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A case report of oral nicotine-associated keratosis and a review of oral mucosal changes in tobacco and similar products


There is a strong association between tobacco use and the development of oral mucosal lesions, often with malignant potential. Nicotine is the primary component of tobacco responsible for addiction. The use of nicotine replacement therapy (NRT) aims to replace nicotine from cigarettes, allowing smoother transition to complete smoking cessation and greatly reducing risks of tobacco-related disease. The role of nicotine as a potential carcinogen is unknown. Use of NRT is associated with development of oral disorders, although it is rarely published. We detail the development of oral hyperkeratotic lesions directly associated with chronic overuse of nicotine replacement products. We also consider the current state of knowledge regarding development of oral lesions associated with other similar products. It is important for dental practitioners to be aware of oral effects associated with recommended nicotine replacement products, especially when offering smoking cessation advice to patients. It is vital that dental practitioners are aware of other potential risk factors for development of potentially malignant oral disorders, in order to make timely referrals of suspected lesions for appropriate investigation and review.

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  1. Benowitz N L, Hukkanen J, Jacob III P. Nicotine chemistry, metabolism, kinetics and biomarkers. In Henningfield J E, London E D, Pogun S (eds) Nicotine Psychopharmacology. pp 29-60. Berlin: Springer-Verlag, 2009.

    Google Scholar 

  2. Stead L F, Perera R, Bullen C et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2012; DOI: 10.1002/14651858.CD000146.pub4.

  3. Sanner T, Grimsrud T K. Nicotine: carcinogenicity and effects on response to cancer treatment - a review. Front Oncol 2015; DOI: 10.3389/fonc.2015.00196.

  4. Holliday R S, Campbell J, Preshaw P M. Effect of nicotine on human gingival, periodontal ligament and oral epithelial cells. A systematic review of the literature. J Dent 2019; 86: 81-88.

    Article  Google Scholar 

  5. Naudi K B, Felix D H. Nicotine replacement lozenges: abuse-related hyperkeratosis of the lateral border of the tongue. A case report. Br Dent J 2007; 203: 305-306.

    Article  Google Scholar 

  6. Awadallah M, Idle M, Patel K, Kademani D. Management update of potentially premalignant oral epithelial lesions.Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 125: 628-636.

    Article  Google Scholar 

  7. Nicaid 4mg lozenges. Available online at (accessed July 2019).

  8. McNeill A, Brose L S, Calder R, Bauld L, Robson D. Evidence review of ecigarettes and heated tobacco products 2018: A report commissioned by Public Health England. 2018. Available at (accessed April 2020).

  9. British National Formulary. Nicotine - Indications and dose. Available at (accessed July 2019).

  10. Chen Y P, Johnson G K, Squier C A. Effects of nicotine and tobacco-specific nitrosamines on hamster cheek pouch and gastric mucosa. J Oral Pathol Med 1994; 23: 251-255.

    Article  Google Scholar 

  11. Samatha Y, Sankar A J, Ganapathy K S, Srinivas K, Ankineedu D, Choudary A L. Clinicopathologic evaluation of lesions associated with tobacco usage.J Contemp Dent Pract 2014; 15: 466-472.

    Article  Google Scholar 

  12. Xue J, Yang S, Seng S. Mechanisms of cancer induction by tobacco-specific NNK and NNN. Cancers (Basel) 2014; 6: 1138-1156.

    Article  Google Scholar 

  13. WHO. 90% of smokeless tobacco users live in South-East Asia. 2013. Available at (accessed April 2020).

  14. Hecht S S. Biochemistry, biology, and carcinogenicity of tobacco-specific N-nitrosamines. Chem Res Toxicol 1998; 11: 559-603.

    Article  Google Scholar 

  15. Roosaar A, Johansson A L, Sandborgh-Englund G, Nyrén O, Axéll T. A long-term follow-up study on the natural course of snus-induced lesions among Swedish snus users. Int J Cancer 2006; 119: 392-397.

    Article  Google Scholar 

  16. Allen C M, Vigneswaran N, Tilashalski K, Rodu B, Cole P. Tobacco use and cancer: a reappraisal. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 80: 178-182.

