|Year : 2019 | Volume
| Issue : 3 | Page : 620-624
A correlation between oral mucosal lesions and various quid-chewing habit patterns: A cross-sectional study
ML Avinash Tejasvi1, CK Anulekha2, Mohd Malik Afroze3, K Prashanth Shenai4, Laxmikanth Chatra4, Harsha Bhayya1
1 Department of Oral Medicine and Radiology, Kamineni Institute of Dental Sciences, Nalgonda, Telangana, India
2 Department of Prosthodontics, Kamineni Institute of Dental Sciences, Nalgonda, Telangana, India
3 Department of Oral Medicine and Radiology, Majmaah Universityk, Al Majma'ah, Saudi Arabia
4 Department of Oral Medicine and Radiology, Yenepoya Dental College, Mangalore, Karnataka, India
|Date of Web Publication||29-May-2019|
Dr. C K Anulekha
Department of Prosthodontics, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda - 508 254, Telangana
Source of Support: None, Conflict of Interest: None
Background and Objectives: Quid-chewing habit is a common and old tradition in India. It causes various potentially malignant disorders. Therefore, a study was undertaken to analyze the association of various quid-chewing habit patterns and different oromucosal lesions.
Materials and Methods: A cross-sectional study was conducted on 150 cases, where all the individuals selected were having quid-chewing habit and oromucosal lesions. Detailed habit history was taken through preformed questionnaire, clinical examination was done, and the lesion was subjected to incisional biopsy and confirmed histopathologically.
Results: The male to female ratio of various quid-chewing habit and oromucosal lesions was 9:1. The middle aged were more commonly involved. Of the various types of quids chewed, a combination of processed betel and processed tobacco which is commercially available was used by majority of the individuals. Oral submucous fibrosis (OSMF) was seen in majority of the cases.
Interpretation and Conclusion: The present study confirms the association between betel, tobacco, and various lesions such as OSMF, leukoplakia, chewer's mucosa, lichenoid reaction, and chemical burn. It also confirms the strong association of betel to OSMF and tobacco to leukoplakia.
Keywords: Chewer's mucosa, cross-sectional study, leukoplakia, lichenoid reaction, oral submucous fibrosis, quid
|How to cite this article:|
Avinash Tejasvi M L, Anulekha C K, Afroze MM, Shenai K P, Chatra L, Bhayya H. A correlation between oral mucosal lesions and various quid-chewing habit patterns: A cross-sectional study. J Can Res Ther 2019;15:620-4
|How to cite this URL:|
Avinash Tejasvi M L, Anulekha C K, Afroze MM, Shenai K P, Chatra L, Bhayya H. A correlation between oral mucosal lesions and various quid-chewing habit patterns: A cross-sectional study. J Can Res Ther [serial online] 2019 [cited 2019 Jun 17];15:620-4. Available from: http://www.cancerjournal.net/text.asp?2019/15/3/620/243489
| > Introduction|| |
Quid has been defined as a “substance, or mixture of substances, placed in the mouth or chewed and remaining in contact with the mucosa, usually containing one or both of the two basic ingredients, tobacco and/or areca nut, in raw or any manufactured or processed form.”
The tradition of quid is age old and deeply rooted in India. It seems likely that the habit was originally developed in the South East Asian region in the moist tropical climates. Today, use of quid has developed into a major cultural and social norm throughout the Indian subcontinent and Indians living abroad, Southeast Asia, and locations in the Western Pacific.
Different types of quid preparations available in India
Pan (betel quid)
Betel quid contains betel leaf (Piper betle), areca nut (Areca catechu), catechu (Acacia catechu), and slaked lime consumed with or without tobacco.
Commercially made preparation which contains areca nut, slaked lime, catechu, and condiments; it is available with or without tobacco.
Used in villages is a mixture of tobacco-slaked lime, finely cut areca nut, camphor, and cloves.
Mawa is sold by vendors in cellophane papers tied like a small ball. 5–6 g of areca nut shredding are placed on cellophane to which 0.03 g of tobacco with a few drops of watery slaked lime sprinkled over it.
Tobacco lime preparations
Mixture of sun-dried tobacco and slaked lime is known as Khaini. This mixture is rubbed in the palm and placed in mouth and sucked from time to time.
Finely powdered air-cured and fire-cured tobacco leaves are used as snuff. It may be dry or moist, used plain or used with other ingredients and may be used orally or nasally. It is carried in a metal container; a twig is dipped into it and applied over the tooth and gingiva.
