As primary healthcare providers in a growing global environment, it is imperative that nurse practitioners (NPs) stay up-to-date with global health concerns and seek learning opportunities that will further their expertise in clinical practice and enhance culturally competent care. NPs are educated to perform exams of the mouth and buccal mucosa to assess for precancerous and cancerous lesions in patients with related history, such as tobacco use. The following case study is reported to educate and raise awareness about betel nut chewing, a growing but lesser-known cause of oral squamous cell carcinoma (OSCC) and oral lesions.
Case presentation
The patient is Mr. H, a 58-year-old male of Hawaiian, Samoan, and Chinese descent, with a history of hypertension, who presents to the clinic for a preemployment physical. He has had inconsistent employment and medical care over the last 4 years but has recently been hired by the City of Honolulu. Mr. H reports to be in good health, although reports inconsistently taking hydrochlorothiazide 25 mg twice daily. He does not exercise but feels to be in fair physical condition. He admits to chewing betel nut for the last 40 years but denies the addition of tobacco. He drinks alcohol rarely and has not used tobacco or illicit drugs in more than 40 years, affirming only social use as a teenager.
Mr. H has not seen a practitioner since being treated in the ED for pneumonia 2 years prior. At that time, he was also diagnosed with hypertension and prescribed hydrochlorothiazide. Mr. H is married with three grown children. Both of his parents passed years ago: his mother from diabetes mellitus and his father from stroke complications. He believes his father had throat cancer and relates he was a heavy tobacco user.
Mr. H was a pleasant, well-developed adult male on physical exam. Vital signs included a temperature of 98.0[degrees] F (36.7[degrees] C), heart rate of 90 beats/minute, and BP of 148/88. A full physical exam was performed and revealed a burnt-red discoloration on the left buccal mucosa, lower lip, and lateral left aspect of the tongue. There was a shallow erythematous ulcer with raised border measuring approximately 4 mm by 10 mm on the left lower buccal mucosa with a larger area of speckled leukoplakia. Mr. H recalls the lesion started a couple of months ago. It is only mildly tender and otherwise he denies fever, weight loss, trouble eating, or swallowing. The remainder of his exam was normal without lymphadenopathy or significant cardiopulmonary findings.
Mr. H was referred to a head and neck surgeon for biopsy. Histopathologic tissue exam revealed Grade I squamous cell carcinoma. He underwent surgical excision without lymph node removal. To date, Mr. H has not required radiation but continues to be followed closely by an oncologist. He was recently seen in the office for a 3-month follow-up and reports having stopped chewing betel nut.
Background
Betel nut is the common preparation of the areca nut, a seed from the Areca palm found commonly throughout the South Pacific as well as parts of Asia and Africa. Areca nut can be consumed on its own but is more commonly combined with lime, spices, or tobacco. Most often it is wrapped in a plant leaf, called the betel, giving it the popular name betel nut or paan.1-3 When tobacco is added, it is called betel quid, although these terms are often used interchangeably in the literature.1-3
Betel nut is one of the most commonly used addictive substances known, fourth in line behind caffeine, nicotine, and alcohol.3,4 Its addictive properties include euphoria, sensation changes, heightened alertness, diminished hunger, and stimulation leading to dependence.3,4 It is estimated that more than 10% of the world's population consumes betel nut in one of its many formulations.3,5 Within the United States, betel nut chewing has been a concern mostly limited to the Hawaiian Islands; however, in recent years, commercially produced products have become available online and in many Asian markets, increasing accessibility within the Continental United States and globally.6-8 Although some countries have restricted the sale of these addictive substances, they are still legal and relatively unregulated within the United States.3
The history of betel nut chewing and oral cancer has been long established. For over a century, researchers have linked betel nut to higher incidences of oral cancer.9,10 In the last few decades, a growing body of evidence has shown betel nut, with or without the addition of tobacco, causes cancers of the oral cavity, pharynx, esophagus, liver, biliary tracts, and uterus, culminating in the 2003 International Agency for Research on Cancer classification as a Group 1 carcinogen.11
Since that report, a growing body of evidence has been published linking betel nut to many other health issues, including metabolic syndrome, cardiovascular disease, subclinical atherosclerosis, and infectious diseases such as HIV and tuberculosis as well as other health conditions.12-15 Arecoline is the primary active ingredient responsible for the systemic adverse health effects caused by betel nut.15 It is a nicotine-like substance that acts as a partial agonist on the muscarinic acetylcholine receptors, causing parasympathetic effects, such as central nervous system stimulation, euphoria, vasodilation, and bronchoconstriction.16
Clinical manifestations
Signs and symptoms of betel nut use can most commonly be identified in the oral cavity; however, other clinical signs are seen that practitioners should be aware of. As the areca nut ripens, it turns a reddish-orange color. In order to use the nut as chew, it is often cut, ground, or dried. Manipulating the ripe nut causes a reddish-brown finger staining, which can be seen in betel nut chewers who make their own preparation. Other nonspecific findings such as tachycardia and obesity may also be present.
