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Nicotine stomatitis


Author: Sanketh DS, MDS


Nicotine stomatitis is a common form of keratosis of the hard palate seen in long-term smokers. It is commonly associated with pipe smokers, although it is seen in cigar and cigarette smoking as well. Long-term use of extremely hot beverages could also cause similar changes in the hard palate. Patients are usually either unaware of the lesion or might have had it for years.

The lesion develops due to the heat generated from the tobacco product which as result induces a reactive process causing inflammation, hyperplasia and keratinization of the palatal mucosal epithelium. Nicotine stomatitis does not arise as a result of the chemical carcinogens in the tobacco smoke and hence is not potentially malignant by nature and should not be confused for leukoplakia.  

Keratosis and other changes seen on the hard palate could be intensified and has a significant risk of becoming malignant when…

…the tobacco product is reverse smoked with the lit/burning end of the cigarette inside the oral cavity. This form of smoking is called reverse smoking and the palatal change occurring as a result is called “reverse smoker’s palate”. This lesion has significant potential to become squamous cell carcinoma. 


Nicotine stomatitis is seen exclusively on the hard palate, is more prevalent in men than women and could appear in any age although it may be commonly seen in the 4th to 5th decades of life. The lesion is asymptomatic and may cause slight irritation rarely. The lesion starts initially as erythematous red changes on the palate subsequently progressing to become diffusely white, thickened and fissured and may also extend to the lingual gingiva and the interdental papilla.

The palate appears diffusely white or greyish-white with elevated papules having red dots at the centre. The palate has numerous minor salivary glands and the red dots represent their inflamed ducts.


Under the microscope, nicotine stomatitis reveals hyperkeratosis and hyperplasia of the epithelium. There may be mild chronic inflammation in the stroma and around salivary glands. Salivary gland excretory ducts may show squamous metaplasia.


Nicotine stomatitis is a reversible lesion, and regresses within 1-2 weeks on cessation of smoking. Although nicotine stomatitis is not premalignant, care must be taken to screen other high risk areas for any suspicious mucosal changes due to smoking. However, exercise precaution if the palatal lesion does not regress even after a month of smoking cessation. Such lesions must be considered as true leukoplakias and may warrant a biopsy to rule out dysplastic or malignant changes.


Oral and Maxillofacial Pathology.Neville,Damm,Allen,Chi. South Asian Edition.

Oral Pathology: Clinicopathologic correlations.Regezzi,Sciubba,Jorda.5th Edition.

Keiles DG. Nicotine Stomatitis. 2016. Available at


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