Stomatitis nicotina is a diffuse white patch on the

hard palate The hard palate is a thin horizontal bony plate made up of two bones of the facial skeleton, located in the roof of the mouth. The bones are the palatine process of the maxilla and the horizontal plate of palatine bone. The hard palate spans ...

, usually caused by

tobacco smoking Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believed ...

, usually pipe or cigar smoking. It is painless, and it is caused by a response of the palatal

oral mucosa The oral mucosa is the mucous membrane lining the inside of the mouth. It comprises stratified squamous epithelium, termed "oral epithelium", and an underlying connective tissue termed ''lamina propria''. The oral cavity has sometimes been descri ...

to chronic heat. A more pronounced appearance can occur with

reverse smoking Reverse smoking is a kind of smoking where the burnt end of a hand rolled tobacco leaf is put in the mouth rather than the unlit end of the cigar. It is practiced in some parts of Andhra Pradesh, India, Lusaka, Zambia and the Philippines. Reverse sm ...

, sometimes distinguished from stomatitis nicotina by the term reverse smoker's stomatitis. While stomatitis nicotina that is caused by heat is not a premalignant condition (i.e. it does not carry an increased risk of transformation to

oral cancer Oral cancer, also known as mouth cancer, is cancer of the lining of the lips, mouth, or upper throat. In the mouth, it most commonly starts as a painless white patch, that thickens, develops red patches, an ulcer, and continues to grow. When on ...

), the condition that is caused by reverse smoking is premalignant.

Signs and symptoms

The palate may appear gray or white and contain many

papule A papule is a small, well-defined bump in the skin. It may have a rounded, pointed or flat top, and may have a dip. It can appear with a stalk, be thread-like or look warty. It can be soft or firm and its surface may be rough or smooth. Some h ...

s or nodules that are slightly elevated with red dots in their center. These red dots represent the ducts of minor salivary glands which have become inflamed by heat. The condition is painless. If a

denture Dentures (also known as false teeth) are prosthetic devices constructed to replace missing teeth, and are supported by the surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable (removable partial denture or ...

is normally worn while smoking, then the mucosa underneath the denture appears unaffected by the condition. In severe cases, the mucosa may show fissuring and develop a "dried lake bed" appearance. Other changes associated with tobacco use may be evident such as brown or black extrinsic staining of teeth from tar and other components of tobacco smoke.

Causes

The cause of nicotine stomatitis is thought to be chemical or thermally induced

keratosis Keratosis (from '' kerat-'' + '' -osis'') is a growth of keratin on the skin or on mucous membranes stemming from keratinocytes, the prominent cell type in the epidermis. More specifically, it can refer to: * actinic keratosis (also known as solar ...

. The chemicals in tobacco may act as irritants in this condition. Chronic heat exposure is also responsible.

Pipe smoking Pipe smoking is the practice of tasting (or, less commonly, inhaling) the smoke produced by burning a substance, most commonly tobacco, in a pipe. It is the oldest traditional form of smoking. Regular pipe smoking has been cited to carry serious ...

produces more heat on the palate than any other forms of smoking. Long-term drinking of very hot

beverage A drink or beverage is a liquid intended for human consumption. In addition to their basic function of satisfying thirst, drinks play important roles in human culture. Common types of drinks include plain drinking water, milk, juice, smoothies a ...

s can also cause a similar condition. The severity of the changes correlates with the frequency of the habit. The prevalence depends on a society's use of consuming hot beverages and of smoking in its various forms. A similar, but more pronounced palatal keratosis occurs with reverse smoking. This is where the lit end of the cigar or cigarette is held in the mouth, another form of smoking associated with high levels of heat in the mouth. This form of the condition is sometimes termed "reverse smoker's keratosis", and is a

premalignant A precancerous condition is a condition, tumor or lesion involving abnormal cells which are associated with an increased risk of developing into cancer. Clinically, precancerous conditions encompass a variety of abnormal tissues with an increased ...

lesion A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals. Types There is no designated classifi ...

. That is, the condition is associated with an increased risk of malignant transformation to oral

squamous cell carcinoma Squamous-cell carcinomas (SCCs), also known as epidermoid carcinomas, comprise a number of different types of cancer that begin in squamous cells. These cells form on the surface of the skin, on the lining of hollow organs in the body, and on the ...

(a type of

). Some sources do not distinguish between reverse smoker's keratosis and smoker's palate that is caused by heat. As such, these sources tend to state that stomatitis nicotina is a premalignant condition. Some reports show that there is an increased risk of tonsillar cancer,

lung cancer Lung cancer, also known as lung carcinoma (since about 98–99% of all lung cancers are carcinomas), is a malignant lung tumor characterized by uncontrolled cell growth in tissue (biology), tissues of the lung. Lung carcinomas derive from tran ...

and tumors of the posterior oral cavity in people who develop stomatitis nicotina.

