10.
5005/jp-journals-10011-1314
Saba Khan et al
ORIGINAL ARTICLE
A Study to analyze the Different Patterns of Quid Usage
among Subjects with Chewer’s Mucosa
Saba Khan, Laxmikanth Chatra, K Prashanth Shenai, KM Veena, Prasanna Kumar Rao
ABSTRACT
Aim: Betel chewer’s mucosa, although not considered as a
potentially malignant lesion, has been suggested to be a
precursor of oral submucous fibrosis (OSMF). Thus a study
was undertaken to asses various quid chewing patterns in
patients with chewer’s mucosa and to evaluate possible
association between chewer’s mucosa and a particular quid
usage pattern.
Materials and methods: The study was done on 150 subjects
clinically diagnosed of having chewer’s mucosa lesion. After
complete oral examination, a detailed habit history was taken
through preformed questionnaire. The data obtained was
analyzed using Chi-square test.
Results: Among the 150 subjects males to female ratio was
8:2. Majority of the subjects were within the age group of 20 to
30 years and chewed a combination of betel leaf, arecanut,
tobacco, lime. Majority of the subjects of chewer’s mucosa used
the quid for a duration of 1 to 5 years, a frequency of three to
five quid per day.
Conclusion: In the present study, chewer’s mucosa was seen
in majority of the subjects who used the quid for a duration of
1 to 5 years, a frequency of three to five quid per day and chewed
the quid containing betel leaf, arecanut, tobacco, lime as its
constituents.
Keywords: Quid, Cross-sectional study, Chewer’s mucosa,
Arecanut, Gutkha.
How to cite this article: Khan S, Chatra L, Shenai KP, Veena
KM, Rao PK. A Study to analyze the Different Patterns of Quid
usage among Subjects with Chewer’s Mucosa. J Indian Aca
Oral Med Radiol 2012;24(4):284-287.
Source of support: Nil
Conflict of interest: None declared
INTRODUCTION
Chewing is one of the oldest ways of consuming tobacco
leaves. Native Americans in both North and South America
chewed the leaves of the plant, frequently mixed with lime
and betel. The tradition of chewing betel leaf or pan is age
old and deeply rooted in India and has developed into a
major cultural and social norm. Predominantly in then
Asian–Pacific region, smokeless tobacco and areca nut were
used, either singly or in various combinations of ‘betel quid’
or ‘pan’.1
Betel chewer’s mucosa was first described in 1971 by
Mehta et al. This lesion was observed in betel quid chewers
and so called betel chewer’s mucosa. The most conspicuous
clinical finding is a brownish red discoloration of the
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affected mucosa which may vary considerably depending
on the number of betel quids chewed per day and the
composition of the chew. The brownish material is not easily
removed or scrapped off and the underlying surface is
irregular, macerated rough and some epithelial tags may be
seen. Some lesions may show areas of desquamation with
total or partial loss of the epithelium or in some cases oral
mucosa may show a dried out appearance. It is thought to
be caused by constant chewing of the betel quid which may
cause the traumatization of the oral mucosa. As such the
etiology of betel chewer’s mucosa can be traumatic,
mechanical or chemical. However, as per the present
knowledge betel chewer’s mucosa does not seem to be a
precancerous lesion. It has been suggested, however, that it
can be a precursor lesion of oral submucous fibrosis.2
Therefore, a need for the study arose to assess the various
quid chewing patterns in patients with chewer’s mucosa
and to evaluate possible association between chewer’s
mucosa and a particular quid usage pattern.
MATERIALS AND METHODS
The present cross-sectional study was carried out in
Department of Oral Medicine and Radiology, over a period
of 1.5 years from November 2009 to May 2011 on subjects
reporting to the Dental College OPD or the rural dental
camps. The study group comprised of 150 chewer’s mucosa
subjects of either sex, satisfying the clinical features of
chewer’s mucosa as per the criteria set by Mehta et al.2 The
patients were subjected to complete oral examination
including buccal mucosa, labial mucosa, tongue, floor of
the mouth and palate to look for chewer’s mucosa lesion.
Following diagnosis the patients were subjected to a
preformed questionnaire regarding the chewing habits and
the product used and the data obtained was analyzed using
Chi-square test.
RESULTS
In the present study, males were seen to be affected more
than females with M:F ratio of 8:2. Maximum number of
the subjects of chewer’s mucosa 46% (69) were with in age
group of 20 to 30 years and the minimum number
of subjects, 2% (3) were in the age group of more than
70 years (Table 1).
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A Study to analyze the Different Patterns of Quid Usage among Subjects with Chewer’s Mucosa

