3 9

EFFECT OF BETEL CHEWING ON THE ORAL MUCOSA

G. E. TENNEKOON AND G. C. BARTLETT
From t h e De p a rt me n t s of P a t h ol og y a n d De n t i s t ry , Un i v e rs i t y of Ce y l on , P e ra d e n i y a , Ce y l on
Re c e i v e d f or p u b l i c a t i on Oc t ob e r 3 0 , 1 9 6 8
THE i n c i d e n c e of b u c c a l c a rc i n oma i s t h e h i g h e s t a mon g c a n c e rs i n Ce y l on .
Ou t of a t ot a l of 5 9 6 3 c a n c e rs a d mi t t e d t o t h e Ge n e ra l Hos p i t a l Col omb o b e t w e e n
t h e y e a rs 1 9 3 7 a n d 1 9 4 2 , 2 4 9 6
( 4 2 . 0 % ) w e re c a n c e rs of t h e mou t h ( Coora y , 1 9 4 4 ) .
Ca n c e r of t h e mou t h a n d p h a ry n x a c c ou n t e d f or 2 5 7 5
( 2 7 . 7 % )
ou t of 9 2 8 7 ma l i g -
n a n t n e op l a s ms i n g ov e rn me n t h os p i t a l s i n Ce y l on d u ri n g t h e y e a r 1 9 6 3 - 6 4
( Di re c t or of He a l t h Se rv i c e s 1 9 6 3 - 6 4 . )
A s i mi l a r h i g h i n c i d e n c e h a s b e e n re c ord e d i n In d i a a n d i n Bu rma ( Orr, 1 9 3 3 ;
Na t h a n d Gre w a l , 1 9 3 5 , 1 9 3 7 , 1 9 3 9 ; Kh a n ol k a r, 1 9 4 4 a n d
1 9 5 0 ) . In Ce y l on t h e
c h e e k i s t h e c ommon e s t s i t e a f f e c t e d w i t h i n t h e mou t h . Of 1 1 3 0 b u c c a l c a n c e rs ,
7 4 3 w e re i n t h e c h e e k , 1 6 8 i n t h e t on g u e a n d 8 1 i n t h e g u ms ( Coora y , 1 9 5 3 ) .
Be t e l c h e w i n g i s a c ommon h a b i t i n t h i s p a rt of t h e w orl d . Th e i n g re d i e n t s
c h e w e d c on s i s t of t h e b e t e l l e a f ( p i p e r l e a f ) , a re c a n u t ( Are c a c a t e c h u ) , d ri e d
t ob a c c o l e a f ( Ni c ot t i a n a t a b a c u m) a n d l i me or " c h u n a m " . Ea c h q u i d c on s i s t s of
t h e b e t e l l e a f s me a re d w i t h l i me a n d w ra p p e d a rou n d s l i c e d or c h op p e d a re c a n u t
a n d a f ra g me n t of d ri e d t ob a c c o l e a f . A f e w t o a b ou t t w e n t y s u c h q u i d s ma y b e
c h e w e d e a c h d a y . Ea c h " c h e w " ma y b e k e p t i n t h e mou t h f or a f e w mi n u t e s t o
s e v e ra l h ou rs .
Th e re i s a g e n e ra l b e l i e f t h a t t h e h i g h i n c i d e n c e of b u c c a l c a n c e r i s a s s oc i a t e d
w i t h t h e b e t e l c h e w i n g h a b i t a s t h e re a p p e a rs t o b e a re l a t i on s h i p b e t w e e n t h e
g e og ra p h i c a l d i s t ri b u t i on of b u c c a l c a rc i n oma a n d b e t e l c h e w i n g . Th e p re s e n t
i n v e s t i g a t i on w a s u n d e rt a k e n t o f i n d ou t w h e t h e r b e t e l c h e w i n g c a u s e d mu c os a l
c h a n g e s w h i c h c ou l d s u b s e q u e n t l y re s u l t i n c a n c e r.
