Traditional classification of<unk> . *Acute<unk> : *pseudomembranous<unk>  <unk>  thrush) *atrophic<unk>  *Chronic<unk> : *atrophic<unk>  *hyperplastic<unk>  *chronic<unk>  (Candida leukoplakia)<unk>  endocrinopathy syndrome *chronic localized mucocutaneous<unk>  *chronic diffuse<unk> . ---- Classification of<unk> . *Primary<unk>  (group I) *Pseudomembranous (acute or chronic) *Erythematous (acute or chronic) *Hyperplastic: plaque-like, nodular *Candida-associated lesions: Denture related stomatitis, angular stomatitis, median rhomboid glossitis, linear gingival erythema *Secondary<unk>  (group II) *Oral manifestations of systemic mucocutaneous<unk>  (due to diseases such as thymic aplasia and<unk>  endocrinopathy syndrome)<unk>  is a mycosis (fungal infection). Traditionally,<unk>  is classified using the Lehner system, originally described in the 1960s, into acute and chronic forms (see table). Some of the subtypes almost always<unk> cur as acute (e.g., acute pseudomembranous<unk> , and others chronic. However, these typical presentations do not always hold true, which created problems with this system. A more recently proposed classification of<unk>  distinguishes primary<unk> , where the condition is confined to the mouth and perioral tissues, and secondary<unk> , where there is involvement of other parts of the body in addition to the mouth. The global human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pandemic has been an important factor in the move away from the traditional classification since it has led to the formation of a new group of patients who present with atypical forms of<unk> . By appearance Three main clinical appearances of<unk>  are generally recognized: pseudomembranous, erythematous (atrophic) and hyperplastic. Most often, affected individuals display one clear type or another, but sometimes there can be more than one clinical variant in the same person. Pseudomembranous Acute pseudomembranous<unk>  is a classic form of<unk> , commonly referred to as thrush. Overall, this is the most common type of<unk> , accounting for about 35% of<unk>  cases. It is characterized by a coating or individual patches of pseudomembranous white slough that can be easily wiped away to reveal erythematous (reddened), and sometimes minimally bleeding, mucosa beneath. These areas of pseudomembrane are sometimes described as "curdled milk", or "cottage cheese". The white material is made up of debris, fibrin, and desquamated epithelium that has been invaded by yeast cells and hyphae that invade to the depth of the stratum spinosum. As an erythematous surface is revealed beneath the pseudomembranes, some consider pseudomembranous<unk>  and erythematous<unk>  stages of the same entity. Some sources state that if there is bleeding when the pseudomembrane is removed, then the mucosa has likely been affected by an underlying process such as lichen planus or chemotherapy. Pseudomembraneous<unk>  can involve any part of the mouth, but usually it appears on the tongue, buccal mucosae or palate. It is classically an acute condition, appearing in infants, people taking antibiotics or immunosuppressant medications, or immunocompromising diseases. However, sometimes it can be chronic and intermittent, even lasting for many years. Chronicity of this subtype generally<unk> curs in immunocompromised states, (e.g., leukemia, HIV) or in persons who use corticosteroids topically or by aerosol. Acute and chronic pseudomembranous<unk>  are indistinguishable in appearance. Erythematous Erythematous (atrophic)<unk>  is when the condition appears as a red, raw-looking lesion. Some sources consider denture-related stomatitis, angular stomatitis, median rhomboid glossitis, and antiobiotic-induced stomatitis as subtypes of erythematous<unk> , since these lesions are commonly erythematous/atrophic. It may precede the formation of a pseudomembrane, be left when the membrane is removed, or arise without prior pseudomembranes. Some sources state that erythematous<unk>  accounts for 60% of<unk>  cases. Where it is associated with inhalation steroids (often used for treatment of asthma), erythematous<unk>  commonly appears on the palate or the dorsum of the tongue. On the tongue, there is loss of the lingual papillae (depapillation), leaving a smooth area. Acute erythematous<unk>  usually<unk> curs on the dorsum of the tongue in persons taking long term corticosteroids or antibiotics, but<unk> casionally it can<unk> cur after only a few days of using a topical antibiotic. This is usually termed "antibiotic sore mouth", "antibiotic sore tongue", or "antibiotic-induced stomatitis" because it is commonly painful as well as red. Chronic erythematous<unk>  is more usually associated with denture wearing (see denture-related stomatitis). Hyperplastic This variant is