Association of DSM-5 Betel-Quid Use Disorder With Oral Potentially Malignant Disorder in 6 Betel-Quid Endemic Asian Populations.

Importance: Betel-quid (BQ) is the fourth most popular psychoactive agent worldwide. An emerging trend across Asia is the addictive consumption of BQ, which is associated with oral cancer and other health consequences. Objective: To investigate the validity and pattern of DSM-5-defined BQ use disorder (BUD) and its association with oral potentially malignant disorder (OPMD) among Asian populations. Design, Setting, and Participants: In-person interviews were conducted from January 1, 2009, to February 28, 2010, among a random sample of 8922 noninstitutionalized adults from the Asian Betel-quid Consortium study, an Asian representative survey of 6 BQ-endemic populations. Statistical analysis was performed from January 1, 2015, to December 31, 2016. Main Outcomes and Measures: Participants were evaluated for BUD using DSM-5 criteria for substance use disorder and for OPMD using a clinical oral examination. Current users of BQ with 0 to 1 symptoms were classified as having no BUD, those with 2 to 3 symptoms as having mild BUD, those with 4 to 5 symptoms as having moderate BUD, and those with 6 or more symptoms as having severe BUD. Results: Among the 8922 participants (4564 women and 4358 men; mean [SD] age, 44.2 [0.2] years), DSM-5 symptoms showed sufficient unidimensionality to act as a valid measure for BUD. The 12-month prevalence of DSM-5-defined BUD in the 6 study populations was 18.0% (mild BUD, 3.2%; moderate BUD, 4.3%; and severe BUD, 10.5%). The 12-month proportion of DSM-5-defined BUD among current users of BQ was 86.0% (mild BUD, 15.5%; moderate BUD, 20.6%; and severe BUD, 50.0%). Sex, age, low educational level, smoking, and drinking were significantly associated with BUD. Among individuals who used BQ, family use, high frequency of use, and amount of BQ used were significantly linked to moderate to severe BUD. Compared with individuals who did not use BQ, those who used BQ and had no BUD showed a 22.0-fold (95% CI, 4.3-112.4) risk of OPMD (P < .001), whereas those with mild BUD showed a 9.6-fold (95% CI, 1.8-56.8) risk (P = .01), those with moderate BUD showed a 35.5-fold (95% CI, 4.3-292.3) risk (P = .001), and those with severe BUD showed a 27.5-fold (95% CI, 1.6-461.4) risk of OPMD (P = .02). Individuals with moderate to severe BUD who used BQ and had the symptom of tolerance had a 153.4-fold (95% CI, 33.4-703.6) higher risk of OPMD than those who did not use BQ, and those with moderate to severe BUD who used BQ and had a larger amount or longer history of BQ use had an 88.9-fold (95% CI, 16.6-476.5) higher risk of OPMD than those who did not use BQ. Conclusions and Relevance: This international study gathered data about BQ users across 6 Asian populations, and it demonstrates that DSM-5 symptoms could fulfill a BUD construct. Most current Asian users of BQ already have BUD, which is correlated with risk of OPMD. Among individuals with moderate to severe BUD who used BQ, tolerance and a larger amount or longer history of BQ use are the key symptoms that correlated with enhanced risk of OPMD. These findings play an important role in providing a new indication of an additional psychiatric management plan for users of BQ who have BUD.

Betel-quid dependence domains and syndrome associated with betel-quid ingredients among chewers: an Asian multi-country evidence.