The present study is an attempt to assess and compare the various quid-chewing habits and their association with oral lesions among different age sex groups attending the outpatient department of the institution.
| > Materials and Methods|| |
This population-based cross-sectional study was conducted on Mangalore population in Mangalore, Karnataka. The study consisted of a total of 150 patients with the habit of quid chewing and patients with oral mucosal lesions, who visited the dental clinic of Department of Oral Medicine and Radiology, for around 3 years. An ethical clearance was obtained from the Institutional Review Board.
Based on the type of the quid used, the patients were divided into the following groups:
- Category I – Betel Nut + Leaf + Lime
- Category II – Betel Nut + Leaf + Lime + Tobacco
- Category III – Processed Tobacco + Lime
- Category IV – Processed Tobacco + Processed betel.
Patients having quid-chewing habits and patients having quid-related oral mucosal lesion within the age group of 18–50 years were included in the study. The presence of any systemic diseases, presence of nonquid-related mucosal lesions, and patients with smoking habit were excluded from the study. All the patients fulfilling the above criteria were enrolled for the study; they were informed regarding the nature of the study and informed consent was obtained. Following which, they were interviewed for their habits and each individual was examined by the two observers independently and diagnosis was made. The patient's demographic details, information regarding the type of habit, duration, frequency, site of placement, period of contact with the mucosa, and history of discontinuation of habit were recorded using the standardized interviewer-based questionnaire. All patients were then clinically examined using mouth mirrors and gauze under good illumination. The lesions' location, color, size, and consistency were recorded. If a lesion was clinically suspicious for any premalignant lesion or premalignant condition, biopsy was performed. Excised specimen was subjected to histopathological evaluation, and final diagnosis was made. All the lesions were diagnosed in accordance with international recommendations. The data thus obtained from the procedures were tabulated; descriptive statistical analysis was carried out using IBM SPSS software version 20 (Armonk, NY, USA: IBM Corp). Chi-square test was applied to find the significance of study parameters.
| > Results|| |
One hundred and fifty cases were recorded in the study who were diagnosed to have quid-related oromucosal lesion. Sex distribution in the study is shown in [Table 1]. Among the total of 150 individuals with quid-chewing habit and associated mucosal lesions, 90% (135) were males and 10% (15) were females. Age distribution in the study is shown in [Table 2]a. The minimum age of the individuals was 18 for males and 22 for females whereas the maximum age was 50 for both males and females among all the 150 individuals included in the study. Age and sex distribution in the study are shown in [Table 2]b. In the present study, majority of the individuals with quid usage and oral mucosal lesions were within the age group of 20–30 years, i.e., 46.0% (69). The quid in the form of processed observed to be used more in study subjects as shown in the [Table 3]. Quid usage and sex distribution are shown in [Table 4]; among 100% (135) males, majority of them, i.e., 58.8% (79) individuals were chewing Category IV followed by 17% (24) of them using Category III type of quid. Out of 15 females, majority of them, i.e., 26% (4) individuals were using Category IV and 26% (4) individuals were using Category I type of quid. 46% of the study group were within the age of 20-30 years followed by 22.7% in the age group of 30-40 years. Association between type of quid usage and age is shown in [Table 5]. Lesions encountered in the study were oral submucous fibrosis (OSMF), leukoplakia, chewer's mucosa, lichenoid reaction, and chemical burn with respect to various quid chewing habits as shown in [Table 6].
|Table 2A: Age distribution in the study|
Table 2B: Age-sex distribution in the study
Click here to view
Category I chewers had all lesions except leukoplakia; OSMF was predominant in this category. In Category II chewers, all lesions were seen and OSMF was again more pronounced. In Category III quid chewers, all lesions were seen and lichenoid reaction was more predominant. In Category IV type of quid chewers, majority had OSMF.
| > Discussion|| |
Among 150 individuals, males were more encountered with habit and lesion. In a similar study conducted in 1998 on 36 patients with betel quid and tobacco quid-chewing habit with OSMF have reported that males were affected more (62.7%) than females (37.3%), the ratio of male to female being 1.7: 1. A similar study by Ranganathan et al. has reported male to female ratio of 9:9.1. Tobacco-related oromucosal lesions were present as early as among 18 years old; 46% (69) of individuals had tobacco-related oromucosal lesions between 20 and 30 years of age. This clearly indicates the early appearance of these lesions and need of early diagnosis. Most of the studies conducted in Indian subcontinent also show that in average age of 21–30 years, tobacco-related oromucosal lesions were present.
