Swedish smokeless tobacco and its impact on oral health: a systematic review
DOI:
https://doi.org/10.2340/aos.v85.45421Keywords:
Health, Nicotine, Snus, TobaccoAbstract
Objective: Swedish smokeless tobacco, or ‘snus’, has a long history of use and has undergone significant transformations, including the introduction of portion-packed snus and tobacco-free nicotine pouches. This systematic review evaluates the impact of Swedish snus on oral health, focusing on gingivitis, gingival recession, periodontitis, caries, tooth wear, and oral cleft malformations.
Material and methods: The databases PubMed, Scopus, and EMBASE were used, terminating the searches on 11th June 2025. Original scientific articles written in the English or Scandinavian languages were screened by two independent researchers, finally including 26 out of 2,176 articles. The included articles were exported to the Elicit Pro library for quality assessment performed using the Joanna Briggs Institute’s Critical Appraisal Tool for Systematic Reviews. Premalignant and malignant changes were excluded from the search.
Results and conclusion: The findings indicate that Swedish snus is associated with gingival recession, particularly among users of loose snus, with mechanical pressure and cytotoxic effects contributing to these lesions. Gingivitis was more prevalent among snus users, even after controlling for plaque levels, though no significant association with periodontitis was observed. Evidence regarding caries risk was inconsistent, with some studies reporting higher caries indices values among snus users, while others found no correlation. Additionally, maternal use during pregnancy was linked to a 48% increased risk of oral cleft malformations in offspring. Tooth wear and self-reported temporomandibular disorder (TMD) symptoms were also associated with snus use. These findings underscore the importance of public health measures to regulate snus use, particularly among populations such as pregnant women and adolescents, where they have increased in popularity.
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References
Jonson M. Snus! : historia, märken, tillverkning & konsten att snusa. 7e upplagan edn: Bokförlaget Semic: Stockholm; 2017.
Dennison Himmelfarb CR, Benowitz NL, Blank MD, Bhatnagar A, Chase PJ, Davis EM, et al. Impact of smokeless oral nicotine products on cardiovascular disease: implications for policy, prevention, and treatment: a policy statement from the American Heart Association. Circulation. 2025;151:e1–21. https://doi.org/10.1161/CIR.0000000000001293 DOI: https://doi.org/10.1161/CIR.0000000000001293
Siddiqi K, Husain S, Vidyasagaran A, Readshaw A, Mishu MP, Sheikh A. Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries. BMC Med. 2020;18:222. https://doi.org/10.1186/s12916-020-01677-9 DOI: https://doi.org/10.1186/s12916-020-01677-9
Karati D, Mukherjee S, Das S, Saha A. Unraveling nitrosamine-induced carcinogenesis: toxicological aspects and molecular insights. Toxicol Mech Methods. 2025:1–20. https://doi.org/10.1080/15376516.2025.2584504 DOI: https://doi.org/10.1080/15376516.2025.2584504
Song MA, Marian C, Brasky TM, Reisinger S, Djordjevic M, Shields PG. Chemical and toxicological characteristics of conventional and low-TSNA moist snuff tobacco products. Toxicol Lett. 2016;245:68–77. https://doi.org/10.1016/j.toxlet.2016.01.012 DOI: https://doi.org/10.1016/j.toxlet.2016.01.012
Carlsson S, Andersson T, Araghi M, Galanti R, Lager A, Lundberg M, et al. Smokeless tobacco (snus) is associated with an increased risk of type 2 diabetes: results from five pooled cohorts. J Intern Med. 2017;281:398–406. https://doi.org/10.1111/joim.12592 DOI: https://doi.org/10.1111/joim.12592
Byhamre ML, Araghi M, Alfredsson L, Bellocco R, Engström G, Eriksson M, et al. Swedish snus use is associated with mortality: a pooled analysis of eight prospective studies. Int J Epidemiol. 2021;49:2041–50. https://doi.org/10.1093/ije/dyaa197 DOI: https://doi.org/10.1093/ije/dyaa197
Rodu B, Plurphanswat N. Heterogeneity and other problems in a pooled analysis of snus use and mortality. F1000Res. 2021;10:388. DOI: https://doi.org/10.12688/f1000research.52127.1
Kallischnigg G, Weitkunat R, Lee PN. Systematic review of the relation between smokeless tobacco and non-neoplastic oral diseases in Europe and the United States. BMC Oral Health. 2008;8: 1-20 https://doi.org/10.1186/1472-6831-8-13 DOI: https://doi.org/10.1186/1472-6831-8-13
Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5:210. https://doi.org/10.1186/s13643-016-0384-4 DOI: https://doi.org/10.1186/s13643-016-0384-4
Elicit. Elicit: the AI research assistant. Pro version. 2023. Available from: https://elicit.com [cited June 7th, 2025]
Moola S, Tufanaru C, Aromataris E, Sears K, Sfetcu R, Currie M, et al. Systematic reviews of etiology and risk. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI: Adelaide, South Australia. JBI manual for evidence synthesis. 2020. DOI: https://doi.org/10.46658/JBIRM-17-06
Andersson G, Warfvinge G. The influence of pH and nicotine concentration in oral moist snuff on mucosal changes and salivary pH in Swedish snuff users. Swed Dent J. 2003;27:67–75.