METHODS
Ma t e ri a l w a s t a k e n f rom ma l e i n d i v i d u a l s w h o v i s i t e d t h e Un i v e rs i t y De n t a l
Hos p i t a l , P e ra d e n i y a . Th e i r h i s t ori e s a s re g a rd s c h e w i n g h a b i t s a n d s mok i n g
w e re n ot e d . Th e i n g re d i e n t s of a c h e w w e re a s c e rt a i n e d . Con t rol s w e re n on - b e t e l
c h e w e rs . In ord e r t o a v oi d c omp l i c a t i n g f a c t ors l i k e t h e i n f l u e n c e of n i c ot i n e t a rs ,
h e a t e t c . on l y n on - s mok e rs w e re s e l e c t e d f or t h i s i n v e s t i g a t i on . Th e c on t rol s w e re
c h os e n a s f a r a s p os s i b l e i n t h e s a me a g e g rou p a s t h e p a t i e n t s .
Th e c omp os i t i on of t h e q u i d i n re g u l a r b e t e l c h e w e rs w a s b e t e l , a re c a n u t ,
c h u n a m ( l i me ) , a n d t ob a c c o l e a f . An oc c a s i on a l i n d i v i d u a l w h o d i d n ot u s e
t ob a c c o l e a f w a s n ot c on s i d e re d i n t h i s s e ri e s .
For mi c ros c op i c e x a mi n a t i on t h e f ol l ow i n g p roc e d u re w a s a d op t e d . A p a rt i c u -
l a r s i t e , t h e ora l mu c os a op p os i t e t h e mol a r re g i on , w a s s e l e c t e d . If t h e re w a s a
c a ri ou s or j a g g e d t oot h , t h e op p os i t e s i d e w a s c h os e n . Be f ore e a c h b i op s y t h e
p u rp os e of t h e i n v e s t i g a t i on w a s e x p l a i n e d t o t h e s u b j e c t a n d h i s w ri t t e n c on s e n t
f or i n v e s t i g a t i on ob t a i n e d .
4
G. E. TENNEKOON AND G. C. BARTLETT
A p i e c e of mu c ou s me mb ra n e 0 5 mm. x 5 mm. w a s re mov e d u p t o t h e d e p t h of
mu s c l e l a y e r u n d e r l oc a l a n a e s t h e s i a . Us u a l l y t h e re w a s n o b l e e d i n g . If i t w a s
n e c e s s a ry a s u t u re w a s i n s e rt e d . Th e s p e c i me n w a s i mme d i a t e l y f i x e d i n
1 0 %
f orma l i n a n d h i s t ol og i c a l e x a mi n a t i on w a s d on e b y on e of u s ( G. E. T. ) w h o w a s
u n a w a re of t h e h i s t ory , a g e or a n y ot h e r p a rt i c u l a rs of t h e i n d i v i d u a l . Al l s e c t i on s
w e re s t a i n e d w i t h Ha e ma t ox y l i n a n d Eos i n .
RESULTS
In t h e f i rs t i n s t a n c e t h e s u b j e c t s , c h e w e rs a n d c on t rol s , w e re d i v i d e d i n t o
g rou p s a c c ord i n g t o a g e a n d f re q u e n c y of c h e w s , t h e l a t t e r b e i n g a rb i t ra ri l y d i v i d e d
i n t o 2 g rou p s - l i g h t ( 5 c h e w s or l e s s a d a y ) a n d h e a v y ( ov e r 5 c h e w s ) .
Ta b l e I s h ow s t h e a g e d i s t ri b u t i on of l i g h t a n d h e a v y c h e w e rs a n d c on t rol s .
Ta b l e II s h ow s t h e c l a s s i f i c a t i on of t h e t w o g rou p s a c c ord i n g t o d u ra t i on of t h e
c h e w i n g h a b i t .
TABLE
I. - Ag e Di s t ri b u t i on of Li g h t a n d He a v y Ch e w e rs a n d Con t rol s
Ag e g rou p Li g h t He a v y Con t rol s
2 1 - 3 0 . 9 . 1 1 . 9
3 1 - 4 0 1 3 . 1 4 . 1 0
4 1 - 5 0 1 1 . 1 3 . 8
5 1 - 6 0 . 1 0 . 1 4 . 7
Ov e r6 1 . 5 8 . 8
TABLE II. - Du ra t i on of Be t e l Ch e w i n g
Ty p e of Le s s t h a n 6 - 1 0 1 1 - 2 0 Ov e r 2 0
c h e w e r 5 y e a rs y e a rs y e a rs y e a rs
Li g h t . 1 3 . 1 2 . 1 3 . 1 0
He a v y .
1 0
.
1 2
.
1 5
.
