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Many studies have reported a positive association between lower socioeconomic status (SES) and higher head and neck cancer (HNC) risk. Fewer studies have examined the impact of SES on the association between alcohol or cigarette use and HNC risk. The current case‐control study (1104 HNC cases and 1363 controls) investigated the influence of education, a SES indicator, on the association between HNC and the use of alcohol, cigarettes, or betel quids in Taiwan, a country with universal health care. Our results showed a larger increase in HNC risk associated with alcohol among those with lower educational level (odds ratio [OR] = 2.07; 95% confidence interval [CI], 1.53‐2.80) than those with higher educational level (OR = 1.38; 95% CI, 1.04‐1.85) (heterogeneity‐P = .03). Educational level had an influence on the association between alcohol use and HNC risk among those with genetic susceptibility (ALDH2‐deficient) to the carcinogenic effect of alcohol. The association between cigarette or betel quid use and HNC risk was similar between the high and low educational groups. National policies and social interventions have led to the decline in the prevalence of cigarette and betel quid users in Taiwan. In contrast, due to the lack of adequate alcohol control policies, alcohol consumption in Taiwan has continued to rise. A higher impact of alcohol on HNC risk among lower SES individuals even with universal health care could be the result of insufficient alcohol control policies in Taiwan.

Arecoline, a component of betel nuts, is a known carcinogen that causes oral cancers among those who chew betel nuts. Betel nut chewing is also associated with an increased risk of chronic kidney disease (CKD), but the role of arecoline in this association is unclear. This in vitro study investigates the effects of arecoline on cultured human kidney (HK2) cells. We observed that arecoline had no effect on cell viability but increased cell migration in a dose-dependent manner. Western blot analysis showed that arecoline treatment caused a dose-dependent decrease in E-cadherin expression and dose-dependent increases in N-cadherin, vimentin, α-SMA, and collagen expression; reverse transcriptase-polymerase chain reaction analysis revealed dose-dependent increases in α-SMA and collagen mRNA. Arecoline treatment upregulated the expression of phosphorylated extracellular signal-regulated kinase through epithelial mesenchymal transition and renal fibrosis in HK2 cells. These findings demonstrate that arecoline plays a role in inducing the epithelial mesenchymal transition and fibrogenesis in renal tubule cells and suggest that arecoline promotes the progression of CKD.

Taking betel nut (Betel catechu L.) kernel as raw materials, to analyze the browning mechanism of betel nut kernel. First, we extract and separate the phenolic substances and polyphenol oxidase (PPO) from the betel nut kernel and then find out how O2 penetrates into the kernel, study the above 3 key factors of enzymatic browning so as to prove the possibility of enzymatic browning, and further study the browning products to clarify the mechanism of browning of betel nut kernel during storage process. The results showed that 11 kinds of phenolic compounds were isolated and identified from the betel nut kernel by liquid chromatography–mass spectrometry, among which chlorogenic acid was the highest, followed by dopamine and L‐epicatechin, and other contents were relatively low. Meanwhile, PPO was also separated from the betel nut kernel by DEAE–Sepharose Fast Flow and Phenyl–Sepharose 6 Fast Flow column chromatography. On this basis, scanning electron microscopy showed that the damage of the betel nut tissue was aggravated with the prolonged storage time, the wax was gradually decomposed, and the stratum corneum of the peel is destroyed in a honeycomb‐shaped; the lignification of the flesh was aggravated, and the interstitial space was increased; and the crack of the kernel membrane was also enlarged. These changes of structure contribute to increase gas exchange within and outside the organization, including the entry of O2. Finally, the oxidation products generated from simulated reaction of chlorogenic acid, dopamine, and epicatechin with purified PPO under aerobic conditions in vitro were compared with the products extracted from naturally brown betel nut, and the same absorption spectra were found. Therefore, it indicates that the browning of betel nut kernel is an enzymatic browning caused by the reaction of phenolic substrates were oxidized by PPO.

Betel leaf or ‘Paan’ (Piper betle) is an integral component of the addictive chewing stimulant ‘betel quid’ which is traditionally consumed by a large population in the Asian countries. Betel essential oil is also heavily used by the flavour industries. Often, it constitutes of carcinogenic and genotoxic phenylpropanoids. High incidence of the oral carcinogenesis in this part of the world has been linked to the chewing of betel quid as well as Paan. In this study, Piper betleoides C. DC. (wild Paan) was identified as the edible plant source from north‐east India possessing betel‐scented essential oil which was highly rich in sesquiterpenoids majorly germacrene D and β‐caryophyllene. Identity of the plant was confirmed through critical taxonomic studies. Further, the essential oil yield and composition were investigated across different vegetative (young and mature leaves, stem) and reproductive (male and female inflorescence) tissues of P. betleoides through gas chromatography‐mass spectrometry (GC‐MS) and nuclear magnetic resonance (¹H, ¹³C NMR) spectroscopic analyses. The comparative quantitative investigation showed a high dominance by sesquiterpenoids (>90%) in the leaves of P. betleoides with no detection of phenylpropanoids. On the contrary, a high level of phenylpropanoids (>75%) was found in P. betle (Bangla Paan). In effect, P. betleoides can be a potential alternative source of betel‐scented sesquiterpene‐rich essential oil.

Schizophrenia and substance involvement frequently co-occur in individuals, and a bidirectional relationship between the two has been proposed; shared underlying genetic factors could be an alternative explanation. This study investigated the genetic overlap between schizophrenia and substance involvement, including tobacco, alcohol and betel nut use. The study subjects were recruited from the Taiwan Biobank, and genome-wide genotyping data was available for 18 327 participants without schizophrenia. We calculated the Psychiatric Genomics Consortium-derived polygenic risk score (PRS) for schizophrenia in each participant. The significance of the schizophrenia PRS associated with substance involvement was evaluated using a regression model with adjustments for gender, age and population stratification components. The modified effect of gender or birth decade was also explored. The schizophrenia PRS was positively associated with lifetime tobacco smoking in women (OR in per SD increase in PRS = 1.12 with 95% CI 1.04-1.20, P = .002), but not in men (OR = 0.99 with 95% CI 0.95-1.04, P = .74), and the gender-PRS interaction reached significance (P = .006). The OR between PRS and lifetime tobacco smoking increased with the birth decade (P of birth decade-PRS interaction = .0002). In women, OR increased from 0.97 (P = .85) for subjects with a birth decade before 1950 to 1.21 (P = .04) for subjects with a birth decade after 1980; in men, the corresponding OR increased from 0.88 (P = .04) to 1.13 (P = .11). There was no association between schizophrenia PRS and alcohol/betel nut use phenotypes. This study provides evidence for the genetic overlap between schizophrenia and tobacco use in women, and this overlap was stronger in the younger population.

The intriguing molecular pathways involved in oral carcinogenesis are still ambiguous. The oral squamous cell carcinoma (OSCC) ranks as the most common type constituting more than 90% of the globally diagnosed oral cancers cases. The elevation in the OSCC incidence rate during past 10 years has an alarming impression on human healthcare. The major challenges associated with OSCC include delayed diagnosis, high metastatic rates, and low 5-year survival rates. The present work foundations on reverse genetic strategy and involves the identification of genes showing expressional variability in an OSCC case lacking addictive proclivities for tobacco, betel nut, and/or alcohol, major etiologies. The expression modulations in the identified genes were analyzed in 16 patients comprising oral pre-cancer and cancer histo-pathologies. The genes SCCA1 and KRT1 were found to down regulate while DNAJC13, GIPC2, MRPL17, IG-Vreg, SSFA2, and UPF0415 upregulated in the oral pre-cancer and cancer pathologies, implicating the genes as crucial players in oral carcinogenesis.

