History

Patients may present asymptomatically, admitting only to the use of smokeless tobacco or to the presence of other predisposing risk factors (eg, use of alcohol, exposure to chronic irritants) for premalignant and cancerous lesions. In more advanced disease, patients may report pain, swelling, or dysphagia.

Gingivitis

Gingivitis appears as inflammation and swelling of the gums that may associated with redness and bleeding. Gums may be tender when touched.

Leukoplakia

Leukoplakia refers to a filmy white or yellow patch involving the oral mucosa. The patch may appear translucent or opaque and raised or ulcerated. It may be pumicelike. Leukoplakia is a clinically descriptive term, and other diseases must be ruled out.^[43]

Erythroplasia

Erythroplasia appears as a patch with varying degrees of erythema. It most commonly occurs on the floor of the mouth.

Speckled leukoplakia

The lesions are white patches with interspersed areas of erythema. Two thirds of the lesions are located on the buccal mucosa; the tumors are commonly nodular.

Tobacco-associated keratosis

Tobacco-associated keratosis is an ill-defined area of white thickening at the sites where oral smokeless tobacco is habitually placed; most commonly, these areas involve the mandibular labial and buccal mucosal folds. The continued use of smokeless tobacco causes the affected areas to become corrugated and grayer.

Verrucous carcinoma

The lesions appear as exophytic growths with papillary projections, they may be large at the time of diagnosis, and they can cause local tissue destruction. They appear rough surfaced with a broad-base attachment.

Squamous cell carcinoma

The lesions usually have a mixed red and white appearance, with ulceration or inflammation in some cases. The lesions are most commonly found on the floor of the mouth and on the ventral and lateral surfaces of the tongue. Those cancers associated with smokeless tobacco may arise in differing locations associated with quid placement and/or the buccal folds. Swelling or induration is characteristic of invasive growth.

Differential Diagnoses

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Media Gallery

Verrucous carcinoma.
Oral leukoplakia.

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Author

Carol E Cheng, MD Assistant Clinical Professor of Dermatology, University of California, Los Angeles, David Geffen School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Maryanne Makredes, MD Resident Physician, Division of Dermatology, University of Massachusetts Medical Center

Maryanne Makredes, MD is a member of the following medical societies: Phi Beta Kappa

Disclosure: Nothing to disclose.

Alexa Boer Kimball, MD, MPH Professor of Dermatology, Harvard Medical School; Senior Vice President, Service Excellence and Practice Improvement, Massachusetts General Physicians Organization, Vice Chair, Department of Dermatology, Director, Clinical Unit for Research Trials in Skin (CURTIS), Massachusetts General Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS Consulting Staff, Dermatology of Southwest Ohio

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Additional Contributors

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: Received consulting fee from Orfagen for consulting; Received consulting fee from Maruho for consulting; Received consulting fee from Astellas for consulting; Received consulting fee from Abbott for consulting; Received consulting fee from Leo Pharma for consulting; Received consulting fee from Biogenoma for consulting; Received honoraria from Janssen for speaking and teaching; Received honoraria from Medac for speaking and teaching; Received consulting fee from Dignity Sciences for consulting; .

Acknowledgements

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

Disclosure: Nothing to disclose.