Periodontitis presenting among betel quid users: A case series

Abstract

Background

Betel leaf chewing habit has been studied extensively, as it has been an ancient practice in many Asian countries. Although betel leaf has been reported to have potential beneficial properties, it has also been shown to have a strong association with oral diseases, including periodontitis. This case series addresses the presentation of periodontitis among betel quid users, to help clinicians identify and manage such patients when they are encountered in settings outside the countries and territories where betel quid use is common.

Methods

Four patients of Asian ethnicity were referred to The Ohio State University College of Dentistry Graduate Periodontology clinic for periodontal treatment. Targeted questioning resulted in all four patients reporting a past and current betel leaf chewing habit, established at a young age, typically in a family setting, and long before their immigration from their native country.

Results

All four patients exhibited similar reddish‐brown staining on the teeth and generalized radiographic bone loss. Notably, the patients disclosed the betel chewing habit only after different vernacular names for betel quid were used during questioning, which complicated history taking. Severe periodontitis (stage III/IV, grade C) was diagnosed in all four patients, who were given appropriate periodontal treatment plans.

Conclusion

Betel leaf chewing, prevalent in many Asian countries, is associated with periodontitis and may present with extensive tooth staining. Oral healthcare providers should consider this cultural habit and pursue thorough assessment and history taking for their patients originating from countries where the habit is common practice.

Key points

• Clinicians should be aware of the clinical presentation and oral findings in betel quid users.

• Given the increasing diversity of the patient pool that clinicians are encountering, knowledge of vernacular names for betel quid usage can prove valuable in history taking.

• A protocol for betel quid cessation should be incorporated into the management strategy for these patients in clinical practice.

Plain Language Summary

Betel quid (paan) chewing is a widespread cultural habit, especially in Asia. The chewing of betel quid, whether alone or with tobacco, has been strongly associated with periodontitis and other oral conditions, such as leukoplakia, oral cancer, and oral submucous fibrosis. This report illustrates the typical presentation of periodontitis patients who habitually chew betel quid, highlights the associated clinical features, such as reddish‐brown tooth staining and severe bone loss, and underlines the challenge of obtaining a complete history because of the very many vernacular names used for betel quid in different countries and the fact that for many of the patients, this is considered a routine cultural tradition. It is unusual to encounter patients chewing betel quid in this country because the practice is not common. However, immigrants from countries where betel quid chewing is commonplace may continue the habit after they move to the United States. Oral healthcare providers should be aware of this possibility and elicit the relevant information from the patients. This will help practitioners to properly address this underlying factor and to provide appropriate care to these patients, including cessation advice and support, and establishment of routine oral screenings and regular periodontal maintenance.

INTRODUCTION

Betel leaf chewing after meals is an ancient Indian practice that dates back to 400 BC. It is considered the fourth most commonly used drug in the world, preceded only by alcohol, tobacco, and caffeine. ¹ Ancient books have described it as having medicinal properties including detoxification, antioxidation, and even antimutation effects. ² The potentially beneficial properties of betel leaf have been recognized in recent times when purified compounds from the leaf were shown to possess anti‐cancer and immunomodulatory activities. ³ Most recently, a novel betel leaf toothpaste was shown to significantly improve gingival bleeding in gingivitis patients. ⁴

Today, betel leaves are typically used as a wrap containing areca nut ⁵ , ⁶ (the seed of the fruit of the Areca palm (Areca catechu)), mineral slaked lime, and occasionally tobacco. ⁷ This mixture of substances is called quid, or paan; it is placed between the teeth and the buccal mucosa, and it is actively chewed over an extended period of time. Sweeteners may be added to mask the bitterness in order to cater to a younger audience. ⁵ , ⁸ Betel quid goes by different names in the various Asian and Pacific Island countries where the custom is prevalent. ¹

Several studies have shown that betel quid chewing habit is strongly associated with oral diseases and conditions such as oral cancer, ⁹ , ¹⁰ , ¹¹ oral submucous fibrosis, ⁷ , ⁹ , ¹⁰ lichenoid reactions, ⁹ periodontal, ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ and peri‐implant ¹⁸ disease. However, despite the multitude of reports of periodontitis in betel quid users, the available literature only includes studies in Asian and South Pacific Island populations. In the early 2000s, the use of paan was identified for the first time as an emerging oral health threat in the United States, especially among immigrant communities, and particularly associated with a markedly increased risk of oral cancer. ⁵ To the best of the authors’ knowledge, there have been limited reports of periodontitis associated with betel quid chewing from patients in the United States. ⁵ , ¹¹ Therefore, the purpose of this report is to present a series of cases of betel quid chewing periodontitis patients seeking care in a North American Dental School clinic, to highlight the typical presentation of such patients, and to stress the likelihood that such cases could be encountered by oral healthcare providers whose patient roster may include individuals from these immigrant communities. The limited literature on this practice and its effects is also reviewed.