Background Monocyte chemoattractant protein-1 (CCL2) is a major profibrotic mediator with a proven role in fibrosis of different organs of the body. Recently, increased fibrosis in oral submucous fibrosis (OSMF) is linked with betel quid-related chronic irritation and myofibroblast. Hence, this study is designed to investigate expression of CCL2 in OSMF and its correlation with myofibroblasts. Materials and Methods Paraffin-embedded specimens of 30 OSMF and 10 tissues of normal buccal mucosa were subjected to immunohistochemical analysis for CCL2 and alpha-smooth muscle actin (α-SMA) expression. Results CCL2 expression in basal cells (CCL2-B) and connective tissue (CCL2-CT), and α-SMA showed significantly increased expression in advanced OSMF as compared with early OSMF and controls. Significant differences were observed in the expression of CCL2-B between control vs. OSMF (P = 0.002), control vs. advanced OSMF (P = 0.005), and early vs. advanced OSMF (P = 0.0377). Similarly, differences in the CCL2-CT expression were statistically significant between control vs. OSMF (P = 0.00086), control vs. early OSMF (P = 0.02914), and control vs. advanced OSMF (P = 0.0006). For α-SMA expression, significant differences were observed between control vs. OSMF (P = 0.0003), control vs. early OSMF (P = 0.036), control vs. advanced OSMF (P = 0.00008), and early vs. advanced OSMF (P = 0.0009). In OSMF group, a significant correlation was observed between CCL2-B and CCL2-CT (P < 0.00001), CCL2-B and α-SMA (P < 0.00001), and CCL2-CT and α-SMA (P < 0.00001). Conclusion CCL2 could be responsible for pathogenesis of OSMF by recruiting myofibroblasts.

The betel nut trade in Papua New Guinea is big business. Betel nut, a mild indigenous stimulant, is considered the ‘green gold of the grassroots’. It is the country's most significant domestic cash crop and, in terms of rural incomes, a rival to the dominant export cash crops. Its sale is an important livelihood strategy in both rural and urban areas, the most visible manifestation of a flourishing informal economy. In betel nut marketplaces money ‘flows’ and ‘overflows’, traders wield large wads of cash, and vast sums change hands. Whether seeking their fortunes or only tinned fish, people trade betel nut first and foremost to make money, but such interests in trade do not automatically displace other forms of value. This paper is concerned with marketplaces and trade in contemporary Papua New Guinea and what is conveyed in those transactions between buyer and seller. Against the often impersonal and utilitarian rendering of trade, this paper seeks to foreground the sociability of trade and the multiple forms of value that may be simultaneously attached to monetised market transactions. This is not to conceal the discrete, unenduring, and competitive dynamics of trade, which prominently feature in many betel nut transactions, but instead to examine an important dynamic often overlooked. Market transactions, far from being asocial, or even socially destructive, have the capacity to generate and sustain diverse social relations including those of kinship and friendship.

Approximately 600 million people worldwide practise the carcinogenic habit of betel nut/quid chewing. Carcinogenic N-nitroso compounds have been identified in saliva or urine of betel chewers and the betel alkaloid arecoline in hair from habitual betel quid chewers. However, the pharmacokinetic parameters of these compounds have been little explored. Assessment of betel use by biomarkers is urgently needed to evaluate the effectiveness of cessation programmes aimed at reducing betel consumption to decrease the burden of cancers in regions of high betel consumption. In the search for biomarkers of betel consumption, we measured by liquid chromatography-mass spectrometry (LC-MS) the appearance and disappearance of betel alkaloids (characteristic for betel nuts), N-nitroso compounds, and chavibetol (characteristic for Piper Betle leaves) in saliva (n=4), hair (n=2), and urine (n=1) of occasional betel nut/quid chewers. The betel alkaloids arecoline, guvacoline, guvacine, and arecaidine were detected in saliva of all four participants and peaked within the first 2 h post-chewing before returning to baseline levels after 8 h. Salivary chavibetol was detected in participants consuming Piper Betle leaves in their quid and peaked ~1 h post-chewing. Urinary arecoline, guvacoline, and arecaidine excretion paralleled saliva almost exactly while chavibetol glucuronide excretion paralleled salivary chavibetol. No betel nut related compounds were detected in the tested hair samples using various extraction methods. From these preliminary results, we conclude that betel exposure can only be followed on a short-term basis (≤8 h post-chewing) using the applied biomarkers from urine and saliva while the feasibility of using hair has yet to be validated. Copyright © 2015 John Wiley & Sons, Ltd.

Objectives Cultural practices may compromise the accuracy of salivary hormone measurements and must be considered when designing human biology research protocols. This study aims to evaluate the acute effect of one common human practice—chewing betel nut—on the measurement of salivary cortisol levels under field conditions. Materials and Methods Data were collected from 17 adult habitual betel nut users (males = 11; females = 6; mean age = 32.8 years) from a small rural community in Papua New Guinea. Saliva was collected in time series from each participant before and at 0, 15, 30, 45, 60, and 75 min after chewing betel nut. Samples were analyzed by radioimmunoassay and cortisol levels were compared across time using linear mixed effects modeling. Results Measured mean cortisol concentration fell nearly 40% immediately following betel nut use and remained significantly below baseline levels for the following 45 min (all P 0.16). Discussion Chewing betel nut is associated with a transient but significant reduction in measured levels of salivary cortisol. Future research must take this into account in populations where betel nut use is prevalent. Am J Phys Anthropol 158:151–154, 2015. © 2015 Wiley Periodicals, Inc.

Cytogenetic alterations underlie the development of head and neck squamous cell carcinoma (HNSCC), whether tobacco and alcohol use, betel nut chewing, snuff or human papillomavirus (HPV) causes the disease. Many of the molecular genetic aberrations in HNSCC result from these cytogenetic alterations. This review presents a brief introduction to the epidemiology of HNSCC, and discusses the role of HPV in the disease, cytogenetic alterations and their frequencies in HNSCC, their molecular genetic and The Cancer Genome Atlas (TCGA) correlates, prognostic implications, and possible therapeutic considerations. The most frequent cytogenetic alterations in HNSCC are gains of 5p14-15, 8q11-12, and 20q12-13, gains or amplifications of 3q26, 7p11, 8q24, and 11q13, and losses of 3p, 4q35, 5q12, 8p23, 9p21-24, 11q14-23, 13q12-14, 18q23, and 21q22. To understand their effects on tumor cell biology and response to therapy, the cytogenetic findings in HNSCC are increasingly being examined in the context of the biochemical pathways they disrupt. The goal is to minimize morbidity and mortality from HNSCC using cytogenetic abnormalities to identify valuable diagnostic biomarkers for HNSCC, prognostic biomarkers of tumor behavior, recurrence risk, and outcome, and predictive biomarkers of therapeutic response to identify the most efficacious treatment for each individual patient's tumor, all based on a detailed understanding of the next generation biology of HNSCC.

Background The purpose of this study was to investigate the influence of genetic polymorphisms of the matrix metalloproteinase-11 (MMP-11) gene on the susceptibility of oral squamous cell carcinoma (OSCC). Methods Four single-nucleotide polymorphisms (SNPs) of the MMP-11 gene from 595 patients with oral cancer and 561 noncancer controls were analyzed by real-time polymerase chain reaction (PCR). Results MMP-11 gene polymorphisms exhibit synergistic effects of environmental factors (betel nut chewing and tobacco use) on the susceptibility of OSCC. Furthermore, among patients with OSCC with betel nut consumption, those who have at least one polymorphic C allele of MMP-11 rs738792 have an increased incidence of lymph node metastasis when compared with those patients homozygous for T/T. Conclusion Our results showed that the combined effects of the MMP-11 gene polymorphisms and environmental carcinogens are related to an increased risk for the development of OSCC and may be a predictive factor for tumor lymph node metastasis in Taiwanese with OSCC. © 2014 Wiley Periodicals, Inc. Head Neck 37: 1425–1431, 2015

