
that may increase the likelihood of actinic cheilosis transforming into squamous cell
carcinoma include tobacco use and immunosuppression.
25. • Actinic cheilosis exhibits a predilection for men >40 years old. Early
lesions often appear as ill-defined, pale areas on the lower lip
vermilion. Fissures and dryness also may be evident, and the
transition between the vermilion and adjacent skin often becomes
blurred. With progression, the lesion can develop into a rough,
crusted, white and/or red plaque. Persistent ulceration, nodularity,
and bleeding may indicate either actinic cheilosis with severe
dysplasia or transformation into squamous cell carcinoma.
26. • Clinical management of actinic cheilosis includes patient education
(e.g., sun avoidance, wide-brimmed hat and sunscreen when
outdoors). For lesions with severe dysplasia, vermilionectomy can
be performed. Conventional surgery allows for microscopic
examination to rule out carcinoma. For lesions with mild to
moderate dysplasia, alternative treatments include topical agents
(e.g., 5-fluorouracil, imiquimod), laser ablation, electrosurgery,
cryotherapy, and photodynamic therapy. After treatment, long-term
clinical follow-up is recommended.
27.
28.
29.
30. Perioral dermatitis
• Perioral dermatitis does not refer to every rash that occurs around
the mouth but is specific for a unique inflammatory skin disease that
involves the cutaneous surfaces surrounding the facial orifices.
Because the disorder also often involves the paranasal and periorbital
skin, periorificial dermatitis is the most appropriate designation.
31. • Although the process is idiopathic, the dermatitis is associated strongly
with uncritical use of potent topical corticosteroids on the facial skin.
Fluorinated toothpaste and overuse of heavy facial cosmetics, creams,
and moisturizers also are implicated in many patients. Weaker
correlations have been seen with systemic corticosteroids, corticosteroid
inhalers, and nasal corticosteroids. Heavy exposure to ultraviolet light,
heat, and wind appears to worsen the dermatitis.
32. • Perioral dermatitis appears with
persistent erythematous papules,
papulovesicles, and papulopustules
that involve the skin surrounding the
vermilion border of the upper and
lower lips. In addition, involvement of
the perinasal skin is seen in
approximately 40% of affected
patients, and 25% have periorbital
dermatitis
33. Treatment
• Most cases resolve with “zero therapy,” which includes discontinuation of
corticosteroids, cosmetics, and facial creams.
• Discontinuation of potent topical corticosteroid use often is followed by a
period of exacerbation, which can be minimized by substitution of a less
potent corticosteroid before total cessation. Oral tetracycline is considered
the therapeutic gold standard for perioral dermatitis but must be avoided
during childhood and pregnancy.
34. • perioral dermatitis also responds well to topical pimecrolimus or topical
erythromycin.
• Weaker therapeutic recommendations include topical metronidazole,
clindamycin, tacrolimus, tetracycline, adapalene, or azelaic acid, plus
systemic erythromycin or isotretinoin. The pathosis typically demonstrates
significant improvement within several weeks and total resolution in a few
months. Recurrence is uncommon.
35. Cheilocandidosis
• There have been several reported cases in which the lips become the site
for a heavy candidal infection. These lesions are reported as occurring
bilaterally, predominantly on the lower lip, and appear as ulcerated
granular areas from which C. albicans can be freely cultured. This is
reported to occur in generally healthy patients, but there are strong
suggestions of prior local abnormality that might lead to a secondary
candidal infection, for example, solar irritation in some Australian
patients..
36. • In some cases the cheilitis has been associated with chronic intraoral
candidosis. These lesions have been considered by several authors to
represent candidal infection affecting intrinsically unstable epithelium
and it is suggested that, as in chronic hyperplastic candidosis
(candidal leukoplakia), early treatment by antifungals might lead to
resolution, whereas delay might lead to increasing epithelial dysplasia
37.
38. A, Candidal infection of the perioral skin caused by use of a petrolatum-based product. The condition started as
angular cheilitis, but the patient continuously applied petroleum jelly to the corners of the mouth and perioral
skin, sealing moisture into the keratin layer of the epidermis, thereby allowing the candidal organisms to thrive.
B, Two weeks after discontinuing the petroleum jelly and using topical iodoquinol with triamcinolone.
39. Orofacial
granulomatosis
•Orofacial granulomatosis (OFG) is an uncommon
condition very similar to Crohn disease, due to
granulomatous inflammation and often presents
with granulomatous with angular stomatitis
and/or cracked lips ,ulcers, mucosal tags,
cobble-stoning or gingival hyperplasia.
40. The onset is usually in adolescents and young adult life
and has no known racial predilection.
41. Aetiology and pathogenesis
•The cause of OFG is unknown, but it may be
related to, or may be, Crohn disease and there
may be a genetic predisposition. A delayed type
of hypersensitivity reaction appears to be
involved, although the exact antigen inducing
the immunological reaction appears to vary in
individual patients.
42. Predisposing factors
•OFG sometimes arises from an adverse reaction
to various foods or additives which include
cinnamic aldehyde, benzoates,
butylated hydroxyinosole or dodecyl gallate (in
margarine), or menthol (in peppermint oil).
43. Clinical features
• 1- Non-tender swelling and enlargement of one or both
lips
• 2-Thickening and folding of the oral mucosa produces a
‘cobblestone’ type of appearance and mucosal tags
• 3-Ulcers appear: classically involving the buccal sulcus
where they appear as linear ulcers, often with
granulomatous masses flanking them
• 4-some times: head ache, fever, cervical lymph node
enlargement, loss of taste and decreased salivary
secretion.
44. • 5- occasionally, deficits of cranial nerves (olfactory, facial,
auditory, glossopharyngeal, vagus and hypoglossal) may
arise. Facial palsy occurs in up to 30% of cases, more
commonly develops late, but may precede the attacks of
swelling by months or years.
• 6-A fissured or plicated tongue (seen in 20–40% of cases),
• which is part of the Melkersson–Rosenthal syndrome,
present from birth.
48. Treatment
•Conservative management usually includes
topical corticosteroids, intralesional
corticosteroid injections (such as low-volume,
high-concentrate, extended-release
triamcinolone) or topical tacrolimus.
49. Angioedema
•This is a potentially lethal condition.
Angioedema manifests with rapid development
of oedematous swelling of the lip(s), tongue and
oral or facial swelling.
51. Aetiology and pathogenesis
• Allergic angioedema is a type 1 hypersensitivity
reaction that
• may be induced by:
• ■ Foods: nuts are a well-known cause but many other
foods
• (e.g. shellfish, eggs, milk) may be implicated
• ■ Latex
• ■ Drugs especially:
• ■ antibiotics, ■ aspirin
52. Clinical features
• The acute oedema, which appears < 2 h of antigen exposure,
• can cause pronounced itchy labial and periorbital swelling,
urticaria
• And can involve any oral site.
• Diagnosis : Angioedema is diagnosed clinically and from a
history of atopic disease and/or exposure to allergen, and
sometimes By allergy testing (prick test).
53. Aids that might be helpful in diagnosis/
prognosis/management in some patients
suspected of
having angioedema :
•Serum complement C3 and C4 levels
•C1 esterase inhibitor activity.
54. Treatment
• ■ In severe cases, especially if there is any potential or real threat
to the airway, the emergency should be managed with
• intramuscular adrenaline (epinephrine), and with systemic
• corticosteroids and/or antihistamines, such as chlorphenamine
• or loratidine.
• ■ Mild angioedema may respond to antihistamines, or to a
• sympathomimetic agent, such as ephedrine, by mouth.
• ■ The rare intractable chronic cases may respond to systemic
• corticosteroids
