As its name suggests, "nicotine stomatitis" is caused by tobacco use. It is the smoke of pipes, cigars, and cigarettes directed upon the mucosa of the hard palate that produces this lesion.

The clinical features are unique. The hard palate becomes a gray to white color depending on the amount of smoke directed toward it. Scattered raised areas with red centers complete the clinical picture. The raised areas are clumps of minor salivary glands and the central red dots are the openings of their ducts. Because the ducts do not keratinize, they remain red while the remainder of the palate, which does keratinize, appears white.

As the white color of the lesion suggests, keratin is prominent. The remaining epithelial layers are usually normal; however, it is possible for dysplasia or anaplasia to be present.

Attempts should be made to eliminate tobacco use. If that is successful, the lesion will subside. If not, incisional biopsies are needed to rule out the presence of dysplasia and cancer. Invasive cancer of the hard palate is uncommon; therefore, it is unlikely that the lesion will progress to invasive cancer; however, it should be remembered that while the palatal effects of smoking may not be serious, the habit might cause mucosal dysplasia or carcinoma elsewhere.