MATERIALS AND METHODS

All four cases reported here were patients of Indian and South Asian origin who presented to the Graduate Periodontology Clinic of The Ohio State University College of Dentistry, between September 2022 and June 2023. The four patients were all referred to the clinic by primary care dentists in the community. The patients provided consent for the use of their clinical and radiographic images in a publication. In this report, the terms betel quid and paan leaf will be used interchangeably.

RESULTS

Case 1

A 33‐year‐old Nepalese female, who immigrated in 2003, was referred by her general dentist because she wanted to save her periodontally‐involved teeth. Her medical history was unremarkable. She reported that her previous dentist had warned her three years prior of the possibility of becoming completely edentulous, but the patient was seemingly proud of not having lost any teeth yet. She denied the usage of any tobacco products including cigarettes, chewing tobacco, and electronic cigarettes. Clinical examination demonstrated staining suggestive of betel quid chewing (Figure 1A). When questioned about “betel quid” use, she denied it, but when she was subsequently asked about “paan” usage, she readily confirmed that she did indeed chew on occasion, ever since she was a young teenager. The patient explained that it is customary in her culture to enjoy paan‐leaf‐wrapped meat dishes during festivals and special celebratory occasions.

FIGURE 1.

Case 1: (A) Representative clinical appearance of gingival inflammation, calculus, and reddish‐brown staining present on teeth. (B) Panoramic radiograph with evident generalized moderate to severe bone loss and widened periodontal ligament spaces. The patient acknowledged betel quid chewing only when asked specifically about the use of “paan”.

A periodontal examination, during which the patient was especially sensitive, revealed generalized bleeding on probing (BOP), deep probing depths (range: 5–11 mm), and significant mobility on all posterior teeth (Miller II and III ¹⁹ ). Generalized moderate to severe bone loss (∼60%) and widened periodontal ligament spaces were evident radiographically (Figure 1B). A thorough clinical examination revealed no signs of oral malignancy or other disease. A diagnosis of generalized stage IV grade C periodontitis ²⁰ was made. A comprehensive periodontal treatment plan, along with betel quid cessation strategies was presented to the patient.

Case 2

A 37‐year‐old Indian male, who immigrated in 2011, was referred by his general dentist for pockets ≥ 6 mm. The patient reported having an accident a year ago, resulting in a concussion and lower back pain. The patient denied taking any medication except for ibuprofen as needed for back pain. He was a current cigarette smoker with a 5.25 pack‐year history. He denied usage of recreational drugs and other tobacco products, including chewing tobacco.

Clinical examination revealed reddish‐brown staining suggestive of betel quid chewing, especially on the lingual aspect of the mandibular anterior teeth (Figure 2A) and the posterior dentition (Figure 2B). When asked about other chewing habits, the patient reported that he chewed paan leaves with areca nuts. According to their ethnic custom, at family gatherings, the elders would introduce pre‐teenagers to paan leaf chewing. This custom was commonly practiced among the males in the family during family gatherings and festivals. The patient also reported that he had reduced the frequency of paan leaf chewing in the past few years. Upon clinical examination, generalized attrition was noted throughout the dentition (Figure 2A,B). The patient was negative for oral cancer or other oral disease.

FIGURE 2.

Case 2: (A) Reddish‐brown staining and calculus on the lingual surfaces of the mandibular anterior teeth. (B) Representative reddish‐brown staining on the posterior dentition. (C) Periapical radiograph of maxillary right side indicating the presence of calculus and severe bone loss and suggesting existing furcation involvement. Note generalized tooth attrition (A, B).

Periodontal examination revealed probing depths ranging between 1–5 mm, with the presence of localized BOP, and no tooth mobility. Furcation involvement (Glickman class I and II ²¹ ) on maxillary and mandibular right posterior teeth was detected. Localized moderate to severe bone loss (∼80%) was evident radiographically (Figure 2C). Localized stage III grade C periodontitis ²⁰ was the rendered diagnosis, and a comprehensive treatment plan including cessation of the habit was presented to the patient.

