RISK FACTORS OF ANGULAR CHEILITIS AT GUSTI HASAN AMAN DENTAL HOSPITAL SOUTH KALIMANTAN

Background: The second highest burden of all diseases in world population includes infectious disease with a total of 28% cases. Angular cheilitis is an infectious condition on the corner of the mouth that may initiate masticatory, facial expression and speech dysfunction due to the involvement of orbicularis oris muscle surrounding the lips. The management of angular cheilitis comprises the elimination of causative microbes using antifungal agent. Therapeutic failure reveals the disregard of any related risk factor. Purpose: To analyze the risk factors of angular cheilitis in Gusti Hasan Aman Dental Hospital year 2019. Method: This study resorted analytical descriptive design of quantitative approach using crosssectional method. Samples were 65 dental statuses of patients in Oral Medicine Clinic of Gusti Hasan Aman Dental Hospital year 2019. Result: Univariate data analysis presented the distribution of children category aged ≤ 18 years old (75.8%), men (54.8%), not consuming vegetable and fruit behaviour (46.8%), duration of treatment 1-7 days (56.4%), and incidence of angular cheilitis (75.8%). Fisher exact test unveiled the relationship between age and angular cheilitis (p<0.05) in which age ≤ 18 years old was 4.266 fold higher to experience angular cheilitis, while the relationship between gender and angular cheilitis (p<0.05) demonstrates the predilection of male with 4.853 fold at risk than female. Conclusion: Age and gender are risk factors in the incidence of angular cheilitis at Gusti Hasan Aman Dental Hospital year 2019.


INTRODUCTION
Angular cheilitis is an inflammatory condition on the corner of the mouth caused by body's inability to compensate tissue destruction as the result of infection. 1,2,3 Clinically, skin and mucosal surface will reflect maceration, fissure, ulceration as well as crust which occur unilaterally or bilaterally. 2,3 Lesions develop at the junction of orbicularis oris muscle that forms the corners of the mouth so that it can interfere with mastication, facial expression and speech. The prevalence of angular cheilitis ranges from 0.7% to 3.8% in the global population, but has increased in certain population groups. 3,4 At the Oral Medicine Profession Clinic of Gusti Hasan Aman Hospital, South Kalimantan Province between the period of 2014-2017, angular cheilitis was the most common disease (94.5%) treated in the infection group. 5 Pathogenic microorganisms are the most common etiology of angular cheilitis in which Candida spp. shows implications for clinical lesion development. Candida spp. is a normal polymorphic microorganism of the oral cavity which presents in 80% of the population without signs and symptoms of disease. 6 Candida species were identified at the corners of the mouth with a frequency of 48.4%-70% in cases of angular cheilitis. 3,7 Strong signal transduction and sustainability was detected when Candida spp. undergo a transition from yeast form to hyphae and bind to the surface of the mucosal epithelium in response to the danger of invading microorganisms into the tissue. Adhesion to the mucosal surface initiates tissue destruction through membrane degradation and recruitment of immune cells. There are two factors that affect the ability of Candida species to cause tissue damage, namely the characteristics of the host and the environment. 8 The structure of tissue on the corners of the mouth is a local defense that affects the individual's susceptibility to Candida albicans infection. Anatomically, the corner of the mouth is a direct meeting of the vermilion of the upper and lower lips to form a fold that is influenced by the height of the lower third of the face. This anatomical structure facilitates the accumulation of moisture from the surrounding salivary and sebaceous glands. 9 This structure is also directly adjacent to the oral mucosa, allowing the interaction of normal flora on the skin and oral cavity. 10 Management of angular cheilitis with antifungal medicaments is reported as the first-line therapy, but treatment failure can occur if the predisposing factors that increase the risk of disease development have not been eliminated. 3,11,12 A person's risk to develop angular cheilitis increases in the pediatric age group, poor nutritional status, and those living in rural areas. The incidence of angular cheilitis is doubled in men. 13 The incidence of angular cheilitis is relatively high, but studies on risk factors for angular cheilitis in South Kalimantan Province have never been performed so that factual data on risk factors that support the occurrence of angular cheilitis are not yet available. Identification of risk factors for angular cheilitis is an important step to identify the determinants that influence the incidence of disease as the basis for formulating health policies. Identification of risk factors can also be used in providing inclusive health promotion and Dental Health Education (DHE) to the community. Based on the above, it is necessary to analyze the risk factors for angular cheilitis at RSGM Gusti Hasan Aman