also sometimes termed "plaque-like<unk> " or "nodular<unk> ". The most common appearance of hyperplastic<unk>  is a persistent white plaque that does not rub off. The lesion may be rough or nodular in texture. Hyperplastic<unk>  is uncommon, accounting for about 5% of<unk>  cases, and is usually chronic and found in adults. The most common site of involvement is the commissural region of the buccal mucosa, usually on both sides of the mouth. Another term for hyperplastic<unk>  is "candidal leukoplakia". This term is a largely historical synonym for this subtype of<unk> , rather than a true leukoplakia. Indeed, it can be clinically indistinguishable from true leukoplakia, but tissue biopsy shows candidal hyphae invading the epithelium. Some sources use this term to describe leukoplakia lesions that become colonized secondarily by Candida species, thereby distinguishing it from hyperplastic<unk> . It is known that Candida resides more readily in mucosa that is altered, such as may<unk> cur with dysplasia and hyperkeratosis in an area of leukoplakia. Associated lesions Candida-associated lesions are primary<unk>  (confined to the mouth), where the causes are thought to be multiple. For example, bacteria as well as Candida species may be involved in these lesions. Frequently, antifungal therapy alone does not permanently resolve these lesions, but rather the underlying predisposing factors must be addressed, in addition to treating the<unk> . Angular cheilitis Angular cheilitis Angular cheilitis is inflammation at the corners (angles) of the mouth, very commonly involving Candida species, when sometimes the terms "Candida-associated angular cheilitis", or less commonly "monilial perlèche" are used. Candida organisms alone are responsible for about 20% of cases, and a mixed infection of C. albicans and Staphylococcus aureus for about 60% of cases. Signs and symptoms include soreness, erythema (redness), and fissuring of one, or more commonly both the angles of the mouth, with edema (swelling) seen intraorally on the commissures (inside the corners of the mouth). Angular cheilitis generally<unk> curs in elderly people and is associated with denture related stomatitis. Denture-related stomatitis This term refers to a mild inflammation and erythema of the mucosa beneath a denture, usually an upper denture in elderly edentulous individuals (with no natural teeth remaining). Some report that up to 65% of denture wearers have this condition to some degree. About 90% of cases are associated with Candida species, where sometimes the terms "Candida-associated denture stomatitis", or "Candida-associated denture-induced stomatitis" (CADIS), are used. Some sources state that this is by far the most common form of<unk> . Although this condition is also known as "denture sore mouth", there is rarely any pain. Candida is associated with about 90% of cases of denture related stomatitis. Median rhomboid glossitis Median rhomboid glossitis This is an elliptical or rhomboid lesion in the center of the dorsal tongue, just anterior (in front) of the circumvallate papillae. The area is depapillated, reddened (or red and white) and rarely painful. There is frequently Candida species in the lesion, sometimes mixed with bacteria. Linear gingival erythema This is a localized or generalized, linear band of erythematous gingivitis (inflammation of the gums). It was first observed in HIV infected individuals and termed "HIV-gingivitis", but the condition is not confined to this group. Candida species are involved, and in some cases the lesion responds to antifungal therapy, but it is thought that other factors exist, such as<unk>  hygiene and human herpesviruses. This condition can develop into necrotizing ulcerative periodontitis. Others Chronic multifocal<unk>  This is an uncommon form of chronic (more than one month in duration) candidal infection involving multiple areas in the mouth, without signs of<unk>  on other mucosal or cutaneous sites. The lesions are variably red and/or white. Unusually for candidal infections, there is an absence of predisposing factors such as immunosuppression, and it<unk> curs in apparently healthy individuals, normally elderly males. Smoking is a known risk factor. Chronic mucocutaneous<unk>  This refers to a group of rare syndromes characterized by chronic candidal lesions on the skin, in the mouth and on other mucous membranes (i.e., a secondary<unk> . These include Localized chronic mucocutaneous<unk> , diffuse mucocutaneous<unk>  (Candida granuloma),<unk> –endocrinopathy syndrome and<unk>  thymoma syndrome. About 90% of people with chronic mucocutaneous<unk>  have<unk>  in the mouth.
Oral candidiasis
Geographic tongue
Denture-related stomatitis
Leukoplakia
Contact stomatitis
Aphthous stomatitis
Caviar tongue
Head lice infestation