Case 3

A 44‐year‐old Nepalese male, who immigrated to the United States in 2008, was referred by his general dentist for periodontitis and non‐surgical periodontal therapy. The patient had an unremarkable medical history. The patient disclosed the usage of paan leaf with tobacco. Clinical examination revealed staining suggestive of paan leaf chewing (Figure 3A–C), generalized tooth attrition (Figure 3A–C), and absence of oral cancer or other oral disease. The patient reported that as a younger man, he began chewing during festivals when offered by elders in the family. Out of respect for the elders, the patient was never allowed to reject the offer; in fact, it was considered disrespectful to not participate in the custom. He related that he continues to chew about one pack daily.

FIGURE 3.

Case 3: Clinical images of mandibular posterior (A), maxillary posterior (B), and mandibular anterior (C) dentition. Reddish‐brown staining, calculus, and generalized tooth attrition are evident (A–C). Radiographic image of mandibular anterior teeth illustrating alveolar bone loss (D).

A comprehensive periodontal examination revealed deep probing depths (range: 2–7 mm), generalized BOP, mobility on lower anterior teeth (Miller I ¹⁹ ), and multiple molars with furcation involvement. Generalized moderate to severe bone loss (50%), especially on the anterior dentition, was evident radiographically (Figure 3D). A diagnosis of generalized stage III grade C periodontitis ²⁰ was made. A comprehensive periodontal treatment plan with paan and tobacco cessation was presented to the patient.

Case 4

A 35‐year‐old Nepalese male, who immigrated in 2009, was referred by his general dentist for deep pockets. The patient's medical history was unremarkable, and he denied any tobacco product usage. Clinical examination revealed extensive calculus deposits (Figure 4A), gingival recession, 5–15 mm probing depths, furcation involvement on several multirooted teeth, and a highly mobile (depressible) maxillary right lateral incisor with alveolar bone loss ≥90% around that tooth (Figure 4B). The patient was diagnosed with generalized stage IV grade C periodontitis. ²⁰ Clinical examination also revealed staining suggestive of paan leaf use, that is, reddish‐brown staining on the cervical regions of molar teeth (Figure 4C,D). Upon specific questioning, he confirmed the long‐term habit of paan leaf chewing with areca nut. He reported that when he lived in Nepal, he used to chew more regularly, however since immigrating to the United States, he has been chewing only during holiday celebrations and festivals. A comprehensive periodontal treatment plan with habit cessation counseling was presented to him. The characteristics of the four cases are summarized in Table 1.

FIGURE 4.

Case 4: Frontal clinical view (A), with evident calculus, gingival recession, and tooth migration. Radiographic image (B) of severe bone loss on the maxillary right lateral incisor. Clinical appearance of the lingual aspect of mandibular (C) and maxillary (D) posterior teeth with reddish‐brown staining.

TABLE 1.

Case characteristics summary.

Case	Sex	Age	Country of Origin	Periodontal Diagnosis 20 (Stage, Grade)	Quid Type	Name Used by Patient	Other Information
Case 1	F	33	Nepal	IV, C Generalized with widened PDL spaces	Paan leaf‐ wrapped meat dishes	Paan
Case 2	M	37	India	III, C Localized	Paan leaf and areca nut	Paan	5.25 pack‐year tobacco use Generalized attrition
Case 3	M	44	Nepal	III, C Generalized	Paan leaf and tobacco	Paan	Generalized attrition
Case 4	M	35	Nepal	IV, C Generalized	Paan leaf and areca nut	Paan

DISCUSSION

The present report documents the clinical presentation of four patients of Indian and South Asian origin who had a paan leaf chewing habit. The patients, who were referred by their general dentists, were between the ages of 33 and 44, were diagnosed with severe periodontitis (stage III/IV, grade C ²⁰ ), and shared a clinical presentation that included generalized reddish‐brown staining of the teeth. This form of staining, with variable degrees of reddish‐brown coloration, typically seen around the cervical lingual/palatal region of all teeth, is almost exclusively associated with this cultural chewing habit. ⁹

On the rare occasion when this staining pattern is encountered in countries where such custom is unknown, the staining may fail to sufficiently raise the suspicion level of oral healthcare providers to question the patient regarding any chewing habits. Even if the staining prompts the caregiver to seek relevant information from the patient, the multiple vernacular names ¹ , ²² used for paan in different countries (Table 2), may complicate the history taking. For all four patients, the use of paan leaf was part of their cultural background and most reported it only after specific questioning, which emphasizes the need for targeted history taking.