Majority of the individuals in the present study were involved in Category IV quid-chewing habit. A study conducted by Mehta et al. showed a range of betel quid usage prevalence of 3.3% to 37%. In a similar study in Ernakulam, Kerala. A prevalence study conducted in 1995 on 1110 residents of 2 states, 5–74 years, with an age distribution similar to that of the whole population, found that 72% of males and 80% of females chewed areca nut (betel quid), 80% of whom incorporated tobacco in their quid. In a study conducted by Reddy et al. in 901 individuals, all smokeless tobacco users were surveyed in this cross-sectional study. A prestructured questionnaire which included information on type and amount of smokeless tobacco used, duration and frequency of use, and location of placement of tobacco in the oral cavity was used for assessment, which was followed by oral examination for the presence of lesions. Results revealed that out of 901 individuals with smokeless tobacco habits, 55.8% revealed no clinically detectable oral mucosal changes and 44.1% showed mucosal changes, of which 63.8% were males and 36.1% were females. The most common finding was chewers mucositis (59.5%) followed by submucous fibrosis (22.8%), leukoplakia (8%), lichenoid reaction (6.5%), oral cancer (2.7%), and lichen planus (0.5%). This study provides information about different smokeless tobacco habits and associated mucosal lesions among this population.
Category I chewers had all lesions except leukoplakia OSMF which was predominant. In Category II chewers, all lesions were seen where OSMF was more pronounced. In Category III quid chewers, all lesions were seen where lichenoid reaction was more predominant. In Category IV type of quid-chewing habit, majority of them had OSMF. A similar study on oral mucosal lesions related to chewing habits in Thailand. The lesions of the oral mucosa (preleukoplakia, leukoplakia, and chewer's mucosa) were recorded. Leukoedema was observed in 12.4%, preleukoplakia in 1.8%, leukoplakia in 1.1%, and chewer's mucosa in 13.1%. In a study on Betel chewer's mucosa in 102 elderly rural Cambodian women who chewed betel quid, thirty-eight (37.3%) did not show any oral mucosal lesion. Sixty-two (60.8%) showed betel chewer's mucosa. Homogeneous leukoplakia was found in three women (2.9%). Symposium in 1999 by Zain et al. has proposed the term “betel-quid lichenoid lesion” to describe the OLP-like lesion. A causal role for betel quid in OLP has been identified. A study was conducted by Yang et al. to investigate the risk of areca/betel quid chewing and reported a statistically significant association between OSF and areca/betel quid-chewing habit A hospital-based, cross-sectional study was carried out by Patil  et al. (2013) at SDM Dental College (Dharwad, Karnataka, India). A total of 2400 individuals (1200 individuals with and 1200 individuals without habits) attending the dental hospital were interviewed and examined by trained professionals to assess any oral mucosal changes. Oral mucosal lesions were found in 322 (26.8%) individuals who had tobacco smoking and chewing habits as compared to 34 (2.8%) individuals without those habits. Oral leukoplakia (8.2%) and OSF (7.1%) were the prevalent oral mucosal lesions found in individuals who had those habits, while the other lesions (1.7%) such as oral candidiasis, median rhomboid glossitis, recurrent aphthous ulcer, frictional keratosis, and oral lichen planus (0.9%) were frequently reported among individuals without those habits.
The odds of developing oral lesions in individuals with tobacco habits were nearly 11.92 times that of abstainers (odds ratio = 11.92, 95% confidence interval = 10.61%–14.59%).
A cross-sectional study was carried out by Holla et al. with 250 cases clinically and histologically diagnosed as having OSF lesion that were selected and subjected to a detailed habit history which was recorded through preformed questionnaire. The data obtained were statistically analyzed. Results revealed that among the 250 individuals, males were seen to be affected more than females within the age group of 26–35 years and were having clinical Stage I OSF. A combination of processed areca nut and processed tobacco was used by the majority of the individuals with duration of 1–5 years, at a frequency of 3–5 quids per day. Present study confirms the association between OSMF and the quid containing processed areca nut and processed tobacco and also highlights the increasing youth population using the processed forms of areca nut.
