The effects of betel-nut chewing on the buccal mucosa: a histological study

Study of salivary arecoline in areca nut chewers

Aims:

Arecoline, a predominant alkaloid present in arecanut, has been implicated in the pathogenesis of several oral diseases because of its mutagenic and carcinogenic potential. The response of cultured cells to arecoline is highly dependent on its concentration; arecoline stimulates cultured cells above 0.1 μg/ml and is cytotoxic above 10 μg/ ml. Although this alkaloid seems important for areca nut induced oral diseases and carcinogenesis, little is known of the levels achieved before, during and after chewing. Also, it is prudent to understand its effects in arecanut chewers for a comprehensive understanding of its pathogenesis. Accordingly, the present study quantified the salivary arecoline levels in arecanut chewers.

Materials and Methods:

The study participants were divided into Study Group A & B and Control Group C; unstimulated whole saliva was collected by spitting method for a period of 5 min. Then, participants in Group A and C chewed 0.5 g of areca nut without any other additives while in Group B were asked to chew 0.5 g of inert rubber base impression material. Stimulated whole saliva from all three groups was collected into graduated tubes during chewing at time intervals of 1, 3, 5, 10, 15, 20 and 25 min. Then, all participants were asked to remove nut particles or inert rubber base material from the mouth, and saliva samples were collected further up to 20 min, changing tubes at 5 min interval. Salivary arecoline was quantitated by HPLC-MS. The tabulation and descriptive statistics of the study were carried out.

Results:

In the present study, baseline levels of arecoline were zero in all three groups, whereas mean salivary arecoline levels during chewing were 76.93 ng/ml, 129.83 ng/ml and 64.83 ng/ml and after chewing were 196.17 ng/ml, 321.12 ng/ml and 43.75 ng/ml in Groups A, B and Control respectively, which were significantly higher than reported threshold levels.

Conclusions:

The data from this study reveals that a significant amount of arecoline would be trapped in oral cavity, or being re-circulated between blood and saliva might have resulted in surprisingly high levels of arecoline even 10 mins after chewing in both groups after which the levels started declining. The higher levels of salivary arecoline achieved during and after chewing are enough to cause cytotoxic and genotoxic effects on oral tissues over a period of time in chronic chewers. The great differences in salivary arecoline levels achieved during chewing, may contribute to the variable response to areca nut seen in communities where this habit is widespread. Areca nut users have persistent background salivary arecoline levels long after chewing, whereas concentrations achieved are highly variable and consistent with a role in oral pre-malignancy and malignancy..

Effect of lysozyme chloride on betel quid chewing aggravated gastric oxidative stress and hemorrhagic ulcer in diabetic rats

AIM: To evaluate the protective effect of lysozyme chloride on betel quid chewing (BQC) aggravated gastric oxidative stress and hemorrhagic ulcer in rats with diabetes mellitus (DM).

METHODS: Male Wistar rats were challenged intravenously with streptozotocin (65 mg/kg) to induce DM. Rats were fed with regular pellet food or BQC-containing diets. After 90 d, rats were deprived of food for 24 h. Rat stomachs were irrigated for 3 h with normal saline or simulated gastric juice. Rats were killed and gastric specimens were harvested.

RESULTS: An enhancement of various gastric ulcerogenic parameters, including acid back-diffusion, mucosal lipid peroxide generation, as well as decreased glutathione levels and mucus content, were observed in DM rats. After feeding DM rats with BQC, an exacerbation of these ulcero-genic parameters was achieved. Gastric juice caused a further aggravation of these ulcerogenic parameters. Daily intragastric lysozyme chloride dose-dependently inhibited exacerbation of various ulcerogenic parameters in those BQC-fed DM rats.

CONCLUSION: (1) Gastric juice could aggravate both DM and BQC-fed DM rat hemorrhagic ulcer; (2) BQC exacerbated gastric hemorrhagic ulcer in DM rats via enhancing oxidative stress and reducing defensive factors; (3) lysozyme chloride effectively protected BQC aggravated gastric damage in DM rats.

