eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa

Smokeless Tobacco Lesions: Differential Diagnoses & Workup

Author: Jacqueline Dolev, MD, Assistant Clinical Professor, Director for the Advancement of Medical Education in Dermatology, Department of Dermatology, University of California, San Francisco Medical Center
Coauthor(s): Maryanne Kazanis, Doris Duke Clinical Research Fellow, Clinical Unit for Research Trials in Skin, Department of Dermatology, Brigham and Women's Hospital; Alexa F Boer Kimball, MD, MPH, Associate Professor of Dermatology, Harvard University School of Medicine; Vice Chair, Department of Dermatology, Massachusetts General Hospital; Director of Clinical Unit for Research Trials in Skin (CURTIS), Department of Dermatology, Massachusetts General Hospital and Brigham and Women's Hospital
Contributor Information and Disclosures

Updated: Nov 12, 2008

Differential Diagnoses

Keratoacanthoma
Nicotine Stomatitis
Oral Frictional Hyperkeratosis
Oral Lichen Planus

Other Problems to Be Considered

Chronic hyperplastic candidiasis
Focal frictional hyperkeratosis
Idiopathic leukoplakia
Leukoedema
Traumatic ulceration
White hairy tongue
White sponge nevus

Keratoacanthoma is a benign epithelial proliferation from unknown causes. It is usually found on the vermilion border, but it may also occur on the oral mucosa. It appears as a firm, white nodule with a roughened, central region. It grows rapidly and then stabilizes or regresses in size. Histologically, it appears as epithelial thickening with a central plug, without evidence of atypia.

Nicotinic stomatitis is a diffuse, rough, white thickening with erythematous papules on the hard palate caused by exposure to heat from smoke or burning tobacco. The lesions may also present as umbilicated nodules with central red spots. The erythematous papules or red spots are caused by irritation to the openings of the minor salivary glands. Stomatitis is asymptomatic, benign, and typically found in middle-aged and elderly men. When biopsy samples are obtained, the epithelium shows reactive hyperplasia with ductal squamous metaplasia and chronic inflammation. See Nicotine Stomatitis for more information.

Workup

Laboratory Studies

No blood tests are available to help diagnose cancers of the oral cavity.

Imaging Studies

Typically, imaging studies are reserved for staging purposes once oral cancer has been diagnosed. Chest radiography, barium swallow, MRI, and positron emission tomography scanning may be used to rule out the involvement of other organ systems.

Other Tests

A thorough history, including an assessment of the risk factors, and a careful examination of the oral cavity are the most important clinical tools in diagnosing oral lesions. The physical examination must include an assessment of the cervical lymph nodes.

Procedures

In order to better visualize lesions of the throat, base of the tongue, and larynx, indirect pharyngoscopy and laryngoscopy may be performed. In addition, if suspicion for a head or neck cancer is strong, endoscopy may be performed to more thoroughly examine the oral cavity, oropharynx, larynx, esophagus, trachea, and bronchi.

Exfoliative cytology of a suggestive lesion may be performed, but oral cancer can only be definitively diagnosed based on findings from an incisional biopsy.

Histologic Findings

Tobacco-associated keratosis appears as epidermal thickening or hyperkeratosis and acanthosis. Dysplasia is uncommon in this lesion.

Leukoplakia appears as hyperkeratosis due to chronic irritation in approximately 80% of cases. A minority of lesions shows precancerous changes with varying degrees of dysplasia.

Speckled leukoplakia exhibits both epithelial hyperplasia and epithelial atrophy. Dysplasia occurs in 50-70% of all lesions, but carcinoma is rarely diagnosed. Candidal infection may be a common finding, with an inflammatory infiltrate of lymphocytes and plasma cells in the underlying connective tissue. The role of candidal species in causation of the lesion is unclear.

Erythroplasia shows mild-to-moderate epithelial dysplasia in only 9% of lesions obtained from biopsy samples. Severe dysplasia, CIS, or SCC is often apparent. The clinical size of the lesion is not correlated with microscopic severity.

CIS refers to severe dysplasia extending the full thickness of the epithelium. Grossly, CIS may appear as leukoplakia, speckled leukoplakia, erythroplasia, or keratosis.

At histologic examination, SCC shows increased cellular proliferation, atypical mitotic figures, loss of cell cohesion, and/or atypical keratinization. Invasive growth is indicated by the invasion of tumor cells into the epithelial basement membrane. Verrucous carcinoma is a specific form of SCC that exhibits a high level of differentiation.

Staging

See the American Cancer Society detailed guide on oral cavity and oropharyngeal cancer: " How Are Oral Cavity and Oropharyngeal Cancers Staged." 

More on Smokeless Tobacco Lesions

Overview: Smokeless Tobacco Lesions
Differential Diagnoses & Workup: Smokeless Tobacco Lesions
Treatment & Medication: Smokeless Tobacco Lesions
Follow-up: Smokeless Tobacco Lesions
Multimedia: Smokeless Tobacco Lesions
References
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References

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Further Reading

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Keywords

oral lesions, premalignant leukoplakia, leukoplakia, speckled leukoplakia, carcinoma in situ, CIS, squamous cell carcinoma, SCC, oral cancer, buccal mucosal cancer, erythroplasia, erythroplakia, tobacco-associated keratosis, verrucous carcinoma, snuff dipper's cancer

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Contributor Information and Disclosures

Author

Jacqueline Dolev, MD, Assistant Clinical Professor, Director for the Advancement of Medical Education in Dermatology, Department of Dermatology, University of California, San Francisco Medical Center
Jacqueline Dolev, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, and California Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Maryanne Kazanis, Doris Duke Clinical Research Fellow, Clinical Unit for Research Trials in Skin, Department of Dermatology, Brigham and Women's Hospital
Maryanne Kazanis is a member of the following medical societies: Phi Beta Kappa
Disclosure: Nothing to disclose.

Alexa F Boer Kimball, MD, MPH, Associate Professor of Dermatology, Harvard University School of Medicine; Vice Chair, Department of Dermatology, Massachusetts General Hospital; Director of Clinical Unit for Research Trials in Skin (CURTIS), Department of Dermatology, Massachusetts General Hospital and Brigham and Women's Hospital
Alexa F Boer Kimball, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Medical Editor

Jacek C Szepietowski, MD, PhD, Professor, Vice-Head, Department of Dermatology, Venereology and Allergology, Wroclaw Medical University; Director of the Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Poland
Disclosure: Stiefel Salary Employment; Orfagen Consulting fee Consulting; Maruho Consulting fee Consulting; Astellas Consulting fee Consulting

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Drore Eisen, MD, DDS, Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati
Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, and American Dental Association
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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