The cancer of upper aerodigestive tract (UADT) is a common cancers in the world. However, its lifetime risk by consumption of alcohol, betel and cigarettes remain to be elucidated. This study aimed to estimate lifetime risk of distinct UADT cancers and assess their associations with alcohol, betel and cigarette consumption. Three cohorts of 25,611 men were enrolled in 1982-1992 in Taiwan. The history of alcohol, betel and cigarette consumption was enquired through questionnaire interview. Newly developed UADT cancers were ascertained through computerized linkage with national cancer registry profile. Lifetime (30-80 years old) risk and multivariate-adjusted hazard ratio (HRadj) of distinct UADT cancers by alcohol, betel and cigarette consumption were estimated. A total of 269 pathologically confirmed cases of UADT cancers were newly-diagnosed during 472,096 person-years of follow-up. The lifetime risk of UADT cancer was 9.42 and 1.65% for betel chewers and nonchewers, 3.22 and 1.21% for cigarette smokers and nonsmokers and 4.77 and 1.85% for alcohol drinkers and nondrinkers. The HRadj (95% confidence interval) of developing UADT cancer was 3.36 (2.51-4.49), 2.02 (1.43-2.84), 1.90 (1.46-2.49), respectively, for the consumption of betel, cigarette and alcohol. Alcohol, betel and cigarette had different effect on cancers at various anatomical sites of UADT. The cancer risk from the mouth, pharynx, esophagus to larynx increased for alcohol and cigarette consumption, but decreased for betel consumption. Alcohol, betel and cigarette consumption are independent risk predictors for distinct UADT cancers.

Background Chewing betel nut is a tradition extending from Southeast Asia to the Pacific. Globally, betel nut is the fourth main psychotropic substance containing a stimulant, arecoline, that has a similar effect to nicotine. In Palau, there is broad acceptance of betel nut chewing. One of the largest immigrant groups in Hawaii is the Palauans. Chewing betel nut has significant social implications that make it difficult for those who engage in this practice to separate potential oral disease from the social importance. However, little is known about the social impact of oral disease from chewing betel nut on Palauans in Hawaii. Aim The study aimed to describe the perceptions of betel-chewing Palauans in Hawaii regarding betel nut and to determine the social impact of oral disease among these individuals. Methods Descriptive study conducted on the island of Oahu, Hawaii with 30 adult Palauans. Data were collected using the Oral Health Impact Profile-14 to measure perceptions of social impact of oral disease on well-being. Demographic and general health information was collected. Results Participants perceived little negative social impact of oral disease on well-being. Discussion Families, peers and society exert a strong influence on the decision to chew betel nut, a known carcinogen. Participants in this study showed little concern on the impact of betel nut chewing on their oral health. They continue the habit in spite of the awareness of potential for oral disease. Implications for nursing and health policy Nurses face challenges in educating Palauans about the negative aspects of bethel nut, particularly those related to oral health especially when they do not perceive problems. Nurses must be involved in the development of health policies to design and implement strategies to promote behavioural change, and to ensure clinical services that are culturally sensitive to bethel nut chewers.

BACKGROUND Areca nut (Areca catechu L.) or betel nut, a commercial cash crop, is a rich source of polyphenols but also contains toxic alkaloids, mainly arecoline. Separation of these bioactive polyphenols from toxic constituents could propel the safe and beneficial use of betel nut; also it will help arecanut processing industries to produce arecoline-free products. With the aim to develop an effective method for maximum extraction of polyphenols with minimum arecoline, several factors such as nature of the solvent, pH (2–10), substrate concentration (6–14 %) and extraction time (30–150 min) under shaking conditions were evaluated. Qualitative analysis was done using spectrophotometry and high-performance liquid chromatography (HPLC). RESULTS Maximum extraction of polyphenols (407.47 mg GAE g−1), total tannin and its antioxidant activity with minimum arecoline (1.73 mg g−1 of sample) was achieved by using 80% acetone at pH 4 for 90 min with 10% w/v substrate under shaking conditions. CONCLUSION Solvent extraction under optimized parameters gave maximum polyphenols with minimum extraction of arecoline, and highest ratio of polyphenols to arecoline. HPLC and liquid chromatography–mass spectrometry results confirmed the presence of catechin and epicatechin in the extract, which suggests its potential as a source of bioactives. © 2013 Society of Chemical Industry

Chewed tobacco or betel nut is also associated with an increasedrisk.Investigators have recently reported thatsmokers with polymorphisms of a geneencoding the cytochrome P450 enzymehave a significantly increased risk ofdeveloping laryngeal cancer compared with smokers without the polymorphism,suggesting there may be a genetic basis to a predisposition to the effect oftobacco smoke.

Betel quid chewing is associated with cytotoxicity, genotoxicity and carcinogenicity in diseases such as oral cancer, liver cirrhosis, hepatocellular carcinoma and diabetes mellitus. Arecoline and arecaidine, which are the main alkaloids in the areca nut, are potential exposure biomarkers in habitual betel quid users. This study developed a method of detecting arecoline- and arecaidine-protein adducts by mass spectrometry (MS). First, bovine serum albumin was used to predict and confirm the binding sites of proteins modified by arecoline or arecaidine. Cells were then treated with arecoline to identify new protein adducts after cellular metabolic processing. Finally, human plasma was used to model long-term exposure to arecoline and arecaidine. Following isolation proteins were tryspin digested. The peptides afforded were separated and analyzed by nano-scale liquid chromatography with MS using an LTQ Orbitrap mass spectrometer. The experimental findings showed that cysteine is the predominant amino acid in protein adduct formation. The goal of this study was to establish a screening platform for identifying novel protein adducts that form covalent bonds with arecoline or arecaidine. Use of this strategy to survey new protein-toxic adducts may help to identify novel biomarkers of betel nut exposure. Copyright © 2012 John Wiley & Sons, Ltd.

Areca nut (betel nut) consumption occurs in a variety of forms, either on its own or with the addition of a number of products. This habit is prevalent in the Indian Subcontinent and South-East Asia. Recent immigration statistics indicate that 30% of new arrivals in Australia are from these geographical regions and are known to perpetuate this custom long after migration. The objective of this paper is to highlight the variety of oral presentations that may occur as a result of areca nut consumption in these particular demographic subgroups. Dental practitioners must be familiar with the wide spectrum of oral lesions that may present in this setting. More significantly, they must be aware that some of these lesions possess the potential for malignant transformation and hence require more specific management. Best practice mandates that dental practitioners in a multicultural society must: (1) be capable of recognizing the expatriate populations in which this custom is widely practised; (2) incorporate this particular line of questioning into the routine risk factor analysis that is undertaken for every patient from these particular sub-populations; and (3) institute appropriate referral and follow-up of these lesions if required.

Little is known about any consequences of swallowing tobacco-free betel-quid (TF-BQ) juice/remnants following chewing and its carcinogenic impact on the upper aerodigestive tract (UADT) to gastrointestinal tract (GIT). We investigated the neoplastic impact of TF-BQ on different anatomical locations along UADT and GIT, and differences according to their histological categories. We conducted a multicenter case–control study examining patients with 2,163 pathology-proven UADT and GIT cancers, comparing them with 2,250 control subjects. Generalized additive models, piecewise regression and polytomous logistic models were applied to identify possible dose-dependent structures and cancer risks. Contrary to nonsignificant GIT-adenocarcinoma risk (aOR = 0.9), TF-BQ users experienced a 1.7- to 16.2-fold higher risk of UADT-squamous cell carcinomas than nonusers, with the peak risk discovered in oral neoplasms. We separately observed a curvilinear and linear TF-BQ dose-risk relationship in oral/pharyngeal/esophageal and laryngeal cancers. Chewers of betel inflorescence were generally at a greater UADT cancer risk. A higher first-piecewise increased risk of esophageal cancer was recognized among areca-fluid swallowers than among nonswallowers (continuous aOR = 1.12 vs. 1.03). TF-BQ use accounted for 66.1–78.7% and 17.8–33.2% of the cases of oral/pharyngeal and esophageal/laryngeal cancers, respectively. However, a reduction from heavy TF-BQ consumption to low-to-moderate consumption only reduced 11.3–34.6% of etiologic fraction of oral/pharyngeal cancers. Alcohol supra-additively modified the risk of TF-BQ in determining the development of oral, pharyngeal and esophageal cancers. In conclusion, the interplay of TF-BQ and alcohol/tobacco use, combined with how chewing habit is practiced, influences carcinogenic consequences on anatomically diverse sites of UADT and GIT cancers, and histologically different types.

