Abstract
Introduction
Nicotine pouches, a tobacco-free alternative to smokeless tobacco, have grown rapidly in popularity since 2019. Despite being marketed as safer than cigarettes, their effects on oral health are poorly documented.
Case presentations
Two otherwise healthy young men presented with localized oral pathology corresponding to habitual nicotine pouch placement. A 22-year-old reported daily pouch use for 11 months at the maxillary canine sites, with clinical findings of isolated gingival recession and leukoplakia. Comprehensive assessment, including periodontal charting, mucosal inspection, and periapical radiographs, excluded generalized periodontal disease, occlusal trauma, and aggressive brushing. A biopsy was recommended but declined. A 25-year-old with prior restorative dental work reported daily pouch use for 18 months, predominantly in the maxillary premolar–canine region. Clinical examination with probing, radiographs, and biotype evaluation demonstrated localized buccal recession without generalized periodontal involvement.
Discussion
Both cases highlight a site-specific association between pouch placement and gingival or mucosal changes, suggesting localized chemical and mechanical insult. The leukoplakia observed raises concern given established premalignant risk in smokeless tobacco users, though histologic confirmation was lacking.
Conclusion
Nicotine pouch use may cause localized gingival recession and mucosal pathology. Thorough clinical evaluation—including periodontal charting, radiographic imaging, and mucosal inspection—is essential to rule out alternative etiologies. Clinicians should routinely inquire about pouch use, recommend cessation, and obtain biopsy of suspicious lesions to exclude dysplasia or malignancy.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12903-025-07320-4.
Keywords: Gingival recession, Leukoplakia, Nicotine pouches, Oral mucosa, Tobacco alternatives
Background
Gingival inflammation, alveolar bone loss, tooth loss, and delayed postoperative healing are all frequently linked to cigarette smoking [1, 2]. Many people turned to smokeless tobacco products like snus and chewing tobacco as awareness of these risks has increased. Smokeless tobacco use was reported by almost 6 million American adults in 2019; men were more likely than women to use it [3]. Despite being promoted as a safer alternative to cigarettes, smokeless tobacco is still associated with significant risks to oral health [4].
Nicotine pouches have become a popular smokeless substitute in more recent years. Since their 2019 introduction to the European, American, and Japanese markets, they have become extremely popular, especially with smokers [5, 6]. They don’t contain tobacco leaf, dust, or stem like snus does [6, 7], and unlike chewing tobacco, their contents are sealed inside a sachet, so there’s no need to spit [8]. They usually include nicotine along with food-grade flavorings, sweeteners, and fillers. Concerns have been raised regarding their uptake among young adults who have never smoked due to their discrete design and flavored varieties [6].
There is little data on their effects on gingival and oral health, despite their growing use. These results have not yet been particularly discussed in case reports. Here, we outline two instances that show how using a nicotine pouch may affect oral health.
Case presentations
Case 1
A 22-year-old man with no relevant medical history presented with localized gingival recession and leukoplakia involving the maxillary canines (#13 and #23). He reported daily use of “Fox” brand nicotine pouches for 11 months, consistently placed in the same buccal sites. He denied aggressive toothbrushing or parafunctional habits. Clinical examination revealed isolated gingival recession and localized leukoplakia (Figs. 1 and 2), with no evidence of generalized periodontal involvement. Management included scaling, oral hygiene instruction, and counseling regarding nicotine pouch cessation. A biopsy of the leukoplakic lesion was recommended but declined by the patient. He was subsequently lost to follow-up.
Fig. 1.
Clinical photo of case 1: A showing localized gingival recession and leukoplakia at #13 and #23. B nicotine pouch at the upper canines area
Fig. 2.
