Diagnostic Considerations

Also consider the following:

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. Keratoacanthoma 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, keratoacanthoma 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.

Differential Diagnoses

Workup

Eaton DK, Kann L, Kinchen S, Shanklin S, Flint KH, Hawkins J, et al. Youth risk behavior surveillance - United States, 2011. MMWR Surveill Summ. 2012 Jun 8. 61 (4):1-162. [QxMD MEDLINE Link].
Ali AK, Mohammed A, Thomas AA, Paul S, Shahul M, Kasim K. Tobacco Abuse and Associated Oral Lesions among Interstate Migrant Construction Workers. J Contemp Dent Pract. 2017 Aug 1. 18 (8):695-699. [QxMD MEDLINE Link].
Naveen-Kumar B, Tatapudi R, Sudhakara-Reddy R, Alapati S, Pavani K, Sai-Praveen KN. Various forms of tobacco usage and its associated oral mucosal lesions. J Clin Exp Dent. 2016 Apr. 8 (2):e172-7. [QxMD MEDLINE Link]. [Full Text].
Wahlberg I, Ringberger T. Smokeless tobacco. Davis DL, Nielsen MT, ed. Tobacco: production, chemistry and technology. (United Kingdom): Blackwell ScienceOxford; 1999. 452-460.
Centers for Disease Control and Prevention. From the Centers for Disease Control and Prevention. State-specific prevalence among adults of current cigarette smoking and smokeless tobacco use and per capita tax-paid sales of cigarettes--United States, 1997. JAMA. 1999 Jan 6. 281(1):29-30. [QxMD MEDLINE Link].
Javed F, Altamash M, Klinge B, Engström PE. Periodontal conditions and oral symptoms in gutka-chewers with and without type 2 diabetes. Acta Odontol Scand. 2008 Oct. 66(5):268-73. [QxMD MEDLINE Link].
Arrazola RA, Singh T, Corey CG, Husten CG, Neff LJ, Apelberg BJ, et al. Tobacco use among middle and high school students - United States, 2011-2014. MMWR Morb Mortal Wkly Rep. 2015 Apr 17. 64 (14):381-5. [QxMD MEDLINE Link].
Couch ET, Chaffee BW, Gansky SA, Walsh MM. The changing tobacco landscape: What dental professionals need to know. J Am Dent Assoc. 2016 Mar 14. [QxMD MEDLINE Link].
Warnakulasuriya KA, Ralhan R. Clinical, pathological, cellular and molecular lesions caused by oral smokeless tobacco--a review. J Oral Pathol Med. 2007 Feb. 36(2):63-77. [QxMD MEDLINE Link].
Luo J, Ye W, Zendehdel K, et al. Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a retrospective cohort study. Lancet. 2007 Jun 16. 369(9578):2015-20. [QxMD MEDLINE Link].
Hassan MM, Abbruzzese JL, Bondy ML, et al. Passive smoking and the use of noncigarette tobacco products in association with risk for pancreatic cancer: a case-control study. Cancer. 2007 Jun 15. 109(12):2547-56. [QxMD MEDLINE Link]. [Full Text].
Boffetta P, Aagnes B, Weiderpass E, Andersen A. Smokeless tobacco use and risk of cancer of the pancreas and other organs. Int J Cancer. 2005 May 10. 114(6):992-5. [QxMD MEDLINE Link].
Alguacil J, Silverman DT. Smokeless and other noncigarette tobacco use and pancreatic cancer: a case-control study based on direct interviews. Cancer Epidemiol Biomarkers Prev. 2004 Jan. 13(1):55-8. [QxMD MEDLINE Link].
Greer RO Jr. Oral manifestations of smokeless tobacco use. Otolaryngol Clin North Am. 2011 Feb. 44(1):31-56, v. [QxMD MEDLINE Link].
Sujatha D, Hebbar PB, Pai A. Prevalence and correlation of oral lesions among tobacco smokers, tobacco chewers, areca nut and alcohol users. Asian Pac J Cancer Prev. 2012. 13(4):1633-7. [QxMD MEDLINE Link].
