THIS PPT IS ONLY ABOUT THE LESIONS WHICH IS ASSOCIATION WITH THE USE OF TOBACCO AND IT CAN BE REVERSIBLE

1. BY
J.MANGAIYARKKARASI
CRRI

3.  Smoker’s palate/nicotine palatinus/nicotine
stomatitis/stomatitis nicotina palati

4. The most common effect of smoking are presented clinically
as specific white leathered lesions that develops on the hard
and soft palate .

6. The burning end of the chutta (type of cigar) is being
introduced into the oral cavity.
• In many cultures , hand rolled cigarettes and cigars are smoked with the
burning end within the mouth.
• This habit is called as ‘reverse smoking ‘ and the lesion associated with it
is called reverse smoker palate.

7. • Reverse smoker
palate has a
significant potential
to develop dysplasia
or carcinoma.

8. : in heavy cigarette , pipe and cigar smokers.
• Prevalence : Range - 0.1 to 2.5%.
• Seen in mens with pipe smokers .common in middle age and
elderly adults.

9. • Common Site :palate ,well developed and prominent on
keratinized hard palate.
• Onset :initially there is redness and inflammation of the palate.
• With long term exposure to heat, the
palatal mucosa become diffusely gray
or white ,thickened and fissured.
• Fissures and crakes may appear
producing a wrinkled , irregular
surface.
• Tonsillar pillars are usually
erythematous, numerous slightly
elevated papules are noted, usually
with punctuate red centers .

10. • In this lesion red dots can be
observed representing
ductal orifices of inflamed
accessory salivary glands
,which appears as white
umbilicated nodule with red
center that may be stain
brown by deposits of tar.
• which can be enlarged and
display metaplasia.

11. A heavy brown or black tobacco stain may be present on the teeth.

12. : in
some cases palatal
keratin becomes so
thickened that it impart
fissure or dried mud
appearance.

13. • This extensive leathery ,
white change of the hard
palate is sprinkled
throughout with
numerous red papules,
which represent inflamed
salivary duct openings.
• The gingival mucosa also
is keratotic

14. : it is characterized by
-hyperkeratosis ,
-acanthosis of palatal epithelium and
-mild ,patchy, chronic inflammation of sub epithelial connective
tissue and mucosal glands.
Squamous metaplasia of the excretory ducts is usually
seen and an inflammatory exudate may be noted
within the duct lumina.
In cases with popular elevation ,hyperplastic ductal
epithelium may be seen near the orifice ,
The degree of epithelial hyperplasia and
hyperkeratosis appears to correlate positively with the
duration and level of heat exposure .
Epithelial dysplasia rarely is seen.

15. Etiology : it is due to high
temperature rather than chemical
composition of smoke.
Mild :consisting of red , dot like
opening blanched area,
Severe :marked papules of
5mm or more with
umbilication of 2- 3 mm.
Modrate:characterized by well defined
elevation with central umbilication,

16. Palatal changes :
Keratosis – diffuse whitening of entire palatal
mucosa.
Excrescences -1-3mm elevated nodules ,
often with central red dots corresponding to
the opening of palatal mucous glands.
Patches –well defined ,elevated white plaque
which could qualify for the clinical term
leukoplakia ,
Red areas- well defined reddening of the
palatal mucosa,
Ulcerated area- crater-like areas covered by
fibrin,
Non-pigmented areas- area of palatal mucosa
which is devoid of pigmentation.

17. Clinical diagnosis – history of cigar or pipe smoking and reverse smoking with
generalized lesion of palate is key for the diagnosis
Laboratory diagnosis –in biopsy epithelium shows acanthosis and hyperkeratosis.
epithelium lining of minor salivary gland often shows squamous cell metaplasia and
hyperplasia.
Papillary hyperplasia-the lesion displays cobblestone appearance and in
stomatitis nicotina ,there is red center located on the palate of pipe or cigar
smokers.The papules of the papillary hyperplasia are focal .
Darier’s disease – they appear diffusely on palate in cobblestone pattern.
Focal epithelial hyperplasia-it is not common on palate and they are not
erythematous.
Cowden syndrome-these are multiple papillary nodules commonly seen on
gingiva.

18. Stoppage of habit – it is completely reversible, once the habit is
discontinued . If the lesion resolve within 2 weeks of cessation of
smoking.

19. -
rarely indicated.But biopsy should be performed on
any white lesion of the palatal mucosa tat persists
after 1 month of discontinuation of smoking habit
and it should be considered a true leukoplakia and
managed accordingly.