MATERIALS AND METHODS
This research had obtained ethical approval No.123/KEPKG-FKGULM/EC/IV/2020 issued by the ethics commission of the Faculty of Dentistry, University of Lambung Mangkurat. This research is descriptive analytic study with quantitative approach using cross sectional method. The population of this study is the status card of patients treated by students at the Gusti Hasan Aman Hospital, South Kalimantan Province. The research sample was the patient status cards of the Gusti Hasan Aman Hospital in 2019. Simple random technique was conducted to determine samples of the study comprising 62 documents in accordance with inclusion and exclusion criteria.
Secondary data were collected for this research. The collection of data was processed through several stages, namely: editing, coding, entry and processing, cleaning and tabulating.
Univariate analysis was performed to describe the variables of age, sex, behavior, duration of treatment and angular cheilitis were studied using the frequency distribution and percentage of each group. Bivariate analysis was conducted on the independent variables, namely the risk factors of age and sex with the dependent variable, namely angular cheilitis.

RESULTS
Data comprised of age, gender, behaviour, duration of treatment and angular cheilitis were analyzed using SPSS computerized statistic.    The distribution of behavior based on Figure  3 is the highest in not eating vegetables and fruit group with a total of 29 people (46.80%). While the highest distribution of treatment duration based on Figure 4 is in 1-7 days with a total of 35 people (56.5%). The distribution of the incidence of angular cheilitis in this study based on Figure 5 was 47 (75.8%), while non-angular cheilitis was 15 (24.2%).
Analysis of the relationship between age and angular chelitis using a 2x2 table with the Fisher Exact test can be seen in table 1. Based on table 1, it is revealed that the significance value is 0.035 (p<0.05), which means that the data were statistically significant and there is a difference in the proportion between age and angular cheilitis. Statistical tests show that there is a relationship between age and angular cheilitis at RSGM Gusti Hasan Aman Banjarmasin in 2019. The OR in this study is 4.266, so it can be interpreted that age 18 years has a 4.266 times chance of angular cheilitis compared to age > 18 years.
The analysis of the relationship between gender and angular chelitis using a 2x2 table with the Chi-Square test (χ2) can be seen in table 2.  Table 2 shows that the significance value is 0.017 (p<0.05), which means that it is statistically significant, there is a difference in the proportion between sex and angular cheilitis. Statistical tests show that there is a relationship between gender and angular cheilitis at Gusti Hasan Aman Hospital Banjarmasin in 2019. The OR in this study is 4,853 which can be interpreted that male gender has a 4.853 times chance of angular cheilitis compared to the female.

