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Whether the product is a traditional snus or a tobacco-free nicotine pouch, nicotine is absorbed directly through the oral mucosa when the product is placed between the upper lip and gums. Although these products reduce smoke exposure, they do not eliminate oral health risks.

The term “snus” refers to oral tobacco products placed inside the mouth. Originating in Scandinavia, snus has become increasingly popular in many countries, including Germany. Users are predominantly young individuals, including adolescents, and snus use is increasing among young women.

A more recent trend is the rise of tobacco-free nicotine pouches, often marketed as “white snus.” These small pouches contain nicotine salts, flavors, and other ingredients. Although the sale of traditional snus is prohibited outside Sweden and Norway, these products are readily available through kiosks and online retailers. Their use is not prohibited.

A recent systematic review found that snus use is associated with specific oral health effects, some of which may be irreversible. Local changes that affect the oral mucosa and periodontal tissues are common. Although the review also discussed tobacco-free nicotine pouches, most available evidence came from studies of traditional tobacco-containing snus. The authors noted that data on the oral health effects of nicotine pouches are limited. Throughout this article, “snus” refers to traditional tobacco-containing products.

Snus Lesions

One of the most characteristic findings is the development of snus lesions. This change in the oral mucosa is an adaptive response to the product’s high pH and continuous nicotine exposure. Epithelial hyperkeratosis develops in tissues as a protective response to chronic irritation.

Clinically, these lesions appear as whitish patches on the oral mucosa and are usually reversible. After discontinuation of snus use, the affected tissue often returns to its normal appearance and texture. This distinguishes snus lesions from classic precancerous lesions, although regular dental examinations are advisable.

Gingival Recession

The effects on the attached gingiva and its underlying connective tissues are of greater concern because of their limited regenerative capacity.

The review found a significant, localized increase in gingival recession at the exact sites where snus and nicotine pouches are routinely placed. Positioning snus or nicotine pouches beneath the upper lip directly exposes the upper incisors and surrounding tissues to prolonged chemical and mechanical stress.

Combined with localized inflammation and the mechanical and chemical effects of tobacco and nicotine, this causes irreversible gum recession. This recession exposes sensitive root surfaces and leads to irreversible loss of clinical attachment.

Evidence also suggests that snus promotes gingivitis. Users showed higher levels of gingival inflammation regardless of the plaque index. However, the review found no evidence of an increased risk for periodontitis.

Orofacial Cleft Risk

A large Swedish cohort study involving more than 1 million newborns found that maternal snus use during early pregnancy may contribute to the development of orofacial clefts. Infants born to mothers who used snus during early pregnancy had a statistically significant 48% increased risk for these congenital abnormalities.

Carcinogenic Potential

Scientific studies confirm that prolonged, direct exposure of snus to the oral mucosa is strongly associated with the development of potentially malignant oral lesions.

A recent systematic review found that the risk for malignant changes is substantially lower with Swedish snus than with other forms of smokeless tobacco, including products commonly used in Asia and the US. Researchers attributed this difference, in part, to Swedish manufacturing methods that reduce levels of tobacco-specific nitrosamines.

However, Swedish snus should not be considered harmless. Although the risk for oral squamous cell carcinoma appears lower than that associated with cigarette smoking, prolonged exposure to nicotine and other constituents may still cause chronic irritation of oral tissues. The authors called for additional research evaluating newer nicotine products, including tobacco-free nicotine pouches.

Because snus use is relatively common, clinicians should consider it during routine examinations. Many users view snus as a cleaner and less harmful alternative to smoking because it eliminates combustion, and they may not disclose its use during medical or dental history-taking.

The characteristic findings, including gingival recession affecting the anterior maxilla and whitish mucosal lesions in younger individuals, should prompt clinicians to ask specifically about snus use.

Although the systemic risk may be lower than that with cigarette smoking, the chronic local effects on oral mucosa and periodontal tissues warrant attention. Therefore, early patient education, routine monitoring, and regular follow-up are recommended.

This story was translated from Coliquio, part of the Medscape Professional Network.