Author names: K. Bogdanska, M. Kubik, M. Mazur, A. Dudek, W. Szkudlarek, A. Bogdański, M. Bursy,
J. Linkiewicz, A. Bogdanska
Journal Reference: Bogdanska, K., Kubik, M., Mazur, M. et al. (2025) Oral Health Consequences of
Smokeless Tobacco Use: A Narrative Review. Cureus, 17(9), e92625.
doi:10.7759/cureus.92625
Background
Smokeless tobacco (SLT), including snus, snuff and chewing tobacco (e.g., gutka and
betel quid with tobacco), is defined by the World Health Organisation as “tobacco
consumed in its unburnt form via oral or nasal routes”. Although SLT is now widely
perceived as a safer alternative to smoking, many popular SLT products are highly
addictive and contain harmful substances such as tobacco-specific nitrosamines (TSNAs)
and heavy metals, which are both known carcinogens. With SLT use rising, particularly
among younger populations, concerns have been raised regarding the long-term oral
health implications of consistent use.
SLT is typically chewed or placed directly between the lip and gum, resulting in
prolonged direct exposure of the oral mucosa to harmful substances and possibly
contributing to various oral health complications. This review aimed to synthesise
current evidence on the oral health consequences of SLT use, including mucosal changes,
periodontal disease and potential risk of malignancy.
Methods
This narrative review analysed peer-reviewed studies published between January 1990
and March 2025. Observational studies (including cross-sectional, cohort, or
case-control), meta-analyses, systematic reviews or biomarker studies focusing on SLT
users of any age were included. Studies were selected through a comprehensive literature
search of Web of Science, PubMed/ MEDLINE, Scopus, the Cochrane Library and
Google Scholar, and grouped according to their findings into the following categories:
● Mucosal alterations
● Periodontal effects
● Malignant Transformation
● Biomarkers and mechanistic evidence
Exclusion Criteria included:
● Animal/ in vitro studies
● Case reports or series with fewer than five participants
● Studies solely examining cigarette smoking without providing comparative data
on SLT
Results
A consistent association between SLT use and oral pathological changes was identified,
with the evidence indicating a dose-response relationship. Many users experienced
mucosal changes, including white, plaque-like, hyperkeratinised lesions, found
predominantly at the site of SLT product placement, referred to as SLT keratosis. Studies
reported that prolonged, frequent SLT use resulted in increased lesion severity and
frequency, with regression noted following cessation.
In addition, leukoplakia was identified as a potential consequence of SLT use, specifically
snus. These prototypical oral cancer precursor lesions were a significant concern due to
the possibility of progression to squamous cell carcinoma.
Periodontal disease-related outcomes were mixed, with a general trend of gingival
recession, increased bleeding and poorer periodontal health identified with SLT use,
particularly at sites of direct exposure. These negative consequences were mainly
attributed to the range of harmful constituents of SLT products.
Evidence connecting SLT use to oral cancer remains heterogeneous. Positive findings
were mainly observed in studies from Southeast Asia, whereas European studies
generally did not demonstrate an increased risk. This is likely due to variations in
manufacturing processes, particularly the wider use of fermented SLT products in
Southeast Asia, which results in the formation of TSNAs.
Conclusion
Regular SLT use has been consistently linked to significant oral health risks; thus,
challenging its perception as a safe alternative to traditional smoking and highlighting the
need for further research and awareness in this area.
Research Summary Written By: Aalaa Hurreiz, University of Sheffield – BDS 4