Use of Areca Nuts – Independent risk factor in oral cancer

Introduction :-

Areca nut is the seed of fruit of oriental palm Areca Catechu. It is the basic ingredient of the variety of widely used chewed products. Thin slices of nuts are either used naturally or processed, may be mixed with a variety of substances including slaked lime [ Ca(OH)2 ] and spices such as cardomom, saffron, coconut. Most significantly they can be mixed with tobacco or can be wrapped in leaf of piper betel plant (betel quid) hence Areca nuts are more commonly known as Betel nuts.

Areca nut is chewed by over 200-400 million people worldwide, a tenth of world population.
It is chewed either alone or as a part of a quid known as “Pan”.

The habit of chewing areca nuts is more common in Central, Southern and Southeast Asia. It is used by both men and women. All age groups and social classes use the product.

Areca nut has long history of use and deeply ingrained in sociocultural and religious activities.

There is increasing evidence that areca products induce a true dependency syndrome. A recent study of Gujrati areca users in North West London assesed their degree of dependency as to that of Cocaine users especially if there is tobacco in Pan masala.

Patient describle symptoms as difficulty in abstaining, withdrawl symptoms including headache, sweating and need for morning pan to releive these symptoms. Individual report queuing outside paan shops waiting them to open and continuing sequential use, analogous to chain smoking.

Components :-

The addictive components in preparation have not been identified.
Alkaloid Arecoline a mild stimulant that produces a feeling of wellbeing has been isolated from basic nut and has major effect on various neurotransmitters particularly on cholinergic neurons but there are a variety of other alkaloids namely arecaidine, guracine, guacine and arecolidine as well as unidentified peaks on chromatography of extracts.

Effects on Oral Mucosa :-

From the medical point of view, the most important consideration is the relation between areca nut use and the development of mouth cancer (oral squamous cell carcinoma) and its precursors Leukoplakia and Oral SubMucous Fibrosis (OSMF).
An increased risk for development of oral malignancy in “Areca nut only users” is reported.
Adding tobacco to the quid is indeed confounder in many studies.
There are some populations such as Taiwanese who do not add tobacco to Betel nut / Areca nut.

The reported relative risk for oral cancer among those who chew areca only in Taiwanese pnpulation is 58.4%.

The admix of tobacco products further increases the likehood of developing oral malignancy.
Both duration and daily frequency of areca used, increase the risk of developing cancer, suggesting a dose response relation.

Habitual chewing of betel nuts eventually blackens the teeth and may cause them to decay.

Studies have shown that areca nut extract affects on growth, attachment and protein synthesis of human gingival fibroblast leading to higher prevalence of periodontal disease in areca nut chewers.

Two major oral diseases are less well researched.

1) Areca induced lichenoid lesions – mainly on buccal mucosa or tongue are reported at quid retained sites.

2) In chronic chewers, condition known as betel chewers mucosa, a discolored areca nut encrusted change, is often found where quid particles are retained.

What can be done :-

The role of areca products in causing oral submucous fibrosis, malignancy and possibly contributing other diseases has raised importance of public health issues. There products are inadequetly labelled and there are no health warning labels and no restriction on its sale to children or consumption in public places, so Accurate labelling of the products, especially with respect to admixure with tobacco should be an important requirement.

Health education is needed and health warning should be enacted but outright bans or restriction will probably prove to be counterproductive.

The identification of dependance should be more generally known and facilities for treatment and programme to reduce harm are needed.
In addition further research both clinical and experimental is required on biomedical and psychosocial consequences of areca usage.

What I learned from this topic :-

The danger posed to oral health from chewing tobacco and areca nut are well documented within dental profession but lack of knowledge in community on this subject is exceptionally worrying.

This combination of providing opportunistic advice particularly to stop chewing areca nuts and tobacco products together with regular screening will reduce overall morbidity and mortality from oral cancer and other oral disorders, which will dramatically improve the quality of life of those people who are at greatest risk of these diseases.