Aim: Only few studies have reported that betel nut (BN) chewing is independently associated with chronic kidney disease (CKD); however, the sample size was relatively small. This study was to explore further the association between BN chewing and CKD using a larger case series. Methods: We retrospectively reviewed the records of a health check-up program from 2003 to 2009. Laboratory tests, medical history and status of cigarette smoking, alcohol drinking and BN chewing were compared between CKD and non-CKD groups. We checked interaction effects between BN chewing and all other covariates, and conducted multivariate logistic regression analysis to explore the risk of CKD with BN chewing. Results: A total of 27 482 participants (15 491 females and 11 991 males, mean age 58.02 ± 11.85 years) were included in the study, of whom 4519 (16.4%) had CKD and 1608 (5.9%) chewed BN. CKD prevalence in the chewers was higher than in the non-chewers in all age groups per decade. BN chewing was significantly associated with CKD in overall subjects (odds ratio (OR) = 1.23, P = 0.027) and also in the male (OR = 1.23, P = 0.035), non-drinking (OR = 1.62, P = 0.000), non-diabetic (OR = 1.27, P = 0.021), and non-proteinuric groups (OR = 1.30, P = 0.013). This relationship was insignificant in female, drinking, diabetic and proteinuric groups. Conclusion: The association between BN chewing and CKD seemed conditional on demographics, health behaviours, and underlying co-morbidities. This association should be interpreted cautiously.

J Oral Pathol Med (2012) 41: 9–15 Background: Betel nut chewing, cigarette smoking and alcohol drinking are thought to be major environmental risk factors responsible for the development of oral squamous cell carcinomas. Oncogenic human papillomavirus infections have a well-established association with uterine cervical carcinoma. However, little is known about the exact role of human papillomavirus infections in oral squamous cell carcinomas. This study is designed to elucidate the role of human papillomavirus infections in cancer development and prognosis of oral squamous cell carcinomas. Methods: Molecular techniques including in situ hybridization and immunohistochemistry of p16INK4A and p53 for evidences of human papillomavirus in tissue micro-arrays were investigated. Results: Twenty-four of 65 cases of oral squamous cell carcinomas were found positive for in situ hybridization and 14 were found positive for p16INK4A. The majority of cases without the evidence of human papillomavirus were related to p53 over-expression. There were statistically significant correlations between the results of human papillomavirus test and size or extent of the tumor (P = 0.003) or the stage of oral squamous cell carcinomas (P = 0.015). Kaplan–Meier plot analysis demonstrated a tendency of longer survival in cases of oral squamous cell carcinomas with the evidence of human papillomavirus or positive p16 INK4A. Conclusions: Human papillomavirus infections may play a unique role in oral carcinogenesis. Our data strongly suggest that human papillomavirus-positive oral squamous cell carcinomas comprise a distinct clinical and pathological disease entity that appears related to a better outcome with longer survival and bears a causally associated relationship different from other carcinogenic mechanisms.

Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanBACKGROUND: Recognition of how risk factors affectthe age when cancers are first diagnosed may help toestablish more appropriate cancer screening and pre-ventive strategies.METHODS: To investigate the independent and syner-gistic effects of alcohol, tobacco-free betel-quid (TF-BQ),and cigarette use on diagnosis age and dissemination ofupper aerodigestive tract squamous cell carcinoma(UADT-SCC), we recruited pathology-proven 1522patients with UADT-SCC for study.RESULTS: A 49-, 53-, 57-, and 62-year-old stepwise oldermedian age at carcinoma diagnosis was, respectively,found among patients with oral, pharyngeal, esophageal,and laryngeal cancer. Oral cavity (53.2%) and larynx(11.6%) were separately the dominant and recessive siteswhere the UADT-SCC occurred. Although alcohol andtobacco bestowed increased risks of earlier tumoroccurrence only for oral⁄pharyngeal and oral cancers,respectively, TF-BQ was consistently observed to conferelevated age-associated risks for each UADT-SCC[adjusted hazard ratio (aHR) = 1.6–2.3]. Alcohol andTF-BQ joint consumers experienced a stepwise increasedcumulative risk (CR) of contracting carcinomas of thelarynx (46.2%), esophagus (47.5%), pharynx (53.5%), andoral cavity (60.5–71.0%), with >68% of CRs found amongdrinkers who started chewing before age 20. Alco-hol + Betel + Cigarette and Alcohol + Betel users exhibi-ted earlier diagnosis ages than non-users: 10 years aheadfor oral cancer, 7, 17, and 12 years earlier for pharyngeal,esophageal, and laryngeal cancers. Noticeably, highercumulative cancer risks regarding earlier tumor occur-rence were correspondingly identified for these usersaged 43, 49, 43, and 44 upward.CONCLUSIONS: Tobacco-freebetel-quid,inconjunctionwith alcohol and⁄or tobacco consumption, impacts earlycancer occurrence for specific UADT-SCC and influencestumor site incidence pattern of these neoplasms.J Oral Pathol Med (2011) 40: 684–692Keywords: age; alcohol; betel-quid; tobacco; upper aerodigestivecancerAbbreviations: ABC, alcohol, betel-quid, and cigarette; aHR,adjusted hazard ratio; CR, cumulative risk; SCC, squamous cellcarcinoma; TF-BQ, tobacco-free betel-quid; UADT, upperaerodigestive tract

Background—Coffee consumption has been shown to be inversely associated to type 2 diabetes mellitus (T2DM), but evidence in Chinese populations is limited. We investigated the relationship between coffee consumption and T2DM in a population-based cohort of middle-aged Chinese. Materials and Methods—We studied 2,332 subjects who participated in the Taichung Community Health Study in Taiwan in 2004. The relationships between coffee consumption, T2DM and fasting glucose were assessed. Results—The prevalence of T2DM was 14.0% and 10.4% in men and women. After adjustment for age, body mass index, blood pressure, smoking, alcohol drinking, betel nut chewing, physical activity, income, education level, fat%, protein%, carbohydrate%, and magnesium, coffee intake was inversely associated with T2DM. Habitual coffee drinkers had 38–46% lower risk of T2DM than non-drinkers. Compared to non-drinkers, the adjusted odds ratios (ORs) for T2DM according to subjects with habitual coffee consumption (

Aim: The purpose of this study was to detect the C-deletion mutation of the p53 gene at exon 4 of codon 63 in the saliva of oral squamous cell carcinoma in central India. Methods: The study was carried out in 30 oral squamous cell carcinoma cases and five healthy controls with no habit of betel nut and tobacco chewing. The C-deletion mutation of the p53 gene at exon 4 of codon 63 was detected in the saliva samples by using polymerase chain reaction. Results: In this study, C-deletion at exon 4 of codon 63 was detected in 28 of 30 oral squamous cell carcinoma cases (93.33%), but was negative in all five healthy controls and two oral squamous cell carcinoma cases. Conclusions: The results indicated that C-deletion mutation at exon 4 of codon 63 of the p53 gene in the saliva might be a plausible molecular marker for oral squamous cell carcinoma patients with a habit of betel nut and tobacco lime quid chewing. The results further emphasize the presence of p53 gene mutation in patients with oral squamous cell carcinoma, which can be detected in the saliva through polymerase chain reaction.

