Month: June 2021

Areca Nut (Betel Nut, Guwaha, Supari) – Agents of Oral Cancers

Introduction:

The use of betel nut in various forms is rampant in India. It is being glamorized by the industry and sold in various forms. Rich and poor, male or female, all age groups are consuming it, almost 30% of the population in both rural and urban India consume it freely across all ages and socio-economic sections of the community. That’s why Oral cancer is very prevalent in India and stands at 30% of all cancer cases reported. Betel nut is one of the significant contributors to this. The market size of areca nut is around 100 billion rupees and it is being sold in India in various forms and advertised as mouth fresheners under various names Rajshree, gutkha, mukhwash, tulsi, rajnigandha, etc. Unfortunately, the young generation is being lured into using this harmful product. It is time we create awareness about the dangers of supari.

Areca (Betel) nut is a seed of the fruit of Areca Palm.  It is a stimulant drug.

The betel nut is used in various ways – fresh, dried, boiled, baked, roasted, or cured.

Betel nut consumption is rampant in the northern and eastern zones of the country. A common way of consuming betel nut is by using it as paan betel quids i.e. betel leaf, slaked lime, and betel nut with any other additives like cloves, elaichi, etc. Nowadays it is available in varieties in the market as part of paan masalas.

In many parts of India and Southeast Asia, it is part of social practice/customs, religious practices, and cultural rituals.

Effects of betel nuts:

It is carcinogenic and used with tobacco it causes cancer of the oral cavity, oropharynx, and esophagus. Betel nut affects almost all organs of the body including the brain, heart, lungs, gastrointestinal tract and reproductive organs, and also the endocrine system.

It is a stimulant drug. Like all drugs, there is no safe limit and one needs to be careful. The effect of the drug may vary according to size, weight, and health of the individual and also on the amount consumed. The variety of betel nut also matters.

As a stimulant the person may experience the following:

  • Mild euphoria and feeling of wellbeing
  • Alertness
  • Increased heart rate
  • Increased blood pressure
  • Sweating
  • Redness on the face and feeling warm
  • Tremors
  • Dizziness
  • Upset stomach, diarrhoea, vomiting
  • Psychosis

Long term effects:

  • Oral cavity and dental –
    • Discoloration of teeth and gums
    • Oral ulcers and gum diseases
    • Submucous fibrosis
    • Oral Cancers
  • Heart diseases – myocardial infarction, cardiac arrhythmias
  • Pulmonary – asthma
  • Gastrointestinal system – Stomach ulcers, hepatotoxicity
  • Reproductive system – infertility, harmful effect on the fetus when being used during pregnancy.
  • Endocrine system – diabetes, hyperlipidemia, hypothyroidism, prostate hyperplasia, central obesity
  • Aggravate immune system- suppressed T-cell activity
  • Cancers – oral cavity, oropharynx, esophagus, liver, biliary tract, and uterus.
  • dependency

Pathology and metabolism

Betel nuts contain 4 main alkaloids – Arecholine, arecaidine, guvacoline, and guvacine

The main alkaloid Arecholine has a systemic effect as well as it is a carcinogen. A number of nitrosamines are formed in the oral cavity mainly methylnitrosaminoproprionitrile which is most carcinogenic in the oral cavity causing cancers and submucous fibrosis.

The betel nut is being glamorized by the industry as mouth fresheners sold as Paan Masalas and fresheners. It is a harmful substance and needs to be banned.

The patient is referred to the Tobacco Cessation Intervention specialist to treat the patient for the smoking and chewing tobacco including betel nut, paan masala, gutkha, khaini, etc. One can Call 011-43077695 or visit www.icancare.in/quittobacco for assistance.

(The Author – Dr. Pawan Gupta M.Ch. is Director of Surgical Oncology at Max Super Speciality Hospital, Vaishali. Patparganj and Noida. He is the author of the book – Win Over Tobacco Made Easy, Be Smart Do Not Start and is highly recognized for his work on Oral Cancer and Tobacco Cessation. He is the convenor for Certified Course in Tobacco Cessation under the Gujarat University)

References:

Garg A, Chaturvedi P, Gupta PC. A review of the systemic adverse effects of areca nut or betel nut. Indian J Med Paediatr Oncol. 2014;35(1):3-9. doi:10.4103/0971-5851.133702

Preventing Trismus Following or During Treatment – Surgery and Radiation

Introduction: Trismus is a painful condition in which there is restricted mouth opening. The purpose of this article is to help understand the lockjaw when going through treatment – surgery or radiation to the head and neck region.

