Areca (Betel) Nut and Oral Health Implications

by Hagen BE Klieb DMD, MSc, FRCD(C), Meagan MacKinnis BSc, MD and Karen Burgess DDS, MSc, FRCD(C)

Areca (betel) nut chewing is widely practiced in many parts of Asia as well as in Asian migrant communities throughout the world. Traditional as well as commercially packaged products are now available in Europe and North America and it is estimated that globally, several hundreds of millions of people partake of this habit.1 In fact, areca nut is the fourth most commonly used psychoactive substance in the world, following caffeine, alcohol and nicotine.1 Areca nut has been used since antiquity and has assumed major social, cultural and even religious roles.2 Users often consider it harmless and report a sense of well-being, euphoria, a warm sensation of the body, a heightened alertness and an increased capacity to work.3 Evidence has shown, however, that it is far from harmless and can have multiple oral health implications.

Areca nut use is common in certain areas of the world including India, Pakistan, Sri Lanka, Bangladesh, Thailand, Cambodia, Malaysia, Indonesia, China, and Papua New Guinea.1,4 Increased consumption has been reported from Taiwan, particularly among adolescents.1 With global migration patterns, health care workers, including Canadian dentists, need to be aware of these habits and the resultant effects in the oral cavity. Research suggests that the areca nut use is continued long after migration among first and second generation Asians.5

The areca nut is the fruit of Areca catechu. Patients may refer to it as “betel nut”, but this term is incorrect, as it does not come from the betel plant. Paan, also called Betel quid, consists of the betel leaf from the Piper betle, wrapped around a mixture of areca nut, and slaked lime (calcium hydroxide). Tobacco is often added, as well as a variety of flavouring agents, including spices (cardamom, peppermint and cloves) and sweeteners, which vary according to local preferences and practices.6,7,8 The mixture is placed inside the betel leaf, folded into a triangular package, and then sucked, chewed or slowly swallowed (Figure 1).

Mass-produced, pre-packaged products have become available in Southeast Asian and in countries with Asian migrant communities such as Canada. “Pan masala”, for example, contains areca nut, catechu, cardamom, lime, natural and artificial flavoring and perfuming agents7 (figure 2a). Gutka (or gutkha) is a preparation with the same ingredients as pan masala but also contains chewing tobacco (Figure 2b). Unlike traditional preparations, these are cheap, portable, and they have a longer shelf life. This has expanded the areca nut market and they are popular throughout Indian society, including amongst children, teenagers and women.7 Furthermore, they are often advertised as being safer than conventional cigarettes.7 However, there are real risks attached to the use of these products as most of the ingredients are extracts and concentrates9 and they have been shown to be addictive.7

Areca nut chewing habits are associated with several oral manifestations such as chewer’s mucosa, leukoplakia, erythroplakia, erythroleukoplakia, squamous cell carcinoma and submucous fibrosis. Canadian dentists need to be aware of these conditions, and recognize them in their patients.

Areca nut chewer’s mucosa

“Chewers mucosa” describes a characteristic brownish-red staining of the oral mucosa, often with a wrinkled appearance, stemming from the incorporation of the quid’s ingredients. There is also a tendency for the oral mucosa to desquamate possibly due to the traumatic effects of chewing.8 Chewer’s mucosa is often accompanied by brownish-red staining of the adjacent teeth (Figure 3).

Leukoplakia

White patches in the mouth are commonly seen in patients that use tobacco, areca nut products or both.10 Oral leukoplakia is defined as a white patch or plaque that cannot be characterized clinically or pathologically as any other disease, so other causes for white patches in the mouth (eg. trauma, candidiasis, and lichen planus) must be ruled out before a white patch is called leukoplakia. The leukoplakias seen in areca nut users are usually, but not always seen close to where the areca nut product is placed – eg. buccal mucosa (Figure 3) or lateral tongue.

Erythroplakia and Erythroleukoplakia

Erythroplakias have also been shown to be increased in patients that use areca nut products, with or without tobacco.10 Erythroplakia is defined as a red patch that cannot be clinically or pathologically diagnosed as any other condition. Mixed red and white lesions are called erythroleukoplakias. These terms are clinical descriptions only, and do not describe the histological diagnosis. A biopsy is generally needed to determine if dysplasia or squamous cell carcinoma is present. Treatment is dependant on the histological diagnosis, more than the clinical appearance. Lesions with moderate or severe dysplasia are generally excised if feasible. Lesions with no dysplasia are often watched. The treatment of large lesions or mildly dysplastic lesions depends on numerous factors such as size, location, possible side effects, as well as patient wishes and likelihood that patient will stop areca nut and /or tobacco. These lesions may be excised or may be observed. The difficulty with dysplastic lesions is that they often recur. Close follow-up is essential, as is counseling the patient to stop all areca nut and tobacco products.