A-B Clinical photo showing gingival recession and leukoplakia at the upper canine’s area, the lesion corresponds to the patient’s habitual nicotine pouch placement site (case 1)
Case 2
A 25-year-old man with a history of prosthetic and cosmetic dental work, including a bridge replacing #13 and multiple veneers, presented with gingival recession. Clinical examination demonstrated recession at the buccal aspects of #12, #14, and #23 (Fig. 3). The patient reported daily use of nicotine pouches for 18 months, placed predominantly at these sites. Following clinical cleaning and counseling on the risks of mucosal nicotine exposure, he agreed to discontinue pouch use and was referred for periodontal evaluation. The distribution of gingival changes corresponded precisely to the areas of reported pouch placement.
Fig. 3.
Clinical photo of case 2: A showing localized gingival recession at #12, #14, and #23. B Nicotine pouch at the upper canine’s area (case 2)
Discussion
These reports point to a potential link between localized oral pathology, such as leukoplakia and gingival recession, and the use of nicotine pouches. The lesions appeared at the exact locations of habitual pouch placement in both patients, who were young, otherwise healthy men, indicating a spatially specific relationship.
Localized and repeated exposure to nicotine pouches probably causes mechanical and chemical trauma to the gingiva and oral mucosa, which can lead to soft tissue deterioration. Although the precise mechanism is still unknown, comparisons to smokeless tobacco products, which are known to cause gingivitis, gingival recession, and periodontal pocketing, can be made [9]. Gingival recession and root exposure are the ultimate results of chronic periodontal inflammation, which causes progressive tissue and bone destruction [10].
Notably, leukoplakia was also present in the initial patient. Chronic pressure and exposure to chemical constituents may be contributing factors, even though a direct causal link between nicotine pouch use and these factors cannot be established. Leukoplakia is more common in men, usually diagnosed after the fourth decade of life, and six times as common in smokeless tobacco users as in non-users [11]. Leukoplakia associated with smokeless tobacco has been identified as a premalignant condition [12]. Additionally, according to experimental models, smoking smokeless tobacco may increase oxidative stress, nitric oxide production, and tumor suppressor pathway downregulation, which would provide a biological justification for malignant transformation [13].
Since leukoplakia can range from benign hyperkeratosis to epithelial dysplasia or carcinoma in situ, the lack of biopsy in Case 1 restricts conclusive interpretation. Therefore, histologic confirmation is still crucial for risk assessment and diagnosis.
Clinically, these cases highlight the importance of asking about more recent nicotine products as part of thorough tobacco histories during oral exams. When suspicious mucosal changes are noticed, practitioners should recommend biopsy, offer cessation counseling, and remain vigilant for early lesions.
These reports have limitations, such as Case 1’s lack of histologic confirmation, the absence of baseline clinical images, the unfinished follow-up, and the inherent observational design. Determinative causal inference is hampered by these factors. However, the literature currently in publication supports the consistent anatomical correspondence between pouch placement and lesion development, indicating a likely causal relationship.
Conclusion
Nicotine pouch use may cause localized gingival recession and mucosal pathology, especially if used repeatedly in the same locations. Clinicians should routinely inquire about pouch use, advise discontinuation, and recommend an early histologic examination of leukoplakic lesions to rule out dysplasia or malignancy.
Supplementary Information
Acknowledgements
Osama A. Alkhatib: Conceptualization, Investigation, Writing – Original Draft, Clinical Case Management, Supervision. The author read and approved the final manuscript.
Dr. Osama A. Alkhatib, PhD
Dr. Osama A. Alkhatib, PhD, is a specialist in Fixed Prosthodontics and earned his doctoral degree from Damascus University. His professional and research interests focus on prosthetic rehabilitation, clinical dental materials, and modern restorative techniques.
Authors’ contributions
Osama A. Alkhatib: Conceptualization, Data Collection, Drafting, Clinical Care.
Funding
No external funding received.
Data availability
All data generated or analyzed are included in this article.
Declarations
Ethics approval and consent to participate
Written informed consent was obtained from both patients.
Consent for publication
Written informed consent for publication of the clinical details and identifying images was obtained from both patients.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
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Supplementary Materials
Data Availability Statement
All data generated or analyzed are included in this article.