AIMS: Betel-quid (BQ) contains biologically psychoactive ingredients; however, data are limited concerning the symptoms and syndrome of BQ dependence among chewers. The aims of this study were to evaluate the ingredients-associated BQ dependence syndrome and country-specific chewing features and behaviour for BQ dependence among chewers from six Asian communities. DESIGN: An intercountry Asian Betel-quid Consortium study. SETTING: Six Asian general communities in Taiwan, Mainland China, Indonesia, Malaysia, Sri Lanka and Nepal. PARTICIPANTS: Six multi-stage random samples of BQ chewers in the Asian Betel-quid Consortium study (n = 2078). MEASUREMENTS: All chewers were evaluated for BQ dependence using the DSM-IV and ICD-10 criteria. FINDINGS: The 12-month BQ dependence rate was 12.5-92.6% and 47.9-99.3% (P = 0.023) among tobacco-free and tobacco-added BQ chewers across the six Asian communities, with a higher dependence rate in chewers who used tobacco-free BQ with lime added than without (23.3-95.6% versus 4.0%, P ≤ 0.001). Taiwanese and Hunanese BQ chewers both notably endorsed the dependency domain of 'time spent chewing'. 'Tolerance' and 'withdrawal' were the major dependence domains associated with the Nepalese and Indonesian chewers, with high BQ dependence rates. Malaysian and Sri Lankan chewers formed a BQ dependence cluster linked closely to 'craving'. In Sri Lanka, the quantity consumed explained 90.5% (P < 0.001) of the excess dependence risk for tobacco-added use, and could be a mediator between tobacco-derived psychoactive effect and BQ dependence development. CONCLUSIONS: DSM-IV criteria for dependence apply to a significant proportion of betel quid users in Asian communities, more so if they use it with tobacco or lime.

Analysis of protein expression profile of oral squamous cell carcinoma by MALDI-TOF-MS.

In this study, two-dimensional gel electrophoresis (2-DE) and matrix-assisted laser desorption/ionisation-time of flight mass spectrometry (MALDI-TOF-MS) technology was used to examine differentially expressed proteins in oral squamous cell carcinoma (OSCC) tissues from Norway (n=15) and the UK (n=45). Twenty-nine proteins were found to be significantly overexpressed in the OSCCs examined compared to the normal controls. Identified proteins included, family of annexin proteins that play important roles in signal transduction pathways and regulation of cellular growth, keratin-1, heat-shock proteins (HSP), squamous cell carcinoma antigen (SCC-Ag), cytoskeleton proteins, and proteins involved in mitochondrial and intracellular signalling pathways. The expression of four selected proteins (annexin II and V, HSP-27, and SCC-Ag) was verified using western blot analysis of 76 fresh tissue biopsy specimens in total, from Norway (n=53) and the UK (n=23). Proteomic analysis of OSCCs examined here demonstrated involvement of several proteins that might function as potential biomarkers and molecular targets for early cancer diagnostics, and may contribute to a novel approach to therapeutics and for predicting prognosis of OSCC.

Betel-quid dependence and oral potentially malignant disorders in six Asian countries.

BACKGROUND: Despite gradual understanding of the multidimensional health consequences of betel-quid chewing, information on the effects of dependent use is scant. AIMS: To investigate the 12-month prevalence patterns of betel-quid dependence in six Asian populations and the impact of this dependence on oral potentially malignant disorders (OPMD). METHOD: A multistage random sample of 8922 participants was recruited from Taiwan, mainland China, Indonesia, Malaysia, Sri Lanka and Nepal. Participants were evaluated for betel-quid dependency using DSM-IV and ICD-10 criteria and assessed clinically for oral mucosal lesions. RESULTS: The 12-month prevalence of dependence was 2.8-39.2% across the six Asian samples, and 20.9-99.6% of those who chewed betel-quid were betel-quid dependent. Men dominated the prevalence among the east Asian samples and women dominated the prevalence in south-east Asian samples. 'Time spent chewing' and 'craving' were the central dependence domains endorsed by the Chinese and southern/south-east Asian samples respectively, whereas the Nepalese samples endorsed 'tolerance' and 'withdrawal'. Dependency was linked to age, gender, schooling years, drinking, smoking, tobacco-added betel-quid use and environmental accessibility of betel-quid. Compared with non-users, those with betel-quid dependency had higher pre-neoplastic risks (adjusted odds ratios 8.0-51.3) than people with non-dependent betel-quid use (adjusted odds ratio 4.5-5.9) in the six Asian populations. CONCLUSIONS: By elucidating differences in domain-level symptoms of betel-quid dependency and individual and environmental factors, this study draws attention to the population-level psychiatric problems of betel-quid chewing that undermine health consequences for OPMD in six Asian communities.

Population burden of betel quid abuse and its relation to oral premalignant disorders in South, Southeast, and East Asia: an Asian Betel-quid Consortium Study.

