Use of Gutka and other areca nut products in Sri Lanka: an emerging threat Anura Ariyawardana Betel chewing

has been an integral cultural tradition in ancient and medieval Sri Lanka. A recent national survey conducted by the Ministry of Health reported betel quid chewing prevalence estimates of 34-48 percent for the adult general population in Sri Lanka. Regular betel chewing with tobacco has been found to be associated with several deleterious health consequences most significantly oral cancer and precancer. Oral cancer is a malignant tumour affecting the oral mucosal epithelial tissues. Oral cancer may occur as cancer at its outset or may be preceded by clinically distinguishable changes in the oral mucosa that is termed as oral precancer. The most common oral precancers associated with betel chewing are leukoplakia (white patch), erythroplakia (red patch) and oral submucous fibrosis (OSF).

Sri Lanka has the highest reported incidence of oral cancer in the world (Globocan, 2000). Lip and oral cavity cancers constitute the most common cancer for Sri Lankan men and the same ranks the 6th for women (Cancer Registry, 2000). The population prevalence of oral precancer in Sri Lanka based on one large epidemiological survey on the general population was estimated to be 4.2%. A similar study in tea estate population of central Sri Lanka has shown that 7% of them have oral precancer.

Until the recent past, tobacco has been considered the responsible ingredient in the betel quid for the causation of oral cancer and some precancers (leukoplakia and 1

erythroplakia). However, recent studies have confirmed that areca nut is an independent risk factor for oral cancer. Moreover, areca nut chewing either alone or in combination with other ingredients of betel quid has been found to be the causative factor for OSF, generalized precancerous condition in the oral mucosa with a significant chance of changing into oral cancer.

Gutka is a commercially available value added product containing a variety of ingredients, including chewing tobacco, areca nut, lime and spices (Figure 1). This product has been very popular throughout India. It has now penetrated to Sri Lanka as well and is becoming popular especially among the young generation. The addition of sweeteners and fragrance together with handy packaging easily attract the consumers.

In addition, various other preparations of areca nut are also available now in Sri Lanka. They are readily available in urban areas and near schools in particular. They are relatively cheap and packaged in such a way to attract children. Areca nut contains several psychoactive chemicals and hence consumption may have effects such as improved concentration, relaxation, heightened alertness and diminished hunger. As such there is a potential for the consumers to develop addiction.

Areca nut contains alkaloids such as arecoline, arecaidine, arecolidine, guvacoline and guvacine. These alkaloids undergo nitrosation and give rise to N-nitrosamines which are proven to be carcinogenic. Areca nut alkaloids especially arecoline stimulate the oral mucosal cells that produce collagen (fibroblasts) and collagen fibers are accumulated in

the submucosal tissues leading to a series of clinical and microscopic changes. This change leads to a disabling condition called OSF. In early stages of OSF affected individuals feel burning sensation especially for spicy food. If the condition is left untreated it will gradually progress leading to restriction of mouth opening and the movement of the tongue. As a result of limited mouth opening, maintenance of individuals oral hygiene could be compromised and it may lead to a series of problems such as, dental caries, periodontal disease and bad breath. Moreover, nutrition also may be affected as a result of restriction of mouth opening and the burning sensation.

It is generally regarded that oral cancer and precancer are commonly seen in the elderly individuals for the obvious reasons that the betel chewing habit is more prevalent among them compared to the young. However, according to our experience this trend is changing in that young individuals are increasingly attending hospitals seeking treatment for the above mentioned conditions caused by the use of arecanut products.

Unfortunately, we have observed that school children are affected with common precancer such as OSF and leukoplakia especially because of the habit of gutka and other areca nut products. This is a disheartening situation and prompt action should be taken to protect our young generation.

Although a significant improvement has taken place in the management of oral cancer particularly in the develop world, no substantial improvement has been observed in the prognosis of affected individuals. Moreover, the cost of treatment for oral cancer poses a

significant burden on the countrys health system and the economy. Therefore, it is of paramount importance to prevent such precancer and oral cancer.

Prevention of oral cancer and precancer can be a feasible task if action is taken to prevent individuals indulging in betel and areca nut chewing habit. Proper education regarding the bad effects of such chewing habit is the most important aspect in the prevention process. Education of school children regarding this is of significance and it can be easily done through the school teachers and perhaps by incorporating the prevention of oral diseases as a subject in health education in school curricula. This can be used to pass the message to their families and through them educate the vulnerable adult population of the hazards of betel quid chewing.