    Article  Google Scholar 

  17. Roosaar A, Johansson A L, Sandborgh-Englund G, Axéll T, Nyrén O. Cancer and mortality among users and nonusers of snus. Int J Cancer 2008; 123: 168-173.

    Article  Google Scholar 

  18. Lee P N. The effect on health of switching from cigarettes to snus - a review.Regulat Toxicol Pharmacol 2013; 66: 1-5.

    Article  Google Scholar 

  19. Schildt E B, Eriksson M, Hardell L, Magnuson A. Oral snuff, smoking habits and alcohol consumption in relation to oral cancer in a Swedish case-control study. Int J Cancer 1998; 77: 341-346.

    Article  Google Scholar 

  20. Hirsch J M, Wallström M, Carlsson A P, Sand L. Oral cancer in Swedish snuff dippers.Anticancer Res 2012; 32: 3327-3330.

  21. Anand R, Dhingra C, Prasad S, Menon I. Betel nut chewing and its deleterious effects on oral cavity. J Cancer Res Ther 2014; 10: 499-505.

  22. Jacob B J, Straif K, Thomas G et al. Betel quid without tobacco as a risk factor for oral precancers. Oral Oncol 2004; 40: 697-704.

    Article  Google Scholar 

  23. Lee C H, Ko Y C, Huang H Let al. The precancer risk of betel quid chewing, tobacco use and alcohol consumption in oral leukoplakia and oral submucous fibrosis in southern Taiwan. Br J Cancer 2003; 88: 366-372.

    Article  Google Scholar 

  24. Gupta P C, Pindborg J J, Mehta F S. Comparison of carcinogenicity of betel quid with and without tobacco: an epidemiological review. Ecol Dis 1982; 1: 213-219.

  25. Zanetti F, Sewer A, Scotti Eet al. Assessment of the impact of aerosol from a potential modified risk tobacco product compared with cigarette smoke on human organotypic oral epithelial cultures under different exposure regimens. Food Chem Toxicol 2018; 115: 148-169.

    Article  Google Scholar 

  26. Pemberton M N. Oral cancer and tobacco: developments in harm reduction. Br Dent J 2018; 225: 822.

    Article  Google Scholar 

  27. Bustamante G, Ma B, Yakovlev G et al. Presence of the Carcinogen N-Nitrosonornicotine in Saliva of Ecigarette Users. Chem Res Toxicol 2018; 31: 731-738.

    Article  Google Scholar 

  28. Ganapathy V, Manyanga J, Brame Let al. Electronic cigarette aerosols suppress cellular antioxidant defences and induce significant oxidative DNA damage. PLoS One 2017;DOI: 10.1371/journal.pone.0177780.

    Article  Google Scholar 

  29. Korrapati A, Yu V, Saad M A et al. The carcinogenic effects of electronic cigarettes in oral cancer. Cancer Res 2016; DOI: 10.1158/1538-7445.AM2016-4069.

  30. Bardellini E, Amadori F, Conti G, Majorana A. Oral mucosal lesions in electronic cigarettes consumers versus former smokers. Acta Odontol Scand 2018; 76: 226-228.

    Article  Google Scholar 

  31. Nguyen H, Kitzmiller J, Nguyen K, Nguyen C, Bui T. Oral Carcinoma Associated with Chronic Use of Electronic Cigarettes. Otolaryngol (Sunnyvale) 2017; DOI: 10.4172/2161-119X.1000304.

  32. Flach S, Maniam P, Manickavasagam J. E-cigarettes and head and neck cancers: A systematic review of the current literature. Clin Otolaryngol 2019; 44: 749-756.

    Article  Google Scholar 

  33. Warnakulasuriya S. Oral potentially malignant disorders: A comprehensive review on clinical aspects and management. Oral Oncol 2020; DOI: 10.1016/j.oraloncology.2019.104550.

    Article  Google Scholar 

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Correspondence to Jessie Tebbutt.

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Tebbutt, J., Khan, Z. & Ariyaratnam, R. A case report of oral nicotine-associated keratosis and a review of oral mucosal changes in tobacco and similar products. Br Dent J 228, 757–760 (2020).

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