Our 55 year old patient has multiple tiny papules on the posterior of his hard palate. He was coming in for a routine appointment when we questioned him about this affected area. There was no pain, no history of any kind of trauma or thermal injury reported, but he did admit to a 12 year history of pipe-smoking. In his past dental history, it shows he attended routine exams and has had restorative treatment. When he attended this latest dental appointment, he appeared to be in overall good health. His vital signs were also observed and were within normal limits. We also did an examination of the head and neck region, which showed no palpable lymph nodes. It was when we did the intraoral exam, that we noticed the abnormal papules on his hard palate. They appeared flat-topped, white, small, and there was several of them. In the center of the white keratotic ring, there were tiny red spots that could not be removed by scraping or wiping off. When we observed the surrounding areas, the soft palate looked wrinkled and fissured. There were no other lesions or issues present throughout the rest of the examination.
Nicotine stomatitis is a benign lesion most commonly seen on the posterior of the hard palate, although if severe enough it can extend to the soft palate as well. It has an appearance of raised erythematious papules centered on a white lesion. They are irritated minor salivary glands on the palate and the raised red dots will appear due to the opening of the gland’s ducts. These glands are inflamed from obstruction by keratin at the mucosal opening of the ducts. These issues are typically from pipe and cigar smoking, although it can occur from heavy cigarette smoking too. If a cigarette smoker is smoking this intense, he also has a higher risk of developing malignancy in other locations in the oral cavity and respiratory tract.Nicotine stomatitis can also be from irritation from dental appliances, trauma from hot liquids, squamous cell carcinoma, or atrophic candidiasis. If you have a patient with this complication, they will probably have mild pain if any at all. After evaluating our patient, we would consider his condition to be nicotine stomatitis. The appearance of his condition when doing his intraoral examination is the matching description we have researched. He was unaware that he had a problem and was showing no symptoms, like pain, which is not unusual for this issue. When he reported his history of pipe-smoking and we could not find any other issues with his surrounding mucosa, it has lead us to believe nicotine stomatitis is definitely his diagnosis.
Hyperplastic candidiasis, also known as candidal leukoplakia, is a lesion that does not wipe off from the mucosa when you swab it with gauze. This lesion occurs in adults with no valid susceptibility to infection by candidiasis albicans, and it is deemed to appear as a premalignant lesion. Hyperplastic candidiasis may involve the dorsum of the tongue in a pattern similar to median rhomboid glossitis. It is usually asymptomatic and is generally discovered on routine oral examinations. The lesion is found anterior to the circumvallate papillae and has a rhomboid outline. It may have a smooth, nodular, or fissured surface and may range in color from white to a more characteristic red. It can be on either the tongue or the palate and occasionally will be mildly painful. In our patients report there was no pain and he admitted to a 12 year history of pipe-smoking. From these findings, it would not match up with hyperplastic candidiasis because there is a mild pain involved and smoking is not an indication.
White sponge nevus:
The etiology of white sponge nevus (WSN), or Cannon disease, is an autosomal-dominant condition that appears to be from keratin 4 and/or 13 point mutation. One can either be born with this disorder or it can come on later before puberty. It is a white, wrinkled, soft, folding oral mucosa and no treatment is required. With this disease the buccal mucosa is always affected and in most cases it is bilateral, but the free gingival margin is not altered. It can also be located in other areas such as the tongue and the vestibular mucosa. The lesions are thickened, have a spongy consistency, and they are asymptomatic and benign. We conclude that this disease could not be our diagnosis for our patient mostly because the patient’s lesion is located at the hard palate and white sponge nevus does not affect the palatal region. Also, WSN occurs in adolescence opposed to our 55 year old patient.
Inflammatory Papillary Hyperplasia:
Inflammatory papillary hyperplasia, also known as the “cobblestone” lesion, is a painless lesion located on the hard palate of denture wearers. It is usually red and inflamed as a reaction to a poorly fitted denture. There may be fungal overgrowth, but the lesion may clear up if the denture is taken away and given time to heal. Seeing as how our patient does not wear a denture, his diagnosis could not be inflammatory papillary hyperplasia.
Proliferative Verrucous Leukoplakia (PVL):
Proliferative verrucous leukoplakia starts out as a keratosis and eventually progresses to a verrucous nature. It is persistent, multifocal, and sometimes aggressive. It is also common for it to reoccur. The cause is unknown, but it is believed to be associated with HPV and tobacco use. Our patient’s lesion is not verrucous (wart-like) in nature, and it is only on the hard palate, not multifocal. This leads us to believe that proliferative verrucous leukoplakia is not his diagnosis.
Ibsen, OAC & Phelan, JA., Oral Pathology for the Dental Hygienist, WB Saunders Co., Fifth Edition, 2009, Pgs 52, 125, and 217-218.