Pathology · patient case with 3 questions
Palatal changes beneath a maxillary denture in a tobacco user
Patient: Male, 63 years old
Chief Complaint: Routine review of a maxillary complete denture worn for eight years.
Background: Long-standing pipe and cigarette smoker. Wears the denture day and night.
Current Findings: The hard palate is erythematous with a keratotic, leukoplakic background. Numerous small elevated red papules with punctate central openings — inflamed minor salivary gland duct orifices — are visible across the palatal mucosa.
Question 1
What is the diagnosis?
Show answer and explanation
Correct answer: D. Nicotinic stomatitis (smoker's palate)
- A. Erythroplakia is a velvety RED patch with no keratotic component. It carries the highest malignant transformation risk of any oral lesion and is not the picture here.
- B. Papillary hyperplasia produces a pebbled, cobblestone surface of multiple small nodules on the palatal vault — a fibroepithelial reaction to a poorly fitting denture, not a keratosis with inflamed duct openings.
- C. Denture stomatitis is a well-demarcated ERYTHEMA confined exactly to the denture-bearing area, without keratosis and without the inflamed duct orifices. It is a candidal infection driven by continuous denture wear.
- D. CORRECT. Nicotinic stomatitis is a HEAT-induced hyperkeratosis of the hard palate. The diffuse greyish-white keratotic background is punctuated by red, umbilicated papules representing inflamed and dilated minor salivary gland duct openings. Pipe smoking is the classic cause because of the temperature of the smoke.
Question 2
What is the appropriate management of this palatal lesion?
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Correct answer: D. Tobacco cessation, with reassessment and biopsy of any lesion that persists
- A. Excision is not indicated for a reversible keratosis. Surgery follows a biopsy diagnosis of dysplasia or malignancy, not the clinical appearance alone.
- B. Nystatin is an antifungal and treats DENTURE STOMATITIS. Nicotinic stomatitis is a keratotic response to heat, with no fungal component, and will not respond.
- C. Denture adjustment does not address the aetiology, and a one-year review is too long a delay for a keratotic palatal lesion in a heavy smoker.
- D. CORRECT. Nicotinic stomatitis in a conventional smoker is REVERSIBLE — the palate typically returns to normal within a few weeks of stopping. Cessation is therefore both the treatment and the diagnostic test. Anything that persists after cessation, or that develops induration or ulceration, must be biopsied.
Note: ⚑ SOURCE CORRECTION — this is worth circulating to the group. The recall keys the treatment of nicotinic stomatitis as NYSTATIN. That is wrong; nystatin belongs to the denture stomatitis item. Two further points make this more than a technicality: in a REVERSE smoker (lit end inside the mouth) nicotinic stomatitis DOES carry real malignant potential and needs biopsy, and beneath a denture the palate is shielded from heat, so keratosis appearing there is more suspicious rather than less.
Question 3
Which single instruction most reduces this patient's risk of denture-related mucosal disease?
Show answer and explanation
Correct answer: A. Remove the denture overnight and store it dry or in a cleansing solution
- A. CORRECT. Continuous day-and-night wear is the single strongest risk factor for denture stomatitis. Removing the prosthesis overnight allows the mucosa to be bathed in saliva and mechanically cleansed by the tongue, and it interrupts the biofilm cycle on the fitting surface.
- B. Hot water distorts the acrylic base, ruining the fit.
- C. Conventional toothpaste is too abrasive for acrylic. It scratches the fitting surface, creating retentive irregularities that harbour Candida. A soft brush with soap or a proprietary denture cleanser is correct.
- D. Adhesive compensates for a poorly fitting denture rather than correcting it, and it adds another substrate at the tissue interface.