Nicotine Stomatitis

Nicotine stomatitis (smoker's palate, stomatitis nicotina) is a benign keratotic alteration of the hard palate due to chronic heat and chemical irritation from tobacco smoking, particularly pipe and cigar smoking, and reverse smoking (the lit end held inside the mouth, practised in some Asian and coastal African communities). It also follows the intake of very hot beverages in absence of tobacco, and it is present in about 1 to 10 percent of tobacco users.

Heat stimulates keratinisation of the palatal epithelium and inflammation of the minor salivary gland ducts, which dilate and display a red central punctum (the ductal opening) on the keratinised white background. Reverse smoking carries a high risk of palatal carcinoma. In conventional smokers, nicotine stomatitis itself is not premalignant (the risk is attributed to the tobacco), but it indicates exposure to carcinogens and should prompt a full oral cancer examination. Lesions resolve after cessation, usually in 2 to 4 weeks.

• Diffuse grey white thickening and fissuring of the hard palate, with multiple umbilicated small red papules (inflamed minor salivary duct openings) producing a cobblestone appearance.
• Usually asymptomatic; occasional dryness or irritation.
• Associated: tobacco stained teeth, periodontal disease, oral candidiasis (denture related), and leukoplakia elsewhere.
• Reverse smokers: more extensive ulcerated, white or red areas with leukoplakia, erythroplakia, or carcinoma of the palate.
• Red flags: red patch, ulcer, induration, nodule, or lesion that does not regress 4 to 6 weeks after stopping tobacco; lymphadenopathy.

• Clinical diagnosis from the palatal appearance with tobacco or hot beverage history.
• Complete head, neck and oral examination, including palpation of cervical nodes.
• Assess smoking habits: type (cigarette, pipe, cigar, reverse), number of pack years, and hot drink habits.
• Biopsy of any suspicious area, or if no resolution after 4 to 6 weeks of cessation: hyperkeratosis, acanthosis, chronic inflammation around minor salivary gland ducts, squamous metaplasia of ductal epithelium.
• Smear for Candida species if erythema.
• Exclude palatal candidiasis, denture stomatitis, oral leukoplakia, erythroplakia, lichen planus, squamous cell carcinoma, and papillary hyperplasia.

• Stop smoking or tobacco use, and stop reverse smoking: this is the only effective treatment and results in resolution within 2 to 4 weeks in most cases.
• Smoking cessation support: behavioural counselling plus pharmacotherapy; nicotine patch 21 mg per 24 hours for 6 weeks, then 14 mg for 2 weeks, then 7 mg for 2 weeks, with nicotine gum 2 mg or lozenge as needed; or varenicline 0.5 mg orally once daily for days 1 to 3, 0.5 mg twice daily for days 4 to 7, then 1 mg twice daily for 12 weeks; bupropion SR 150 mg once daily for 3 days then 150 mg twice daily for 7 to 12 weeks (avoid in seizure disorders).
• Allow hot drinks to cool to a drinkable temperature.
• Oral hygiene and denture care: remove dentures at night, clean with chlorhexidine 0.2 percent; treat candidiasis with miconazole oral gel 20 mg/g, 2.5 mL four times daily for 14 days.
• No topical therapy is required; do not use caustic agents.
• Biopsy and specialist referral for any persistent, red, ulcerated or indurated lesion, and in reverse smokers.
• Follow up: review at 4 to 6 weeks to confirm resolution; if not resolved, biopsy; yearly oral cancer screening in current and ex smokers (every 6 months for reverse smokers).
• Counselling: stopping tobacco removes the risk factor; benefits include lowering the risk of oral, pharyngeal and lung cancer.