Shulman JD, Beach MM, Rivera-Hidalgo F. The prevalence of oral mucosal lesions in U.S. adults: data from the Third National Health and Nutrition Examination Survey, 1988-1994. J Am Dent Assoc. 2004 Sep. 135(9):1279-86. [QxMD MEDLINE Link].
Greer RO Jr. Oral manifestations of smokeless tobacco use. Otolaryngol Clin North Am. 2011 Feb. 44(1):31-56, v. [QxMD MEDLINE Link].
Ahmed HG, Mahgoob RM. Impact of Toombak dipping in the etiology of oral cancer: gender-exclusive hazard in the Sudan. J Cancer Res Ther. 2007 Apr-Jun. 3(2):127-30. [QxMD MEDLINE Link].
Scheifele C, Nassar A, Reichart PA. Prevalence of oral cancer and potentially malignant lesions among shammah users in Yemen. Oral Oncol. 2007 Jan. 43(1):42-50. [QxMD MEDLINE Link].
Martin GC, Brown JP, Eifler CW, Houston GD. Oral leukoplakia status six weeks after cessation of smokeless tobacco use. J Am Dent Assoc. 1999 Jul. 130(7):945-54. [QxMD MEDLINE Link].
Sand L, Wallström M, Hirsch JM. Smokeless tobacco, viruses and oral cancer. Oral Health Dent Manag. 2014 Jun. 13(2):372-8. [QxMD MEDLINE Link].
Nilsson R. The molecular basis for induction of human cancers by tobacco specific nitrosamines. Regul Toxicol Pharmacol. 2011 Jul. 60(2):268-80. [QxMD MEDLINE Link].
Rostron BL, Chang CM, van Bemmel DM, Xia Y, Blount BC. Nicotine and Toxicant Exposure among U.S. Smokeless Tobacco Users: Results from 1999 to 2012 National Health and Nutrition Examination Survey Data. Cancer Epidemiol Biomarkers Prev. 2015 Dec. 24 (12):1829-37. [QxMD MEDLINE Link].
Yildiz D, Liu YS, Ercal N, Armstrong DW. Comparison of pure nicotine- and smokeless tobacco extract-induced toxicities and oxidative stress. Arch Environ Contam Toxicol. 1999 Nov. 37(4):434-9. [QxMD MEDLINE Link].
Tilashalski K, Rodu B, Mayfield C. Assessing the nicotine content of smokeless tobacco products. J Am Dent Assoc. 1994 May. 125(5):590-2, 594. [QxMD MEDLINE Link].
Cogliano V, Straif K, Baan R, Grosse Y, Secretan B, El Ghissassi F. Smokeless tobacco and tobacco-related nitrosamines. Lancet Oncol. 2004 Dec. 5(12):708. [QxMD MEDLINE Link].
Gray N, Hecht SS. Smokeless tobacco--proposals for regulation. Lancet. 2010 May 8. 375(9726):1589-91. [QxMD MEDLINE Link].
Mehari A, Hines C, Gillum RF. Smokeless tobacco use and fractional exhaled nitric oxide in men in a national survey. Ann Allergy Asthma Immunol. 2016 Feb 18. [QxMD MEDLINE Link].
Javed F, Tenenbaum HC, Nogueira-Filho G, et al. Oral Candida carriage and species prevalence amongst habitual gutka-chewers and non-chewers. Int Wound J. 2012 Aug 10. [QxMD MEDLINE Link].
Smokeless tobacco report for the year 2006. Federal Trade Commission. 2009.
Christen AG, Armstrong WR, McDaniel RK. Intraoral leukoplakia, abrasion, periodontal breakdown, and tooth loss in a snuff dipper. J Am Dent Assoc. 1979 Apr. 98(4):584-6. [QxMD MEDLINE Link].
Greer RO, Poulson TC, Boone ME, Lindenmuth JE, Crosby L. Smokeless tobacco-associated oral changes in juvenile, adult and geriatric patients: clinical and histomorphologic features. Gerodontics. 1986 Jun. 2(3):87-98. [QxMD MEDLINE Link].
Tomar SL, Alpert HR, Connolly GN. Patterns of dual use of cigarettes and smokeless tobacco among US males: findings from national surveys. Tob Control. 2010 Apr. 19(2):104-9. [QxMD MEDLINE Link]. [Full Text].
Agaku IT, King BA, Husten CG, Bunnell R, et al. Tobacco product use among adults - United States, 2012-2013. MMWR Morb Mortal Wkly Rep. 2014 Jun 27. 63(25):542-7. [QxMD MEDLINE Link].
McClave AK, Whitney N, Thorne SL, Mariolis P, Dube SR, Engstrom M. Adult tobacco survey - 19 States, 2003-2007. MMWR Surveill Summ. 2010 Apr 16. 59(3):1-75. [QxMD MEDLINE Link].
