Betel-nut chewing and submucous fibrosis in Durban

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					 568        SAMT      VOL 74        3 DES 1988

 Betel-nut chewing and submucous fibrosis
 in Durban
 H. A. SEEDAT,                      C. W. VAN WYK

 Summary                                                                                    Muslims in their survey. The manner in which the households
                                                                                            were sampled is not described. They found that 30,7% of
 A stratified random sample among South African Indians                                     women practised the chewing habit while only 5,5% of men
 living in Durban revealed the occurrence of betel-nut chewing                              were chewers. The habit was more common in the elderly -
 and the resultant submucous fibrosis (SF) to be relatively                                 71,9% of women over 60' years and 10,3% of men in the same
 high. Women chewers predominated in a ratio of. 13:1. The                                  age group.
 habit increased with age al1d 30,6% of women over '65 years
                                                                                               Shear er al. 9 undertook a study in the JohannesburglPretoria
 practised the custom. Thirty-eight per cent of chewers
 revealed signs of impending and established SF; women                                      area on 1000 consecutive unselected Indians. The sample was
 predominated 70:1, and the majority of sufferers in this                                   not chosen randomly. The overall prevalence rate of SF,
 instance belonged to the age group 45 - 54 years (12,9%).                                  which was only encountered in women, was 0,5%. Dockrat and
 Forty-six per cent of those with signs associated with SF had                              Shear lo looked at an unselected sample in Durban of I 200
 fibrous bands in the mouth and were regarded as having                                     Indian subjects over the age of 15 years, 800 from a door-to-
 established SF. It was calculated that 5% of the total Indian                              door survey and 400 from a hospital outpatient department.
 population in South Africa could be chewers and that 2,3%                                  The prevalence of the disease was 0,6%.
 may develop SF.                                                                               Randeria",12 observed 28 cases of SF in a Durban hospital
 S AIr Med J 1988; 74:   568-5~1.
                                                                                            between 1969 and 1972. Van Wyk er al. 13 investigated oral
                                                                                            disease among Indians living in Cape Town and found the
                                                                                            occurrence of SF to be 1,25%. However, their study sample
 'Oral submucous fibrosis [SF] is an insidious chronic disease                              was small (N = 300).
 affecting any part of the oral cavity and sometimes the pharynx.                              A study of the prevalence of betel-nut chewing and the
 Although occasionally preceded by and/or associated with                                   presence of impending SF and established SF among South
 vesicle formation, it is always associated with a juxta-epithelial                         African Indians residing in Durban was undertaken with a
 inflammatory reaction followed by a a fibro-elastic change of                              view to initiating preventive and intervention programmes.
 the lamina propria with epithelial atrophy, leading to stiffness
 of the oral mucosa and causing trismus and inability to eat.' 1
 This stiffness and trismus is due to a fibro-elastic change in                             Subjects and methods
 the lamina propria of the oral mucosa. 1 Early signs and
symptoms heralding the onset of the disease are a burning                                   Population
sensation in the mouth often experienced whcm eating spicy
                                                                                               The Indians in South Africa owe their presence to the
food; '-5 blanching of the palate, faucial pillars, buccal mucosa
                                                                                            system of indenture between the British raj in India and the
and lips;6 oral vesicles and ulceration;7 excessive salivation;'
                                                                                            British colonies, which started in 1837 and ended in 1917.
defective gustatory sensation; and dryness of the mouth.' The
                                                                                            They constitute a heterogeneous society composed of many
disease is progressive and once there are palpable fibrous
                                                                                            distinct ethnic groups and many of their attitudes and patterns
bands in the mouth it is established and will not regress.
                                                                                            of social life are traditional. 14 The population is weighted
There is ample evidence that the habit of betel-nut chewing is
                                                                                            towards younger people and can be classified as a relatively
a prime cause. 1
                                                                                            young population (Fig. 1).
   The habit of betel-nut chewing and the resultant SF is
                                                                                               In Durban about 60% of the Indian population is unskilled
primarily confined to Indians and people of south-east Asian
                                                                                            and semi-skilled. Almost 23% are in white-collar jobs, 10% are
stock. It has been reported elsewhere in the world where
                                                                                            skilled workers in the trades and professional people comprise
Indians reside, including South Africa. The RSA has an
                                                                                            about 5%.15 The majoritY are of the Hindu faith (75,26%),
Indian community of almost 1 million, the biggest concentra-
                                                                                            followed by Muslims (13,05%) and Christians (11,69%). The
tion being in the city of Durban.
   Although several studies have reported the presence of the
disease in South Africa, figures reflecting the real occurrence
of the habit and the disease are still lacking. Schonland and
Bradshaw8 carried out a prevalence study of the chewing habit
in Durban among 500 domestic establishments, comprising
659 families. Since the majority of people belonged to the
Hindu faith, adjustments were made to increase the number of