Among 150 subjects, 6.6% (10) subjects were chewing DISCUSSION

category I (betel leaf + arecanut), 10% (15) were chewing Analyzing the results of our study, among 150 subjects
category II (betel leaf + arecanut + lime), 33.3% (50) were chewer’s mucosa with one or other quid chewing habit,
chewing category III (betel leaf + arecanut + lime + tobacco), males were seen to be affected more than females. This was
21.3% (32) were chewing category IV (tobacco + lime), in contradiction to the studies by Reichart et al2 and
4% (6) were chewing category V (processed arecanut), Saraswathi et al3 where prevalence of chewer’s mucosa was
24.6% (37) were chewing category VI (processed areca nut found more in females. This could be due to the social
+ processed tobacco) (Table 2).
pattern of our study area. Also men get easy access to
Analyzing the duration of quid usage in our study it
commercially available products more readily than females.
was found that among 150 subjects majority of the subject,
While analyzing the age distribution in our study
49.3% (74) chewed quid for duration of 1 to 5 years whereas
maximum number subjects with quid chewing habit were
minimum number of subjects, 11.3% (17) chewed quid for
in age range of 20 to 30 years whereas minimum number of
a duration of 0 to 12 months. This could be due to the early
subjects were in age range of more than 70 years. This may
occurrence of the lesion and progression to oral submucous
be due to the fact that chewer’s mucosa is a lesion seen in
fibrosis (OSMF) on chewing for a longer duration of time.
initial phases of quid usage when the quid chewing habit is
Among those subjects who chewed the quid for 1 to
initiated by an individual. The packaging revolution has
5 years it was observed that majority of them, 33.7% (25)
made tobacco products portable, cheap and convenient, with
chewed category VI quid (tobacco + lime) and minimum
the added advantage of a long shelf-life, which could have
number of subjects, 4.5% (3) chewed category I (betel leaf
made these individuals get attracted to these ready to use
+ arecanut) and category V (processed arecanut) (Table 3).
packets in a younger age.
Analyzing the frequency of quid usage in our study it
This result was coinciding with the study of Kumar et al4
was found that, among 150 subjects of chewer’s mucosa
who reported that gutkha consumption was significantly
majority of the subjects, 54% (81) chewed quid for three to
higher in youngsters (<25 years) whereas in traditional
five times a day, whereas minimum number of subjects,
2.6% (4) chewed quid for more than 10 times a day.
This may be due to the fact that on chewing more than Table 2: Type of quid usage

three to five times a day, the chewer’s mucosa lesion would Type of quid Frequency Percentage
progress to OSMF (Table 4). Category I 10 6.6
In our study maximum number of subjects who had Category II 15 10
Category III 50 33.3
chewer’s mucosa lesion and were chewing the quid for Category IV 32 21.3
minimum duration (0-12 months) and minimum frequency Category V 6 4
(1-2 times) were found to be using category III quid (betel Category VI 37 24.6

leaf + arecanut + lime + tobacco). Thus, the quid containing
betel leaf + arecanut + lime + tobacco as its constituents
results in chewer’s mucosa lesion in a shorter period of time.
This association was found to be significant (p = 0.049)
(Table 5).
Total 150 100
(1) Category I (betel leaf + arecanut); (2) Category II (betel leaf +
arecanut + lime); (3) Category III (betel leaf + arecanut + lime +
tobacco); (4) Category IV (tobacco + lime); (5) Category V
(processed arecanut); (6) Category VI (processed arecanut +
processed tobacco)

Table 1: Age and gender-wise distribution of chewer’s mucosa patients

Age groups (years) Male Female Total
20-30 68 1 69
% 98.6% 1.4% 100.0%
30-40 26 6 32
% 81.3% 18.8% 100.0%
40-50 11 8 19
% 57.9% 42.1% 100.0%
50-60 11 7 18
% 61.1% 38.9% 100.0%
60-70 4 5 9
% 44.4% 55.6% 100.0%
>70 0 3 3
% 0.0% 100.0% 100.0%
Total no. of cases 120 30 150
% 80.0% 20.0% 100.0%

Journal of Indian Academy of Oral Medicine and Radiology, October-December 2012;24(4):284-287 285
Saba Khan et al

Table 3: Comparison between duration of chewing habit in different varieties of quid

Duration Type of quid Total (%)
Betel leaf + Betel leaf + Betel leaf + Tobacco + Processed Processed
arecanut arecanut + arecanut + lime arecanut arecanut +
lime lime + processed
tobacco tobacco
0-12 months 2 0 3 0 1 11 17
% 11.7% 0% 17.6% 0% 5.8% 64.7% 11.3%
1-5 years 3 10 17 25 3 16 74
% 4.5% 13.5% 22.9% 33.7% 4.5% 21.6% 49.3%
5-10 years 3 2 13 6 2 9 35
% 8.57% 5.71% 37.1% 17.1% 5.71% 25.7% 23.3%
>10 years 2 3 17 1 0 1 24
% 8.3% 12.5% 70.8% 4.1% 0% 4.1% 16.0%
Total 10 15 50 32 6 37 150
100%
χ2 = 35.137; p = 0.002

Table 4: Comparison between frequency of chewing habit in different varieties of quid