TABLE 2.

Vernacular names for betel leaf in countries where the custom is most prevalent (Modified from Sukumar et al. ¹ and Buente et al. ²² ).

Bangladesh	Gua
Cambodia	Maluu, Klaa/Slaa
China	Wei ye, Bin Lang
East Timor	Malu, Malus, Buo
Guam	Pugua
India	Paan, Vettila, Supari, Paakku, and Adakka
Indonesia	Sirih, Pinang, and Jambe
Laos	Pu and Maak
Maldives	Bilaiy and Fuvah
Micronesia	Papulu, Buuch, and Pugua
Malaysia	Daun Sirih and Pinan
Myanmar	Plu and Kun‐ywet
Nepal	Paan
Papua New Guinea	Daka, Wanwan, Samplea, and Planti
Pakistan	Paan and Chalia Supari
Philippines	Ikma, Bulung Samat, Luyus, and Nga nga
Sri Lanka	Bulath, Vetrilai, and Puwak
Taiwan	Lao‐hwa
Thailand	Plue and Mahk

Although paan leaf usage is not common in this country, an estimated 600 million people worldwide practice paan leaf chewing and most belong to several South Asian ethnic groups. ²³ Just in Mumbai, India, 32% of the adult population chew paan leaf with tobacco while only 0.5% reported chewing areca nut only or paan leaf without any additives. ⁵ Literature has shown that quid chewing habits negatively affect both the hard and soft tissues of the oral cavity, ⁵ , ⁹ , ²⁴ including the periodontium. ²⁵ The severe periodontal damage documented in the cases presented here, especially considering the relatively young age of these patients, could be explained in part by the described deleterious effects of the betel quid components on the periodontal tissues. For example, in vitro studies have reported that areca extract contains arecoline which inhibits the growth, attachment, and protein synthesis of periodontal fibroblasts. ⁹ , ²⁶ , ²⁷ Leukoplakia, known for its potential transformation to malignancy, has also been reported to be a major risk in paan leaf chewers. ⁹ A study by Warnakulasuriya et al found an odds ratio of 5 to find oral leukoplakia in chewers versus non‐chewers. ²⁸ An ultrastructural study of the oral mucosa of paan users has reported finding crystalloid interepithelial material of unknown origin but suggestive of calcium hydroxide from betel quid. ²⁷ Other conditions, including oral submucous fibrosis and oral squamous cell carcinoma, have also been associated with this chewing habit. ⁹ , ²⁵ A list of the most commonly occurring oral/systemic manifestations of betel usage, along with pertinent information, is provided in Table 3; these could be of interest to oral healthcare providers. Fortunately, all four patients reported here were free of any signs of other betel‐associated diseases or conditions.

TABLE 3.

Betel usage‐associated commonly occurring oral or systemic diseases.

Disease/condition of relevance to oral healthcare providers	Pertinent epidemiologic and mechanistic information
Oral cancer	Areca nut usage is associated with an increased risk for oral squamous cell carcinoma in a dose‐dependent manner. 28 Eliminating the chewing habit reduces the risk of oral cancer in women by 89%–91%. 38
Oral submucous fibrosis	Cytotoxic to epithelial cells due to production of reactive oxygen species and increased fibroblast proliferation due to insulin‐like growth factor signaling. 39
Areca‐induced lichenoid reactions	Chronic irritation due to prolonged retaining of betel quid in the buccal vestibule. 9 A delayed type IV hypersensitivity reaction to the constituents has also been suggested. 36
Leukoplakia	Slaked lime causes an increase in oral pH, which leads to the generation of reactive oxygen species. Slaked lime is also shown to result in oral ulceration and cell proliferation, all of which could potentially contribute to leukoplakia development. 40
Periodontitis	Contents in paan reportedly have cholinergic effects, leading to increased salivation and calcium deposition on tooth surfaces. 41 The lime from paan deposits leads to dark brown discoloration. 42 These deposits act as plaque‐retentive factors, thereby contributing to periodontitis. The arecoline in paan negatively affects cell adhesion and migration, reducing cell proliferation and collagen synthesis. 27 , 43
Central nervous system effects (addiction potential, euphoria, and excitability)	Arecoline has parasympathomimetic properties, acting on both muscarinic and nicotinic receptors. 44 Arecoline quickly crosses the blood‐brain barrier, can have addictive effects, and causes adverse effects including insomnia, mood swings, irritability, and anxiety. 45

