Pathology · patient case with 2 questions
Sore mouth corners in a long-term denture wearer
Patient: Female, 85 years old
Chief complaint: “The corners of my lips are all chapped and they sting.”
History: Hypertension, urinary incontinence. Medication: amlodipine. Maxillary and mandibular complete dentures fabricated five years ago and never relined.
Findings: Erythema and white patches at both oral commissures. Diffuse erythema of the palatal mucosa beneath the maxillary denture, conforming exactly to its outline. Reduced facial vertical dimension with over-closure.
Question 1
Which main aetiologic agents are responsible for the commissural lesions?
Show answer and explanation
Correct answer: A. Fungi and bacteria
- A. CORRECT. Angular cheilitis is a MIXED infection. Candida albicans is the dominant organism, joined by Staphylococcus aureus and sometimes beta-haemolytic streptococci. The enabling factor is mechanical: loss of vertical dimension deepens the commissural folds, saliva pools there, and the constantly moist macerated skin becomes a hospitable niche for both organisms.
- B. Bacteria alone underestimates it. Candida is present in the large majority of cases, which is why treatment routinely combines an antifungal with an antibacterial.
- C. The same objection applies — no viral component, and the fungal element is central rather than absent.
- D. Viruses are not implicated. Herpes labialis is the viral lesion of the lip, but it presents as vesicles at the vermilion border that crust over, not as chronic bilateral commissural fissuring.
Note: Treatment has to address the cause, not just the organism. Topical antifungal-antibacterial combinations clear the lesion, but it recurs unless the VERTICAL DIMENSION is restored. Also rule out iron, folate and B12 deficiency in persistent cases.
Question 2
The diffuse palatal erythema conforming to the denture outline is caused by which organism?
Show answer and explanation
Correct answer: A. Candida albicans
- A. CORRECT. Denture stomatitis, or chronic atrophic candidiasis, is Candida albicans proliferating on the fitting surface of the denture and the mucosa beneath it. The giveaway is that the erythema stops precisely at the denture border. It is characteristically ASYMPTOMATIC, which is why patients are unaware of it. Risk factors are continuous denture wear including overnight, poor denture hygiene, and a porous or ill-fitting acrylic surface.
- B. Streptococcus mutans is a caries pathogen and has no role in denture stomatitis — nor is there a tooth surface here for it to colonise.
- C. Staphylococcus aureus contributes to angular cheilitis at the commissures but is not the agent of the palatal lesion.
- D. Herpes simplex causes vesicular, ulcerative lesions on KERATINISED mucosa in its recurrent intra-oral form. It does not produce diffuse erythema shaped like a denture.
Note: Management is threefold: leave the denture out at night, disinfect it by soaking (chlorhexidine, or dilute hypochlorite for acrylic only — never for a denture with metal components), and treat the mucosa with a topical antifungal. Relining or remaking a poorly fitting denture is part of the cure.