Oral submucous fibrosis (OSF) is a premalignant, fibrosing disorder of the mouth, pharynx, and oesophagus, with a malignant transformation rate of 7-13%. OSF is strongly associated with areca (betel) nut chewing and worldwide, over 5 million people are affected. As αvβ6 integrin is capable of promoting both tissue fibrosis and carcinoma invasion, we examined its expression in fibroepithelial hyperplasia and OSF. αvβ6 was markedly up-regulated in OSF, with high expression detected in 22 of 41 cases (p < 0.001). We investigated the functional role of αvβ6 using oral keratinocyte-derived cells genetically modified to express high αvβ6 (VB6), and also NTERT-immortalized oral keratinocytes, which express low αvβ6 (OKF6/TERT-1). VB6 cells showed significant αvβ6-dependent activation of TGF-β1, which induced transdifferentiation of oral fibroblasts into myofibroblasts and resulted in up-regulation of genes associated with tissue fibrosis. These experimental in vitro findings were confirmed using human clinical samples, where we showed that the stroma of OSF contained myofibroblasts and that TGF-β1-dependent Smad signalling was detectable both in keratinocytes and in myofibroblasts. We also found that arecoline, the major alkaloid of areca nuts, up-regulated keratinocyte αvβ6 expression. This was modulated through the M(4) muscarinic acetylcholine receptor and was suppressed by the M(4) antagonist, tropicamide. Arecoline-dependent αvβ6 up-regulation promoted keratinocyte migration and induced invasion, raising the possibility that this mechanism may support malignant transformation. Over 80% of OSF-related oral cancers examined had moderate/high αvβ6 expression. These data suggest that the pathogenesis of OSF may be epithelial-driven and involve arecoline-dependent up-regulation of αvβ6 integrin.

Amarasinghe HK, Usgodaarachchi US, Johnson NW, Lalloo R, Warnakulasuriya S. Public awareness of oral cancer, of oral potentially malignant disorders and of their risk factors in some rural populations in Sri Lanka. Community Dent Oral Epidemiol 2010; 38: 540-548. Ǎ 2010 John Wiley & Sons A/S Abstract-Objective: The aim of this study was to investigate the level of public awareness of oral cancer, of oral potentially malignant disorders (OPMD) and of risk factors for developing these diseases in a province of Sri Lanka, a country with one of the highest incidences of these diseases in the world. Methods: A cross-sectional community-based survey was carried out in Sabaragamuwa province by interviewing 1029 subjects above 30years of age, over a 1-year period from November 2006. Results: The level of public awareness of oral cancer was 84%, but only 23% for OPMD. Awareness was especially poor in low socioeconomic groups. The majority of subjects were not aware of the symptoms of oral cancer and of OPMD. Thirty-two percent were unaware that chewing betel quid was a risk factor for these diseases, as were 65% for tobacco smoking and 81% for heavy consumption of alcohol. Overall, 76% were not aware of any of the dangers inherent in the frequent use of areca nut. The majority of smokers, betel quid chewers and alcohol consumers were not aware that their lifestyles were placing their long-term health at serious risk. Conclusions: Knowledge of oral cancer, OPMD and their associated risk factors was poor among this population, indicating an urgent need to implement public health education and promotion strategies.

Aims Previously reported research suggests a dependence syndrome for areca nut use, though well-designed studies are virtually non-existent. The goal of this study was to examine evidence of areca dependence in a sample of areca-only (i.e. no tobacco) chewers using modified measurement scales. Design A purposive sample of chewers, identified via local informants and advertisements, was surveyed from January to March of 2005. Setting Six villages in Dakshina Kannada District, Karnataka State, India. Participants Fifty-nine daily areca chewers who do not also currently use any form of tobacco. Measurements Questionnaires included modified versions of the Fagerstrom Tolerance Questionnaire, Cigarette Dependence Scale (CDS-5) and the Smokeless Tobacco Dependence Scale (STDS). Additional questions assessed demographic characteristics and patterns of use. Findings Approximately half of respondents reported 1–3 chews/day (mean = 1.9; SD = 0.98). The average number of chewing episodes/day was 4.4 (SD = 3.4) and the average number of nuts/day was 1.2 (SD = 1.1). Users’ typical chew lasts up to 20 minutes and includes spitting out the juices and rinsing the mouth with water. Overall, the levels of reported dependence symptoms were quite low, but approximately 44% of chewers endorsed at least one of the following items: continued use despite illness or mouth wounds, difficulty refraining from chewing in forbidden places, or craving during periods of abstinence. Approximately 15.4% of chewers reported at least one intentional quit attempt and a subset had summary scores indicative of dependence (13.6% had scores >16 on the CDS-5 and 5.3% had scores >11 on the STDS). Dependence scores were positively correlated with frequency of chews/day. Conclusions The symptoms of dependence observed in a subset of areca-only chewers warrant further investigation. Next steps should include well-controlled laboratory evaluation of dependence features.

I. INTRODUCTION Research has clearly established that the consumption of cigarettes, alcohol, and betel nuts has serious health consequences. For example, we now know that heavy levels of smoking and alcohol consumption cause cardiovascular disease and increase the likelihood of cancer and mortality (Vineis and Caporaso 1995). We also know that the chewing of betel nuts is strongly associated with oral cancer. In fact, betel nut consumption leads to more serious central nervous system problems than do caffeine, tobacco, or alcohol (Wu, Lu, and Sung 1999). Because all three substances are popular in most Asian countries, it is critical that governments develop policies that successfully control and discourage their use. In pursuit of this effort, one of the most important steps governments have taken in recent years has been to publicize the constantly growing body of evidence linking severe health risks to consumption of these products. The mass media, too, has reported widely on the damaging effects of alcohol, cigarettes, and betel nuts on human health. However, little empirical evidence exists regarding the relationship between dissemination of health risk information and consumption of addictive substances. In addition, although studies on the impact of risk knowledge on individual health behavior are not new in economic literature, few have performed a countrywide aggregation analysis of this topic from the viewpoint of a single country. Therefore, this study empirically investigates the potential impacts of risk information dissemination on the consumption of cigarettes, alcohol, and betel nuts in Taiwan. It also compares the cross-elasticities of price and risk information. To explore the role of the media in information dissemination, we followed the research of Viscusi (1992). who collected the total number of articles on smoking hazards that appeared in Reader's Digest from 1950 to 1989. The number of articles increased by decade over the period: 12 between 1950 and 1959. 17 between 1960 and 1969, 19 between 1970 and 1979. and 23 between 1980 and 1989. Out of the 71 articles on smoking hazards published between 1950 and 1989. just 18 appeared before the 1964 Surgeon General's report. More specifically, Brown and Schrader (1990) used a medical dataset base and defined the risk information index as the number of articles supporting a link between smoking and lung cancer disease. Since the early 1970s, countries around the world have studied the impact of antismoking publicity and health risk information on demand for tobacco. Hamilton (1972) explored the impact of information on the health risks of smoking on the demand of tobacco among Americans age 14 and above. He found that the Surgeon General's landmark 1964 report on the negative health effects of smoking effectively reduced personal consumption of cigarettes by 146 to 253 units per year between 1964 and 1970. Stavrinos (1987) estimated that personal consumption of cigarettes per year fell by 9.9% to 13.7% between 1968 and 1970 due to the wide dissemination of such information. Numerous studies have used survey data to evaluate the public's perception of risk in regard to smoking behavior. Viscusi (1990, 1991, 1992, 1998). who pioneered such studies, found that the higher an individual's subjective risk is of dying from lung cancer, the less likely it is that the individual will smoke. Kenkel and Chen (2000) researched studies conducted in different countries, including Taiwan (Liu and Hsieh 1995; Hsieh et al. 1996; Hsieh 1998), Spain (Antonanzas et al. 2000), South Africa (Jones and Kirigia 1999), and Sweden (Lund-borg 2007), and concluded that publicizing the health risks from smoking has a negative impact on the number of smokers. To elicit how much information an individual possessed about the health risks of smoking, Kenkel (1991) adopted an alternative indicator: measuring the number of smoking-related diseases an individual could name. …

