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Smokeless Tobacco Lesions

Practice Essentials

The use of smokeless tobacco has been increasing over the last decade in the United States. Smokeless tobacco is a risk factor of cancer of the oral tissues and pharynx, oral soft tissue lesions (eg, leukoplakia), periodontal disease, gingivitis, caries, halitosis, tooth loss, tooth stains, and nicotine addiction, and it has been associated with low–birth-weight babies and pancreatic cancer.

Signs and symptoms

Patients may present asymptomatically, or, in more advanced disease, patients may report pain, swelling, or dysphagia. The presentation for smokeless tobacco lesions can vary widely, depending on the duration and frequency of use and the predisposition conditions and other comorbidities of the individual, and it may include the following conditions:




Speckled leukoplakia

Tobacco-associated keratosis

Verrucous carcinoma

Squamous cell carcinoma


A thorough history, including an assessment of the risk factors, and a careful examination of the oral cavity are the most important clinical tools in diagnosing oral lesions.

Indirect pharyngoscopy and laryngoscopy may be performed to help visualize lesions of the throat, base of the tongue, and larynx.

If a lesion is suspicious for an oral cancer, incisional biopsy should be performed for histologic confirmation.


To reduce the risk of progression to oral cancer, smokeless tobacco use should be minimized, with cessation encouraged.

Biopsy should be performed on lesions of erythroplasia that are suggestive of cancer based on their appearance or location in the oral cavity or those that have failed to resolve within 2-3 weeks.

Premalignant lesions and carcinoma in situ (CIS) may be permanently cured after excision or biopsy.

Primary and invasive squamous cell carcinoma are treated with varying combinations of surgery and/or radiation.

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