20.  It is also called as snuff pouch, tobacco pouch keratosis,
spit tobacco keratosis, smokeless tobacco keratosis.
:
 Chewing tobacco (used by men in conjunction with
outdoor activity) ,

21.  Moist snuff and
 Dry snuff (contains nitrosamines and nitrate).
 Moist stuff is the most popular& the increase in popularity may be
in part to the convenience of small, prepackaged pouches that can
be used discretely.

22.  The habit of chewing tobacco is called as smokeless tobacco or
spit tobacco use which increases the toxicity of the compounds.
 There is definitive association between this form of smokeless
tobacco and oral cancer.
 Common in young men and high school students.

23. In India tobacco is combined with
- betal leaf,
- sliced areca nut and
- powered slaked lime.

25. • Nicotine—the compound N-nitroso-nor-nicotine
(NNN), which is derived partly from bacterial action
on nicotine during the curing process, is
contributed by the action of salivary nitrites, when
tobacco is held in the mouth; occurs in greater
concentration in snuff tobacco because of the
ready absorption of nicotine and other molecules
through the oral mucosa.

26. • Location— It occurs in mucosal surface, where snuff is habitually held..
• Teeth—there is brown black extrinsic stain typically present on the enamel ,
cementum surface of the teeth adjacent to the tobacco use. There is also cervical
erosion of teeth with more prevalence of dental caries (because of high sugar
content of some brands).

27. Gingival recession is
accompanied by destruction of
facial surface of the alveolar bone
and correlates well with the
quantity of daily uses and duration
of the smokeless tobacco habit
—there is painless loss of gingival and
periodontal tissue in the area of tobacco contact .

28. HALITOSIS if a frequent finding in chronic users.
Localized or generalized wear of occlusal or incisal
sufaces especially in those using the product in dusty
environment.

29. :
It is white plaque present in the mucosa where
chewing tobacco is kept.
It is thin, gray or gray-white translucent lesion .
Margin of the lesion blends gradually into
surrounding mucosa.
sometimes mild peripheral erythema is present.

30. DEVELOPMENT OF THIS LESION is most strongly
influenced by
• duration,
• brand of tobacco used,
• early onset of smokeless tobacco use,
• total hours of daily use ,
• use of different tobacco leaves.
• amount of tobacco consumed daily,and
• number of sites routinely used for tobacco
placement.

31. • The altered mucosa typically has a
soft velvety feel on palpation and
stretching of the mucosa often reveals
a distinct ‘pouch’
• Caused by flaccidity in the chronically
stretched tissues in the area of tobacco
placement, because the tobacco is not
in the mouth during a clinical
examination , the usually stretched
mucosa appears fissured or rippled in
a fashion resembling the sand on a
beach after an ebbing tide .

32. • A soft , fissured ,
gray-white lesion
of the lower labial
mucosa located in
the area of chronic
snuff placement.
MILD TOBACCO POUCH KERATOSIS :

33. • It takes 1 to 5 years to
develop.
• once it occurs, however, the
keratosis typically remains
unchanged indefinitely
unless the tobacco contact
time is altered.
• In some cases the white
lesion gradually becomes
thickened to the point of
appearing leathery or
nodular
SEVERE TOBACCO POUCH KERATOSIS

34. The World Health Oraganization International Agency for
Re-search on cancer established in its report from 2004
that “overall ,
There is sufficient evidence that smokeless tobacco
causes oral cancer & pancreatic cancer in humans and
sufficient evidence of carcinogenicity from animals”.
• Stoppage of habit—maximum lesion is regress
following the cessation of habit.

35. :
Any lesion which remains after 6 months quitting the habit should
be send for biopsy.

36. verrucous carcinoma has been reported to occur
from snuff dipper lesion. This is also called as snuff dipper cancer

37.  Seen commonly in smokers of Nonfiltered cigarettes
come in short stubby packs, and don't have a filter end.
 These filter have tiny , invisible perforations are
present. As smoke flows through the filter, quite a bit of
air flows through the perforations and mixes in with the
smoke.
 With each drag, the smoker receives a lot of air and
much less smoke, and therefore less tar and nicotine.

39.  They are generally flat or slightly elevated nodular
white lesion on one or both lips, corresponding to the site
at which the cigarette is held and apparently smoked
down to an extremely short length.
 There is increased redness and stippling of lip in
localized area.
 Margin has elliptical, circular or irregular borders.
 Color is pale to white and is slightly elevated with
nodular or papillary shape.

41.  Leukoplakia, lichen planus, mechanical fiction, chemical
burn, chronic lip biting, candidiasis
 Cessation or reduction of smoking.