Clues and missed opportunities

The following is a piece I wrote for a medical news website that never ended up getting published. I find it so odd how people may commission your services or help with expressed urgency, only for you to end up leading the charge on the matter. I think one of the most ancient common sense ideas is that if you plan to do something do it well. Many variation exists but one I came across is one from Saint Ignatius Loyola, the founder of the Jesuit Order, when he offered advice for the resilient worker:  Age Quod Agis. Literally translates to “do what you are doing”. Often times I wish I learned Latin or Greek. So many powerful and catchy phrases.

I have learned over the years that sometimes you can’t wait for those who are not willing to live by that moto. I think a big part of this is intentionality and conscientiousness. I happen to treat work as a form of worship. That idea of devotion. This is not to say that you ought to wither with work. For when work becomes detrimental, it has lost its reverence.

“Whatever you do, do it well. Do it so well that when people see you do it, they will want to come back and see you do it again, and they will want to bring others and show them how well you do what you do.”

Walt disney

The mouth is the window to the rest of the body”. While the statement can be considered truism, us dentists should really be wearing that statement on our shirts. Many a time did a dentist help reveal undiagnosed hypertension because they decided, responsibly, to pull the sphygmomanometer out from the cabinet prior to extracting a tooth for a patient. But often, we need not even break a sweat or get off our chairs to uncover signs of systemic disease in the mouth. Better yet, sometimes the patient need not even open their mouth.

Angular cheilitis is one of those conditions whose name, somehow, was easily memorable. To dentists, that red, broken and painful looking skin at the corner of the mouth should not just trigger unresolved anxieties from that 3rd year oral pathology exam: it should also make them suspicious of possible vitamin B12 deficiency. A recommendation to follow up with the family physician for bloodwork is prudent. Vitamin B12 (or cobalamin) and folate deficiency are readily implicated in megaloblastic anemia, which incidentally, have many oral manifestation including: glossitis, aforementioned angular cheilitis, recurrent oral ulcer, oral candidiasis, diffuse erythematous mucositis and pale oral mucosa.

Angular cheilitis can also be seen as a component of chronic multifocal candidiasis. We will learn how that is relevant for dentists and doctors in a minute, but first: a short dental lesson! In dental lingo, loss of vertical dimension (VDO, O for occlusion) isn’t our fancy way of describing someone getting shorter. Rather, it indicates a condition seen in elderly patients manifesting as “collapsed bite”. Elderly patients with advanced tooth loss especially in the posterior mandible or maxilla, typically shift to relying on anterior teeth for mastication. Over time those patients wear down their teeth significantly and jaw overclosure starts to become evident. This is especially true when prosthetic treatment with dentures (or other modalities) is delayed. If you’ve seen an elderly patient with that characteristic “inverted smile”, you can now tell them that they have lost VDO. 

The corners of the mouth (or the commissure) in those elderly patients with angular cheilitis may not be only suggestive of B12 deficiency, it could also be indicative of a condition called denture stomatitis. This condition is a candida-mediated inflammation of the mucosa contacting denture surfaces. Saliva pools easily in the collapsed folds at the commissures of those patients. And if we know anything about candida, it is that they like growing in warm, moist, and creasy areas. Often, those patients with denture stomatitis, don’t properly care for their dentures. Many might be wearing them to sleep or seldom taking them out to brush them and clean them (liquid soap and a good brush is often adequate, or you can get a fancy Polident tablet). Interestingly, in those patients fungal swabs from the skin contacting dentures comes back negative. But the culprit can be found under that  (drumroll) – you guessed it – poorly cleansed denture.


I am a general dentist and hospitalist with an expansive interest in education research. I come from a basic science, and immunology research background, and am currently pursuing a master in community health with a health practice education focus.

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