Department of Maxillofacial Surgery, King Edward VDI
Hospital, Durban
H. A. SEEDAT, M.B. B.CH., B.D.S., PH.D.
Oral and Dental Research Institute, University of Stellen-
bosch, Parowvallei, CP
C. W . VAN WYK, B.CH.D., F.D.S., R.CS., PH.D.                                                   18        11                 o

Reprint requests [0: Professor C. w. van Wyk, Oral and Dental Research Institute, Private
Bag X I, Tygerberg, 7505 RSA.                                                               Fig. 1. The age and sex distribution of the South African Indian
Accepted 5 Joo 1988.                                                                        population in 1980.                                      .
                                                                                                                       SAMJ      VOL 74   3 DEC 1988        569

overwhelming maJonty are English speaking. According to                    home language (vernacular), religion and indulgence in the
Durban City Council statistics, there were 364 752 Indians in              betel-ehewing habit. The intra-oral examination consisted of a
the metropolitan area in 1978; this figure had increased to                visual inspection and palpation and was carried out under
almost 400 000 in 1980, the date that this survey was planned.             natural light near a window or doorway. Artificial light was
  From the status of know edge regarding the prevalence of                 used when there was insufficient natural light. Only one
betel-nut chewing and SF in South Africa, it was calculated                author (H.A.S.) undertook the examination and interviewing.
that a sample size of 2400 subjects would be sufficient.                      Indicators of impending 'early' SF were a history Of betel-
Personal contact and enquiry into the betel habit by one of the            nut chewing with two or more of the following symptoms and
authors (H.A.S.) revealed that it is almost exclusively practised          signs: (I) a history of a burning sensation on eating spicy foods;
by adults and very infrequently by children. It was therefore              this would have to be a new symptom for people used to
decided that the sample should include subjects of 10 years                eating spicy foods; (il) dry mouth; (iil) complaint or exhibition
and older only, and that it would be stratified into the age               of vesicles and ulcers; (iv) localised blanching of the palate,
groups 10 - 14, 15 - 24, 25 - 34, 35 - 44, 45 - 54, 55 - 64 and 65+        faucial regions, cheeks and lips; (v) smooth silk)' mobile feeling
years, and include equal numbers of each sex in each age                   of the mucosa lost and replaced by a linen- or leather-like
group.                                                                     sensation; this feature was included because of its common
  From maps available in the city of Durban, 38 Indian                     occurrence in patients referred to hospital with SF. A diagnosis
suburbs were identified in metropolitan Durban and it was                  of established SF was made if the chewer also had palpable
planned that the sampling points would be proportionally                   fibrous bands in the mouth.
distributed according to the size of the residential areas.
However, owing to redevelopment in some suburbs and because
others were too small, some areas were disregarded and others              Results
consolidated, resulting in 29 well-delineated areas. This reduced
the sample size to 2058 and accordingly 147 subjects were                  The survey started during 1981 and was completed in 1983.
needed for each age-sex stratum. One hundred and forty-                      Since equal numbers per age/sex strata were selected it was
seven clusters of 14 individuals were to be examined at each               not possible to correlate the sample characteristics with the
sampling point. Special maps were used to determine the                    population characteristics. However, when those parameters
sampling points. They showed the respective density of the                 which the sampling method did not influence, such as place of
population in the various areas and were of the scale 1:6000               birth, home language and religion, were compared an acceptable
and 1:15000, which showed all the streets and plot numbers.                correlation was found. Ninety-nine per cent of the subjects
  A grid was placed over a specific area of the map and two
numbers from a set of random numbers were then selected.
The first number was used as a co-ordinate on the X axis and
the other on the Y axis. The sampling point was taken where
                                                                            TABLE I. AGE AND SEX DISTRIBUTION OF ALL CHEWERSIN
the projections met. This procedure was repeated until all
sampling points had been selected.
  Provision was made before the sampling for a number of                    Age (yrs)             Total (%)*            Females (%)             Males (%);
eventualities such as the selection of houses on the same side              10-14                   2 ( 0,7)                1    ( 0,7)           1 (0,7)
of the street, the opposite side of the street, around corners              15 -24                  6 ( 2,0)                6    ( 4,1)           o
and in apartment buildings. These rules were followed until                 25-34                  17 ( 5,8)               17    (11,6)           o
the required 14 subjects were interviewed.                                  35 - 44                32 (10,9)               32    (21,8)           o
                                                                            45-54                  41 (13,9)               37    (25,0)           4 (2,7)
                                                                            55-64                  37 (12,6)               35    (23,8)           2 (1,4)
                                                                            65+                   ~(17,3)                  ~(30,6)               ~(4,1)
House interviews                                                                 Total            186                      173                   13
  These interviews consisted of a screening questionnaire and               • % of total, 294 per age group.
an intra-oral examination if required. A questionnaire was                  t % of females    ~   147 per age group.
completed for each selected subject detailing the age, sex,                 : %of males       5
marital status, occupation, birthplace (India or South Africa),

