“Oral cancer occurs much more frequently in smokers than in non-smokers”

We have asked Professor Emeritus FDSRCSEd Mats Jontell at the Institute of Odontology, Sahlgrenska Academy at University of Gothenburg how nicotine pouches and other nicotine products might affect the gum, what are the long-term effects and are there any specific recommendations for users in order mitigate the adverse effects of the products in question?

What are the differences between the impact of nicotine pouches versus other oral nicotine products?

• Cigarettes
  – Oral cancer occurs much more frequently in smokers than in non-smokers. Smokers also have relatively more calculus (tartar) and gingivitis (inflammation of the gums). Other common side effects are increased risk for periodontal diseases, discolorations of teeth and the gingiva (gums), dental restorations, halitosis (bad breath), diminished taste, smell acuity and dental implant failure.

Smoking cessation significantly decreases the risk of oral cancer, may halt the disease progression and improve the outcome of periodontal treatment.

• Snus
  – Evidence has historically not suggested any association between snus and oral cancer. However, some individual cases of oral squamous cell carcinoma (the most common form of gum cancer) have been suggested to be associated with snus. A study showing increase in the incidence of the combined category of oral and pharyngeal cancer (cancer in the back of the mouth) cannot be lightly ignored even if the risk of snus use is significantly lower than that of smoking. Synthetic nicotine should entail an even lower risk as it does not contain tobacco-specific nitrosamines (potentially carcinogenic substance found in certain food and which can be ingested via tobacco smoking and snus) at all.
• Nicotine pouches

–  This is a newly launched product so the scientific knowledge is limited but both the impact on oral mucosa (the soft tissue lining of the oral cavity) and oral lesions (mouth ulcers or sores which may be painful) seems less than from snus and no studies show that these pouches would cause bleeding gums. There is no evidence that nicotine has carcinogenic properties.

• Other nicotine substitutes
  – Case reports regarding nicotine replacement lozenges (dissolves slowly in the mouth) have been published, but the lesions regressed once the habit was reduced. Sublingual nicotine-containing tablets could possibly cause transient oral mucosal lesions. No significant effect of any oral health parameters from chewing nicotine gum have been reported.

How does nicotine pouches impact gum health?

– Nicotine pouches are a relatively new product that contain a powder made up of nicotine salts and filling materials. These pouches have only been on the market since 2019 so the scientific knowledge is therefore limited and the long-term consequences for gum and oral health are not known. This also pertains to flavored pouches.

– It is not likely though that nicotine pouches would cause bleeding gums. It appears that both the number of oral lesions, and the impact on the oral mucosa, decreases when snus users switch to nicotine pouches. However, gingival retraction (receding of the gums exposing the dental roots) seems to be close to three percent and a likely explanation is that bone remodeling occurs when the bone is subjected to increased pressure. This also happens after incorrect tooth brushing.

– Effects on the oral mucosa following the use of nicotine pouches varies most likely from one individual to another depending on several factors as for example the brand, frequency, duration, availability of saliva, inherent resistance and how often the application site is changed.

Could nicotine cause cancer?

– There is no evidence that synthetic nicotine in nicotine pouches can cause cancer. However, small trace amounts of nitrosamines – generally below one percent of snus – could be found in nicotine extracted from tobacco. It is advisable to use products which declare that the concentrations of such substances are below the detection limit.

What are the long-term effects?

– Nicotine pouches have only been available for a couple of years. The long-term effect of nicotine pouches on the oral mucosa is therefore not known. But it seems like nicotine pouches has less ability to affect the oral mucosa compared to regular snus.

Are there any specific recommendations concerning gum health for users of nicotine pouches?

– Individuals who use nicotine pouches should be examined by a dentist during the regular, annual dental visit for possible mucosal damage and to look for changes such as inflammatory lesions (mouth ulcers or sores which may be painful) and gingival recessions (the term used to characterize the apical shift of the marginal gingiva from its normal position on the crown of the tooth to the levels on the root surface beyond the cemento-enamel junction). Both these changes are mitigated by less frequent use and alteration of the pouch application site. If obvious changes are noticed between the planned examinations, contact should be made with a dentist for follow-up.