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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 33  |  Issue : 4  |  Page : 421-427

Role of areca nut and smokeless tobacco-related habit in altering physical properties of saliva – A comparative study


1 Department of Oral Medicine and Radiology, Gujarat University, Ahmedabad, Gujarat, India
2 Department of Oral Medicine and Radiology, Government Dental College and Hospital, Ahmedabad, Gujarat, India
3 Department of Oral Medicine and Radiology, Ahmedabad Dental College and Hospital, Ahmedabad, Gujarat, India

Date of Submission17-Dec-2020
Date of Decision07-Jul-2021
Date of Acceptance11-Aug-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Roseline A Patel
25/Nijripunj Society, Behind Radha Swami Satsung, Ranip, Ahmedabad - 382480
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_226_20

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   Abstract 


Context: Saliva performs multiple functions and is of paramount importance for the maintenance of oral health. Hence, alterations in its physical properties like salivary flow rate, buffering capacity and pH can be deleterious to the oral cavity. Areca nut and smokeless tobacco products are known to alter the mucosa as well as the saliva. Aims and Objectives: The study is aimed to compare the alteration in the salivary properties like stimulated salivary flow rate, pH, and buffering capacity between subjects with areca nut and smokeless tobacco habit and without in subjects without habit. A correlation between the habit frequency, duration, and exposure on the same parameters was also ascertained. Settings and Design: It is a comparative study using purposive sampling, comprising of 100 subjects within age group 18–50 years of any gender. The sample size constituted of 50 subjects (group A) with a habit of areca nut and smokeless tobacco and 50 subjects (group B) without any habit. Salivary properties like salivary flow rate, buffering capacity, and pH were analyzed in both groups to test a hypothesis that the habit results in changes in the salivary properties and that there is a correlation between the changes and the frequency, duration, and exposure of the habit. Materials and Methods: Saliva samples were collected from these subjects for analysis of salivary flow rate (SFR), pH, and buffering capacity using the GC Saliva Check Buffer Kit. Statistical Analysis Used: Data were analyzed by using the SPSS software program, version 27.0. Results: The mean stimulated salivary flow rate among group A was 3.34 ± 1.32 and pH was 6.50 ± 0.54. The mean stimulated salivary flow rate among group B was 4.42 ± 1.48 and the pH was 7.04 ± 0.47. The difference in these values was found to be statistically significant. Conclusion: Alterations in SFR and salivary pH and buffering capacity are observed in habitual chewers of areca nut alone and areca nut with other products. The alteration is dependent on the type of habit and the habit exposure frequency and duration.

Keywords: Areca nut habit, buffering capacity, pH, salivary flow rate, smokeless tobacco habit


How to cite this article:
Patel RA, Shah JS, Dudhia BB, Patel PS. Role of areca nut and smokeless tobacco-related habit in altering physical properties of saliva – A comparative study. J Indian Acad Oral Med Radiol 2021;33:421-7

How to cite this URL:
Patel RA, Shah JS, Dudhia BB, Patel PS. Role of areca nut and smokeless tobacco-related habit in altering physical properties of saliva – A comparative study. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2022 May 21];33:421-7. Available from: https://www.jiaomr.in/text.asp?2021/33/4/421/333870




   Introduction Top


Whole saliva is a unique body fluid continually bathing the mucosa of the oral cavity, oropharynx, and part of the larynx. It is a clear, slightly acidic, complex muco-serous secretion derived from the salivary glands, gingival fold, and oral mucosal transudate, in addition to containing mucous of the nasal cavity and the pharynx, non-adherent oral bacterial, food remainders, desquamated epithelial and blood cells as well as traces of medications or chemical.[1] Like the serum, saliva also contains hormones, antibodies, growth factors enzymes, microbes, and their products. Many of these constituents enter saliva through blood via passive diffusion, active transport or extracellular ultra-filtration. Therefore, saliva can be seen as a reflection of the physiological function of the body.[2]

A normal flow of saliva is a luxury we enjoy unconsciously throughout our lives, little realizing the distressing effects that one experiences when this mechanism fails due to different reasons. When the process of secretion of saliva is diminished, the oral tissue becomes susceptible to infection, and the ability to masticate, swallow, speak and taste may be disturbed.[3]

Alteration in salivary flow due to any reason can in turn cause changes in its pH, altering the buffering action. Alteration in these parameters has deleterious effects on the oral mucosa and leads to an aggravation of different oral conditions like caries to periodontitis to mucosal lesions and also oral cancer. This hurts the quality of life.[4] Areca nut and tobacco products are reported to be substances that can cause mucosal changes.[5]

However, their role in alteration in salivary flow is not very clear.[6] Hence, this study was carried out to evaluate changes if any in the salivary properties in subjects having such deleterious habits and was compared with subjects without any habit.