OBJECTIVES: We investigated the population burden of betel quid abuse and its related impact on oral premalignant disorders (OPDs) in South, Southeast, and East Asia. METHODS: The Asian Betel-Quid Consortium conducted a multistage sampling of 8922 representative participants from Taiwan, Mainland China, Malaysia, Indonesia, Nepal, and Sri Lanka. Participants received an interviewer-administered survey and were examined for oral mucosal disorders. RESULTS: The prevalence of betel quid abuse was 0.8% to 46.3% across 6 Asian populations. The abuse frequency was over 40.5% for current chewers, with the highest proportion in Nepalese and Southeast Asian chewers (76.9%-99.6%). Tobacco-added betel quid conferred higher abuse rates (74.4%-99.6%) among Malaysian, Indonesian, and Sri Lankan men than did tobacco-free betel quid (21.8%-89.1%). Gender, lower education level, younger age at chewing initiation, and clustering of familial betel quid use significantly contributed to higher abuse rates. Indonesian betel quid abusers showed the highest prevalence of OPDs and had a greater risk of OPDs than did nonabusers. CONCLUSIONS: Betel quid abuse is high in regions of Asia where it is customarily practiced, and such abuse correlates highly with OPDs. By recognizing abuse-associated factors, health policies and preventive frameworks can be effectively constructed to combat these oral preneoplasms.

Intercountry prevalences and practices of betel-quid use in south, southeast and eastern Asia regions and associated oral preneoplastic disorders: an international collaborative study by Asian betel-quid consortium of south and east Asia.

Health risks stemming from betel-quid (BQ) chewing are frequently overlooked by people. Updated epidemiological data on the increased BQ use among Asian populations using comparable data collection methods have not been widely available. To investigate the prevalence, patterns of practice and associated types of oral preneoplastic disorders, an intercountry Asian Betel-quid Consortium study (the ABC study) was conducted for Taiwan, Mainland China, Malaysia, Indonesia, Nepal and Sri Lanka. A random sample of 8,922 subjects was recruited, and the data were analyzed using survey-data modules adjusted for the complex survey design. Chewing rates among men (10.7-43.6%) were significantly higher than women (1.8-34.9%) in Taiwan, Mainland China, Nepal and Sri Lanka, while women's rates (29.5-46.8%) were higher than that for men (9.8-12.0%) in Malaysia and Indonesia. An emerging, higher proportion of new-users were identified for Hunan in Mainland China (11.1-24.7%), where Hunan chewers have the unique practice of using the dried husk of areca fruit rather than the solid nut universally used by others. Men in the Eastern and South Asian study communities were deemed likely to combine chewing with smoking and drinking (5.6-13.6%). Indonesian women who chewed BQ exhibited the highest prevalence of oral lichen planus, oral submucous fibrosis and oral leukoplakia (9.1-17.3%). Lower schooling, alcohol drinking and tobacco smoking were identified as being associated with BQ chewing. In conclusion, the ABC study reveals the significant cultural and demographic differences contributing to practice patterns of BQ usage and the great health risks that such practices pose in the Asian region.

Adverse effects of Sudanese toombak vs. Swedish snuff on human oral cells.

BACKGROUND: The high incidence of oral cancer in Sudan has been associated with the use of toombak, the local type of smokeless tobacco. However, its specific effects on human oral cells are not known. We aimed to investigate the effects of toombak on primary normal human oral keratinocytes, fibroblasts, and a dysplastic oral keratinocytic cell line, and to compare them with the effects induced by Swedish snuff. METHOD: Aqueous extracts were prepared from moist toombak and Swedish snuff and added in serial dilutions on in vitro monolayer cultured cells. Cell viability, morphology and growth, DNA double-strand breaks (gammaH2AX staining), expression of phosphatidylserine (Annexin V staining), and cell cycle were assessed after various exposure time periods. RESULTS: Significant decrease in cell number, occurrence of DNA double-strain breaks, morphological and biochemical signs of programmed cell death were detected in all oral cell types exposed to clinically relevant dilutions of toombak extract, although to a lesser extent in normal oral fibroblasts and dysplastic keratinocytes. G2/M-block was also detected in normal oral keratinocytes and fibroblasts exposed to clinically relevant dilutions of toombak extract. Swedish snuff extract had less adverse effects on oral cells, mainly at non-clinically relevant dilutions. CONCLUSION: This study indicates a potential for toombak, higher than for Swedish snuff, to damage human oral epithelium. Dysplastic oral keratinocytes were less sensitive than their normal counterparts, suggesting that they might have acquired a partially resistant phenotype to toombak-induced cytotoxic effects while still being prone to DNA damage that could lead to further malignant progression.