2 3
We h a v e e x a mi n e d t h e b i op s i e s w i t h re g a rd t o t h e i t e ms a s h y p e rp l a s i a ,
k e ra t os i s , p a p i l l a ry f orma t i on s , a n d d ow n g row t h s of t h e e p i t h e l i u m. Wh e n w e
s t u d y t h e b i op s i e s of t h e c on t rol s i t a p p e a rs d i f f i c u l t t o s a y w h a t t h e n orma l a p p e a r-
a n c e s s h ou l d b e . We re g a rd e p i t h e l i u m a b ou t 1 5 t o 2 0 c e l l s t h i c k w i t h s l i g h t
k e ra t os i s a n d a s l i g h t l y u n d u l a t i n g b a s e me n t me mb ra n e a s n orma l . Ep i t h e l i a
ov e r 2 5 t o 3 0 c e l l s t h i c k w e re re g a rd e d a s h y p e rp l a s t i c . In s ome of t h e s e c on t rol s
t h e c e l l s w e re f ou n d t o b e a c a n t h ot i c . Ge n e ra l l y , a s l i g h t d e g re e of c h ron i c i n f l a m-
ma t ory c e l l re a c t i on w a s ob s e rv e d . Ta b l e III b ri n g s t o l i g h t t h e re ma rk a b l e f a c t
t h a t t h e e p i t h e l i a l c h a n g e s i n t h e b u c c a l mu c ou s me mb ra n e of b e t e l c h e w e rs a n d
c on t rol s a re more or l e s s a l i k e . Th e c h a n g e s of h y p e rp l a s i a a n d k e ra t os i s s h ow on l y
a s l i g h t l y h i g h e r i n c i d e n c e a mon g t h e b e t e l c h e w e rs . Th e t h re e c a s e s a mon g t h e
h e a v y b e t e l c h e w e rs i n d u l g i n g i n t h e h a b i t f or ov e r 2 0 y e a rs w h i c h a re c a l l e d "
p re -
c a n c e rou s
" s h ow e d d ow n g row t h s , u n d e f i n e d b a s e me n t me mb ra n e , a n d ma rk e d
mi t ot i c a c t i v i t y , a t y p i c a l i t y , a n d
h y p e rc h roma t i s m. Th e
a g e d i s t ri b u t i on i n
Ta b l e II of t h e c on t rol s s h ow s t h a t t h e c h a n g e s a re p re s e n t b ot h i n t h e y ou n g e r a s
w e l l a s t h e " c a n c e r a g e
"
g rou p . Th e re s u l t s a p p e a r t o s h ow t h a t t h e e f f e c t of t h e
b e t e l c h e w i n g on p re c a n c e rou s c h a n g e
i n t h e b u c c a l mu c os a a re
n e g l i g i b l e , e x c e p t i n
a f e w h e a v y c h e w e rs w h o h a v e c on t i n u e d t h e h a b i t f or
l on g p e ri od s
of t i me .
Th e ob s e rv a t i on s w e h a v e ma d e on t h e h i s t ol og y of t h e c on t rol s a re ra t h e r
s t a rt l i n g . It a p p e a rs a s t h ou g h t h e re a re a n u mb e r of ot h e r f a c t ors w h i c h s e e m t o
4 0
BETEL CHEWING AND ORAL MUCOSA
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G. E. TENNEKOON AND G. C. BARTLETT
a f f e c t t h e b u c c a l mu c os a . For e x a mp l e , t h e s oc i a l s t a t u s of t h e i n d i v i d u a l , d i e t a ry
h a b i t s , t h e ma i n t e n a n c e of ora l h y g i e n e n e e d t o b e i n v e s t i g a t e d . Th e Kh a n a n d
CL. d on e on s ome of t h e p a t i e n t s w e re f ou n d t o b e n e g a t i v e .
DISCUSSION
Ou r re s u l t s s h ow t h a t a b ou t
1 4 %
of h e a v y c h e w e rs w h o h a v e c on t i n u e d t h e
h a b i t f or ov e r 2 0 y e a rs s h ow c h a n g e s i n t h e ora l mu c os a w h i c h c a n b e re g a rd e d a s
p re c a n c e rou s i n t h a t t h e re w a s h y p e rc h roma t i s m, l os s of p ol a ri t y a n d a t y p i c a l i t y of
t h e e p i t h e l i u m. P e op l e w h o h a v e i n d u l g e d i n t h e b e t e l c h e w i n g h a b i t f or t h i s l on g
f a l l i n t o t h e " c a n c e r a g e " g rou p .