   Materials and Method Top


This study is a comparative study conducted in a Dental institution and the study sample was taken from the patients attending its outpatient Department of Oral Medicine and Radiology and willing to participate in the study with prior written informed consent. It was carried out to test a hypothesis that the areca nut and smokeless tobacco habit results in changes in the salivary properties and that there is a correlation between the changes and the frequency, duration, and exposure of the habit.

The study protocol followed the principles laid down in the Helsinki declaration and ethical approval for the study was obtained from the Institutional Ethical committee, Government Dental College and Hospital (IEC GDCH/5.9 2017).

Sample size estimation:

The Sample size(n) was calculated from the following formula.



Where,

Zα = 1.96(assuming the distribution is normal and confidence limit is 95%)

p = The proportion of alteration in salivary properties as observed in pilot study (in %) = 50

q = 1 – p (in %) = 50

L = Permissible error in estimation of p =15% of p (standardized) = 15% of 50 = 7.5

Substituting the values in the formula

Sample size (n) for subjects with alteration in salivary properties = 87.11 which was rounded to 100

A total number of 100 subjects belonging to the age group of 18-50 were selected using purposive sampling and divided into the following two groups by stratified sampling method:

  1. Group A- 50 Subjects having a habit of areca nut with/without smokeless tobacco/lime/masala/gutkha for more than one year.
  2. Group B- 50 Subjects without any oral adverse habit (control group). They were gender matched with group A.


The following subjects were excluded from the study:

  1. Subjects with a habit of smoking form of tobacco and alcohol consumption.
  2. Subjects having oral lesions which were not associated with the above-mentioned habits.
  3. Subjects above 50 years of age, as salivary output get affected with age.
  4. Subjects with an underlying major systemic disease or drug therapy that alter salivary parameters.
  5. Subjects who were pregnant.
  6. Subjects with a history of radiotherapy.


The oral cavity of the selected subjects was examined thoroughly and a detailed case history was taken. All the subjects' demographic characteristics, complete habit history (type, duration, frequency and exposure) with any associated lesions due to the same were recorded in a pre-determined proforma. Stimulated saliva was collected and salivary properties like stimulated salivary flow rate, pH, and buffering capacity of the selected subjects were determined using the GC SALIVA CHECK –BUFFER KIT. [Figure 1]
Figure 1: GC BUFFER KIT was used for saliva collection and parameter testing

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Saliva collection

The selected subjects were recalled in the morning hours between 9 a.m. to 12 p.m. to avoid the diurnal variation. They were instructed not to eat or drink 1 hour before saliva sampling, which was done using the spit method. [Figure 2] Unstimulated saliva was tested for pH, whereas stimulated saliva was tested for stimulated salivary flow rate and buffering capacity. Unstimulated and stimulated saliva was collected as mentioned below:
Figure 2: Collection of Stimulated Saliva was Done Using the Spit Method

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Unstimulated saliva

The patient was instructed not to expectorate or swallow saliva for 1 minute and then expectorate any pooled saliva into the collection cup. A pH strip was placed into the sample for 10 seconds and the color change was observed. Color change to red indicated pH between 5.0-5.8 as highly acidic. The color change to yellow indicated a pH of 6.0 -6.8 as moderately acidic. Color change to green indicated a pH range of 6.8-7.8 as healthy. [Figure 3]
Figure 3: Estimation of pH Using the pH Strip

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Stimulated saliva

Stimulated whole saliva was collected by chewing on a standardized lump of paraffin. Instructions were given to chew for 1 minute and thereafter to spit out or swallow any saliva produced. The saliva secreted during this 1 minute was not taken for study. The subject was then asked to continue chewing paraffin block and saliva was collected into the collection cup five times at a regular interval of 1 minute each. The salivary flow of <3.5 ml at 5 min was considered very low, 3.5–5.0 ml at 5 min was considered low and >5.0 ml at 5 min was considered normal.

Using a pipette, sufficient saliva was drawn and one drop was dispensed on the buffering test strip. Results were recorded in 2 minutes. The buffering capacity of the collected saliva was considered as very low, low, and normal according to the color chart [Figure 4]
Figure 4: Estimation of Buffering Capacity

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All the data obtained were recorded in the proforma and subjected to statistical analysis. The collected data were subjected to the Statistical package for social sciences (SPSS) version 27.0 for statistical analysis.