The oral health consequences of chewing areca nut

Deleterious effects of areca nut on oral soft tissues are published extensively in the dental literature. Its effects on dental caries and periodontal tissues, two major oral diseases, are less well researched. Areca-induced lichenoid lesions mainly on buccal mucosa or tongue are reported at quid retained sites. In chronic chewers a condition known as betel chewer's mucosa, a discoloured areca nut-encrusted change, is often found where the quid particles are retained. Areca nut chewing is implicated in oral leukoplakia and submucous fibrosis, both of which are potentially malignant in the oral cavity. Oral cancer often arises from such precancerous changes in Asian populations. In 1985 the International Agency for Research on Cancer concluded that there is limited evidence to conclude that areca chewing may directly lead to oral cancer. There is, however, new information linking oral cancer to pan chewing without tobacco, suggesting a strong cancer risk associated with this habit. Public health measures to quit areca use are recommended to control disabling conditions such as submucous fibrosis and oral cancer among Asian populations.

Role of areca nut in betel quid-associated chemical carcinogenesis: current awareness and future perspectives

Betel quid (BQ)-chewing is a popular oral habit with potential links to the occurrence of oral cancer. Many of the literature-based studies reveal that areca nut (AN) extract may demonstrate mutagenic and genotoxic effects, in addition to inducing preneoplastic as well as neoplastic lesions in experimental animals. Areca nut should, thus, be highly suspected as a human carcinogen. Toxicity studies relating to AN-contained polyphenols and tannins are not conclusive, with both carcinogenic and anti-carcinogenic effects being reported. The mutagenicity and genotoxicity of areca alkaloids has been detected by many short-term assays. However, their genotoxicity to oral fibroblasts and keratinocytes, the target cells of BQ, has not been identified. It would thus appear that AN toxicity is not completely due to its polyphenol, tannin and alkaloid content. The single agent which is responsible for AN carcinogenicity awaits further clarification. Reactive oxygen species produced during auto-oxidation of AN polyphenols in the BQ-chewer's saliva, are crucial in the initiation and promotion of oral cancer. Nitrosation of areca alkaloids also produces AN-specific nitrosamines, that have been demonstrated to be mutagenic, genotoxic and are capable of inducing tumors in experimental animals. Arecaidine and AN extract are further suggested to be tumor promoters. Antioxidants such as glutathione and N-acetyl-L-cysteine can potentially prevent such AN-elicited cytotoxicity. Further studies are needed to delineate the metabolism of AN ingredient and their roles in the multi-step chemical carcinogenesis, in order to enhance the success of the future chemoprevention of oral cancer and oral submucous fibrosis.

Effects of areca nut on growth, differentiation and formation of DNA damage in cultured human buccal epithelial cells

Because the high incidence of oral cancers in South-East Asia is causally linked to the common habit of betel quid chewing, the effects of an aqueous extract of areca nut, one of the main ingredients of the quid, on growth, differentiation, morphology and DNA damage were studied in cultured human buccal epithelial cells. An acute exposure (3 hr) of the cells to the extract altered their morphology and induced ridges in the plasma membrane, with indications of internalization of extract particles. Such exposure also caused formation of DNA single-strand breaks which accumulated during post-treatment culture, indicating continuous exposure to residual particles and/or the possibility of inhibited DNA repair. The extract accelerated terminal differentiation of the cells, measured as involucrin expression at relatively non-toxic levels. The extract caused similar loss of colony-forming efficiency in normal cells and in a buccal carcinoma cell line (SqCC/YI) which was defective in its ability to undergo differentiation, indicating that extract toxicity could occur independently from this response. Finally, the genotoxicity of the salivary areca-nut-specific carcinogen 3-(N-nitrosomethyl-amino)propionaldehyde, was demonstrated by the formation of DNA protein cross-links and DNA single-strand breaks in normal buccal epithelial cells. These findings in vitro suggest that betel quid carcinogenesis in the human oral cavity may involve cytopathic alterations of normal cell morphology, growth and differentiation, as well as formation of DNA damage by areca-nut-related agents extracted or formed in saliva.

