Practice Essentials
Nicotine stomatitis (smoker's palate), a lesion of the palatal mucosa, has been described in the literature since 1926. In 1941, Thoma named the lesion stomatitis nicotine because it is almost exclusively observed in individuals who smoke tobacco. [1] The name is a misnomer because it is not the nicotine that causes the lesion, but the concentrated heat stream of smoke from tobacco products. [2, 3] These mucosal changes are most often observed in pipe and reverse cigarette smokers and less often in cigarette and cigar smokers. The condition has also been noted in electronic cigarette users. [4] Generally, nicotine stomatitis is asymptomatic or mildly irritating. Patients typically report that they are either unaware of the lesion or have had it for many years without changes.
The mechanism of action of nicotine stomatitis (smoker's palate) is heat and chemical irritation from a tobacco product that acts as a local irritant, stimulating a reactive process, including inflammation, hyperplasia, and epithelial keratinization. Dentures often protect the palate from these irritants in patients who wear them.
(See the image below.)
Classic nicotine stomatitis. Note the speckled white and red appearance from the hyperkeratosis and minor salivary gland openings.
Rawal et al reported 2 cases of patients using marijuana with oral manifestations. They observed nicotine stomatitis–like lesions in addition to gingival hyperplasia and uvulitis. [5] The heat from smoking marijuana causing minor salivary gland inflammation theoretically should produce similar lesions as tobacco smoking.
Nicotine stomatitis first becomes visible as a reddened area and slowly progresses to a white, thickened, and fissured appearance. The palate has numerous minor salivary glands. They become swollen and the orifices become prominent, giving the tissue a speckled white and red appearance. Patients with nicotine stomatitis are usually asymptomatic. An association of nicotine stomatitis with human papillomavirus (HPV) infection, alcohol intake, genetics, and diet are unknown. [6]
Nicotine stomatitis affects the oral mucosa of the hard palate posterior to the rugae and the adjacent soft palate. [7, 8] . Lesions are not seen on the anterior hard palate, since there are no minor salivary glands present where the rugae are present. The red orifices of the lesions are inflamed salivary gland ducts, as shown in the image below.
If unable to make the diagnosis of nicotine stomatitis by clinical appearance or if the lesion does not resolve after cessation of smoking, perform a 5-mm punch biopsy or scalpel biopsy. A biopsy is also indicated in a patient with a symptomatic lesion, even if it appears consistent with a benign smoker’s palate, or if the patient reports that he or she is a reverse smoker.
Histologically, nicotine stomatitis lesions appear acanthotic and hyperkeratotic, with some mild-to-moderate chronic inflammation. The epithelium of the minor salivary ducts often shows squamous metaplasia.
Epidemiology
The incidence of nicotine stomatitis in the United States is unknown. However, approximately 40 million Americans smoke. [9] A large study in Saudi Arabia showed that 29.6% of all smokers had nicotine stomatitis and that 60% of pipe smokers had nicotine stomatitis. There also have been studies of smokers in India, [10] Turin, [11] and China. [12]
The appearance of nicotine stomatitis is related directly to the population that smokes tobacco products. Men and women who smoke tobacco products are affected equally by nicotine stomatitis. Women smoke pipes less often than men; therefore, nicotine stomatitis is less prevalent in women. Nicotine stomatitis is related to duration, intensity, and types of smoking and is not related to the age of the smoker. [13]
Prognosis
Nicotine stomatitis is generally a reversible lesion once the irritant is removed. The prognosis for nicotine stomatitis is excellent. Although nicotine stomatitis is caused by smoking tobacco products, it is generally not associated with dysplastic or malignant changes. [14] Essentially, it has the same malignant potential as normal hard and soft palate. [15] The exception to this is in individuals who reverse smoke. Reverse smoking is common in some parts of the Caribbean and Southeast Asia. The concentrated heat and chemicals increase the potential for malignant change. [16] Nicotine stomatitis is an indicator of heavy smoking tobacco use. Careful oral examination in these patients is needed, since these patients may have a higher risk for premalignant and malignant mucosal lesions on other oral mucosal surfaces. [17]
-
Classic nicotine stomatitis. Note the speckled white and red appearance from the hyperkeratosis and minor salivary gland openings.
-
Fissured appearance of nicotine stomatitis. Notice the gingival-palatal areas where a partial denture protects the mucosa from the heat and smoke.
-
Nicotine stomatitis in a reverse smoker. Notice the increased hyperkeratosis, hyperplasia, and swelling of minor salivary glands.
-
Inflamed salivary gland ducts in nicotine stomatitis.
