Association of Nicotine Pouch Use Patterns and Nicotine Dependence with Self-Reported Gingival Symptom Burden Among Adults in Saudi Arabia: A Cross-Sectional Analytical Study

Nicotine pouches have expanded rapidly across the Gulf region, yet population-based evidence on gingival health remains scarce and users differ widely in intensity of consumption. We examined the association between nicotine pouch use and self-reported gingival symptom burden among 655 adults in Saudi Arabia using a bilingual self-administered online questionnaire. All data, including the outcome, were self-reported; no clinical periodontal examination was performed, so the study does not provide a clinical diagnosis of periodontal disease. Self-reported gingival symptom burden was assessed with a ten-item screening scale validated in Saudi adults, analysed as a continuous score and dichotomised at the sample median, and dependence among users was quantified with a six-item index adapted from the Fagerström Test for oral nicotine products. Tobacco exposure was modelled as a single four-level mutually exclusive variable. An above-median self-reported gingival symptom score was present in 277 participants (42.3%), and 180 (27.5%) reported pouch use. Pouch use status was not associated with the outcome (adjusted odds ratio 1.06, 95% CI 0.67–1.69). Among 179 users, the screening score rose by 1.63 points per dependence stratum (95% CI 0.88–2.37), and prevalence rose from 28.2% at low dependence to 38.9% and 58.3% at moderate and high dependence (Kendall τ-b = 0.186, p = 0.002), with adjusted odds of 5.86 (95% CI 2.30–14.96) for high dependence and a per-stratum trend of 2.43 (95% CI 1.52–3.87). The gradient persisted after additional adjustment for smoking status, former smoking and use of other tobacco products (trend odds ratio 2.53–2.65), and across ten sensitivity analyses. Self-reported gingival recession showed the steepest gradient across dependence strata, whereas gingival bleeding showed none. Self-reported gingival symptom burden among pouch users was associated with intensity of consumption rather than with use status; these findings are hypothesis-generating rather than evidence of a clinical effect, and require confirmation by studies with clinical periodontal assessment and longitudinal follow-up.