An example of the use of quantitation in histological diagnosis by a comparison of normal human cheek mucosa and cheek mucosa affected by lichen planus

As an example of the use of quantitation in histological diagnosis the features of normal human cheek mucosa (NHCM) and non-ulcerative lichen planus of the cheek mucosa (LPCM) have been systematically studied and quantified in order to establish normal and pathological features which are constant. The technique enabled the quantitative verification of previously held concepts relating to NHCM and LPCM. A number of interesting features which have been given little attention in past literature were also noted. It is proposed that a reliable quantifiable range of characteristic histological features should be established for use in diagnosis where possible rather than relying on the subjective approach currently employed.

Studies on the pathological effects of feeding betel-nut meal in albino rats

The pathological effects of betel-nut meal consumption in weaned albino rats were studied for a period of 4 weeks. In higher concentrations (60-100%), toxic effects were observed. The rats showed severe diarrhoea and died within 1-3 weeks depending upon the amount of betel-nut meal consumed. In lower concentrations (5-10%), no grossly detectable pathological changes were observed in any one of the experimental rats. With the increase in the concentration of betel-nut meal in the experimental diets, the pathological changes were intensified gradually. The pathological changes observed in the rats fed with experimental diets containing more than 15% betel-nut meal were necrosis of the buccal and intestinal mucosa, splenomegaly, fatty changes in the liver and stunted skeletal growth. Catarrhal enteritis was observed in the rats fed with 15% betel-nut meal and haemorrhagic gastroenteritis was observed when the concentration of the betel-nut meal was raised above 15%.

Changes in vitamin A conditioned hamster cheek pouch epithelium on exposure to commercial shell lime (calcium hydroxide) and tobacco. I-Optical histopathology

Epidemiologically a high incidence of oral cancer and addiction to tobacco, singly or in combination with other ingredients of the betel quid, are closely correlated. Attempts at the induction of malignancy in laboratory animals on exposure to these ingredients have hitherto failed. Studies are reported on cheek pouch epithelium of 152 Syrian golden hamsters exposed to commercial shell lime (calcium hydroxide) and tobacco, singly and in combination, with parallel conditioning by Vitamin A palmitate. The abnormal changes found especially in lime and lime-plus-tobacco treated epithelia are massive hyperplasia, keratinization anomalies, marked edema and dysplasia. The most significant findings are (1) greater epithelial alteration caused by lime, lime plus vitamin A, tobacco plus vitamin A, lime plus tobacco and lime plus tobacco and vitamin A, than by tobacco alone; (2) increasing epithelial dysplasia in response to longer periods of exposure to the test substances; and (3) enhancement of tissue changes in the presence of vitamin A.

Why are white lesions white? Observations on keratin

It is proposed that oral keratoses appear white because of the ability of abnormal oral keratin to evenly reflect the visible light spectrum because of the hydration of the keratin layer in a manner similar to the reaction of the stratum corneum of the epidermis to water. Thickening of the keratin layer per se or the over-all thickness of the epithelium does not appear to be the primary factor in causing an intraoral lesion to appear white. The white appearance is related to thickness only insofar as it takes a certain amount of abnormal keratin to be clinically evident. It appears that an accumulation of only 10 to 20 microns of abnormal keratin is sufficient to cause a lesion to appear very white. This is about the amount seen on the normal human palate. It seems likely that, when a normally nonkeratinized area, such as the buccal mucosa or floor of the mouth, is stimulated to produce keratin, the keratin thus produced would be different from normally occurring oral keratin. This difference apparently manifests itself clinically as hydration of the keratin layer. A more complete understanding of why white lesions are white awaits further elucidation in regard to the role of lipids, keratohyaline granules, membrane-coating granules, and intercellular cement. Characterization of the oral keratins as to their amino acid residues and types of bondings, as well as insight into the events transpiring when the prickle cell becomes keratinized, may not only shed light on the etiology of these lesions but also have prognostic implications.