Dental hygienists should be prepared to advise patients on strategies to cease chewing betel nut and should be aware of the negative effects caused by this habit on oral cavities. Chewing betel nut is another oral habit that impacts oral health. Dental hygienists are equipped to educate patients on all aspects of tobacco use.
The nut is the fruit found within the fruit of the areca palm tree, which has gray-white markings with brown mottling. Users report that it is beneficial for improving focus and endurance, aiding in bowel movements, and promoting digestive and oral health. They also describe it as having a mildly bitter taste.
The user expels it.3 After thoroughly chewing it, the leaf packet is then sucked on or chewed for 15 to 20 minutes (Figure 3). These components are then combined with a calcium hydroxide paste (traditionally known as slaked lime) and tobacco and wrapped in a betel leaf (Figure 1 and Figure 2). Betel nuts can be blended with catechu gum, which is derived from the sap of the catechu tree; menthol; sandal oil; spices, such as cloves, anise seed, cinnamon, and nutmeg; and finely pounded gold or silver metal.2 Once amalgamated, the term most commonly used to describe this chewable substance is betel quid.2 Betel nuts can be chewed on their own, but many cultures mix them with a combination of ingredients.
2. The stimulated central nervous system triggers a sense of elation and can lead to heightened sweating and crying, narrowing of the pupils, and diarrhea. 3,5. Arecoline, the main component in betel nut, when combined with calcium hydroxide paste, generates a substance that stimulates the central nervous system. 4. The compound generates sensations of elation or calmness, or generates a surge of vitality.
The betel nut, also known by other names such as daka pinang, mak, gua, puwak, supari, gutka, masala, and Paan, is chewed throughout large parts of Bangladesh, India, the Philippines, Indonesia, Thailand, and rural areas in South Pacific, South Africa, and East Malanasia. Health professionals are likely to encounter patients who regularly engage in this habit, with approximately 200 million people chewing quid regularly.
The cost of betel nut chewing has become increasingly popular among young people, especially due to its low price of approximately $1 per sachet. These sachets, containing compounds added for chewing, are easily found in two specific areas. The habit of chewing betel nut, which comes from immigration, has also increased in popularity among young people. The United States has the second highest number of legal immigrants, with Bangladeshis, Pakistanis, and other South Asian and Indian immigrants coming to the country. In addition, large cities in California, followed by Philadelphia, Chicago, Long Island, and Northern New Jersey, have concentrated populations of these immigrants in the Northeast metropolitan areas.
A traditional practice that may not be well-known to Western healthcare and dental professionals is the act of chewing betel quid, which is closely connected to social traditions, cultural ceremonies, and religious rituals. However, it is important to note that this is not very common, although betel nuts that are imported can potentially be confiscated by officers from the US Customs and Border Protection if they violate any food, agricultural, or medicinal regulations. It should be mentioned that betel quid is not classified as a controlled substance in the US, but individuals who frequently travel to their home countries often bring back betel quid with them. The fact that it is widely available globally allows individuals to bring a part of their homeland with them, and the continued use of betel quid can be seen as a way to stay connected to their cultural roots.
The fourth most addictive substance in the world is considered to be betel nut, following caffeine and alcohol, and then tobacco. A study examining whether the use of betel nut could lead to addiction reported multiple attempts at abstinence and knowledge of its harmful effects by the participants. Additionally, symptoms of withdrawal such as sadness, fatigue, anxiety, and cravings are also experienced.
Among both females and males, the practice of chewing betel quid starts as early as 7 years old in certain areas. Habitual users engage in chewing betel quid throughout the entire day. A few mothers mention providing their babies with premasticated quids.
The teeth, gums, and lining of the mouth are discolored by chewing betel quid (Figure 4 and Figure 5). Depending on how it is prepared and how long it is used, the color of the stain can range from deep red to black. Chronic users may also develop betel chewer’s mucosa, a condition characterized by deep red or brownish-red discoloration of the lining of the mouth with wrinkled crusts that can be scraped off. This localized lesion is usually found where the betel quid is placed, typically on the inside of the cheek. The lining of the mouth may also shed or peel, with loose pieces of tissue visible. In some cultures, this change in color is considered attractive. Even if some chewers try to reduce discoloration by brushing their teeth vigorously, significant staining will still occur if they do not receive regular professional dental care. This stain naturally sticks to grooves and crevices, tartar, rough dental fillings, and naturally rough areas of the teeth.
The loss of tooth structure in the cervical area, and eventually, the occurrence of abfraction, can be attributed to the ongoing tension, compression, and flexion caused by chewing betel quid. Chronic betel quid users may also experience root fractures due to the constant burden of habit and mastication. The degree of attrition is dependent on how long and how often betel quid is chewed, as well as the consistency of the quid. Chewing betel quid consistently often leads to severe wear on the tooth surfaces and occlusal incisal.
Table 1 presents potential ways in which betel quid can inhibit caries. Reasons for this opposite correlation vary, from an elevation in saliva production and the presence of substances that prevent tooth decay in the betel quid, to the high alkalinity of the quid that counteracts the acidity in the mouth. Despite the significant wearing down of teeth that betel users undergo, their likelihood of developing cavities is decreased.5,13
Studies have also shown that nonusers of betel nut may experience increased formation of calculus and periodontal attachment loss compared to more experienced users. Additionally, betel nut may hinder periodontal reattachment and exacerbate pre-existing periodontal diseases, as it has been found to be cytotoxic to periodontal fibroblasts. In vitro studies have shown that arecoline, the active ingredient in betel nut, inhibits the growth of attachment in periodontal fibroblasts.
