Snuff lesions are benign changes to the oral mucosa that can be caused by the use of snuff but also by tobacco-free snuff, white snuff or nicotine pouches. Snuff lesions are characterized by folds and wrinkles on the mucosa where the snuff has been placed, as well as a whitish discoloration that may be bumpy or patchy. Snuff lesions are reversible, i.e. they disappear if you stop snuffing, but they can be cosmetically disturbing and cause discomfort. Some Swedish dentists spell snuff lesions as “snuff lesions”.
The Axell scale
To assess the severity of snuff lesions, Professor Tony Axell, a Swedish specialist dentist and researcher, has developed a four-step scale called the Axell scale. The scale is based on clinical and histological criteria, and divides snuff lesions into the following categories:
- Grade 1: Slight change. The mucosa is smooth and whitish, without folds or wrinkles. Histologically, a thickening of the outermost layer of the mucosa (keratinization) is seen.
- Grade 2: Moderate change. The mucosa is whitish and has folds or wrinkles, but no red features or irregularities. Histologically, there is further thickening of the keratin layer, as well as thickening of the underlying connective tissue layer (fibrosis).
- Grade 3: Severe change. The mucosa is whitish and has distinct folds or wrinkles, as well as red features or bumps. Histologically, there is severe thickening of the keratin and connective tissue layers, and inflammation of the mucosa (granuloma).
- Grade 4: Severe change. The mucosa is whitish with deep folds or wrinkles, and red streaks or bumps that may be bleeding or ulcerated. Histologically, there is extreme thickening of the keratin and connective tissue layers, and severe inflammation of the mucosa with signs of cellular changes (dysplasia).
The Axell scale is a useful tool for monitoring snus users and assessing the risk of snus lesions developing into cancer or precancer. However, there is no clear link between the degree of snuff lesions and the risk of cancer, and other factors such as genetics, immune system and lifestyle may also play a role. The degree of damage caused by snuff lesions is mainly influenced by: how much you snuff, how long you snuff, when you snuff and how many years you have been snuffing in total.
Prevent or reduce the incidence of snuff lesions
To prevent or reduce snuff lesions, it is best to stop snuffing altogether, or at least reduce consumption and vary the location of snuff.
How common are snuff lesions in snus users?
In a clinical dental study conducted by University of Gothenburg 2022, 70-90% of the participating snus users were found to have snus lesions of various degrees of damage and 54-57% had gingival retractions of the gums i.e. receding gums.
In a Norwegian study of Norwegian snus users in 2023, 79% of the participants had snus lesions.
In a survey conducted by Sting Free AB with over 1000 snus-using men and women in Sweden in 2022, 59% of the participants responded that they had experienced snus lesions. 51% responded that they had receding gums (gingival retractions).