This work investigated the effects of extraction temperature on the quality of extract and the kinetics of solid-liquid extraction of betel leaves. In this study, the effects of extraction temperature on the quality of extract were evaluated by comparing the concentration of its active compounds, including hydroxychavicol (HC) and eugenol (EU). The results indicate that the increase of extraction temperature led to the increase of the concentration of HC. EU concentration was decreased when temperatures higher than 60C were used. The kinetics data show that the extraction process reached equilibrium in a short time – about 40 min. Two models, namely equilibrium-dependent solid-liquid extraction (EDSLE) model and diffusion-dependent solid-liquid extraction model were applied to describe the extraction process. By comparing the values of correlation coefficients, the EDSLE model was found to be more suitable in describing the extraction process as it provided a better fit to the experimental data. PRACTICAL APPLICATIONS Betel leaves is one of the invaluable medicinal plants that has multiple useful bioactivities found in Malaysia. In this work, the effect of extraction temperature on the quality of the extract of betel leaves was investigated by quantifying the change of two active compounds, namely hydroxychavicol and eugenol. This is because the bioactivities depend on the content of the phytochemicals within the plant. The critical extraction temperature was determined based on the findings. Aside from this, the kinetics of the extraction process was also studied. Two mathematical models including equilibrium-dependent solid-liquid extraction (EDSLE) model and diffusion-dependent solid-liquid extraction model were used to predict the extraction process. EDSLE, which is simple and easy to be solved, was applicable in simulating the extraction process. The findings from this study are useful in understanding and optimizing the solid-liquid extraction process of betel leaves.

Background: The characteristic of oral submucous fibrosis (OSF) is related with the disturbance of synthesis and degradation of extracellular matrix. Arecoline, the areca nut (betel nut) component of betel quid, plays a major role in pathogenesis of OSF. But the exact mechanism how arecoline influences the collagen metabolism is unclear. Methods: Oral keratinocytes and fibroblasts were cocultured and keratinocytes were pre-treated by arecoline. Fibroblasts alone, fibroblasts stimulated by arecoline, fibroblasts cocultured with keratinocytes and fibroblasts cocultured with keratinocyte pre-treated by arecoline were included as the four groups in the present study. The concentration of collagen, the content and activity of matrix metalloproteinase (MMP) and the concentration of tissue inhibitor of metalloproteinase (TIMP) were assessed. Results: The collagen production of fibroblasts decreased when cocultured with keratinocytes; when cocultured with keratinocytes pre-treated by arecoline, fibroblasts produced more soluble collagen than non-pretreated coculture group. MMP-9 was produced only in coculture groups. There was no significant difference in the two coculture groups. The activation ratio of pro-MMP-2 in arecoline pre-treated keratinocytes-fibroblasts coculture group was significantly higher than that of non-coculture groups, but no significant difference existed in the two coculture groups. TIMP-1 produced by arecoline pre-treated keratinocytes-fibroblasts coculture group was significantly higher than those by the other three groups. Conclusion: TIMP-1 and the interaction of oral keratinocytes and fibroblasts play important role in pathogenesis of OSF.

Huang H-L, Lee C-H, Yen Y-Y, Chen T, Chen F-L, Ho P-S, Lai T-C, Tsai W-L, Hsu C-C. School-level contextual factors associated with betel quid chewing among schoolchildren in Taiwan. Community Dent Oral Epidemiol 2009; 37: 58-67. The Authors. Journal compilation � 2008 Blackwell Munksgaard Abstract - Objectives: Previous to this research, no literature had explored the clustering of betel quid chewing at the school-level and the contextual factors contributing to this behavior among elementary schoolchildren. This study therefore examines this in clusters stratified according to school geography and the rate of aboriginal students in each school. Individual-level characteristics are controlled in the study. Methods: The data used derive from student and parent surveys of the School Smoking Survey Project from a sampling of third and fourth grade children from 13 elementary schools in Tao-Yuan County, Taiwan (n = 1585). The individual- and school-level characteristics regarding betel quid chewing were estimated using multi-level logistic regression analysis. Results: Compared to their counterparts, students attending schools with higher percentages of aboriginal students (OR = 3.60, 95% CI: 1.31-9.95), or those schools located in a mountainous region (OR = 2.82, 95% CI: 1.19-6.70), were found to have a greater risk of chewing behavior. Other observed characteristics having a significant relationship to student chewing behavior were drinking alcohol and smoking cigarettes. Conclusions: The new findings from this study suggest that the specific school attended is an important point of intervention. Therefore, effective policies and preventive programs should be strongly considered for implementation in schools that are putting students at the greatest risk for betel quid chewing behavior. Our study also confirmed the relationship between betel quid chewing, cigarette smoking, and alcohol drinking, suggesting that multifaceted intervention strategies need to be considered in regard to such behaviors among elementary schoolchildren.

Oral submucous fibrosis (OSF) is a disease of the mouth and oropharynx characterised by progressive deposition of collagen leading to severe limitation of movement of the jaw in advanced cases. It is almost completely confined to inhabitants of, or migrants from India who chew 'betel nut'. The histopathological and clinical features suggest that autoimmune mechanisms may be involved. Because all chronic autoimmune diseases show disturbance in the frequencies of HLA antigens, we have HLA typed 50 OSF patients and a similar number of healthy subjects of the same ethnic origin. Raised frequencies of A10 and DR3 were observed. The results support the concept that OSF is a chronic autoimmune disease, initiated by constituents of betel nut, and occurring in genetically susceptible individuals. Genes situated in the HLA region are important determinants of genetic susceptibility in OSF.

Leukoplakia is an asymptomatic, potentially malignant change in the oral mucosa. Previous studies have reported that smoking and betel quid chewing are associated with increased risk of leukoplakia; few studies have reported on these associations in populations where betel quid does not contain tobacco. We conducted a case-control study nested in a cross-sectional study in Papua New Guinea and a systematic review of studies that included chewers of betel quid without tobacco. Our study recruited 1,670 adults. We recorded betel quid chewing and smoking. The prevalence of leukoplakia was 11.7%. In the nested case-control study of 197 cases and 1,282 controls, current betel chewing was associated with increased risk of leukoplakia with an adjusted odds ratio for current chewers of 3.8 (95% CI 1.7, 8.4) and in the heaviest chewers of 4.1 (95% CI 1.8, 9.1) compared to non-chewers. Current smoking was associated with an increased risk of leukoplakia with an adjusted odds ratio for current smokers of 6.4 (95% CI 4.1, 9.9) and amongst heaviest smokers of 9.8 (95% CI 5.9, 16.4) compared to non-smokers. The systematic review identified 5 studies examining risk of leukoplakia associated with betel quid chewing in populations where betel quid did not contain tobacco and that controlled for smoking. In studies that adjusted for smoking, the combined random effect odds ratio was 7.9 (95% CI 4.3, 14.6) in betel quid chewers. The results of this study and systematic review of similar studies provide evidence of the role of betel quid not containing tobacco and leukoplakia.

Many of the disorders today are based on the imbalances of immunological processes. This necessitates the search for newer and safer immunomodulators. Thus, the objective of the present study was to explore the immunomodulatory activity of the methanolic extract of Piper betel L. (MPb) (Family: Piperaceae). The MPb consists of mixture of phenols, flavonoids, tannins and polysaccharides. Both in vitro as well as in vivo evaluation was carried out. The effects of MPb on lymphocyte proliferation, interferon-gamma receptors and the production of nitric oxide were measured in vitro. Further, the extract at different dose levels was studied in vivo for the humoral and cellular immune responses on mice immunized with sheep red blood cells. P. betel significantly suppressed phytohaemagglutinin stimulated peripheral blood lymphocyte proliferation in a dose-dependent manner. The decrease in antibody titre and increased suppression of inflammation suggests possible immunosuppressive effect of extract on cellular and humoral response in mice. Thus, the MPb could be explored extensively as a therapeutic agent to treat various immune disorders including autoimmune disorders.

