Lesion on the hard palate

In the case of burns from food or liquids, the patient will tell you that he drank or ate something hot, and he’ll have a red lesion on the tongue or roof of his mouth.

Squamous cell carcinoma of the hard palate is part of the differential diagnosis because smoking increases a patient’s risk of this form of oral cancer. Squamous cell carcinoma of the palate accounts for 5% to 15% of intraoral carcinomas, depending on whether it is on the hard or soft palate.¹ The lesions are typically red or red/white in color and have ulcerated and/or necrotic surfaces. The lesions can become exophytic if left untreated. In comparison, nicotine stomatitis does not ulcerate unless there is a concomitant disease process, which should prompt the clinician to perform further diagnostics tests.

Atrophic candidiasis is also part of the differential, and in the case of our patient, it was a concomitant infection. Candidiasis has a variable presentation, but typically presents with plaques in the oral cavity—commonly referred to as thrush. In the case of atrophic candidiasis, the lesion is usually raised and erythematous, giving a red velvety appearance of the oral mucosa.¹ It is caused by the invasion of the candidal organism into the mucosal surface. Oral candidiasis presents in patients who are immunocompromised, taking long-term corticosteroids, and using antibiotics. It is also seen in infants.² Our patient likely developed candidiasis because of his poor oral hygiene.

Pipe smoking is the usual red flag

Nicotine stomatitis is commonly seen in middle-age men who have a history of tobacco use.² It is most commonly seen in pipe smokers, but can occur in cigar and cigarette smokers, as well. The intense heat in the oral cavity generated by smoking causes changes in the oral mucosa—typically on the hard palate. The stem of the pipe increases the amount of heat directed at the hard palate, resulting in a higher incidence of nicotine stomatitis in pipe smokers.^3,4 The severity and extent of the lesion is directly proportional to the frequency of tobacco inhalation. Interestingly, the chemicals in the tobacco are not responsible for the mucosal changes, therefore there is no pre-malignant potential.

The risk of malignancy does, however, come into play if your patient does something called reverse smoking. Members of some Asian cultures practice this form of smoking, in which the lit end of the cigarette is placed in the mouth. This practice raises the risk of malignancy. Any patient with nicotine stomatitis who practices reverse smoking should have a biopsy of the lesion done.⁵