Hellqvist L, Rolandsson M, Hugoson A, Lingström P, Birkhed D. Dental caries and associated factors in a group of Swedish snus users. Swed Dent J. 2015;39:47–54.
Hugoson A, Hellqvist L, Rolandsson M, Birkhed D. Dental caries in relation to smoking and the use of Swedish snus: epidemiological studies covering 20 years (1983–2003). Acta Odontol Scand. 2012;70:289–96. https://doi.org/10.3109/00016357.2011.654247 DOI: https://doi.org/10.3109/00016357.2011.654247
Hellqvist L, Boström A, Lingström P, Hugoson A, Rolandsson M, Birkhed D. Effect of nicotine-free and nicotine-containing snus on plaque pH in vivo. Swed Dent J. 2012;36:187–94.
Hirsch JM, Livian G, Edward S, Noren JG. Tobacco habits among teenagers in the city of Göteborg, Sweden, and possible association with dental caries. Swed Dent J. 1991;15:117–23.
Jacobsen ID, Eriksen HM, Espelid I, Schmalfuss A, Ullbro C, Crossner CG. Prevalence of dental caries among 16-year-olds in Troms County, Northern Norway. Swed Dent J. 2016;40:191–201.
Rolandsson M, Hellqvist L, Lindqvist L, Hugoson A. Effects of snuff on the oral health status of adolescent males: a comparative study. Oral Health Prev Dent. 2005;3:77–85.
Methuen M, Kauppinen S, Suominen AL, Eloranta AM, Väistö J, Lakka T, et al. Dental caries among Finnish teenagers participating in physical activity and diet intervention: association with anthropometrics and behavioural factors. BMC Oral Health. 2021;21:333. https://doi.org/10.1186/s12903-021-01690-1 DOI: https://doi.org/10.1186/s12903-021-01690-1
Päkkilä J, Anttonen V, Patinen P, Nyman K, Valkeapää K, Birkhed D, et al. Profiling of smokers and snuffers among young Finnish men – cross-sectional epidemiological study. Acta Odontol Scand. 2017;75:577–83. https://doi.org/10.1080/00016357.2017.1361548 DOI: https://doi.org/10.1080/00016357.2017.1361548
Petersson GH, Twetman S. Tobacco use and caries increment in young adults: a prospective observational study. BMC Res Notes. 2019;12:218. https://doi.org/10.1186/s13104-019-4253-9 DOI: https://doi.org/10.1186/s13104-019-4253-9
Huttunen M, Kämppi A, Soudunsaari A, Päkkilä J, Tjäderhane L, Laitala ML, et al. The association between dental caries and physical activity, physical fitness, and background factors among Finnish male conscripts. Odontology. 2023;111:192–200. https://doi.org/10.1007/s10266-022-00717-5 DOI: https://doi.org/10.1007/s10266-022-00717-5
Modéer T, Lavstedt S, Ahlund C. Relation between tobacco consumption and oral health in Swedish schoolchildren. Acta Odontol Scand. 1980;38:223–7. https://doi.org/10.3109/00016358009003493 DOI: https://doi.org/10.3109/00016358009003493
Németh O, Sipos L, Mátrai P, Szathmári-Mészáros N, Iványi D, Simon F, et al. Snus use in adolescents: a threat to oral health. J Clin Med. 2024;13. https://doi.org/10.3390/jcm13144235 DOI: https://doi.org/10.3390/jcm13144235
Trullenque-Eriksson A, Derks J, Andersson JS. Onset of periodontitis – a registry-based cohort study. Clin Oral Investig. 2023;27:2187–95. DOI: https://doi.org/10.1007/s00784-023-04923-5
Montén U, Wennström JL, Ramberg P. Periodontal conditions in male adolescents using smokeless tobacco (moist snuff). J Clin Periodontol. 2006;33:863–8. https://doi.org/10.1111/j.1600-051X.2006.01005.x DOI: https://doi.org/10.1111/j.1600-051X.2006.01005.x
Andersson G, Axéll T. Clinical appearance of lesions associated with the use of loose and portion-bag packed Swedish moist snuff: a comparative study. J Oral Pathol Med. 1989;18:2–7. DOI: https://doi.org/10.1111/j.1600-0714.1989.tb00722.x
Kopperud SE, Ansteinsson V, Mdala I, Becher R, Valen H. Oral lesions associated with daily use of snus, a moist smokeless tobacco product. A cross-sectional study among Norwegian adolescents. Acta Odontol Scand. 2023;81:473–8. https://doi.org/10.1080/00016357.2023.2178502 DOI: https://doi.org/10.1080/00016357.2023.2178502