High interstitial fluid pressure in rat tongue cancer is related to increased lymph vessel area, tumor size, invasiveness and decreased body weight.

BACKGROUND: Interstitial fluid pressure (IFP) in most tumors is high, and this high pressure has been correlated with poor prognosis. Measurements of IFP in normal tongue and in tongue cancer are lacking. Recent research suggests the existence of a relationship between increased peritumoral lymph vessels (PTLV) and survival, and a correlation of increased lymphatic vessel density with an unfavorable prognosis has been reported. MATERIALS AND METHODS: In the present study, tongue squamous cell carcinoma (SCC) was induced by adding the carcinogen 4-nitroquinoline oxide in drinking water for 19 weeks. The IFP was measured by micropuncture and immunohistochemistry was used to visualize lymph vessels. RESULTS: In normal tongue, IFP averaged 3.1 +/- 0.3 mmHg. The IFP, both in the tumor (29.1 +/- 2.9 mmHg) and 0.5 cm anterior to it (15.4 +/- 2.1 mmHg) was consistently increased (P < 0.005) with values ranging from 10 to 40 mmHg. The highest IFP values were measured in rats with large tumors (P < 0.05) and low body weight (P < 0.001), suggesting that IFP increases with cancer progression. Lymphatic vessel area (%), as determined with the lymphatic specific marker LYVE-1 antibody, was significantly increased in the peritumoral area when compared to intratumoral and control mucosa (P < 0.05). There was a significant positive correlation between IFP, PTLV area, tumor size and invasiveness. CONCLUSIONS: Our data show that IFP is increased in tongue cancer. Corresponding changes in PTLV area, invasiveness, tumor area and IFP suggest that the increased pressure is caused by defective lymph drainage and solid stress generated by tumor cells growing in a low compliant environment.

Tumour-associated Proteins in Oral Squamous Cell Carcinomas by Proteomics.

Antibody microarrays, two-dimensional electrophoresis and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (2-DE/MALDI-TOF-MS) were used to examine protein changes in 56 oral cancers (OCs)/normal controls (NCs) from Sudanese (41 OCs vs. 31 NCs) and Sri Lankan (15 OCs vs. 15 NCs) patients. Pools of extracted proteins were prepared and used for microarrays/2-DE/MALDI-TOF-MS. From 2-DE, protein spots (differentially-expressed) were cut and identified with peptide mass fingerprinting based on MALDI-TOF-MS, and the proteins were identified by submitting peptide mass profiles to the NCBInr database. By microarrays, 6 and 8 proteins demonstrated significant differences in their abundance values as differentially-expressed in OCs examined from Sudan and Sri Lanka, respectively. For some of the proteins found, like p56dok2 and NEK2, this is the first report in OCs. By MALDI-TOF-MS/2-DE, patterns of OCs/NCs were acquired and tumour-associated proteins, like psoriasin, calgranulin-B and glutathione transferase, were found to be altered in OCs compared to NCs. The proteins found in this work (by two different methods) represent a global protein change specific to OCs from two populations. This might indicates involvement of multiple pathways in the process of tumorgenesis; thus, multiple proteins should be simultaneously targeted in OCs. The finding of few common proteins might suggest involvement of different pathways, which may parallel differences in ethnicity and/or lifestyle.

Recent Advances in Understanding Carcinogenicity of Oral Squamous Cell Carcinoma: From Basic Molecular Biology to Latest Genomic and Proteomic Findings.

The global increase in incidence and mortality, as well as the poor prognosis of oral squamous cell carcinoma (OSCC), has intensified efforts in the field of prevention and early detection of this disfiguring disease. Prevalence of OSCC is common in areas with high consumption of tobacco products and alcohol. Understanding the carcinogenicity of this cancer, using innovative techniques in genomic and proteomic analysis, is the main focus of current research in OSCC, and the hunt for potential molecular biomarkers is accelerating. Although recent advances in preventive, diagnostic and therapeutic techniques related to OSCC have yielded novel molecular targets, partially uncovered signal pathway dominance and advanced early neoplasia detection, the number of deaths attributed to this disease exceeds that reported for cervical cancer, malignant melanoma and Hodgkin's disease. Application of advanced molecular biology techniques for classification, profiling of tumour tissues and/or identification of potential markers of OSCCs is on the rise. This review aims at outlining the available knowledge on epidemiology, aetiology, molecular biology, and genomics and proteomics in relation to OSCCs.