Betel quid chewing has also been associated with tooth attrition, whose severity and extent vary by factors such as the duration of the habit, the hardness of the product used, and the chewing frequency. ²⁴ Among the four cases presented here, two patients exhibited generalized attrition; these were the two oldest patients who also were the two using paan most frequently. Therefore, the attrition findings among the reported cases are consistent with the aforementioned evidence. The lack of associated carious lesions, despite the presence of severe attrition and exposed root surfaces, has been attributed to the combination of high fluoride content released by the betel quid, basic pH of the slaked lime, and the possible increased salivation in quid chewers. ²⁹ The characteristic reddish‐brown staining was detected on the lingual/palatal aspects of most teeth. However, occlusal surface pits and fissures of most posterior teeth were also stained. Reichart et al. ²⁹ determined that the red color was from the betel nut's oxidative changes of polyphenols (18%) and gallotannic acids (11%–26%).

Studies have reported that betel quid users who incorporate tobacco or slaked lime, compared to those who use the quid without these ingredients, are at a higher risk of developing oral lesions that could be potentially malignant, and screening is valuable for identifying such oral lesions. ³⁰ With ample evidence indicating the higher cancer risks amongst paan chewers especially in women, primary prevention is imperative. ³¹ , ³² The Betel Nut Intervention Trial is a registered clinical trial that provides intensive cognitive‐behavioral therapy. ³³ Such intensive cessation programs should be incorporated into dental practice, like smoking cessation. Lee et al ³⁴ comprehensively assessed paan cessation among oral cancer patients and identified four different stages of betel quid cessation. The pre‐contemplation stage is where the individual has a positive interpretation of the habit and provides rational reasoning for continuing the habit. The next stage involves the development or realization of the adverse effects of betel quid chewing. This is then followed by a preparation and action stage where the individual actively pursues cessation of the habit; at this stage, care should be taken to identify and address the addiction potential, withdrawal symptoms, and rebound/relapse. Once cessation is successful, the individual then progresses to a maintenance phase, where they are routinely monitored for recurrence of the habit. The clinician can also, with good history‐taking, notice if the patient is consuming tobacco along with the quid, and if they do, concurrently address tobacco cessation as well. ³⁵ Appropriate referrals for behavior modification techniques such as cognitive behavioral therapy can also be a prudent step in addressing betel quid cessation. ³⁶ Further, antidepressants such as escitalopram and moclobemide have also been shown to be successful in betel quid cessation. ³⁷ Oral healthcare providers who treat betel quid users should emphasize these strategies (routine screenings, regular maintenance, and cessation counseling) to better serve their patients.

Early identification of betel quid users allows for proper and timely intervention, including cessation counseling. Screening and early intervention may significantly reduce the incidence of periodontitis and other mucosal lesions in these patients. The increased number of immigrants from India and South East Asia in the United States, especially in metropolitan areas, where paan is available for purchase, means that oral healthcare providers should be adequately informed on the clinical presentations associated with betel quid use. ⁵ Being able to suspect betel use and appropriately elicit the presenting patient's history by using the right product name should help the clinician provide more patient‐centered care.

CONCLUSION

Betel leaf chewing, prevalent in many Asian countries, is associated with periodontitis and typically presents with characteristic tooth staining. Oral healthcare providers should consider this cultural habit and pursue thorough assessment and history taking for their patients originating from countries where the habit is common practice, to provide appropriate management and prevention approaches.

AUTHOR CONTRIBUTIONS

JVP conceived the presented case report, contributed to case documentation and patient care through therapeutic services, and drafted and revised the manuscript. PKP contributed to case documentation and patient care through therapeutic services and revised the manuscript. DNT contributed to patient care through the supervision of therapeutic services, critically revised the manuscript, and oversaw the completion of the report. All authors reviewed and approved the final version of the submitted manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Park JV, Pitchumani PK, Tatakis DN. Periodontitis presenting among betel quid users: A case series. Clin Adv Periodontics. 2025;15:238–245. 10.1002/cap.10311

DATA AVAILABILITY STATEMENT

Data generated by the examination and treatment of the presented cases are included in this article. Additional data that support the findings of this report are available from the corresponding author upon reasonable request.