A study was done by Khan et al. (2013) on 150 individuals clinically diagnosed of having chewer's mucosa lesion. After complete oral examination, a detailed habit history was taken through preformed questionnaire. The data obtained were analyzed using Chi-square test. Among the 150 individuals, male to female ratio was 8:2. Majority of the individuals were within the age group of 20–30 years and chewed a combination of betel leaf, areca nut, tobacco, and lime. Majority of the individuals of chewer's mucosa used the quid for a duration of 1–5 years, a frequency of 3–5 quids per day. Authors concluded from the study that chewer's mucosa was seen in majority of the individuals who used the quid for a duration of 1–5 years, a frequency of 3–5 quids per day and chewed the quid containing betel leaf, areca nut, tobacco, and lime as its constituents. A study was conducted by Thada and Pai  in (2014) with a study group comprised of 2161 patients with positive history of oral habits. The prevalence of oral habits was 17.54%. Indulgence in habit was seen more among males between age group 26–55 years and most of them had education above high school level. Smoking (51.9%) was most common oral habit, followed by chewing tobacco (47.52%), consuming alcohol (29.7%), and chewing pan without tobacco (16.7%). Tobacco chewing was more common single habit. The prevalence of oral mucosal lesions was 46.1%. Reactive lesions (55.41%) were the most common followed by premalignant lesions/conditions (27.67%), malignant lesions (12.40%), and other lesions (4.49%). Reactive lesions were more common among smokers (68.98%) and alcoholics (40.03%). Premalignant (31.46%), malignant (12.08%), and other lesions (3.99%) were more common among tobacco chewers. Chronicity and increase in number of habits were associated with increase in number of lesions. Authors concluded that oral mucosal lesions were observed in almost half of the individuals with oral habits. The present study concludes stating that OSMF was commonly observed in the individuals when the quid consisted of a betel/areca nut. Leukoplakia was observed only in individuals when the quid had tobacco as one of the constituents.
| > Conclusion|| |
In this study, 150 individuals were screened for various quid-chewing habit pattern and various oromucosal lesions associated with them. Majority of the individuals with quid-chewing habits and oromucosal lesions were males; majority of them were in the age group of 20–30 years. Individuals who were using areca nut/betel as one of the constituents of the quid had OSMF. Individuals who were chewing betel/areca nut quid alone without tobacco as the ingredient of the quid did not have leukoplakia. Leukoplakia was seen in all the individuals who were chewing tobacco as one of the ingredients of the quid.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Zain RB, Ikeda N, Gupta PC, Warnakulasurya KA, Van Wyk CW, Shrestha P, et al
. Oral mucosal lesions associated with betel quid, areca nut and tobacco chewing habits: Consensus from a workshop held in Kuala Lumpur, Malaysia. J Oral Pathol Med 1999;289:1-4.
Shah N, Sharma PP. Role of chewing and smoking habits in the etiology of oral submucous fibrosis (OSF): A case-control study. J Oral Pathol Med 1998;27:475-9.
Ranganathan K, Devi MU, Joshua E, Kirankumar K, Saraswathi TR. Oral submucous fibrosis: A case-control study in Chennai, South India. J Oral Pathol Med 2004;33:274-7.
Gupta PC, Sinor PN, Bhonsle RB, Pawar VS, Mehta HC. Oral submucous fibrosis in India: A new epidemic? Natl Med J India 1998;11:113-6.
Mehta FS, Pindborg JJ, Gupta PC, Daftary DK. Epidemiologic and histologic study of oral cancer and leukoplakia among 50,915 villagers in India. Cancer 1969;24:832-49.
Ysaol J, Chilton JI, Callaghan P. A survey of betel nut chewing in Palau. Isla J Micronesian Stud 1996;4:244-55.
Reddy SS, Prashanth R, Yashodha Devi BK, Chugh N, Kaur A, Thomas N, et al.
Prevalence of oral mucosal lesions among chewing tobacco users: A cross-sectional study. Indian J Dent Res 2015;26:537-41.
] [Full text]
Reichart PA, Mohr U, Srisuwan S, Geerlings H, Theetranont C, Kangwanpong T, et al.
Precancerous and other oral mucosal lesions related to chewing, smoking and drinking habits in Thailand. Community Dent Oral Epidemiol 1987;15:152-60.
Reichart PA, Schmidtberg W, Scheifele C. Betel chewer's mucosa in elderly Cambodian women. J Oral Pathol Med 1996;25:367-70.
Yang YH, Lien YC, Ho PS, Chen CH, Chang JS, Cheng TC, et al.
The effects of chewing areca/betel quid with and without cigarette smoking on oral submucous fibrosis and oral mucosal lesions. Oral Dis 2005;11:88-94.
Patil PB, Bathi R, Chaudhari S. Prevalence of oral mucosal lesions in dental patients with tobacco smoking, chewing, and mixed habits: A cross-sectional study in South India. J Family Community Med 2013;20:130-5.
Holla VA, Chatra LK, Shenai P, Shetty D, Baliga A. A study to analyze different patterns of quid usage among subjects with oral submucous fibrosis in Mangalore population. Adv Med 2016;2016:6124059.
Khan S, Chatra L, Prashanth Shenai K, Veena KM, Rao PK. A study to analyze the different patterns of quid usage among subjects with Chewer's Mucosa. JIAOMR 2012;24:284-287.
Thada SR, Pai KM. Prevalence of habit associated oral mucosal lesions among the outpatients - A prospective cross sectional study. Int J Res Health Sci 2014;2:263-273.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]