   Results Top


[Table 1] shows the distribution of study subjects (N = 100) according to gender. Group A consists of 50 subjects with a habit of areca nut and smokeless tobacco and Group B consists of 50 subjects without any habit. Both groups A and B were gender-matched and consist of 39 male subjects, 11 female subjects in each. The male: female ratio in this study was 3.54. The mean age of subjects in group A is 36.7 years and in the group B is 34.6 years.
Table 1: Distribution of total subjects (n=100) in the study according to gender

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[Pie chart 1] shows that 14 subjects had a habit of chewing areca nut/betel nut (sweetened SUPARI) alone, whereas other 36 subjects had a habit of chewing and/or placement areca nut with other products like mawa (17), as pan masala alone (5), mawa and pan masala together (11) and gutkha (3).



[Graph 1] shows that out of the 50 subjects having a habit, 15 (30%) showed no mucosal changes in the oral cavity, whereas the rest 35 (70%) subjects had lesions related to the habit like OSMF and Betel quid lesion (BQL).



[Table 2] shows that in subjects with habit history, 86% had a frequency of 1–10 times a day, whereas 14% showed a frequency of more than 10 times. 66% of them presented with exposure to habit (placement and/or chewing) for 1–10 min, 26% presented with 11–20 mins, and 8% presented with exposure time to habit as >20 min. 72% of them had the habit of chewing and/or placement of areca nut and tobacco related products between 1 and 10 years, 9% had a habit for 11–20 years, whereas 5% had a habit for more than 20 years.
Table 2: Distribution of subjects with habit by frequency, exposure and duration of habit

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[Table 3] shows that among group A, 28% has less than 3.5 ml Stimulated salivary flow rate (SSFR) in 5 min, 64% had SFR between 3.5 and 5 ml and 8% had SSFR more than 5 ml. In group B 14% of subjects had SSFR less than 3.5 ml, 66% had SSFR between 3.5 and 5 ml and 20% had SSFR more than 5 ml.
Table 3: Comparison of salivary parameters among the subjects with (Group A) and without habit (Group B)

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Among group A, pH was found highly acidic in 8% of subjects, moderately acidic in 64%, and normal in 28% of subjects. Among group B, highly acidic pH was found in 4% of subjects, moderately acidic in 30% of subjects and normal in 66% of subjects.

Among group A, 10% of subjects had very low salivary buffering capacity, 36% had a low buffering capacity and 54% had normal buffering capacity. Among group B, no subjects had very low buffering capacity, whereas 24% showed a low buffering capacity of the saliva and 38% had normal buffering capacity.

[Table 4] shows that the mean stimulated salivary flow rate among group A was 3.34 ± 1.32 units and pH was 6.40 ± 0.54. Although the mean stimulated salivary flow rate among group B was 4.42 ± 1.48 and the pH was 7.04+ 0.4, the difference in these values was found to be statistically significant.
Table 4: Comparison of mean SSFR/min, salivary pH between Group A and Group B

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[Table 5] shows that the subjects with a habit of betel nut alone showed an SSFR of 3.54 ± 0.23 and pH of 6.72 ± 0.28. Subjects with a habit of betel nut with other products like tobacco, slaked lime, pan masala, and gutkha showed an SSFR of 3.14 ± 0.63 and pH of 6.08 ± 0.35. These differences were found to be statistically significant.
Table 5: Comparison of stimulated salivary flow rate and pH among Group A subjects depending on habit pattern

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[Table 6] shows the respondent having OSMF showed an SSFR of 3.51 ± 0.98 and pH of 5.96 ± 0.55. Subjects having only betel quid lesion showed SSFR of 3.6 ± 0.82 and a pH of 6.48 ± 0.57. Although the subjects with both OSMF and betel quid lesions, SSFR was at 2.75 ± 0.35 and pH at 6.1 ± 0.14. The values were found statistically significant.
Table 6: Comparison of salivary parameters among Group A based on the type of lesion

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[Table 7] shows that out of 50 subjects, 34 (68%) had a habit index of <500, 20% had a habit index of 500 – 1000, and 12% had a habit index of more than 1000. The statistical values were significant in showing that the salivary parameters appear altered with the severity of habit.
Table 7: Comparison of salivary parameters among different habit index

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[Table 8] shows that the correlation of the habit parameters to salivary parameters among Group A subjects revealed negative Spearman's coefficient correlation to habit frequency and duration with statistical significance (P < 0.05) suggesting a slight decrease in all the salivary parameters.
Table 8: Correlation of habit frequency, duration and exposure on salivary flow rate among Group A respondents

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   Discussion Top


It is estimated that currently 10% of the world population or nearly 700 million individuals might be consuming betel nut/areca nut in different forms.[7] In Indian mythology areca nut is considered a divine fruit and has an importance in social and cultural customs and also chewing is considered to be a completely innocuous practice.[8],[9]

There is enough evidence that areca nuts can cause oral cancer.[7],[8],[10] However the effects of areca nut are considered habit related and dose dependent, especially with saliva.[11] There are fewer studies and research related to habitual areca nut chewing changes in the physical properties of saliva.[12] This study was undertaken on the physical properties of saliva to evaluate changes due to areca nut and smokeless tobacco related products.