It i s n ot p os s i b l e t o b l a me t h e b e t e l c h e w i n g h a b i t a l on e a s a c a u s e of c a n c e rou s
c h a n g e s i n t h e mu c os a a s t h e c on t rol s s h ow c h a n g e s c omp a ra b l e w i t h t h os e of t h e
b e t e l c h e w e rs .
Th e i n g re d i e n t s of t h e b e t e l q u i d c on s i s t s of t h e b e t e l l e a f , a re c a n u t , l i me a n d
t ob a c c o. Th e b e t e l l e a f c on t a i n s n o p os s i b l e c a rc i n og e n . It s t a s t e i s d u e t o a n
a roma t i c oi l . Mc l a n g ( 1 9 2 6 ) s t a t e s t h a t b e t e l l e a f i s a n a c t i v e b a c t e ri c i d e . Th e
a re c a n u t c on t a i n s t a n n i n , g a l l i c a c i d , v ol a t i l e oi l a n d a l k a l oi d s . Tob a c c o i s a l mos t
a l w a y s u s e d i n t h e b e t e l q u i d .
Con d e n s a t e s of t ob a c c o s mok e a re c a rc i n og e n i c b u t t h e q u e s t i on w h e t h e r t h e
d ri e d t ob a c c o l e a f w h e n c h e w e d i s c a rc i n og e n i c or n ot re ma i n s u n a n s w e re d .
Bors h ( 1 9 0 0 ) a p p l i e d t ob a c c o j u i c e t o s k i n of g u i n e a - p i g s a n d ob t a i n e d h y p e rp l a s i a
on l y . Wy n d e r a n d Bros s ( 1 9 5 7 ) w e re of op i n i on t h a t t ob a c c o c h e w i n g p l a y e d a
l e s s e r p a rt i n c a u s i n g c a n c e r of t h e mou t h t h a n t ob a c c o s mok i n g . Li me i n t h e
q u a n t i t i e s c h e w e d h a s a mi l d l y i rri t a n t a c t i on a n d i s d i l u t e d s u f f i c i e n t l y b y t h e
s a l i v a a n d b e t e l j u i c e s t o re n d e r i t i n n oc u ou s .
Be t e l c h e w i n g a l on e h a s n o d i re c t c a rc i n og e n i c a c t i on b u t i t i s a c a u s e of
p e ri od on t a l d i s e a s e ( Ba l e n d ra , 1 9 4 9 ; Me h t a e t a l . , 1 9 5 5 ) . Ba l e n d ra ( 1 9 4 1 ) s t a t e d
t h a t t h e c omp on e n t s of t h e b e t e l q u i d w e re n ot c a rc i n og e n i c b u t t h a t b e t e l c h e w i n g
c a u s e d g i n g i v i t i s , i rre g u l a ri t i e s of t e e t h a n d g u ms a n d s e p s i s re s u l t i n g i n c h ron i c
i rri t a t i on a n d c a n c e r. Kh a n ol k a r ( 1 9 4 4 ) c on c l u d e d t h a t c h e w i n g of b e t e l a n d
a re c a n u t , e x c e p t i n c a u s i n g p oor ora l h y g i e n e , h a d n o ot h e r rol e i n t h e p rod u c t i on
of b u c c a l c a n c e r, b u t w h e n t ob a c c o w a s u s e d a s w e l l a p os s i b l e a s s oc i a t i on h a s b e e n
s u g g e s t e d ( Sa n g h v i , Ra o a n d Kh a n ol k a r, 1 9 5 5 ; Ma rs d e n , 1 9 5 8 ) . Cook e ( 1 9 6 4 )
s u g g e s t s t h a t f ri c t i on f rom a j a g g e d t oot h a l on e or i n c omb i n a t i on w i t h s mok i n g or
b e t e l c h e w i n g c a n c a u s e
l e u k op l a k i a .