Diagnosis

The diagnosis is normally made based upon the clinical appearance and history. Tissue

biopsy A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a diseas ...

is not usually indicated unless there are areas of ulceration or localized

erythroplakia Erythroplakia is a clinical term to describe any erythematous (red) area on a mucous membrane, that cannot be attributed to any other pathology. The term erythroplasia was coined by Louis Queyrat to describe a precancerous red lesion of the penis ...

(red patches). The

differential diagnosis In healthcare, a differential diagnosis (abbreviated DDx) is a method of analysis of a patient's history and physical examination to arrive at the correct diagnosis. It involves distinguishing a particular disease or condition from others that p ...

is with other causes of white lesions (see

leukoplakia Oral leukoplakia is a ''potentially malignant disorder'' affecting the oral mucosa. It is defined as "essentially an oral mucosal white lesion that cannot be considered as any other definable lesion." Oral leukoplakia is a white patch or plaque th ...

for a more complete discussion). Specific conditions which can produce a similar appearance include

Darier's disease Darier's disease (DAR) is an inherited skin disorder that presents with multiple greasy, crusting, thick brown bumps that merge into patches. It is an autosomal dominant disorder discovered by French dermatologist Ferdinand-Jean Darier. Darier's ...

discoid lupus erythematosus Discoid lupus erythematosus is the most common type of chronic cutaneous lupus (CCLE), an autoimmune skin condition on the lupus erythematosus spectrum of illnesses. It presents with red, painful, inflamed and coin-shaped patches of skin with a sc ...

oral candidiasis Oral candidiasis, also known as oral thrush among other names, is candidiasis that occurs in the mouth. That is, oral candidiasis is a mycosis (yeast/fungal infection) of ''Candida'' species on the mucous membranes of the mouth. ''Candida albica ...

, and

oral lichen planus Lichen planus (LP) is a chronic inflammatory and immune-mediated disease that affects the skin, nails, hair, and mucous membranes. It is not an actual lichen, and is only named that because it looks like one. It is characterized by polygonal, fl ...

. If a biopsy is taken, the histopathologic appearance is one of

hyperkeratosis Hyperkeratosis is thickening of the stratum corneum (the outermost layer of the epidermis, or skin), often associated with the presence of an abnormal quantity of keratin,Kumar, Vinay; Fausto, Nelso; Abbas, Abul (2004) ''Robbins & Cotran Patholo ...

and acanthosis. There may be

squamous metaplasia Squamous metaplasia is a benign non-cancerous change (metaplasia) of surfacing lining cells (epithelium) to a squamous morphology. Location Common sites for squamous metaplasia include the bladder and cervix. Smokers often exhibit squamous me ...

of excretory ducts, which results in the visible papules if the ducts become

hyperplastic Hyperplasia (from ancient Greek ὑπέρ ''huper'' 'over' + πλάσις ''plasis'' 'formation'), or hypergenesis, is an enlargement of an organ or tissue caused by an increase in the amount of organic tissue that results from cell proliferatio ...

Neutrophil Neutrophils (also known as neutrocytes or heterophils) are the most abundant type of granulocytes and make up 40% to 70% of all white blood cells in humans. They form an essential part of the innate immune system, with their functions varying in ...

s may fill some ducts. It is characterized as a "fissured" or "dried mud" appearance from excess

keratin Keratin () is one of a family of structural fibrous proteins also known as ''scleroproteins''. Alpha-keratin (α-keratin) is a type of keratin found in vertebrates. It is the key structural material making up scales, hair, nails, feathers, ho ...

production by

cells Cell most often refers to: * Cell (biology), the functional basic unit of life Cell may also refer to: Locations * Monastic cell, a small room, hut, or cave in which a religious recluse lives, alternatively the small precursor of a monastery w ...

Dysplasia Dysplasia is any of various types of abnormal growth or development of cells (microscopic scale) or organs (macroscopic scale), and the abnormal histology or anatomical structure(s) resulting from such growth. Dysplasias on a mainly microscopic ...

is rarely seen.

Treatment

When the appearance is caused by heat, the lesion is usually completely reversible within a few weeks if the smoking habit is stopped. This is the case even if the condition has been present for decades. Without stopping smoking, spontaneous remission of the lesion is unlikely. If the lesion persists despite stopping smoking, this is usually then considered to be a true leukoplakia rather than a reactionary keratitis, and may trigger the decision to carry out a biopsy to confirm the diagnosis. Since this condition almost always develops in the setting of long term heavy smoking, it usually indicates the need for regular observation for cancers associated with smoking, e.g. lung cancer.

Epidemiology

The condition is uncommon. It occurs usually in elderly males who have a history of heavy pipe smoking, but it also can occur in cigar or cigarette smokers. The condition was once common, but has become more rare as habits such as pipe and cigar smoking have decreased in popularity.

References

* Kahn, Michael A. Basic Oral and Maxillofacial Pathology. Volume 1. 2001.

External links

{{Smoking nav Conditions of the mucous membranes Smoking Oral mucosal pathology Health effects of tobacco