Background. The margin status is an important prognosticator for the survival of patients with tongue cancer. Although a positive margin is associated with a poor prognosis, those with clear margins do not always have good clinical out- comes. Methods. We investigated the margin status, pattern of tu- mor invasion (POI), and tumor satellite distance (TSD) in 119 freshly treated tongue cancers and assessed their association with the characteristics and clinical outcomes. Results. A close or clear margin and POI were not associ- ated with overall survival. Tumor satellites occurred in 92% of tumors and were significantly associated with betel nut expo- sure. Patients with TSD 0.5 mm had significantly better overall survival. Patients with TSD >0.5 mm had a higher incidence of local recurrence, shorter intervals to neck recurrence, and a higher propensity to contralateral or bilateral cervical nodal me- tastasis. Conclusion. TSD is associated with local recurrence, contra- lateral neck metastasis, and the overall survival of patients with tongue cancer. V C 2008 Wiley Periodicals, Inc. Head Neck 30: 631-638, 2008

Background: Although the effect of betel quid chewing and smoking on oral cancer has been well documented, both influences, dose and duration during life time, on multistate progression of oral pre-malignancy are hardly addressed. Methods: By recruiting a group of male chewers from different occupation groups, we modeled the effects of both duration and quantity of betel quid chewing and smoking on annual incidence rate of developing leukoplakia and average dwelling times (ADTs) staying in leukoplakia and erythroleukoplakia. Results: The annual incidence rate (per year) of leukoplakia was estimated as 0.35% (95% CI: 0.22–0.48%). The ADTs were 24 years for leukoplakia and 7 years for erythroleukoplakia. Annual incidence rate of leukoplakia with high consumption and long duration of betel quid and smoking was higher. Both quantity and duration of smoking and betel quid chewing play minor roles in the influence of ADT. The risks of developing oral cancer after 20 years of follow-up were 42.2% for leukoplakia and 95.0% for erythroleukoplakia. Conclusion: The effects of betel quid chewing and smoking on multistate progressions between oral pre-malignancies were elucidated. These results can be applied to predict long-term risk of malignant transformation varying with different duration and quantity of betel quid and cigarette.

BACKGROUND: To report on Areca chewing (AC) in Xiangtan, Hunan province, China, and to test the knowledge of chewers related to side effects of the habit. METHODS: Interviews with 276 individuals were performed. A questionnaire including general data, chewing habits, educational level and knowledge about side effects were used. Data were analysed using SPSS. Chi-square test was used at a significance level of P < 0.05. RESULTS: Around 257 individuals were chewers (male: 54.1%; female: 45.9%) and 19 were former chewers (male: 31.6%; female: 68.4%). Mean age of chewers was 36.1 years. Around 42.4% of chewers smoked; 58.0% had a drinking habit. Average period of chewing was 11.2 years. Around 88.3% of chewers did not include the nut (seed). Around 79.0% considered AC habits negative for general health and 85.2% for oral health. CONCLUSIONS: Most respondents did not know that AC may induce oral submucous fibrosis and oral cancer.

Background: Oral squamous cell carcinoma and the most common oral pre-malignancies appear to be related to the habit of betel-quid chewing in Sri Lanka. Although hypermethylation of the tumour suppressor genes in oral cancer have been well documented, little information has been available concerning hypermethylation in oral pre-cancerous lesions. In the present study, we investigated the hypermethylation of p14, p15 and p16 in pre-cancerous lesions including epithelial dysplasia and submucous fibrosis. Methods: All samples were obtained from patients with a betel-quid chewing habit in Sri Lanka. Sixty-four patients were clinically diagnosed with leukoplakia, and histopathologically diagnosed with mild or severe dysplasia. Ten patients were diagnosed with submucous fibrosis without epithelial dysplasia. CpG island hypermethylation was assessed by a methylation-specific PCR method. Immunohistochemical staining was performed using anti-p53 antibodies. Results: A high frequency of hypermethylation of p14, p15 and p16 was detected in the pre-cancerous lesions, although no hypermethylation was found in normal epithelium. The frequency of hypermethylation was higher than that of positive staining for p53 mutation except in the case of p16 in mild dysplasia. No significant correlation was observed between p53-positive reactions and hypermethylation in any lesions. The hypermethylation was highly detectable even in p53-negative lesions, suggesting that hypermethylation of p14, p15 and p16 occur regardless of whether the lesions have p53 mutations or not. Conclusions: The present study indicates that hypermethylation may be involved in the pathogenesis of oral pre-cancerous lesions associated with betel-quid chewing in Sri Lanka.

The consumption of alcohol, tobacco and betel quid has been found to be an important contributor to esophageal squamous cell carcinoma (ESCC) in Taiwan. The genotoxic effect of the ADH1B and ALDH2 genes modulating an individual's alcohol-metabolizing capacity on ESCC may be linked to drinking behavior, intake pattern and other exogenous factors. To investigate the interplay of these genetic and environmental factors in determining the risk of ESCC, a multicenter case-control study was conducted. Here, 406 patients with pathology-proven ESCC, as well as 656 gender, age and study hospital matched controls were recruited. Genetic polymorphisms of ADH1B and ALDH2 appeared to correlate with the abstinence of alcohol, though not with tobacco and betel quid. Within the same levels of alcohol consumption, carcinoma risks increased along with an increase in the numbers of ADH1B*1 and ALDH2*2 alleles. The inactive ALDH2*1/*2 genotype was found to multiplicatively interact with a low-to-moderate (0.1-30 g/day) and a heavy (>30 g/day) ethanol intake to increase the ESCC risk (the joint aOR = 14.5 and 102.6, respectively). Among low-to-moderate drinkers, a smoking-dependent carcinogenetic effect for the ADH1B*1/*1 and ALDH2*1/*2+*2/*2 genotypes was recognized, with significant risks found in smokers, but not in nonsmokers. Further, a supra-multiplicative combined risk of ESCC for alcohol and tobacco use was identified among carriers of the ADH1B*1/*1 genotype (p for interaction = 0.042). In conclusion, the interplay of the ADH1B and ALDH2 genotypes, in conjunction with a behaved drinking habit and a practiced drinking pattern, along with continued tobacco consumption, plays an important pathogenic role in modulating ESCC risk.

Background: To screen for oral cancer or not is being debated, but for high-risk populations with minimal access to regular dental care systematic oral examinations could provide some benefit. Methods: We undertook oral mucosal examinations of labourers employed in tea estate plantations in Sri Lanka. In a two-stage screening procedure, first by estate medical officers and then by visiting specialists, we examined 12 716 persons at their workplaces achieving a coverage of one-sixth of the total workforce. Results: Fourteen oral cancers and 848 subjects with oral pre-cancer (6.7%) were detected giving population prevalences of 46.1 per 1000 for leukoplakia and 16.4 per 1000 for oral submucous fibrosis. Among subjects with any oral mucosal disorder (n = 1159) proportions of current users of betel quid, smokers and alcohol use was recorded at 92%, 31% and 61% respectively. The synergistic effect of these three risk habits on the development of oral leukoplakia was evident in mixed habit groups. Conclusions: The prevalence of oral pre-cancer in tea estate labourers was higher than estimates reported in previous studies. In the absence of state-sponsored preventive activities, it is necessary to improve the capacity of individual health practitioners and small medical centres to participate in oral health promotion and oral cancer/pre-cancer screening.