On analysis of the demographics of the selected subjects, it was observed that the habits were more prevalent in males than females as found in other studies.[13] This could be due to the socio-cultural influences, as well as motives like stress relief, reinforcement, concentration in work, stimulation, and digestions can be attributed to for the dependence of this psychoactive substance.[14],[15],[16],[17] According to National Family Health Survey found 36.5% of men and 8.4% of women aged 15–49 years have the habit of chewing some form of areca nut and tobacco, “including pan masala, gutkha, and other tobacco” (IIPS, 2007).[18]

In this study it was found that habit of areca nut in mawa mixture form was more. Mawa consists of cured areca nut, with tobacco and slake lime. It is a popular areca nut habit in Gujarat.[19] Consumption of chewing sweetened areca nut was the second most common habit in our study. The sweet form of areca-nut is flavored, fragranced, tasty, inexpensive, and also highly addictive. Use of packaged areca nut in panmasala and gutkha habit was also found. These packages consist of areca nut with other substances like lime, spices and flavoring substances. It has been reported that its popularity is gaining among the masses not only because they are convenient and inexpensive but there is aggressive marketing by the companies as well.[18],[19]

It is reported that areca nut consists of at least six alkaloids of which arecoline is the main constituent. Arecoline exerts an addiction potential just like the nicotine of the tobacco.[20] It is also known to cause mucosal changes like increased keratinization of the epithelium, or ulcerations as seen in quid induced lesion or oral submucous fibrosis, and even carcinogenesis.[21] These mucosal changes were evident in our study [Graph 1]

In our study, it was found that number of subjects who consumed areca nut with other products was comparatively more. It was also found that the habit in such subjects was more frequent during the day with increased duration and more number of years.[18],[22],[23]

The average daily flow of the whole saliva varies in health between 1 and 1.5 L.[24] Several factors influence salivary secretion and composition.[25] Chewing of various areca nut constituents may generate reactive oxygen species (ROS) (O2, H2O2, OH), which elicit the potentially toxic damage by (1) Directly gene mutations, (2) Attack salivary proteins and oral mucosa—structural changes—penetration of various objects, (3) Inflammatory cell infiltration—more ROS—mutation of adjacent cells.[26] These may be responsible for salivary alterations in subjects with the habit. In this study, the stimulated salivary flow was more towards lower side among the subject of group A with habit. Similar findings were observed by S Siddabasappa et al. in their study.[27]

As the pH is dependent on the buffering capacity of saliva,[28] it was found that in group A, salivary buffering capacity and the pH were on the lower side. These similar findings were observed in other studies.[11],[14],[27],[28].

In this study, it was found that in Group A those who chewed areca nut alone, had a comparatively higher SFR and pH as compared to chewers of areca nut with other products mainly lime. Increased SFR in areca nut chewers is reported to be due to the parasympathetic activity of arecoline. These findings were also similar to other studies.[11],[14],[29] This can be due to the conversion arecoline to arecaidine and the presence of lime in the quid.[11],[27]

A statistically significant correlation has been found in between SFR and Habit Index. Those having a Habit Index of >1000 showed severe reduction in SFR as shown in the table. However, no significant correlation can be established between the pH and buffering capacity of saliva with the Habit Index. Chronic use of areca nut reverts its stimulant property and increases fibrosis thereby inducing xerostomia.[11],[14],[27],[28] Studies have also reported histopathological degenerative changes in the salivary glands structures as there is progression in OSMF.[29] Findings similar to the present study were also observed by Chung-Jung Chiu et al.[30] In 2002, xerostomia was seen in 72.2% patients with mouth opening 35 mm.

This was further confirmed by subjecting the data to the spearmen's coefficient of correlation tests. A negative correlation was found between the salivary properties and frequency duration and exposure of habit. This indicates that there is a moderate decrease in the salivary flow and the pH. Such similar findings were also found in other studies.[11],[14],[29]

Limitations and Future Prospects

The above study indicates deleterious changes in the quality of saliva due to habits of areca and related products. However, the study was conducted in a limited sample confined to a particular geographic area. Further research in a bigger population covering a broader area should be carried out to understand the results better.


   Conclusion Top


Our study concluded that there was a definite reduction in salivary flow and change in the pH as well as the buffering capacity of the salivary flow in subjects with areca nut and tobacco-related habits. The dose-dependent relationship of areca nut and smokeless tobacco habit with the changes in the oral cavity was further confirmed. It was concluded that there was a correlation of exposure, frequency, and duration of habit with changes in the salivary properties.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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