Localized gingival recession and leukoplakia associated with nicotine pouch use: two clinical case reports

INTRODUCTION: Nicotine pouches, a tobacco-free alternative to smokeless tobacco, have grown rapidly in popularity since 2019. Despite being marketed as safer than cigarettes, their effects on oral health are poorly documented. CASE PRESENTATIONS: Two otherwise healthy young men presented with localized oral pathology corresponding to habitual nicotine pouch placement. A 22-year-old reported daily pouch use for 11 months at the maxillary canine sites, with clinical findings of isolated gingival recession and leukoplakia. Comprehensive assessment, including periodontal charting, mucosal inspection, and periapical radiographs, excluded generalized periodontal disease, occlusal trauma, and aggressive brushing. A biopsy was recommended but declined. A 25-year-old with prior restorative dental work reported daily pouch use for 18 months, predominantly in the maxillary premolar–canine region. Clinical examination with probing, radiographs, and biotype evaluation demonstrated localized buccal recession without generalized periodontal involvement. DISCUSSION: Both cases highlight a site-specific association between pouch placement and gingival or mucosal changes, suggesting localized chemical and mechanical insult. The leukoplakia observed raises concern given established premalignant risk in smokeless tobacco users, though histologic confirmation was lacking. CONCLUSION: Nicotine pouch use may cause localized gingival recession and mucosal pathology. Thorough clinical evaluation—including periodontal charting, radiographic imaging, and mucosal inspection—is essential to rule out alternative etiologies. Clinicians should routinely inquire about pouch use, recommend cessation, and obtain biopsy of suspicious lesions to exclude dysplasia or malignancy.