Photo Quiz

Lesions on the Roof of the Mouth


Am Fam Physician. 2019 Mar 1;99(5):327-328.

A 29-year-old man presented with a painless, white area on the roof of his mouth that had been present for three months. He had no difficulty with eating or drinking. He was otherwise healthy with no medical conditions, although he had poor dentition. He had smoked cigarettes and used chewing tobacco for 11 years.

The oral examination revealed multiple brown to red punctate lesions against a white background on the palate (Figure 1).

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Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Leukoedema.

B. Nicotine stomatitis.

C. Oral candidiasis.

D. Oral lichen planus.


The answer is B: nicotine stomatitis. Tobacco and its combustion products can cause a wide variety of lesions in the oral cavity, including leukoplakia, leukoedema, black hairy tongue, and nicotine stomatitis. Nicotine stomatitis commonly occurs in pipe smokers because the heat from the pipe stem is directed toward the palate. It can also occur in cigarette smokers who reverse smoke and in people who drink hot tea and coffee. The classic presentation is multiple red, umbilicated papules against a gray-white background (smoker's palate).1

The brown to red punctate lesions are inflamed mucous gland orifices, which predominate over the posterior part of the hard palate. The diffuse white background is secondary to increased keratinization. Histopathology shows hyperkeratosis, parakeratosis, and acanthosis1 and may demonstrate a chronic sialodochitis (inflammation of the salivary ducts). Nicotine stomatitis lesions are asymptomatic

Address correspondence to Keshavamurthy Vinay, MD, DNB, MNAMS, MRCP (SCE), at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


1. Prabowo DM, Widodo HB. Nicotine stomatitis in smokers: a case report. J Dentomaxillofac Sci. 2018;1:58–60.

2. Martin JL. Leukoedema: a review of the literature. J Natl Med Assoc. 1992;84(11):938–940.

3. Gupta S, Jawanda MK. Oral lichen planus: an update on etiology, pathogenesis, clinical presentation, diagnosis and management. Indian JDermatol. 2015;60(3):222–229.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

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