Swedish smokeless tobacco and its impact on oral health: a systematic review.
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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.