Investigating the oral and dental effects of nicotine pouches: findings from a patient and professional survey with in-person assessment.

Background: Nicotine pouches (NPs) are increasingly popular tobacco-free nicotine products, particularly among young people. Despite growing use, evidence regarding their oral health effects remains limited. Methods: We employed a mixed-methods approach comprising: (1) a national cross-sectional survey of NP users, (2) a survey of UK dental professionals, and (3) in-person clinical assessments of NP users. Survey data explored patterns of NP use, oral and dental side effects, and perceptions of risk. Clinical assessments included comprehensive oral examinations, periodontal assessments, and histopathological investigation of lesions where indicated. Results: A total of 3,659 NP users completed the public survey. Participants were predominantly male (89%) and aged 16-22 years (78%). Overall, 45% reported at least one oral or dental side effect. The most commonly reported effects were gingival recession (60%), burning sensations (41%), white patches (30%), and dry mouth (29%). Higher nicotine exposure was associated with increasing numbers of reported side effects. Among 126 dental professionals, oral lesions associated with NP use were commonly observed clinically, while only 17% reported seeing no oral or dental effects. Thirty-three NP users underwent in-person assessment. Ten lesions were biopsied; six demonstrated hyperkeratosis and four showed oral epithelial dysplasia (three mild, one moderate). All dysplastic lesions occurred at pouch placement sites. In two cases, clinical follow-up demonstrated partial or complete resolution of lesions following cessation of NP use. Periodontal assessments demonstrated generally low levels of periodontal disease and gingival recession across the cohort. Conclusions: Oral and dental side effects associated with NP use were commonly reported by users and observed by dental professionals. Histopathological assessment identified biopsy-confirmed oral epithelial dysplasia in lesions occurring at pouch placement sites, representing, to our knowledge, the first such report associated with NP use. Evidence of lesion improvement following discontinuation of use suggests that at least some NP-associated oral changes may be reversible. Although causality cannot be established, these findings highlight the need for vigilance among dental professionals and urgent longitudinal research to determine the incidence, progression, and reversibility of NP-associated oral lesions.