More ov e r t h e re i s mu c h v a ri a t i on i n t h e c a n c e r i n c i d e n c e i n d i f f e re n t b e t e l
c h e w i n g p op u l a t i on s , a s s e e n i n t h e l ow i n c i d e n c e of b u c c a l c a n c e r i n t h e Du t c h
Ea s t In d i e s ( Sn i j d e rs a n d St ra u b , 1 9 2 3 ) , i n Sou t h Formos a ( Ma x w e l l , 1 9 2 4 ) , i n
Gu a m ( We l l s , 1 9 2 5 ) a n d i n Ne w Gu i n e a ( Ei s e n , 1 9 4 6 ) . Ge n e t i c i n f l u e n c e s ( Sa n g h v i
a n d Kh a n ol k a r, 1 9 4 9 ) a n d d i e t a ry f a c t ors s u c h a s v i t a mi n d e f i c i e n c i e s ( Orr, 1 9 3 3 ;
Sa t h e e t a l . , 1 9 5 7 ) , s p i c e d f ood s
( Loe f f l e r, 1 9 5 5 ) h a v e b e e n s u g g e s t e d a s c on t ri b u t ory
t o t h e p re v a l e n c e of ora l c a n c e r i n Sou t h Ea s t As i a .
Se n e v i ra t n e ( 1 9 6 8 , u n p u b l i s h e d re s u l t s ) i mp l a n t e d t h e c omp on e n t s of t h e b e t e l
q u i d , s e p a ra t e l y a n d t og e t h e r, i n c orp ora t e d i n j a k l a t e x i n t h e c h e e k s of a l b i n o
mi c e . Al l a n i ma l s s h ow e d e p i t h e l i a l h y p e rp l a s i a b u t 2 ou t of 1 8 mi c e g i v e n a re c a
n u t a l on e d e v e l op e d p a p i l l oma t a of t h e s k i n a f t e r 4 0 w e e k s . Woe f e l e t a l . ( 1 9 4 1 )
c ou l d ob t a i n n o t u mou rs w h e n t h e y t e s t e d f ra c t i on s of a re c a n u t on mi c e . P ro-
l on g e d s u b c u t a n e ou s i n j e c t i on s of t a n n i n a n d g a l l ot a n n i n p rod u c e d c i rrh os i s of
4 2
BETEL CHEWING AND ORAL MUCOSA 4 3
t h e l i v e r b u t n o l oc a l t u mou rs ( Korp a s s y e t a l . , 1 9 5 0 ) . Mu i r a n d Ki rk ( 1 9 6 0 )
p a i n t e d mi c e w i t h a b e t e l / t ob a c c o e x t ra c t a n d f ou n d t u mou rs i n 3 ou t of 5 3 mi c e .
Ou r re s u l t s s h ow t h a t w h i l e b e t e l c h e w i n g f or l on g p e ri od s of t i me ma y b e c on -
t ri b u t ory i n c a u s i n g b u c c a l c a n c e r, s i mi l a r c h a n g e s i n t h e c on t rol s s u g g e s t t h a t
ot h e r f a c t ors s u c h a s d i e t a ry h a b i t s or d e f i c i e n c i e s a n d p oor ora l h y g i e n e ma y p l a y a
p a rt i n t h e g e n e s i s of ora l c a n c e r.
SUMMARY
Ab n orma l i t i e s of t h e b u c c a l mu c os a w h i c h ma y b e c a u s e d b y t h e b e t e l c h e w i n g
h a b i t w e re i n v e s t i g a t e d . It w a s f ou n d t h a t 1 4 % of p e rs on s w h o c h e w e d ov e r
5 q u i d s a d a y f or ov e r 2 0 y e a rs ma y s h ow c h a n g e s w h i c h ma y b e re g a rd e d a s " p re -
c a n c e rou s " . How e v e r, c on s i d e ri n g t h e c h a n g e s s e e n i n t h e c on t rol s i t i s p os s i b l e
t h a t t h e re a re ot h e r f a c t ors s u c h a s f a u l t y d i e t a n d p oor ora l h y g i e n e w h i c h ma y
a c c ou n t f or s ome of t h e a b n orma l i t i e s i n t h e ora l mu c os a .
REFERENCES
BALENDRA, W. - ( 1 9 4 1 ) J . Ce y l on Brc h Br. me d . As s . , 3 8 , 4 7 . - ( 1 9 4 9 ) P a p e r re a d a t
An n u a l Me e t i n g of De n t a l As s oc i a t i on a t Sc a rb orou g h , En g l a n d .
BORSH, A. - ( 1 9 0 0 ) V i rc h ow s Arc h . p a t h . An a t . P h y s i ol . , 1 6 2 , 3 2 .
COOKE, B. E. D. - ( 1 9 6 4 ) An n . R. Col l .
Su rg . ,
3 4 , 3 7 0 .
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