                                             AND ESTABLISHED SF
                                                                                            Chewers with impending and
                                           Chewers without SF                                    established SF
          Age (yrs)          Total (%)*      Females (%It     Males (%);            Total (%)*    Females (%)t      Males (%)t
          10 -14               1 ( 0,3)           o              1 (0,7)               1 (0,3)                  1 ( 0,7)              o
          15-24                2 ( 0,7)           2 ( 1,4)      o                      4 (1,5)                  4 ( 2,7)              o
          25-34                4 ( 1,5)           4 ( 2,7)      o                     13 (4,4)                 13 ( 8,8)              o
          35-44               19 ( 6,5)          19 (12,9)      o                     13 (4,4)                 13 ( 8,8)              o
          45-54               21 ( 7,1)          18 (12,2)      3 (2,0)               20 (6,8)                 19(12,9)               1 (0,7)
          55-64               28 ( 9,5)          26 (17,7)       2 (1,4)               9 (3,1)                  9 ( 6,1)              o
          65+                 40 (13,6)          34 (23,1)      6 (4,1)               11 (3,7)                 11 ( 7,5)              o
              Total          m                  103            12                     71                       70                     1
          • % of fofal. 294 per age group.
          t % of temales ~ 147 per age group.
          ; % of males      ~
          Without SF ratio F:M 8,6:1.
          With SF ratio F:M 70:1.
    570     SAMT VOL 74 3 DES 1988

   were born in South Mrica, 72,5% belonged to the Hindu faith,               The estimated crude prevalence rates of this smdy differ
   17,8% were Muslim and 9,7% were Christian. Very few subjects            markedly from the findings of Schonland and Bradshaw,8 who
   were not able to converse in English.                                   found that 30,7% of females and 5,5% of males in Durban
      Of the 2058 subjects examined, 186 (9,04%) indulged in the           chewed betel nut. The above smdy was not a random survey,
   chewing habit and 71 (3,4%) of the sample had signs and                 making comparison difficult. Should one accept that the fmd-
   symptoms of impending (early) and established SF. The symp-             ings reflect the situation at that stage, then it means a drastic
   toms and signs were as follows: burning and pain 9, history of          reduction in the practice has taken place. Some reduction is
   \'esicles and ulcers 9, linen- or leather-like mucosae 71, blanch-      probable as there is a growing awareness of the inherent
   ing 63, and fibrous bands 33.                                           danger of betel-nut chewing.
      Females far outnumbered males in all age groups (Table I).              On the other hand, the prevalence rates for people with
   The habit was age-related. However, when the age distribution           signs indicating the onset of the disease or having the disease
   was compared between the chewers without SF and those with              is substantially higher than the results of Shear et al. 9 (0,5%)
   feamres of impending and established SF a significant dif-              and Dockrat and Shear 10 (0,6%) obtained in Pretoria-Johannes-
   ference was found (chi-square test = 23,572; df = 5; P <                burg and Durban. The rates for people with fibrous bands in
   0,001). The majority of chewers without signs of SF were in             this smdy were similar to the findings of Van Wyk et al.
   the age group 65 years and older while the majority of those            (1,25%).13
   with signs of the disease fell in the age group 45 - 54 years              A similar discrepancy is noted in results recorded in India
   (Table 11).                                                             (Table IV). The differences may be partly related to the
      There were no significant differences between the two groups         method of sampling but it is more likely that the diagnostic
   with regard to marriage, occupation, birthplace, home language          criteria we used resulted in the diagnosis of a wider spectrum
   or religion.                                                            of SF cases. As mentioned earlier, we included subjects who,
                                                                           we believed, had early signs of SF as well as those with fully
                                                                           established disease. The occurrence of established cases is
   Discussion and conclusions                                              higher than the majority of Indian smdies but corresponds to
                                                                           the Trivandrum study of Zachariah et al. 18 (Table IV).
   This survey was stnitified according to age and gender, which
   allows for the calculation of related prevalences in the popula-
   tion. The survey was planned according to the required criteria
   for such a type of survey, thus there was every reason to               TABLE IV. PREVALENCE OF SUBMUCOUS FIBROSIS IN INDIA
   believe that the fmdings reflected the true position in Durban.
   The Indian population of Durban in 1980 constimted 46% of                                                                     Prevalence
   the total Indian population of South Mrica, which is over-                Source                Location                        rate (%)
   whelmingly urban. According to Meer 1 the age, religion,
                                               ;                             Pindborg et al.'·     Lucknow                          0,51
   language and social distribution (including the customs) are                                    Bombay                           0,50
   similar for Indians throughout the country. Therefore it can              Pindborg et alY       Bangalore                        0,18
   be argued that the findings in Durban can be extrapolated to              Zachariah et al.'8    Trivandrum                       1,22
   the rest of the country.                                                  Pindborg et al.'9     Andhra Pradesh (Srikakulam)      0,04
      By using the 1980 census figures for this group of South                                     Bihar (Darbhanga)                0,07
   Mricans (Fig. 1), it· was possible to make rough estimates                                      Gujarat (Bhavnagar)              0,16
   regarding the prevalence of chewers and people showing signs                                    Kerala (Ernakulam)               0,36
   of established and impending SF. It is estimated that 5% of               Wahi etal. 20         Uttar Pradesh (Mainpuri)         0,59
   the population (38699) are chewers and that 2,3% (18884)                  Mehta et al. 21       Maharashtra (Poona)              0,03
   could develop the disease (Table Ill). If only established SF             Pindborg et al. 22    Parakadavu                       0,14
   (the presence of palpable fibrous bands in the mouth) was                 Gupta et al.23        Kerala (Ernakulam)               0,65
   considered then the calculated crude prevalence of the disease                                  Gujarat (Bhavnagar)              0,06
   in the total population comes to 1,2% (9844) and 1,6% in
   people older than 10 years (Table Ill).