DISCUSSION
Angular cheilitis (angular stomatitis or parleche) is the term used for an inflammation that occurs in the corners of the mouth. This term consists of the word 'angulus' which means angle in Latin, the word 'cheil' which means lips, and 'itis' which means inflammation in Greek. 1,2,3 Angular cheilitis is the most common disease (94.5%) in the group of infectious diseases treated at the Oral Medicine Profession Clinic of Gusti Hasan Aman Hospital, South Kalimantan Province for the period 2014-2017. 5 The results of this study based on Figure 1 reveals that the highest distribution for age is in the category of children aged 18 years with a total of 47 sample (75.8%). Statistical tests show that there is a relationship between age and angular cheilitis at Gusti Hasan Aman Hospital Banjarmasin in 2019 with an OR of 4.266. This is in line with Sriwahyuni's research (2017) which shows that the risk of patients developing angular cheilitis increases in the pediatric age group 13 .
Angular cheilitis often affects children, especially when their condition is poor. The activity of the immune system in children is inferior to adults because immune cells are still in the maturation stage. Induction of cytokines and pro-inflammatory chemokines was reported to be lower in children because the number of myeloid dendritic cells was still low where the expression of HLA, CD80 dan CD86 was lower than adults. Children get the body's defense from IgG which is obtained through breast milk thus becoming susceptible to infection after the period of breastfeeding. 14 Angular cheilitis in children also frequently occurs due to nutritional deficiencies such as lack of vitamin B complex (riboflavin), iron and folic acid. 15 The results for gender distribution of sample in this study are presented in Figure 2. The highest distribution was male 34(54.8%). The result of this study is in line with the research of Sriwahyuni (2017) which showed that the risk of patients developing Angular cheilitis was increased in men. 13 Human gender is divided into male and female structurally at the chromosomal level. Female have two X chromosomes while male have one Y chromosomes and one X chromosomes. The X chromosomes has been widely associated with the non-specific and adaptive immune system. 16 Risk factors based on gender are also influenced by reproductive hormones which have different levels between men and women. Men have higher testosterone levels, while women show higher levels of estrogen and progesterone based on ovarian cycle. 17 Hormones were also reported as one of the factors that significantly correlated with maturation and keratinization of oral epithelial cells where an increase estrogen hormone in women can accelerate the metabolism and growth of epithelial cells. 18,19 Higher estrogen levels in women cause women to be more resistant to microbial infections and show a higher defense response during pathogen invasion, but it also affects the estrogen receptors present in Candida albicans. 6,9,20 The highest behavior of the sample based on Figure 3 is not eating vegetables and fruits by 29 samples (46.8%). Vegetables and fruits contain nutrients and vitamins that keep the body healthy. Lack of consumption of vegetables and fruits can lead to nutritional deficiencies which are certainly bad for the body. Micronutrients play a vital role, for example iron is important for the differentiation and growth of epithelial tissue. Vitamin A and zinc are important for the integrity of skin and mucous cells. Vitamin C is important for synthesis of collagen in epithelial cells and supports the differentiation of keratinosis, lipid synthesis, the proliferation and migration of fibroblasts. 21 Epithelial integrity can be compromised if the supply of oxygen and nutrient intake are insufficient for the synthesis of nucleic acids and amino acids, which are the basic structure of epithelial cells and mucosal tissue, is not met. Meanwhile, the intake of B vitamins and iron affects the production of cytokines and T lymphocyte cells so that patients with nutritional deficiencies become susceptible to infection. 22 The sample in this study also had frequent snacking behavior (skewered meatballs) 6(9.70%) and like to eat fried food 5(8.10%). The group of children who like to eat snacks experienced more angular cheilitis due to the consumption of less nutritious food. 23 Wetting the corners of the lips with the tongue was done by 16 (25.80%) samples in this study and 6 (9.70%) were affirming excessive salivation during sleep. This habit can support the occurrence of angular cheilitis through a mechanism that allows the accumulation of moisture in the corners of the lips. Excessive saliva will be trapped in the corners of the lips creating a moist environment so that it is the perfect environment for fungus or bacteria to grow and thrive. 13 Angular cheilitis is an inflammatory condition that can last several days or become a chronic problem. Based on Figure 4, the distribution of treatment duration for the highest study sample was 1-7 days by 35(56.5%). The distribution of duration of treatment in the other categories was 8-14 days by 17(27.4%) and >14 days by 10(16.1%). Treatment of Angular cheilitis includes repair of painful macerated lesions, ulceration, crusts and fissures. Ulcers and fissures are lesions that involve the loss of all layers of the epidermis and part of the dermis with clinical differences in the form of vertical lesions in the fissures and lesions in the form of craters on the ulcers. 24 In lesions involving partial loss of the dermis layer in healthy individuals, the healing process will take between 5 and 7 days. 25