Consequences of inadequate mouth opening (trismus)

  1. Feeding – the person will have difficulty in taking large bites of food.
  2. Difficulty in Chewing and Swallowing
  3. Poor oral hygiene – oral cleaning is inadequate causing foul smell and inflammation in the mouth. Poor dental hygiene with increase risk of caries. Difficulty in doing any dental procedure.
  4. Difficulty in speaking – some individuals find it difficult in communicating as they experience loss of words because of trismus
  5. Tingling sensation and hypersensitivity to certain foods and spices.
  6. Difficulty in the inspection of the oral cavity by self or by your doctor.
  7. Difficulty in surgery or for any procedure in the oral cavity
  8. Difficult anaesthesia – the endotracheal tube insertion may be difficult.

What is an adequate mouth opening?

The mouth opening of at least 3.5 cm measured between the front incisors (front teeth) of the upper and lower jaw. The range of mouth opening for a healthy individual would be 3.5 – 5.5 cms. The measurement can be done by TrisCaRe. Or for general purpose 4 vertical fingers or at least 3 vertically placed fingers can be put between the jaws.

Reasons for Trismus in patients for head and neck cancers –

  1. In India, most patients already have Submucosal Fibrosis at present due to the regular use of tobacco and beetle (Areca) nuts.
  2. Healing by Fibrosis – Following surgery of the oral cavity the healing is by fibrosis of the mucosa, flap, and muscles
  3. Radiation – to the masticatory muscles especially the masseter and temporalis causes inflammation and heals by fibrosis.

The trismus can develop during treatment or even a long time after treatment. Once trismus develops it is quite difficult to treat. Preventive steps to be taken from the beginning.

Diagnosis and Grading

The diagnosis is based on the mouth opening of the person. The measurement is made between the front teeth of the upper and lower jaws. The measurement can be done with TrisCaRe which is an instrument with a measurement scale.

Grading of Trismus: Trismus was graded as:

Mild

Grade I

35 – 26mm

Moderate

Grade II

25 – 16mm

Severe

Grade III

15 – 0mm

PREVENTION

  1. Preoperative assessment and intervention- Most patients with oral cancer would present with some degree of trismus. This is mostly due to the presence of associated submucosal fibrosis due to beetle nut and tobacco chewing. These patients would benefit from interventions at the beginning itself.
  2. Patients planned surgery for the oral cavity are advised about trismus and preventive steps to be taken.
  3. All patients for Radiation of the head and neck advised trismus care before the start of treatment.

What to do for treating Trismus?

  1. Massage and Exercises of the oral cavity
  2. Mechanical Stretching of the oral cavity
  3. Posture management
  4. Good Oral Hygiene

1.

Massage – The masseter muscles. Keep your fingers on the cheek palpate. Move your fingers in a circular fashion for 30-60 secs repeat 2-3 times a day.

 

Exercise – Mouth opening – open your mouth fully till you feel a stretch, keep for 10 seconds

 

Exercise – side movement -Right and left – Move your jaw to right hold for 3 seconds. Now move to the opposite side and hold for 3 secs.

 

Exercise – Circular motion – Move your lower jaw in a circular motion first clockwise and then anticlockwise. Repeat this 3-5 times

2.

Mechanical Stretch – With TrisCaRe – keep the blades between the two jaws. Open slowly with the screw, till you can comfortably open. Now turn few more rounds on the screw and open it till you feel the stretch. Keep it for 30 secs. Repeat this 5 times per day

3.

Posture exercises – to keep your body straight and aligned.

