Nicotine pouches are small, tobacco-free packets containing nicotine and other ingredients designed to be placed between the gum and lip. As a relatively new product in the nicotine market, they are often marketed as a safer alternative to traditional tobacco products like cigarettes and chewing tobacco[1]. The primary appeal of nicotine pouches lies in their ability to deliver nicotine without the need for inhalation, potentially reducing some health risks associated with smoking[1]. However, despite their growing popularity, particularly among youth and young adults, there is ongoing debate about their safety and impact on oral health, especially concerning gum health[2].

Research on the effects of nicotine pouches on gums is still in its early stages, but preliminary findings raise concerns about potential adverse effects. Users may experience reduced blood flow to the gums, irritation, and an increased risk of gum disease and recession due to the nicotine content[3]. Nicotine has been associated with oral mucosal lesions, gingival recession, and periodontal disease, raising alarms among dental health professionals who caution against their prolonged use[4]. These issues are compounded by the fact that nicotine pouches can contribute to dry mouth, exacerbating oral health problems such as tooth decay and bad breath[3].

The popularity of nicotine pouches has prompted calls from public health organizations for more rigorous research to fully understand their long-term health implications[5]. Regulatory bodies in various countries are grappling with how to classify and regulate these products, as they straddle the line between traditional tobacco and newer nicotine delivery systems[6]. In the United States, the Food and Drug Administration has taken steps to monitor and regulate the sale of nicotine pouches, especially concerning underage consumers[7]. These regulatory efforts reflect broader concerns about the potential for nicotine pouches to serve as a gateway to other forms of nicotine addiction, particularly among younger demographics[2].

While nicotine pouches offer an alternative for those looking to avoid the health risks associated with smoking, the potential impact on oral health, especially gum health, cannot be overlooked. As evidence continues to emerge, healthcare professionals are encouraged to guide patients on the risks associated with these products and to support cessation efforts when necessary. This proactive approach aims to mitigate potential adverse health outcomes while providing individuals with the resources needed to make informed decisions about their nicotine use[4].

Nicotine pouches are designed as an alternative to traditional tobacco products, and their composition is carefully crafted to provide a nicotine experience without the inclusion of tobacco. The primary active ingredient in these pouches is nicotine, which is often derived from tobacco plants but is purified to exclude the burning or inhalation associated with traditional tobacco products[1]. This process ensures that the nicotine is delivered effectively while minimizing exposure to harmful substances typically found in tobacco smoke.

The base of nicotine pouches consists of fillers, which are commonly plant fibers like cellulose or other natural substances that provide structure to the pouch[1]. This structure is important as it maintains the form and usability of the pouch during use. Additionally, specific nicotine pouches, such as those from the brand on!, include nicotine bitartrate dihydrate as the nicotine source[2]. They also utilize acesulfame K as a sweetener to enhance flavor, maltitol and cellulose powder as binders, and sodium carbonate as a pH adjuster to balance the pouch's chemistry[2].

The absence of tobacco in these pouches contributes to a cleaner taste compared to traditional smokeless tobacco products, offering a distinct experience for users[3]. This cleaner taste is achieved through the selection of ingredients that avoid the bitter or harsh flavors typically associated with tobacco, making nicotine pouches an appealing option for those seeking to manage nicotine intake without the complexities of tobacco consumption.

Nicotine consumption, whether through smoking or the use of smokeless nicotine products such as nicotine pouches, has significant effects on oral health. These effects include a variety of adverse outcomes such as oral mucosal lesions, gingival recession, and periodontal disease[4]. The rise in popularity of nicotine pouches, particularly among youth and young adults, underscores the need for public policy interventions to curb their use[5].

Recent research highlights several health challenges associated with nicotine use, including developmental delays, addiction, mental health issues, lung and cardiovascular diseases, and alterations in the immune system[6]. Additionally, nicotine exposure is linked to epigenetic changes that may increase susceptibility to lifelong diseases and health challenges[7].

The effects of nicotine on oral health are particularly concerning. Users of nicotine pouches may develop oral mucosal white lesions in areas where the products are placed[8]. These lesions can manifest as hyperkeratotic or erythroplakic lesions, commonly found in users of smokeless tobacco products[4]. Furthermore, gingival recession and periodontal attachment loss are reported near areas where nicotine pouches or smokeless tobacco are held in the mouth, contributing to severe periodontal disease[4].

Dental professionals play a crucial role in addressing the oral health impacts of nicotine use. By assessing patients' use of smokeless tobacco and offering tailored cessation support, dental professionals can help mitigate these adverse health effects and support patients in quitting these products[4].

Nicotine pouches, despite not containing tobacco, can have significant adverse effects on gum health due to their nicotine content and other ingredients[9]. The use of these pouches has been associated with a reduction in blood flow to the gums, irritation of gum tissues, and an increased risk of gum disease and recession[9]. Regular use of nicotine pouches can also lead to dry mouth, which exacerbates the risk of gum disease and contributes to tooth decay and bad breath[9].

Research indicates that the potential oral health impacts extend beyond just gum issues, as nicotine can harm overall oral tissues[10]. The presence of nicotine in these pouches can contribute to gum recession, further deteriorating gum health and potentially leading to periodontal disease[9]. This aligns with findings regarding smokeless tobacco, which has been shown to cause gingival recession and periodontal attachment loss in areas where the product is held in the mouth[4].

