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PHOTO ROUNDS Denise Rizzolo, PA-C, MS Lesion on the hard palate Care Station, Springfield, NJ [email protected] Our patient came in seeking relief from upper respiratory Thomas A. Chiodo, DDS Oral and maxillofacial surgeon, symptoms, but left with a referral to an oral surgeon private practice, Somerville, NJ; UMDNJ Dental School, Newark, NJ 58-year-old patient came into ly painful, but there was no firmness the office complaining of sinus along the soft palate, buccal mucosa, EDI TO R congestion with sinus pressure, or tongue. The patient had poor oral Richard P. Usatine, MD A University of Texas Health sore throat, and postnasal drip that had hygiene, multiple missing and carious Science Center at San Antonio been getting progressively worse over teeth, and a removable partial denture. the past week. He had tried over-the- All other mucosal surfaces were within counter decongestants, but his symp- normal limits. toms were not resolving. He told the As the patient suspected, he did have physician’s assistant (DR) that he’d had a sinus infection. He left the office with a sinus infections in the past and that he prescription for an antibiotic. He also left thought he had one now. with a referral to an oral maxillofacial sur- When asked about his general health, geon for further evaluation of the lesion. the patient indicated that he vaguely re- membered being told years ago that his FAST TRACK cholesterol was elevated, but at the time, z What is your diagnosis? The patient declined any medical treatment. He indi- cated that he hadn’t had a physical ex- z How would you manage smoked a pack amination in years. He said that he only this condition? of cigarettes a day went to the doctor when he was “sick.” for 35 years The patient was a cigarette smoker FIGURE 1 and had smoked a pack a day for 35 Lesion on the hard palate years. He said that while he smoked mostly cigarettes, he would also have an occasional cigar. He said that he had never smoked tobacco through a pipe. He also indicated that he drank 3 to 4 beers daily. While inspecting his pharynx during the physical examination, DR noted a lesion on the posterior hard palate that extended to the soft palate (FIGURE 1). It appeared macular and erythematous, and had an eroded surface. The borders of the lesion were diffuse and irregular, measuring approximately 2 cm x 3 cm. a 58-year-old man with an erythematous lesion on the During palpation, the lesion was mild- posterior hard palate that extended to the soft palate. www.jfponline.com VOL 57, NO 1 / JANUARY 2008 33 ROUNDS z Diagnosis: In the case of burns from food or Nicotine stomatitis liquids, the patient will tell you that he The oral maxillofacial surgeon (TAC) drank or ate something hot, and he’ll PHOTO concurred with the previous examina- have a red lesion on the tongue or roof tion findings. He was concerned by the of his mouth. appearance of the lesion and the history Squamous cell carcinoma of the hard of tobacco use and performed a biopsy palate is part of the differential diagnosis of the lesion. The pathology report re- because smoking increases a patient’s risk vealed that the patient had nicotine sto- of this form of oral cancer. Squamous matitis with a concomitant candidiasis cell carcinoma of the palate accounts infection. for 5% to 15% of intraoral carcinomas, Nicotine stomatitis is a common mu- depending on whether it is on the hard cosal keratosis caused by smoking tobac- or soft palate.1 The lesions are typically co. It is localized to the hard palate of the red or red/white in color and have ulcer- mouth, but can extend to the soft palate. ated and/or necrotic surfaces. The lesions The mucosa of the hard palate becomes can become exophytic if left untreated. white and thickened due to hyperkerato- In comparison, nicotine stomatitis does sis of the tissue.1 Thin red lines of nor- not ulcerate unless there is a concomitant mal mucosa can be seen throughout the disease process, which should prompt the lesion. Red dots or papules can appear in clinician to perform further diagnostics the center of the lesion, which represent tests. irritated salivary glands with inflamed Atrophic candidiasis is also part of duct openings (FIGURE 2).2 the differential, and in the case of our Our patient’s lesion had an atypi- patient, it was a concomitant infection. cal presentation. Classically the lesions Candidiasis has a variable presentation, are whiter, but in this case, the patient’s but typically presents with plaques in lesion was more erythematous. The the oral cavity—commonly referred to reason: A super-infection of candi- as thrush. In the case of atrophic can- FAST TRACK diasis caused an atrophic form of the didiasis, the lesion is usually raised It's not the condition. and erythematous, giving a red