The most common clinical manifestations of betel nut chewing are found on the incisal and occlusal tooth surfaces where habitual chewing results in severe wear. The reddish-brown discoloration may again be found within the oral cavity and can stain the teeth.1,3,17 Prolonged betel nut use may damage the soft tissue structures of the oral cavity. Two common findings include lichenoid lesions and betel chewers' mucosa (BCM), which are frequently seen among older adults with substantial chewing history. Lichenoid lesions are type IV contact hypersensitivity-type lesions and are commonly described as subtle paralleling undulating keratotic lines radiating from a central atrophic area within the buccal mucosa, usually seen at the site of quid application.1,3
In contrast, BCM is similar to the areca staining of the teeth and fingers and is characterized by a reddish-brown oral mucosa discoloration with embedded quid particles that are often difficult to remove.1,2
Leukoplakia and oral submucous fibrosis (OSF) are associated with potentially malignant changes and are more worrisome clinical findings.1-3,17 Practitioners are skilled at identifying the characteristic white or speckled patches common to leukoplakia, a condition also found in tobacco users. They may be less aware of the changes associated with OSF, which is characterized by fibrosis or stiffening of the oral mucosa. OSF is associated with epithelial atrophy, which can lead to a burning sensation in the oral cavity and can ultimately result in restricted mouth opening. Patients may complain of intolerance to spicy foods, taste disturbances, and impaired ability to speak.1-3,17
As discussed previously, literature demonstrates betel nut consumption-with or without the addition of tobacco-causes OSCC, and a growing body of evidence associates betel nut use with cancers of the esophagus, liver, pancreas, larynx, and lung.3 The clinical presentation of OSCC can vary depending on the location and the stage of the cancer. It is most commonly identified by unhealing ulcerations or tumors on the buccal mucosa, tongue, or lips but can present with other clinical presentations, such as leukoplakia or erythroplakia. (See OSCC of the palate.) Patients often report minimal pain early in the disease growth.18
If found, primary care NPs should refer patients to a head and neck surgeon for surgical excision and an oncologist to consider any further treatment. Surgical excision may be all that is needed depending on the severity of the disease. More advanced stages may require excision and radiation. The carcinoma's location can be useful in judging its severity. Lesions on the bottom lips are less aggressive and less likely to metastasize than lesions found on the upper lips. The survival rate for lesions on the floor of the mouth tends to be longer than for those located on the tongue.18,19
Moving forward
Given the growing diversity of the population in the United States, global travel, immigration, and increased accessibility to commercially manufactured products, portions of the population may be at risk for oral cancers and other significant health effects from using betel nut. While government- and community-based efforts are needed to make a global impact, as stakeholders in the health of patients, NPs need to be able to recognize signs of betel nut chewing in order to provide appropriate patient education and early intervention.
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