| Abstract: |
The first mention of the betel quid dates from 504 BC, from Sri Lanka, written in Pali (Krenger 1942). Thus over a 2000 year written history of betel quid chewing. The first mention for oral cancer attributed to betel nut chewing was from Tennent (1860). Other early references include Bala Ram (1902), Niblock (1902), and Boak (1906), about the chewing of betel quid alone or with tobacco. Reason why they chew betel quids: increased salvation, anthelmintic properties, to satisfy hunger, to sweeted the breath. \bMajor Components\b Areca nut (Betel nut) is the fruit of the \iAreca catechu\i L. tree. Areca is a small genus comprising of 20 species of slender palms in the Palmacae family. The palm is native to South Asia and is found throughout South and Southeast Asia and in several Pacific islands. The fruit grows in large bunches at the base of the leaves, and varies in size and shape. The fruit itself is orange-yellow in color when ripe and is generally the size of small egg. In processing the nut, the eternal shell is removed then the nut is either sliced fresh, sun dried, or cured. Before curing, the fruits are first shelled
the kernel is the sliced or kept whole and boiled in water, to which is added water left from previous years' curing. Curing results in uniform color, softens the nut and reduces the tannin content (Arjungi 1976). Betel leaf (\iPiper betle\i L.) is the leaf used and is found in hot and humid climatic conditions. \iLime\i, is prepared from silicious covering of marine invertebrates (sea shells), harvested along the coastline or from quarried stone. It is made into a paste and mixed with water in order to release calcium hydroxide (Kandarkar and Sirsit 1977). \iCatechu\i is the resinous extract from the matrix of the \iAcacia\i tree, usually \iA. catechu\i or \iA. suma\i (Muir and Kir 1960
Millot 1965). A betel quid is betel leaf on which lime is smeared a betel nut slice is placed, wrapped, and placed between the cheeck and buccal groove. Tobbaco is also added on occasian, and depending on taste, spices wuch as cardamon, cloves (Muir and Kirk 1960), grated fresh coconut (Schonland and Bradshaw 1969), ginger (Arjungi 1976), and sugar (Millot 1965). Generally the quid is chewed after meals, but the frequency of chewing by regula chewers ranges from 15-20 time a day. The areca nut is also chewed alone, and in Assam and south-western regions of India, it is chewed raw. \bGeographic differences and current practices\b In 1958, it was estimated that there were five to 10 million quid chewers in India (Chopra et al 1958), and in 1979 the total world-wide estimate was 200 million (Burton-Bradley 1979). In\b India\b, a substantial proportion of the population chew betel quids. The higest consumption is found in the coastal areas of South India, Assam, Bengal, Uttar Pradesh and Madya Pradesh (Chopra et al 1958). Moderate chewing is found in Maharashtra, Punjab, Gujarat, and Rajasthan. The inclusion of tobacco varies from region to region. In Uttar Pradesh, finely cut areca nut and powdered cloves or camphor are commonly mixed with tobacco. In\b Indonesia\b, the habit is practiced with leaf, nut, lime, and catechu. Once the quid is thoroughly chewed, a piece of finely cut tobacco is used to remove the remnants of the betel quid ahering to the teeth and buccal grooves. The piece of saturated tobacco is then placed close to the labial commissure until a ephoric stateis achieved (Möller et al 1977). In \bJava and Bali\b, a study of dental caries and betel chewing (Möller et al 1977), found chewing to be more common among women than men. While the number of person practicing the habit was decreasing, the % of chewers is much has among women >35 years, than among those aged <35 years. The habit is usually acquired between 15 and 20 years of age. In \bPapua New Guinea\b, the different is very different than in \bSoutheast Asia\b. The areca nut is chewed when it is ripe but not cured
most often, leaves, seeds and part of the stem from the \iPiper betle\i are added. When the chewing has lasted a minite or so, slaked lime is added in large quantities. The pulverized lime is put on a moistened stick and applied to the buccal mucosa. At the time of withdrawl, the stick is pressed towards the labial commissure and licked clean. Tobacco is never added. Prevalence of chewers was analyzed by Pindborg et al (1968) and Schamschula et al (1977). Betel chewing is also widspread on the island of Hainan in China. The betel leaf is smeared with slaked lime and placed in the mouth with pieces of areca nut that have been peeled and sliced in millimetre sections. Tobacco is never added (Pindborg et al 1984). The toxic and pharmacological effects of betel quid have been reviewed by Arjungi (1976) and Mujumdar et al. (1982). The perception of taste is dulled due to the presence of an essential oil in the betel leaf and to the astringent action of the lime. Betel quid also stimulates salivary secretion and the saliva a red color. Chewing a quid of tobacco, areca nut and lime increased chemically-induced (10 citric acid) but not mechanicaly-induced (forced spitting) salivary flow (Reddy et al. 1980). Increased nitrite levels after 1 hour, but no increased when used with tobacco. Quid with tobacco slightly increased salivary pH. Quid did not alter thiocyanate levels in saliva, but the presence of tobacco increased these levels significantly (Shivapurkar et al. 1980b). The immediate effects of betel-quid chewing appear to be the results of stimulation of the parasympathetic nervous system by areciline, which are manifested in contraction of the sphincter of the iris, depression of heart muscle tonus, dilation of blood vessels, contraction of the bronchiolar smooth muscle, contraction of the walls of the gut but relaxation of the sphincters and contraction of the bladderr. In addition, secretion of gastric juices, and of sweat, tears and saliva in increased (Katzung 1982). Mehta et al. (1955) was the first study to demonstrate a detrimental influence of betel chewing upon the periodontal tissues [india]. See also Gupta (1964)[india]
Waerhaug (1967)[sri lanka]
Chandra and Desai (1970)[india]
Möller et al (1977)[java and bali]
Schamschula et al (1977)[PNG]
and Howden (1982)[PNG] Howden (1982) found no correlation of periodontal frequency with betel quid chewing of 75 Papua New Guineans. While the first mention of betel quid chewing was in 504BC, one of the earliest Asian written descriptions of oral cancer was in the \iSushruta Samhita\i, a treatise on Indian surgery written in Sangkrit around 600BC. Tobacco would be introduced as least in India around 16th century. In PNG, oral cancer is generally the most common form of cancer, and the betel quid without tobacco is the most common. \bsee pages 170-181 for frequency by country of oral cancer from betel quids with or without tobacco\b \bSummary of Data\b The habit of betel quid chewing is Southeast Asia and the South Pacific islands and people of Indian origin is widspread. The quid usually contains areca nut, lime and catechu wrapped in a betel leaf. Tobacco is often added. These habits often results in exposure to areca nut alkaloids, N-nitroso compounds derived from these alkaloids, polyphenols, and, when the habit includes tobacco, tobacco-specific nitrosamines. There is \isufficient evidence\i that the habit of chewing quids containing tobacco, and/or sming of tobacco is carcinogenic to humans. There is\i inadequate evidence\i that the habit of chewing quids without tobacco is carcinogenic to humans. There is \iinadequate\i data to allow an evaluation of the carcinogenicity of betel leaf or arecoline to experimental animals.
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