velvety appearance of the oral mucosa.1 It is chemicals in the caused by the invasion of the candidal tobacco, but the z Differential Dx includes organism into the mucosal surface. Oral heat in the oral squamous cell carcinoma candidiasis presents in patients who are cavity that is The differential diagnosis in a case of immunocompromised, taking long-term nicotine stomatitis includes: corticosteroids, and using antibiotics. responsible for the • irritation from dental appliances It is also seen in infants.2 Our patient mucosal changes • trauma from hot liquids likely developed candidiasis because of • squamous cell carcinoma his poor oral hygiene. • atrophic candidiasis. Ill-fitting dentures can cause erythem- atous lesions along the hard palate and z Pipe smoking is gingiva. The erythema from dentures is the usual red flag usually uniform in color without ulcer- Nicotine stomatitis is commonly seen in ation and follows the outline or shape of middle-age men who have a history of the oral appliance. In contrast, nicotine tobacco use.2 It is most commonly seen stomatitis will typically present on ex- in pipe smokers, but can occur in cigar posed areas of the palate and not follow and cigarette smokers, as well. The in- any specific pattern. Most lesions caused tense heat in the oral cavity generated by by irritations or trauma resolve within 2 smoking causes changes in the oral mu- weeks of removal of the offending agent. cosa—typically on the hard palate. The 34 VOL 57, NO 1 / JANUARY 2008 THE JOURNAL OF FAMILY PRACTICE Lesion on the hard palate FIGURE 2 ogy report revealed a thickened epithe- Classic presentation lial layer with no evidence of atypia or of nicotine stomatitis dysplasia. The minor salivary glands showed chronic inflammatory cells con- sistent with nicotine stomatitis. The area biopsied also contained a large amount of hyphae, consistent with candidiasis. z Treatment hinges on smoking cessation Primary treatment for nicotine stomatitis is for the patient to stop smoking. Most lesions will resolve within several months 1 This case of nicotine stomatitis of the hard palate of smoking cessation. The lesion is in- shows the typical opacification and thickening of the dicative of heavy tobacco use and other mucosa, with classic punctuate areas representing mucosal tissues of the oralpharyngeal minor salivary ducts. tract may have similar damage. There- stem of the pipe increases the amount of fore, the oropharyngeal cavity should be heat directed at the hard palate, resulting thoroughly evaluated for dysplastic or in a higher incidence of nicotine stoma- malignant lesions. titis in pipe smokers.3,4 The severity and Our patient received counseling extent of the lesion is directly propor- on tobacco cessation and oral hygiene tional to the frequency of tobacco inha- practices. He also received clotrimazole lation. Interestingly, the chemicals in the troches for the Candida infection. Two tobacco are not responsible for the mu- weeks after he started taking the anti- cosal changes, therefore there is no pre- fungal medication, and after he began malignant potential. smoking cessation efforts, the lesion sig- The risk of malignancy does, how- nificantly improved. The patient did not FAST TRACK ever, come into play if your patient does return for additional follow-up visits, so Patients who something called reverse smoking. Mem- we do not know whether the lesion re- bers of some Asian cultures practice this solved completely. n practice reverse form of smoking, in which the lit end of smoking— the cigarette is placed in the mouth. This Correspondence in which the lit end practice raises the risk of malignancy. Denise Rizzolo, PA-C, MS, 348 East Main Street, First of the cigarette Any patient with nicotine stomatitis who Floor, somerville, nJ 08876; [email protected] practices reverse smoking should have a Disclosure is placed in the biopsy of the lesion done.5 The authors reported no potential conflict of interest mouth—will need relevant to this article a biopsy References z Our approach to the Dx 1. Mark RE, Stern D. Oral and Maxillofacial Pathol- ogy: A Rational for Diagnosis and Treatment. Carol differed from the norm Stream, Ill: Quintessence Publishing Co, Inc; 2003: Typically, you’ll make the diagnosis of chap 7. nicotine stomatitis clinically, since few le- 2. Regezi JA, Sciubba J, Jordan RCK. Oral Pathol- ogy: Clinical Pathologic Conditions. 4rd ed. Phila- 1 sions resemble its appearance. The atyp- delphia, Pa: WB saunders Co; 2003. ical nature of our patient’s lesion, how- 3. Neville BW, Day TA. Oral cancer and precancerous ever, is what prompted a biopsy. You may lesions. CA Cancer J Clin 2002; 52:195–215. 4. Taybos G. Oral changes associated with tobacco also do a biopsy if there is any suspicion use.

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