Bergström J, Keilani H, Lundholm C, Rådestad U. Smokeless tobacco (snuff) use and periodontal bone loss. J Clin Periodontol. 2006;33:549–54. https://doi.org/10.1111/j.1600-051X.2006.00945.x DOI: https://doi.org/10.1111/j.1600-051X.2006.00945.x
Hugoson A, Rolandsson M. Periodontal disease in relation to smoking and the use of Swedish snus: epidemiological studies covering 20 years (1983–2003). J Clin Periodontol. 2011;38:809–16. https://doi.org/10.1111/j.1600-051X.2011.01749.x DOI: https://doi.org/10.1111/j.1600-051X.2011.01749.x
Gunnerbeck A, Edstedt Bonamy AK, Wikström AK, Granath F, Wickström R, Cnattingius S. Maternal snuff use and smoking and the risk of oral cleft malformations – a population-based cohort study. PLoS One. 2014;9:e84715. https://doi.org/10.1371/journal.pone.0084715 DOI: https://doi.org/10.1371/journal.pone.0084715
Ekfeldt A, Hugoson A, Bergendal T, Helkimo M. An individual tooth wear index and an analysis of factors correlated to incisal and occlusal wear in an adult Swedish population. Acta Odontol Scand. 1990;48:343–9. DOI: https://doi.org/10.3109/00016359009033627
Miettinen O, Anttonen V, Patinen P, Päkkilä J, Tjäderhane L, Sipilä K. Prevalence of temporomandibular disorder symptoms and their association with alcohol and smoking habits. J Oral Facial Pain Headache. 2017;31:30–6. https://doi.org/10.11607/ofph.1595 DOI: https://doi.org/10.11607/ofph.1595
Tanner T, Kämppi A, Päkkilä J, Järvelin MR, Patinen P, Tjäderhane L, et al. Association of smoking and snuffing with dental caries occurrence in a young male population in Finland: a cross-sectional study. Acta Odontol Scand. 2014;72:1017–24. DOI: https://doi.org/10.3109/00016357.2014.942877
Wickholm S, Söder PO, Galanti MR, Söder B, Klinge B. Periodontal disease in a group of Swedish adult snuff and cigarette users. Acta Odontol Scand. 2004;62:333–8. https://doi.org/10.1080/00016350410001801 DOI: https://doi.org/10.1080/00016350410001801
Alizadehgharib S, Lehrkinder A, Alshabeeb A, Östberg AK, Lingström P. The effect of a non-tobacco-based nicotine pouch on mucosal lesions caused by Swedish smokeless tobacco (snus). Eur J Oral Sci. 2022;130:e12885. https://doi.org/10.1111/eos.12885 DOI: https://doi.org/10.1111/eos.12885
Franks AL, Slansky JE. Multiple associations between a broad spectrum of autoimmune diseases, chronic inflammatory diseases and cancer. Anticancer Res. 2012;32:1119–36.
Quadri MFA, Kamel AM, Nayeem M, John T, Thacheril A, Tartaglia G, et al. Smokeless tobacco and periodontitis: a systematic review with meta-analysis. J Periodontal Res. 2024;59:1062–70. https://doi.org/10.1111/jre.13274 DOI: https://doi.org/10.1111/jre.13274
Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, et al. Periodontitis: consensus report of workgroup 2 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions. J Clin Periodontol. 2018;45 Suppl 20:S162–70.
Källestål C, Uhlin S. Buccal attachment loss in Swedish adolescents. J Clin Periodontol. 1992;19:485–91. https://doi.org/10.1111/j.1600-051X.1992.tb01161.x DOI: https://doi.org/10.1111/j.1600-051X.1992.tb01161.x
Wouters FR, Salonen LW, Frithiof L, Helldén LB. Significance of some variables on interproximal alveolar bone height based on cross-sectional epidemiologic data. J Clin Periodontol. 1993;20:199–206. https://doi.org/10.1111/j.1600-051X.1993.tb00344.x DOI: https://doi.org/10.1111/j.1600-051X.1993.tb00344.x
Zetterqvist M. CAN:s nationella skolundersökning 2023. In: Thor S, editor. Stockholm: Centralförbundet för alkohol- och narkotikaupplysning (CAN). 2023.
Folkhälsomyndigheten. Vuxnas bruk av tobaks- och nikotinprodukter. 2023. p. 1–11.
Folkhälsomyndigheten. Ungas bruk av tobaks- och nikotinprodukter. 2023. p. 1.
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