Frequency Type quid Total
Betel leaf + Betel leaf + Betel leaf + Tobacco + Processed Processed
arecanut arecanut + arecanut + lime arecanut arecanut +
lime lime + processed
tobacco betel
1-2 times 1 1 6 2 0 11 21
% 10.0% 6.7% 12.0% 6.3% 0.0% 29.7% 14%
3-5 times 8 9 26 20 3 15 81
% 80.0% 60.0% 52.0% 62.5% 50.0% 51.7% 54.0%
6-10 times 1 5 15 10 3 10 44
% 10.0% 33.3% 30.0% 31.3% 50.0% 34.5% 29.3%
>10 times 0 0 3 0 0 1 4
% 0.0% 0.0% 6.0% 0.0% 0.0% 3.4% 2.6%
Total 10 15 50 32 6 37 150
% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
χ2 = 8.86; p = 0.884

Table 5: Association of type III quid with duration and frequency of occurrence of chewer’s mucosa
Duration Frequency Total
1-2 times 3-5 times 6-10 times >10 times
0-12 1 2 0 0 3
CAT-III quid months % 16.7% 7.7% 0.0% 0.0% 6.0%
Betel leaf + arecanut + 1-5 years 5 8 4 0 17
lime + tobacco % 83.3% 30.8% 26.7% 0.0% 34.0%
5-10 years 0 8 5 0 13
% 0.0% 30.8% 33.3% 0.0% 26.0%
>10 years 0 8 6 3 17
% 0.0% 30.8% 40.0% 100.0% 34.0%
Total 6 26 15 3 50
% 100.0% 100.0% 100.0% 100.0% 100.0%
χ2 = 16.97; p = 0.049

tobacco users it starts over 30 years. In a similar study
conducted by Shah and Sharma et al5 it was observed that
subjects below the age of 30 years preferred to chew
commercial pan masala.
In the present study, majority of subjects were chewing
category III quid (betel leaf, arecanut, lime, tobacco)
followed by category VI quid (processed arecanut +
processed tobacco). The above observations were similar
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to those reported by Reichart et al6 in which betel quid was
the causative factor for occurrence of chewer’s mucosa.
In the present study majority of the subjects with
chewer’s mucosa used to chew the quid for a duration of
1 to 5 years and this was statistically highly significant
(p = 0.002), whereas maximum subjects used to chew the
quid with a frequency of three to five quids per day and this
association was not statistically significant. This finding was

A Study to analyze the Different Patterns of Quid Usage among Subjects with Chewer’s Mucosa
consistent with the study by Ranganathan et al7 in which
the duration of the habit was more significant than the
frequency of the chewing habit. This also correlated with
the finding of Reichart et al6 who stated that the presence
of chewer’s mucosa lesion was significantly associated with
the duration of the habit (p < 0.01) and the number of betel
quids per day (p < 0.001).
The present study also revealed that the maximum
number of subjects chewed the quid containing betel leaf,
arecanut, lime, tobacco as its constituents. This association
was statistically significant (p = 0.049). However, this is
inconsistent with the finding of Sinor et al8 who reported
that chewing of tobacco with arecanut, betel leaves and lime
results in later onset of the disease. This may be due to the
fact that chewer’s mucosa lesion is known to be caused
more due to the traumatic effect of the betel nut chewing as
compared to the leeching of the chemical constituents of
the quid into the mucosa. The results of our study were
correlating with the observations made by Gupta and Ray
as stated by Ahmad et al9 that arecanut with smokeless
tobacco causes earlier onset of the disease as compared to
arecanut only.
CONCLUSION
This present study revealed that majority of the subjects
were chewing the quid containing betel leaf, arecanut, lime,
tobacco as its constituents. Majority of the subjects with
chewer’s mucosa used to chew the quid for a duration of
1 to 5 years, with a frequency of 3 to 5 quids per day. Patients
having chewer’s mucosa may develop more severe mucosal
conditions such as OSMF on continued usage of the quid.
Thus, this study emphasises on screening and counseling
the patients with such initial stages of mucosal alterations
so as to prevent their progression into other severe lesions
associated with quid usage.
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ABOUT THE AUTHORS
Saba Khan (Corresponding Author)
Assistant Professor, Department of Oral Medicine and
Radiology, NIMS Dental College, Jaipur, Rajasthan, India
e-mail: dr.sabakhan23@gmail.com
Laxmikanth Chatra
Head and Senior Professor, Department of Oral Medicine and
Radiology, Yenepoya Dental College, Mangalore, Karnataka, India
K Prashanth Shenai
Senior Professor, Department of Oral Medicine and Radiology
Yenepoya Dental College, Mangalore, Karnataka, India
KM Veena
Professor, Department of Oral Medicine and Radiology, Yenepoya
Dental College, Mangalore, Karnataka, India
Prasanna Kumar Rao
Associate Professor, Department of Oral Medicine and Radiology
Yenepoya Dental College, Mangalore, Karnataka, India
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