Squamous cell carcinoma (SCCa)

Areca nut is classified as carcinogenic to humans by the IARC (International Agency for Reasearch on Cancer)11 and there is now evidence associating areca nut chewing without tobacco with oral squamous cell carcinoma and its precursors – leukoplakia and erythroplakia (Figures 3 and 4). Jacob et al (2004) reported chewing betel quid without tobacco conferred an odds ratio of 22.2 (95%CI=11.3, 43.7) for oral leukoplakia, 29.0 (95%CI=5.63, 149.5) for erythroplakia and 28.3 (95%CI=6.88, 116.7) for multiple oral precancerous lesions.10 Both the duration and daily frequency of betel quid increase the risk of developing precancerous lesions. Cigarette smoking may potentiate the effect of betel quid chewing.12

The difficulty in diagnosing oral cancer is that it can have many different appearances. White areas, red areas, mixed red and white areas, ulcers, granular areas or nodules can all turn out to be squamous cell carcinoma, emphasizing the need to biopsy these types of oral lesions, particularly in patients that have a history of areca nut, betel nut or tobacco use. The most common areas for oral squamous cell carcinoma are usually the lateral border of the tongue, ventral tongue and floor of mouth. In areca nut users, however, SCCas are also commonly seen on the buccal mucosa (Figure 5).13 Surgical excision is the usual treatment for oral SCCas. Neck dissections and radiation therapy may also be indicated.

Submucous Fibrosis

Oral submucous fibrosis (OSF) is chronic, progressive, scarring condition of the oral mucosa associated with the chewing of areca nut. It is now well established that the chronic placement in the mouth of areca nut-containing products is the major etiological factor for the submucosal changes. Substances from the areca nut, such as arecoline, are associated with fibroblast proliferation and increased collagen synthesis.14 The frequency, even more than duration, of areca nut exposure appears to be the most influential factor in the development of OSF.14

OSF is seen most commonly in young adult betel quid users although the diagnosis has been made in children and the elderly.2, 15 A female predomina
nce (3:1) has been observed.15 The diagnosis of OSF is usually clinical and is based on physical findings. Patients typically complain of a restricted mouth opening, and eventually, difficulty chewing and swallowing. Dental treatment and diagnostic procedures may be difficult on these patients, due to the limited opening. The mucosa, usually the buccal mucosa and soft palate demonstrates a marble-like pallor (figure 6) and develop a progressive stiffness with palpable fibrous bands.15 Patients may also experience a burning sensation. Although symptoms may show mild improvement with eliminating areca nut use early in the course of the disease, OSF does not usually regress with habit cessation. Treatment of OSF may be attempted to increase oral opening. Many different treatment methods have been studied, including steroid and/or hyluronidase injections, interferon, micronutrients, physiotherapy and surgery with varying degrees of success.16 A recent study showed that physiotherapy improved oral opening (p < 0.0005).16 Surgical options exist for more advanced disease. This involves surgical splitting or excision of fibrous bands to improve mouth opening and mobility.

Close clinical follow-up is also indicated for patients with OSF as this condition is considered to be a high-risk pre-cancerous condition and a significant proportion of affected individual’s progress to oral squamous cell carcinoma. Murti et al. (1985) found a 7.6 percent rate of malignant transformation of OSF over a median 10 year observation period.17

Periodontal disease

A recent study showed that patients that used areca nut (in the form of Gutka) had more severe periodontal conditions such as bleeding on probing, plaque index, and probing depths than non- users. This group of patients was non-smokers, and did not have diabetes.18

The enormous number of people using areca nut worldwide, as well as its increasing use in Canada, means that health care professionals must be knowledgeable about this product and educate at-risk patients. Dentists and physicians should be aware of the clinical changes that can accompany current or previous use. If any of these changes are suspected, a detailed history of areca, betel, paan, gutkha or pan masala use should be obtained from the patient. Patients should be strongly encouraged to stop their habit. Biopsy of affected tissue may be indicated. Histopathologic confirmation of squamous cell carcinoma mandates referral to the appropriate specialists for treatment. Epithelial dysplasias require monitoring and possibly excision.

Regular follow-up should be initiated for all patients with areca nut-related lesions.

During preparation of this manuscript, Hagen Klieb was a resident in oral pathology and oral medicine at the University of Toronto. He now is cross appointed in the departments of dentistry and anatomic pathology at Sunnybrook Health Sciences Centre. He is in private practice at Profile’s Dental Specialists.

Dr. Meagan L. MacInnes is a resident in Radiology at Dalhousie University, Halifax.

Dr. Karen L. Burgess is an Assistant Professor at the University of Toronto, Faculty of Dentistry and is a specialist in Oral Medicine and Oral Pathology at the Princess Margaret Hospital Dental Oncology Clinic and Mt Sinai Hospital Dental Clinic.

Oral Health welcomes this original article

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