McClellan SF, Olde BA, Freeman DH, Mann WF, Rotruck JR. Smokeless tobacco use among military flight personnel: a survey of 543 aviators. Aviat Space Environ Med. 2010 Jun. 81(6):575-80. [QxMD MEDLINE Link].
American Cancer Society. What are the key statistics about oral cavity and oropharyngeal cancers?. Cancer.org. Available at http://www.cancer.org/cancer/oralcavityandoropharyngealcancer/detailedguide/oral-cavity-and-oropharyngeal-cancer-key-statistics. January 27, 2016; Accessed: March 26, 2016.
World Health OrganizationGlobal. facts on tobacco or oral health. Available at http://www.who.int/oral_health/publications/fact_sheet_tobacco/en/index1.html. Accessed: 2005.
Global Data on Incidence of Oral Cancer. World Health Organization - Oral Health. Available at http://www.who.int/oral_health/publications/cancer_maps/en/. Accessed: June 28, 2010.
Siddiqi K, Shah S, Abbas SM, Vidyasagaran A, Jawad M, Dogar O, et al. Global burden of disease due to smokeless tobacco consumption in adults: analysis of data from 113 countries. BMC Med. 2015 Aug 17. 13:194. [QxMD MEDLINE Link].
Oral Cancer Incidence (New Cases) by Age, Race, and Gender. National Institute of Dental and Craniofacial Research. March 20, 2010. Available at http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/OralCancer/OralCancerIncidence.htm.
Bolinder G, Alfredsson L, Englund A, de Faire U. Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. Am J Public Health. 1994 Mar. 84(3):399-404. [QxMD MEDLINE Link]. [Full Text].
Carrard VC, van der Waal I. A clinical diagnosis of oral leukoplakia; A guide for dentists. Med Oral Patol Oral Cir Bucal. 2018 Jan 1. 23 (1):e59-e64. [QxMD MEDLINE Link]. [Full Text].
Ebbert JO, Edmonds A, Luo X, Jensen J, Hatsukami DK. Smokeless tobacco reduction with the nicotine lozenge and behavioral intervention. Nicotine Tob Res. 2010 Aug. 12(8):823-7. [QxMD MEDLINE Link]. [Full Text].
National Spit Tabacco Education Program. Available at http://www.nstep.org. Accessed: June 20, 2002.
Campaign for Tobacco-Free Kids. Knock Tobacco out of the Park. Tobacco Free Baseball.org. Available at http://tobaccofreebaseball.org/content/. Accessed: March 26, 2016.
Ebbert JO, Montori V, Vickers KS, Erwin PC, Dale LC, Stead LF. Interventions for smokeless tobacco use cessation. Cochrane Database Syst Rev. 2007 Oct 17. CD004306. [QxMD MEDLINE Link].
American Cancer Society. What are the risk factors for oral cavity and oropharyngeal cancers?. Cancer.org. Available at http://www.cancer.org/cancer/oralcavityandoropharyngealcancer/detailedguide/oral-cavity-and-oropharyngeal-cancer-risk-factors. January 27, 2016; Accessed: March 26, 2016.
Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline 2008. U.S. Department of Health & Human Services. Available at http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html. 2008; Accessed: March 26, 2016.
Dale LC, Ebbert JO, Hays JT, Hurt RD. Treatment of nicotine dependence. Mayo Clin Proc. 2000 Dec. 75(12):1311-6. [QxMD MEDLINE Link].
Ebbert JO, Fagerstrom K. Pharmacological interventions for the treatment of smokeless tobacco use. CNS Drugs. 2012 Jan 1. 26 (1):1-10. [QxMD MEDLINE Link].

Media Gallery

Verrucous carcinoma.
Oral leukoplakia.

of 2

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.

Smokeless Tobacco Lesions Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

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