Study of oral epithelial atypia among Sudanese tobacco users by exfoliative cytology.

BACKGROUND: Prevalence of oral cancer is high in Sudan and the disease is attributed to N-nitrosamine rich oral snuff consumption. MATERIALS AND METHODS: As part of the development of a screening procedure for oral cancer and precancer, exfoliative cytology (EFC) was applied to a retrospective cohort to assess the presence and severity of oral epithelial atypia (ET) in 300 subjects (100 toombak dippers; 100 cigarette smokers; 100 non-tobacco users) without prior knowledge of the subjects' tobacco exposure. Five patients with oral squamous cell carcinoma (OSCC) were included as internal controls. RESULTS: ET was ascertained in 29 subjects and could not be ascertained in the remaining 271. Among the 29 subjects with ET, there were 11 (38%) toombak dippers, 14 (48%) cigarette smokers and 4 (14%) non-tobacco users. Among the 271 subjects without ET, there were 89 (33%) toombak dippers, 86 (32%) cigarette smokers and 96 (35%) non-tobacco users. ET was found in all the 5 control cases with OSCC. For the ET among toombak dippers and cigarette smokers, adjusted OR and the 95% CI were found to be 3 (0.91-9.7) and 4 (1.2-12.3), respectively. CONCLUSION: In view of these findings, we propose the use of EFC for detection and assessment of oral ET.

Mutations of the cell cycle regulatory genes p16INK4A and p21WAF1 and the metastasis-inducing gene S100A4 are infrequent and unrelated to p53 tumour suppressor gene status and data on survival in oropharyngeal squamous cell carcinomas.

BACKGROUND: Oropharyngeal squamous cell carcinoma (SCC) is probably the most serious cancer to be encountered in the clinic. MATERIALS AND METHODS: Exons 1-3 of the p16 and exon 2 of the p21 genes were examined for mutations by polymerase chain reaction (PCR)/direct DNA sequencing methods in 21 fresh-frozen tissue specimens of oropharyngeal SCCs previously studied for expression and mutation (exons 5-9) of the p53 gene. Mutations in exons 2 and 3 of the S100A4 gene were studied in 10 cases. Findings were examined for correlations with patients' clinicopathological parameters and data on survival. RESULTS: No p16 gene mutations were found in any of the cases examined. Only one tumour, which previously had shown expression and mutation in the p53, had a point mutation at codon 117 of exon 2 of the p21 gene with a resulting Cys-->Tyr amino acid substitution. Exons 2 and 3 of the S100A4 gene were not found mutated in the cases studied. Analysis of survival data showed that, among the 60% (12 out of 20) of patients who died, 50% (6 out of 12) had mutations in p53 while the remaining 50% had no mutations. Of the 50% with mutated p53, 17% (1 out of 6) also had mutation in p21. For the 40% (8 out of 20) who are alive, 63% (5 out of 8) had mutations in p53 and 37% (3 out of 8) had no mutations. CONCLUSION: These findings demonstrate that: (i) mutations of the cell cycle regulatory genes p16 and p21 and the S100A4 gene are infrequent and might be unnecessary in development and/or progression of oropharyngeal SCCs, (ii) the results were not found to relate to previous results of p53, (iii) loss of p21 and/or p53 might not predict for prognosis in these cancers, (iv) the absence of mutations of the three genes examined in the cases previously found mutated for p53 might suggest that these mutations are complementary to p53 mutations in the development of these cancers, but the lack of these mutations in the cases with no mutations in p53 might suggest that the pathogenesis of these cancers may follow other independent pathways. Since p53 and pRb (p16/pRb/cyclin-D1) pathways represent the two main mechanisms for cell cycle control at the G1-S checkpoint, further studies are necessary to examine the possible alterations in the pRb (p16/pRb/cyclin-D1) and the p53 pathways in oropharyngeal SCCs.