Background
Nicotinic 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. Generally, it 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. See the image below.
View Image | Classic nicotine stomatitis. Note the speckled white and red appearance from the hyperkeratosis and minor salivary gland openings. |
Rawal et al reported two cases of patients using marijuana with oral manifestations. They observed nicotine stomatitis–like lesions in addition to gingival hyperplasia and uvulitis.[4] The heat from smoking marijuana causing minor salivary gland inflammation theoretically should produce similar lesions as tobacco smoking.
Pathophysiology
Nicotine stomatitis affects the oral mucosa of the hard palate posterior to the rugae and the adjacent soft palate.[5, 6] . 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.
View Image | Inflamed salivary gland ducts in nicotine stomatitis. |
Etiology
Nicotine stomatitis has been associated with pipe, cigarette, and cigar smoking, and, rarely, with chronic ingestion of high-temperature liquids or other irritants. The mechanism of action 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.
Epidemiology
Frequency
United States
The incidence of nicotinic stomatitis in the United States is unknown. However, approximately 40 million Americans smoke.[7]
International
A large study in Saudi Arabia showed that 29.6% of all smokers had nicotine stomatitis and that 60% of pipe smokers had nicotinic stomatitis. See also studies of smokers in India,[8] Turin,[9] and China.[10]
Race
The appearance of nicotine stomatitis is related directly to the population that smokes tobacco products.
Sex
Men and women who smoke tobacco products are affected equally by nicotinic stomatitis. Women smoke pipes less often than men; therefore, nicotinic stomatitis is less prevalent in women.
Age
Nicotinic stomatitis is related to duration, intensity, and types of smoking and is not related to the age of the smoker.[11]
Prognosis
Nicotine stomatitis is generally a reversible lesion once the irritant is removed. The prognosis for nicotinic stomatitis is excellent. Although nicotine stomatitis is caused by smoking tobacco products, it is generally not associated with dysplastic or malignant changes.[12] Essentially, it has the same malignant potential as normal hard and soft palate.[13] 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.[14] 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.[15]
Patient Education
Educate patients with nicotinic stomatitis concerning the dangers of tobacco use. Many cigar and pipe smokers believe that they are not at risk for cancer because they do not inhale.
History
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 nicotinic stomatitis are usually asymptomatic. An association of nicotinic stomatitis with human papillomavirus (HPV) infection, alcohol intake, genetics, and diet are unknown.[16]
Physical Examination
Lesions of nicotinic stomatitis are exclusively found on the palatal mucosa. They have a white cobblestone appearance, often with a red dot in the center of the cobblestone. The nicotinic stomatitis lesion cannot be wiped off and can have some fissuring. Nicotinic stomatitis is primarily limited to the posterior hard palate and less often to the adjacent soft palate. See the images below.
View Image | Fissured appearance of nicotine stomatitis. Notice the gingival-palatal areas where a partial denture protects the mucosa from the heat and smoke. |
View Image | Nicotine stomatitis in a reverse smoker. Notice the increased hyperkeratosis, hyperplasia, and swelling of minor salivary glands. |
Procedures
If unable to make the diagnosis of nicotinic 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.
Histologic Findings
Histologically, nicotinic stomatitis lesions appear acanthotic and hyperkeratotic, with some mild-to-moderate chronic inflammation. The epithelium of the minor salivary ducts often shows squamous metaplasia.
Approach Considerations
The only definitive treatment for nicotinic stomatitis is smoking cessation. Myung et al reported from a meta-analysis of randomized controlled trials that sufficient clinical evidence exists to support the use of computer- and Internet-based smoking cessation programs in adults who smoke.[17]
If any of the smoking-cessation medications appear to be effective, continue medications in conjunction with support groups. The most effective long-term smoking-cessation results are observed in patients who are members of support groups.
Consultations
If a patient is interested in stopping the tobacco habit, a referral to a comprehensive smoking-cessation program is indicated. This program should include peer-group sessions.[18, 19]
Prevention
To prevent nicotinic stomatitis lesions and other more serious tobacco-induced lesions in the oral cavity, counsel patients on the dangers of tobacco use. Once they understand the need to stop using tobacco products, make a referral to a comprehensive tobacco-cessation program.
Long-Term Monitoring
Monitor patients with nicotine stomatitis. If after smoking cessation the lesion does not resolve, further investigation is warranted.
Medication Summary
Medical therapy for nicotinic stomatitis is directed at smoking cessation.[20, 21] Varenicline decreases the stimulatory effect from consuming nicotine products by blocking nicotine receptors.[22, 23]
Nicotine transdermal system (Nicotrol, NicoDerm CQ, Habitrol)
Clinical Context:
The nicotine transdermal system works best when used in conjunction with a support program (eg, counseling, group therapy, behavioral therapy).
Class Summary
Nicotine substitutes are available as a transdermal patch, gum, an inhaler, or nasal spray.
Bupropion (Zyban)
Clinical Context:
Bupropion inhibits neuronal dopamine reuptake in addition to being a weak blocker of serotonin and norepinephrine reuptake.
Class Summary
These are used in conjunction with a support group and/or behavioral counseling.
Varenicline (Chantix)
Clinical Context:
Varenicline is a partial agonist selective for alpha4, beta2 nicotinic acetylcholine receptors. Its action is thought to result from activity at a nicotinic receptor subtype, where its binding produces agonist activity while simultaneously preventing nicotine binding. Agonistic activity is significantly lower than nicotine. It also elicits moderate affinity for 5-HT3 receptors. Maximum plasma concentrations occur within 3-4 hours after oral administration. Following regular dosing, a steady state reached within 4 days.
Class Summary
Nicotinic acetylcholine receptor partial agonists bind to nicotine receptors and elicit mild nicotine central effects to ease withdrawal symptoms.
Author
James E Cade, DDS, Associate Professor, Chair, Department of Oral Diagnostic Sciences, Meharry Medical College School of Dentistry; Private Practice, Honeycutt Family Dentistry
Disclosure: Nothing to disclose.
Specialty Editors
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
Disclosure: Nothing to disclose.
Drore Eisen, MD, DDS, Consulting Staff, Dermatology of Southwest Ohio
Disclosure: Nothing to disclose.
Chief Editor
Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant Professor, Department of Oral Medicine, University of Washington School of Dental Medicine; (Retired) Attending in Pain Center, University of Washington Medical Center; (Retired) Private Practice in Hawaii and Washington; Director, Oral Care Research Associates
Disclosure: Nothing to disclose.
Additional Contributors
Dana Gelman Keiles, DMD, Assistant Clinical Professor, Department of Stomatology, University of California at San Francisco
Disclosure: Nothing to disclose.
Marjan Garmyn, MD, PhD, Professor, Faculty of Medicine, Katholieke Universiteit Leuven, Belgium; Chair and Adjunct Head, Department of Dermatology, University of Leuven, Belgium
Disclosure: Nothing to disclose.
Sol Silverman, DDS, MA, DipABOM, Professor Emeritus, Department of Orofacial Sciences, University of California at San Francisco
Disclosure: Nothing to disclose.
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