 
  • Neck stretch – Bend head backward and forward
  • Bend head sideways right and left bringing ear to the shoulder
  • Turn your head right and left side
  • Maintain position in each position for 10 secs

 

Head rotation – clockwise and anticlockwise – 5 times each

 

Chin Tuck – Tuck your chin, pulling your head so that the ears line up with shoulders. Hold this position for 3 secs

 
  • Shoulder exercises – up and down – pull your shoulder up and down keep in each position for 5 secs
  • Shoulder rotation – backward and forwards in a circular motion each 5 times
  • Shoulder push back – push both your shoulders backward to bring scapula (shoulder blades) together
  • Hand raise- Raise your hand straight upwards and pull up. Maintain the position for 5 secs.

4.

Oral Hygiene – Maintain oral hygiene regularly – brush your teeth on waking up after every meal and before bed, gargle with non-alcoholic gargles 2-3 times daily, floss regularly.

If you are using dentures remove and clean regularly, remove before going to bed

Self Oral Examination – at least once every month is a must. If you notice any changes and especially decreased mouth opening- do consult your doctor

Start early – if you notice decreased mouth opening during or after your treatment consult a doctor. A physiotherapist may help you with massages and exercise. Mechanical device TRISCaRe is an important adjunct device for all head and neck cancer patients undergoing treatment and would be needed to be used for a lifetime.

TrisCaRe - for Trismus Management and OSMF
TrisCaRe – Mouth Opening Device for Jaw Motion Rehab System

TrisCaRe by ICanCaRe – mechanical mouth opening device to stretch open the jaws. Mechanical Device (TRISCaRe) – TrisCaRe is the optimum device for jaw stretching. TrisCaRe is to be fitted between the upper and lower jaw and the blades are opened with the screw. Jaw stretching with a mechanical device is the only way one can ensure the mouth opening of a patient with trismus. Studies have shown that mechanical jaw stretching can increase mouth opening by 5-10 mm or more even in the severest form of trismus.

Cause – if it is due to tobacco and beetle nuts, the patient is referred to the Tobacco Cessation Intervention specialist to treat the patient for the tobacco disease. Call 011-43077695 or visit www. icancare.in/quit tobacco for assistance in quitting smoking and tobacco.

Conclusion –  Trismus may be acute(temporary) or chronic depending on the cause. Acute responds well to medications and exercises. The chronic long-standing needs long-term intervention with lifelong use of TrisCaRe. For all patients undergoing surgery or radiation for cancers early intervention with TrisCaRe is advised to avoid or reduce the permanent trismus. Early intervention helps for a better outcome.

(The Author – Dr. Pawan Gupta M.Ch. is Director of Surgical Oncology at Max Super Speciality Hospital, Vaishali. Patparganj and Noida. He is the author of the book – Win Over Tobacco Made Easy, Be Smart Do Not Start and is highly recognized for his work on Oral Cancer and Tobacco Cessation. He is the convenor for Certified Course in Tobacco Cessation under the Gujarat University)

Trismus – Restrictive Mouth opening

Introduction: Trismus is a painful condition in which there is restricted mouth opening.

Pathology: The masticator muscles (Chewing Muscles) of the jaw become contracted, inflamed preventing the mouth from opening fully. Or the elastic mucosa gets fibrosed loosing elasticity to allow mouth opening.

Degree of trismus: Mouth opening between 3.5 cm to 5.5 cm is considered normal. In order words around 3 fingers should go into the mouth in vertical position. For fully normal average Indian, mouth opening is found to be 4 fingers.

Consequences of inadequate mouth opening (trismus)

  1. Feeding – the person will have difficulty in taking large bites like rasagolla or panipuri.
  2. Difficulty in Swallowing
  3. Poor oral hygiene – oral cleaning is inadequate causing foul smell and inflammation in the mouth. Poor dental hygiene with increase risk of caries
  4. Difficulty in speaking – many individual experience loss of words and are not able to communicate well because of restrictive mouth opening
  5. Tingling sensation and hypersensitivity to certain foods and spices.

