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Excessive use of tobacco has been associated with several lesions in the oral cavity, which include tooth stain, tobacco-related blanching of mucosa seen in chewers, abrasions, tobacco excrescence, smokers melanosis, periodontal conditions, burns and keratotic patches, hairy tongue, acute necrotising ulcerative gingivitis, stomatitis nicotina palati (smoker’s palate), palatal erosions, leukoplakias and squamous cell carcinomas.

Stomatitis nicotina palati: These lesions appear as red areas progressing to white thickened and fissured areas. Minor salivary glands in these areas swell, and the orifices become more prominent giving a speckled white and red appearance. The lesion is often limited to the posterior hard palate. Generally these lesions are asymptomatic, but mild irritation may be present. This is more common in pipe and reverse smokers and less common among cigarette and cigar smokers. Cessation of smoking is indicated, and a biopsy is recommended if clinically suspicious of malignant transformation or in those with history of reverse smoking.


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Figure 1: Stomatitis nicotina palati. Note the diffuse greyish-white appearance of the hard palate in this 42–year-old man who has been a heavy bidi smoker for the past 20 years. The palatal minor salivary glands appear as white umblicated nodules with red centers which are the orifices of the glands.
Figure 2: Stomatitis nicotina palati or smoker’s palate. Note the diffuse, grayish-white multi-nodular appearance of the hard palate in this 50–year-old habitual smoker. The small red spot in the centre of each nodule corresponds to the opening of the minor salivary gland.
Figure 3: Palatal erythema. Note the palatal excrescences in an individual who has been a heavy smoker for the past 10 years. The elevated red areas are the orifices of the palatal minor salivary glands.
Figure 4: Stomatitis nicotina palati. Note the diffuse blanching and the multi-nodular appearance of the hard palate. The orifices of the palatal minor salivary glands can be appreciated as minute, red spots.
Figure 5A: Central papillary atrophy of the tongue in this bidi smoker. Figure 5B: Regression of the lesion in the same patient after cessation of the habbit.
Figure 6: Betel quid chewers encrustation (arrows) on the right buccal mucosa. Note the heavy tobacco stain on the lingual aspect of the molars.
Figure 7: Note the areas of depigmentation intermingled with pigmentation in the lower lip of this 18–year-old boy who has been using pan masala for the past 4 years.
Figure 8: Blanching of palate and tobacco induced pigmentation following pan masala use for 8 years in this 24–year-old person.
Figure 9: Tobacco-associated lesion in the lower labial mucosa in the region of placement of the smokeless tobacco.
Figure 10: A white hyperpigmented keratotic lesion in the right lateral margin tongue in this regular tobacco chewer.
Figure 11: Note the hyperpigmentation intermingled with blanching in the hard palate of this pan masala user.
Figure 12: Lichenoid reaction (arrow) in this pan masala chewer.
Figure 13: Note the diffuse blanching on the right buccal mucosa of this habitual betel quid chewer. The betel quid stain can be appreciated on the tongue and on the lingual aspect of maxillary teeth which have undergone attrition.
Figure 14: Reverse smoking. The burning end of chutta is being introduced into the oral cavity.
Figure 15: Note the reddish stain on lip and tongue caused by betel quid chewing
Figure 16: Bidi smoker.
Figure 17: Drying tobacco.
Figure 18: Packets of various commercialy available smokless tobacco products in India.
Figure 19: Composition of betel quid: Betel leaves (A) with slaked lime (B), areca nut (C) and tobacco (D).
Figure 20: Preparation of bidi. Bidi is made by rolling a dried rectangular piece of temburni leaf (Diospyros melanoxylon) with 0.15-0.25g of sun dried flaked tobacco into a conical shape and securing the roll with a thread.
Figure 21: Tobacco plant (Nicotiana Tabacum).
Figure 22: Areca catechu palm. Areca nut is the seed of the fruit of this palm.
Figure 23: Betel leaves (piper betel).
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