Fibrosis of the Oral Submucosa
Oral submucous fibrosis (OSF) is a chronic progressive condition characterized by fibrosis of the mucosal lining of the upper digestive tract. It affects approximately 5 to 15 million people. The active ingredient in betel nut, arecoline, may be related to the development of OSF. Calcium hydroxide, a component of betel quid, may also be involved. OSF is regarded as a precancerous condition with a transformation rate to malignancy of 7.6%. It is often accompanied by leukoplakia and patients with OSF frequently experience difficulty in speaking, swallowing, and eating. The disease results in a limited opening of the oral mucosa, which can be either diffuse or localized and has a marble-like appearance. Other symptoms and signs of OSF include a nasalized voice, formation of vesicles on the palate, altered taste, increased saliva, sensitivity to spicy foods, and a history of past pain. The tongue often exhibits limited protrusion and papillary atrophy, and the lips, tongue, soft palate, buccal mucosa, and retromolar areas are frequently affected. Histological findings of OSF show an increase in cross-linking fibers and fibroblasts, as well as an accumulation of excess collagen due to an inability to break it down. The exact etiology and mechanism of OSF, particularly in relation to the active ingredient in betel nut, are unclear.
Treatment and early detection are key factors in the prognosis of oral cancers. Reports indicate that tobacco and betel nut act synergistically to cause oral cancer. Approximately 30% of oral cancers in Southeast Asia are caused by habitual chewing of betel quid containing tobacco. Oral squamous cell carcinomas and oral submucous fibrosis may occur independently but are also associated with each other. Carcinomas associated with chewing betel quid specifically occur along the lateral borders of the buccal mucosa and the tongue. Studies have shown an increased incidence of oral cancer in regions where betel quid is chewed, with India having the largest population of betel quid chewers in the world. Betel quid use, coupled with tobacco, is listed as a carcinogen. Oral cancer kills approximately one person per hour. Oral cancer is the sixth most common malignancy in the world and is more common than bone, brain, and liver cancers.
Management of Clinical Cases
It is recommended to brush your teeth twice a day and visit the dentist regularly to reduce the accumulation of external stains caused by chewing betel quid. Dental hygienists should carefully examine the teeth to record the position and distribution of the stain, rough enamel surfaces, enamel defects, attrition, as well as plaque and calculus buildup. Severe attrition and abfraction areas should be evaluated for fractures and necessary treatment. The external staining caused by this habit should be treated with a thorough dental cleaning after scaling is completed. Both power scalers and hand scalers can remove betel nut stains. Stain removal should be done systematically and carefully to avoid pitting and damaging the enamel surface. The rubber cup polisher should not be used on areas where cementum and dentin are exposed due to the fragile enamel surface in betel quid chewers. Patients with deep-red stains on their teeth, gums, and oral mucosa should be educated about quitting betel quid chewing and improving oral self-care to prevent the stain from recurring.
There are several treatment options available for patients with OSF. These include the use of corticosteroids to relieve early symptoms and decrease collagen formation and proteolytic enzymes. Physical therapy, which focuses on alleviating muscle tension, can be helpful, as well as surgical interventions that focus on relieving the stiffening of the oral cavity by incising the fibrosis bands.
Conducting a self-examination for oral cancer offers information in Table 2. Educating patients on the significance of early detection and positive outcomes is crucial for teaching them how to perform a monthly self-examination for oral cancer. Betel quid users should ensure they receive comprehensive documentation of soft tissue lesions and regular screenings for oral cancer, as they face a higher risk of developing oral cancer and the potential malignancy of OSF.
Strategies for Quitting
Strong encouragement should be provided to promote the cessation of chewing betel quid, and patients should receive assistance in their efforts to quit. A program specifically targeting the cessation of betel quid chewing has not been clearly defined; however, established tobacco cessation models can be applied to this patient population due to the addictive nature of betel quid and the presence of tobacco. Nicotine gum can help address nicotine dependence and replace the habit of chewing. The 5As approach (Ask, Advise, Assess, Assist, Arrange) is a commonly used strategy in tobacco cessation, although it may not be as effective for individuals in the precontemplation or contemplation stage of changing their addictive behavior.
25. The patient continues to employ strategies and methods to stay free from the addictive habit – this is called maintenance and action. The patient also makes specific plans to stop the addictive habit – this is called cessation, expressing a desire to quit and recognizing that the habit is a problem. However, in the precontemplation stage, the patient refuses to consider cessation or believes that the habit is not a problem. The Transtheoretical Model of behavior change encompasses five stages – precontemplation, contemplation, preparation, action, and maintenance. Among users of betel quid, appropriate use of the Transtheoretical Model may elicit behavior changes in quitting the addictive behavior.
Once users are identified, their oral condition should be monitored in assistance and education, with the possibility of treating betel quid chewers. The potential explosion of oral cancer in this growing population of foreign-born individuals is extremely likely to decrease. It is extremely important to regulate the sale and use of purified and preserved betel nut preparations, encouraging policy changes and actively involving dental hygienists in educating the community about the dangers of chewing betel quid. As such, expanded research interventions are needed to address cessation of betel quid chewing. According to the US census reports from 2010, an estimated 40 million residents, or 13% of the total population, are foreign-born. Efforts in the US should focus on treatment and prevention education for conventional tobacco use.