Objective: Patients with oral submucous fibrosis (OSF) suffer from the limitation of the oral opening. The aim of this study was to develop a simple and rapid method to improve the opening of the oral cavity and determine its effect on the incidence of developing oral carcinoma. Methods: We first induced an OSF-like lesion in rabbits which histopathologically resembles OSF in betel nut chewers and evaluated the effects of exogenous collagenase on these lesions. We then applied the collagenase treatment regimen to patients with OSF. Results: Endogenous collagenase activities in normal oral mucosa of patients exhibited 3- to 5-fold higher levels than that of OSF tissues. The collagenase treatment not only resulted in a significant improvement of oral opening, but patients also experienced a striking reduction in hypersensitivity to spices, sour, cold, and heat which helped restore eating function. Sub-mucosal fibrous proliferation, persistently good vascularization, and a mild increase in thickness of the sub-mucosal fibrous tissues were noticed 10 months after collagenase treatment. Within the 2-year follow-up period none of the treated patients developed an oral squamous cell carcinoma. Conclusion: A reduced content of functional collagenase observed in OSF mucosa of patients might be one mechanism responsible for collagen accumulation. Intervention of OSF by collagenase treatment at the early stage may reduce the incidence of developing oral carcinoma.

Alterations of p53 have been explored in Taiwanese oral squamous cell carcinomas (OSCCs) consisting of a betel quid (BQ)/tobacco-related subgroup of 36 subjects and a tobacco-related subgroup of 13 subjects. Mutations in conserved exons were found in 12 tumors. Seven mutations were clustered in a hot-spot region mapped to a region between codons 273-282 in exon 8. The incidence of p53 mutation in BQ/tobacco tumors was 22% (8/36). The frequency of p53 allelic loss (21%, 3/14) in BQ/tobacco tumors approximates to the incidence of mutation. This is the first study demonstrating allelic deletion of p53 in such malignancies. Twenty-four of 43 samples showed positive p53 immunostaining. All tumors harboring mis-sense mutations of p53 in conserved exons exhibited nuclear protein accumulation. The incidence of mutation in conserved exons in BQ/tobacco-associated Asian OSCCs (15%) is significantly different from worldwide OSCCs (46%) related primarily to tobacco consumption (P=0.00001).

The measurement of steroids in saliva is both simple and non-invasive and has been widely used in field and clinical-based research. The observance of particular cultural practices by some populations, however, may hamper accurate hormonal analyses. The present study evaluated the effects of one such practice-the chewing of betel nut-on the accurate measurement of salivary progesterone and estradiol. A time series experiment was conducted among Bangladeshi women who are regular users of betel nut. Salivary steroids were analyzed by radioimmunoassay in samples collected prior to and then 30, 60, 120, and 240 min following betel quid use. Results show no significant difference between basal steroid levels and those obtained 60, 120, and 240 min after chewing betel nut. We conclude that with specific collection protocols that take into account time since chewing, salivary steroid analyses can be undertaken in populations among whom the practice of chewing betel nut is endemic.

Arecoline is an alkaloid of betel nut of Areca catechu. Betel nut is chewed by millions of people in the world and it causes oral and hepatic cancers in human. It has therapeutic value for the treatment of Alzheimer and schizophrenia. Arecoline has immunosuppressive, mutagenic and genotoxic effects in laboratory animals. It also affects endocrine functions. The objective of this study was to investigate the effects of arecoline on pineal-testicular axis in rats. Since pineal activity is different between day and night, the current study is undertaken in both the photophase and scotophase. The findings were evaluated by ultrastructural and hormonal studies of pineal and testicular Leydig cells, with quantitations of fructose and sialic acid of sex accessories. Arecoline treatment (10 mg/kg body weight daily for 10 days) caused suppression of pineal activity at ultrastructural level by showing dilatation of the cisternae of the rough endoplasmic reticulum (RER), large autophagosome-like bodies with swollen mitochondrial cristae, numerous lysosomes, degenerated synaptic ribbons and reduced number of synaptic-like microvesicles. Moreover, pineal and serum N-acetylserotonin and melatonin levels were decreased with increased serotonin levels in both the gland and serum. In contrast, testicular Leydig cell activity was stimulated with abundance of smooth endoplasmic reticulum (SER), electron-dense core vesicles and vacuolated secretory vesicles, and increased testosterone level in the arecoline recipients. Consequently, the testosterone target, like prostate, was ultrastructurally stimulated with abundance of RER and accumulation of secretory vesicles. Fructose and sialic acid concentrations were also significantly increased respectively in the coagulating gland and seminal vesicle. These results were more significant in the scotophase than the photophase. The findings suggest that arecoline inhibits pineal activity, but stimulates testicular function (testosterone level) and its target organs presumably via muscarinic cholinergic receptor in rats.

Background: Oral submucous fibrosis (OSMF) is a chronic, insidious, disabling potentially malignant condition of the oral mucosa seen predominantly in south and Southeast Asia. No reports are hitherto available on the aetiological factors of OSMF based on Sri Lankan patients. Methods: A total of 74 patients with OSMF and 74 controls who consecutively attended the Oral Medicine clinic at the Dental Hospital (Teaching) Faculty of Dental Sciences, University of Peradeniya, Sri Lanka were included in the study. Binary logistic regression analyses were performed to model the influence of betel chewing, smoking and alcohol use and to determine the effects of different combinations of chewing habits on OSMF. Results: Betel chewing was the only significantly associated factor in the aetiology of OSMF (OR = 171.83, 95% CI: 36.35–812.25). There were no interaction effects of chewing, smoking and alcohol consumption in the causation of OSMF. Conclusion: The present study has shown a strong association of betel quid chewing (including tobacco as an ingredient) with the causation of OSMF.

Objective In 2003 esophageal cancer was the sixth leading cause of death among men in Taiwan, but it is the fastest increasing (70%) alimentary tract cancer. The aim of this study was to investigate the impact of different habits of betel nut chewing on esophageal squamous cell carcinoma (SCC) and its interaction with cigarette use and alcohol consumption. Materials and methods All 165 cases were pathologically proven esophageal SCC patients (all male, mean age = 56·0, range = 35–92 years) diagnosed by biopsy during gastroendoscopic examinations. The control group comprised 255 subjects (all male, mean age = 54·8, range = 40–92 years) selected from patients who had visited the Otolaryngology Outpatient or Inpatient Department of KMUH owing to a benign lesion over this field. All were interviewed to collect demographic and substance use information by a trained interviewer using a standardized questionnaire. Results Smoking (aOR = 5·4, 95% CI = 2·4–12·9, PAR = 72%), alcoholic beverage drinking (aOR = 17·6, 95% CI = 9·3–35·2, PAR = 76%) and low education level are independent risk factors for esophageal cancer. Although betel nut chewers only had a borderline significant higher risk than nonchewers (aOR = 1·7; 95% CI = 0·8–3·1), those who chewed with a piece of betel inflorescence (aOR = 4·2, 95% CI = 1·4–16·0) and swallow betel-quid juice (aOR = 3·3, 95% CI = 1·3–9·3) had a significant higher risk. Significant dose–response effects were found in daily quantity of drinking and smoking. There is a synergistic effect of these three substances on the development of esophageal cancer. Conclusion Betel nut chewing plays a relevant role in the development of esophageal SCC but adds to the carcinogenetic effect of smoking and alcohol drinking. Direct mucosal contact of betel juice may contribute to its carcinogenesis

Background: In a previous article, we reported the prevalence rates of oral mucosal lesions in an aboriginal community from an epidemiological survey of oral pre-cancerous lesions. Methods: Since 1997, the authors have started regular follow-up of the study population originally investigated. Thus, it has been possible to obtain incidence rates for the various oral pre-cancerous lesions and conditions. Results: There were 194 persons without any oral lesion in the 1997 screening. During the clinical follow-up investigation and during the analysis of biopsies from pre-cancerous lesions, we discovered six new lesions (including cancer and pre-cancerous lesions) from five participants. All of the five persons were areca/betel quid chewers, and only one mixed areca/betel quid chewing with cigarette smoking habit. The age-standardized incidence rates for quid lesion, oral submucous fibrosis (OSF) and squamous cell carcinoma (SCC) were 267.0, 374.1 and 146.2 per 100 000 person-years, respectively, for areca/betel quid chewers. Conclusions: As compared with the rates from India and the general Taiwanese population, the study community encountered a serious problem of oral lesions.