                               INDIANS ACCORDING TO THE 1980 POPULATION CENSUS
                                                                                           Projected chewers with features of impending
                                   Projected ch ewers                                                   and established SF
              Survey                      General population                     Survey                       General population
Age (yrs)     cases           Females (%)      Males (%)         Total (%)       cases            Females (%)     . Males (%)       Total (%)
10-14           2                  0,7              0,7              0,7          1                   0,7                            0,3
15-24           6                  4,0                               2,0          4                   3,0                            1,5
25-34          17                 12,0                               6,0         13                   9,0                            4,0
35-44          32                 22,0                              11,0         13                   9,0                            4,0
45-54          41                 25,0              3,0             14,0         20                  13,0            0,7             7,0
55-64          37                 24,0              1,4             13,0          9                   6,0                            3,0
65+            51                 31,0              4,0             17,0         11                   7,5                            4,0
10+           186                 12,0              0,5              6,4         71                 6,0             0,06             3,0
All ages                           9,0              0,4              5,0                            4,4             0,04             2,3
                                                                                 Projected occurrence of chewers with fibrous bands (SF)
10+                                                                              33                 3,2                              1,6
All ages                                                                                            2,4                             .1,2
                                                                                                                        SAMJ     VOL 74     3 DEC 1988        571

   The overwhelming preponderance of female chewers reflects                     3. Paymaster JC. Cancer of the buccal mucosa: a clinical study of 650 cases in
                                                                                    Indian patients. Canar 1956; 9: 431-435.
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ance of the betel-nut habit. The above fmdings are in agreement                     Indians with special reference to the betel-chewing habit. Br] Cancer 1969;
with others. 1,4,24                                                                 23: 670-682.
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                                                                                    Afr 1977; 32: 589-592.
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that the pattern of the practice, such as frequency of chewing,                     691-694.
                                                                                15. Meer F. Porlrail of Indian Soulh Africans. Durban: Avon House, 1969: 86.
or individual susceptibility for the disease may induce early                   16. Pindborg H, Kalapessi HK, Kale SA, Singh B, Talyerkhan BN. Frequency
onset.                                                                              of oralleukoplakias and related conditions among 10000 Bombayites.] AI/-
                                                                                    India Denl Assoc 1965; 37: 228-229.
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                                                                                    villagers in Maharashtra, India. 1nl] Cancer 1972; 10: 134-141.
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                                                                                    Incidence and early forms of oral submucous fibrosis. Oral Surg 1980; 22:
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