Furthermore, emerging evidence suggests that nicotine pouches can cause oral mucosal changes, such as white lesions, revealing significant cellular level impacts on oral tissues[11]. While these lesions may be reversible upon cessation, the exact mechanisms of these changes remain unclear[12]. As such, it is crucial for individuals using nicotine pouches to be aware of these risks and to consider limiting their use to prevent potential oral health complications[9]. Dental professionals play an essential role in assessing nicotine pouch use and providing cessation support tailored to reducing the risks associated with these products[4].

The potential impact of nicotine pouches on oral health has become an area of increasing research interest due to their rising popularity, especially among youth and young adults[5]. Nicotine pouches are marketed as tobacco-free products, consisting of pre-portioned white granular packets containing nicotine that are placed between the gums and lips[13]. These products are considered by some to be a reduced-risk alternative to traditional tobacco products[14].

Several studies have explored the relationship between nicotine pouch usage and oral health, with mixed findings due to the novelty of these products and the limited amount of available research. A systematic review of the literature revealed that the evidence remains limited and is characterized by a high risk of bias[15]. This review highlighted that individuals using nicotine pouches might have a higher tendency to develop oral mucosal white lesions in areas where these products are placed, compared to other nicotine delivery systems[15][8]. Additionally, self-reported adverse effects among current users have included oral lesions, sore mouth, and sore throat[8].

Despite these concerns, definitive conclusions on the long-term effects of nicotine pouch usage on oral health remain elusive due to the insufficient quantity of high-quality studies[8]. As a result, organizations such as the American Heart Association have called for more comprehensive research to fully understand the health implications of smokeless oral nicotine products and to develop public policy solutions to mitigate their use among vulnerable populations, including youths[16].

Nicotine pouches, while marketed as a tobacco-free alternative, are not without significant health risks. One of the primary concerns is the impact on oral health, particularly on the gums. The use of nicotine pouches can reduce blood flow to the gums, irritate oral tissues, and increase the risk of gum disease and recession[9]. Although these products do not contain tobacco, their nicotine content and other ingredients can negatively affect gum health, contributing to conditions like gum recession and tooth decay[9].

The dental and medical communities are calling for more comprehensive research to fully understand the long-term effects of these increasingly popular nicotine products on oral health[17]. Current findings suggest that nicotine pouches can lead to dry mouth, gum disease, and an increased risk of other oral health issues such as bad breath[9]. There is also evidence that regular use can result in oral mucosal lesions, such as hyperkeratotic or erythroplakic lesions, especially where the product is held in the mouth[4][8]. These lesions, along with dental erosion and periodontal attachment loss, highlight the potential adverse effects on oral health[4].

Beyond oral health, nicotine pouches can cause systemic health concerns. Studies indicate that acute consumption of nicotine pouches can result in a clinically relevant elevation of heart rate, which could pose a risk to cardiovascular health[18]. Moreover, nicotine exposure has been linked to broader health challenges, including addiction, mental health and behavioral changes, cardiovascular and endocrine disorders, diabetes, and cancer[6][7].

Given these potential risks, it is crucial for healthcare providers, particularly dental professionals, to assess the smokeless tobacco use status of their patients and offer cessation support tailored to quitting smokeless products[4]. This approach can help patients minimize the adverse health effects associated with nicotine pouch usage.

The regulation of nicotine pouches varies significantly across different countries. Generally, countries regulating both synthetic and tobacco-derived nicotine pouches rely on either existing tobacco product or medicine policies, or they develop new regulatory classifications that specify nicotine as the substance of concern rather than associating regulations exclusively with tobacco products[19][20]. Such policies can serve as a guide for jurisdictions aiming to implement effective measures for controlling the use of nicotine pouches and other non-medicinal nicotine products[20].

In the United States, the Food and Drug Administration (FDA) has been actively involved in monitoring the sale of nicotine pouches, particularly to underage consumers. As part of its regulatory approach, the FDA has conducted operations using youth decoys to purchase nicotine pouches from retailers across the country[21]. This action is aimed at ensuring compliance with age restrictions and protecting public health, especially among youth and adolescents[16].

Health implications of nicotine pouches have been a topic of concern, prompting organizations like the American Heart Association to issue policy statements on the matter. These statements highlight the increased popularity of smokeless oral nicotine products among young people and underscore the necessity for public policies to mitigate their usage[16]. Despite the growing prevalence of these products, there remains limited evidence regarding their effects on oral health. Systematic reviews indicate a high risk of bias in existing studies and suggest that users of nicotine pouches may be more likely to develop oral mucosal white lesions in the areas where these products are placed, compared to other nicotine delivery systems[15][8].

When considering alternatives to nicotine pouches, individuals often explore options that reduce exposure to nicotine or eliminate its use altogether. Nicotine pouches, though marketed as a safer alternative to smoking, still carry health risks, particularly concerning oral health and addiction potential[22][10].

The growing popularity of nicotine pouches, particularly among youth and young adults, has prompted significant concern from public health organizations, such as the American Heart Association. According to a policy statement published in Circulation, the flagship scientific journal of the Association, there is a pressing need for public policy interventions to curb the usage of these smokeless oral nicotine products, especially among adolescents[16][5].

The policy statement also emphasizes the importance of understanding the health implications of nicotine pouches, identifying critical research needs to further investigate their impact on public health[16]. The limited evidence available, due to the novelty of these products, suggests a potential risk of developing oral mucosal white lesions in areas where nicotine pouches are placed, although the evidence quality is compromised by a high risk of bias[15].

The potential health challenges linked to nicotine use, including developmental delays, addiction, and various diseases, underscore the importance of studying both short- and long-term effects of nicotine pouches on oral health and overall well-being[26][6]. This underscores the call for comprehensive research to better understand and mitigate these health risks[26].