Common Causes – Trismus occurs due to damage or injury to mucosa or the masticator muscles due to:

  1. Submucosal fibrosis due to paan masala and tobacco chewing – the main ingredient is the beetle nut also known as areca nut.
  2. Trauma – due to jaw bone fracture
  3. Oral Surgery – injury of the muscles due to hyperextension or stretch on the muscle for mouth opening for the procedure
  4. Wisdom tooth extraction – mostly the lower last molars.
  5. Mandibular joint with skull bone (temporomandibular joint) dysfunction – This joint is very special as it allows many different movement of the jaw like sliding, rotation, side to side etc. The joint may get affected by trauma, arthritis, habitual clenching and grinding of teeth due to stress, and genetics.
  6. Radiation to head and neck – most who receive radiation to head and neck would have trismus. This is due to radiation can affect the temporomandibular joint, the masticator muscles – pterygoids and masseter causing inflammation and fibrosis. The risk of trismus increases with the dose of radiation.
  7. Painful ulcers of oral cavity – buccal mucosa may also cause trismus
  8. Cancer – ulcers or nodules of the buccal mucosa can lead to trismus by itself
  9. Mucosa surgery – for cancer or PML or otherwise heals with scar formation restricting the mouth opening.
  10. Partial skin grafting of the mucosa following surgery – especially when whole of the buccal mucosa from upper to lower BG sulcus is involved, or when buccinator muscle is removed.
  11. Inadequate flap – the dimensions where inadequate at the beginning or if the flaps get partial necrosis which heals with fibrosis.

Diagnosis and Grading: The diagnosis is based on the mouth opening of the person. The measurement is made between the front teeth of the upper and lower jaws. The measurement can be done with TrisCaRe which is an instrument with measurement scale.

Grading of Trismus: Trismus was graded as mild/grade I (35–26 mm), moderate/grade II (25–16 mm), and severe/grade III (15-0 mm)

For a complete diagnosis assessment is made by the doctor. The doctor would take the history of onset and cause assessment. Following which a clinical examination is done. Radiological examination may be advised as per the requirement.

Treatment:

  1. Cause – if it is due to tobacco and beetle nuts, the patient is referred to the Tobacco Cessation Intervention specialist to treat the patient for the tobacco disease. Visit www.icancare.in/quittobacco or call 011-430-77695 for seeking professional help for quitting tobacco and smoking.
  2. Mechanical Device (TRISCARE) – TrisCaRe is the optimum device for jaw stretching. TrisCaRe is to be fitted between the upper and lower jaw and the blades are opened with the screw. Jaw stretching with mechanical device is the one and the only way one can ensure mouth opening of a patient with trismus. Studies have shown that mechanical jaw stretching can increase mouth opening by 5-10 mm or more even in severest of form of trismus.
  3. Medicines – painkillers, anti-inflammatories and muscle relaxants may be given as per the need. If there is suspicion of infection appropriate antibiotics may be advised.
  4. Massages and exercises – two or three times a day. Advised to do massaging and exercise as follows:
    1. Massage – the painful area in circular motion with your fingers for 30 seconds.
    2. Right and left Jaw movement – move your jaw to right and left. Hold at each position for 30 seconds
    3. Circular movement of the jaw – make circular movements of the jaw in left direction and then in right direction repeat each circular motion for 5 times.
    4. Stretch open your mouth little more than what you are comfortable. Hold for 30-60 seconds
    5. Head movement – flex your neck with chin onto your chest, then bring your head back. Now move your head left and then to right. Hold in each position for 30 seconds. Finally, move the head in a circular motion clockwise and anticlockwise 5 times each.

Conclusion –  Trismus may be acute(temporary) or Chronic depending on the cause. Acute responds well to medications and exercises. The chronic long standing needs long term intervention with lifelong use of TrisCaRe. For all patients undergoing surgery or radiation for cancers early intervention with TrisCaRe is advised to avoid or reduce the permanent trismus. Early intervention helps for a better outcome.

(The Author – Dr. Pawan Gupta M.Ch. is Director of Surgical Oncology at Max Super Speciality Hospital, Vaishali. Patparganj and Noida. He is author the book – Win Over Tobacco Made Easy, Be Smart Do Not Start and is highly recognized for his work on Oral Cancer and Tobacco Cessation. He is the convenor for Certified Course in Tobacco Cessation under the Gujarat University)