A new study from oncologists in Bangalore has found that the oral precancerous lesions in persons using chewing tobacco products like gutkha and pan-masala is largely linked to the fluoride content, contrary to popular belief that the copper content in areca nut is the primary cause. The fluoride in the chewing tobacco products is said to be the new cause of development of precancerous lesions in the oral cavity and the severity of the cancer in those affected.
Gutkha and Pan Masala, popular chewing tobacco products in India, contain high levels of fluoride, which is absorbed and stored in the oral tissues in large amounts, leading to the development and increased severity of a pre-cancerous condition called Oral Submucous Fibrosis (OSMF), as per the research finding. The study points out that the fluoride content leads to OSMF, stiffening of oral tissues and decrease the ability to fully open your mouth.
The research done by the team of oncologists and researchers from HCG Cancer Hospital has been published in the Journal of Oral Pathology and Medicine, on February 28, 2024. It has also been published in the British Journal of Oral and Maxillofacial Surgery and in Medical Hypotheses. As per the research, the fluoride accumulation could be a potential new cause for OSMF, contrary to popular belief that the primary cause was the copper content in areca nut (which is used to prepare gutkha and pan masala).
According to the researchers, the fluoride content in gutkha and pan masala could not only lead to the development of OSMF, but its continuous use could also potentially contribute to malignant transformation. This raises serious concerns about the risk of oral cancer, they say.
Speaking to Happiest Health, Dr US Vishal Rao, group director-head and neck surgical oncology and robotic surgery, HCG Cancer Hospital, Bangalore, says that tobacco-related submucous fibrosis is a problem that is indigenous to India and South Asian countries.
“It is considered as a premalignant condition, which means that it is a precursor to cancer. People who chew tobacco all the time, eventually get scarring inside the mouth, which prevents their mouth from opening. In the long run, their mouth completely closes. However, this problem does not have a treatment till date and not much research done on it. So, we decided to do a deep dive to analyze the connection with fluoride,” Dr Rao said.
Dr Rao says that this research is one of the first steps towards shaping treatment for the condition and prevention.
“For the first time, we’re able to pinpoint, instead of just blaming tobacco, certain specific elements which are being used inside tobacco, possibly as an adulterant and to improve nicotine delivery as the cause,” Dr Rao adds.
The researchers of the study included Dr Shekar Patil, senior medical oncologist and Dr Gururaj Arakeri, program director, HCG oncology.
What is gutkha and pan masala?
Gutkha is a combination of sun-dried and finely chopped tobacco, areca nut, slaked lime, catechu, flavorings, and sweeteners. Pan Masala also contains tobacco, areca nut, slaked lime, catechu, flavourings, and sweeteners. These are the two popular forms of smokeless tobacco products which are widely consumed in India, according to the International Agency for Research in Cancer (IARC) of the World Health Organization.
According to numbers available with the agency, as of August 2021, 21.4 % of the population surveyed in India reported being current users of smokeless tobacco.
Fluoride in gutkha and pan masala
Dr Rao says that certain chemicals are added to the tobacco leaves and areca nut during the preparation of gutkha, pan masala to improve the nicotine delivery process. “Fluoride is one such substance added and that’s a key culprit here,” says Dr Rao, adding that while consuming chewing tobacco products, the fluoride content directly touches the inside of one’s cheek. “It is directly, regularly in contact with the skin in the oral cavity, gets absorbed into the skin and then triggers scarring,” he says.
Knowing that the fluoride in the tissues can trigger scarring, the researchers conducted a preliminary study comparing two groups- one group of those who didn’t consume any form of tobacco, pan masala and the other group who chewed tobacco specifically. “And we clearly found that the levels of fluoride in the group that consumed tobacco was very, very high compared to zero in the non-tobacco group,” says Dr Rao.
More public awareness, stronger regulation required
Researchers behind the study are now calling for increased public awareness and stronger regulatory measures to address the overlooked health risk posed by the fluoride content in gutkha and pan masala.
They have also pointed towards the need for further research into the effects of fluoride on oral health and for this research to potentially aid the discovery of new preventative measures and treatment plans for OSMF and oral cancer.
Further research needed
The doctors at HCG Cancer Hospital say they are planning to conduct further research, with a larger sample size, to validate their results and are also looking to incorporate molecular studies into their research. “This includes studies on malignant transformation, which could provide more insights into the progression from oral submucous fibrosis to oral cancer,” they said in a statement.
Takeaways
New research from doctors at HCG Cancer Hospital, Bangalore, has identified fluoride as a potential new cause of Oral Submucous Fibrosis (OSMF), a pre-cancerous condition in people using gutkha and pan masala. It was earlier believed that the copper content in areca nut was the primary culprit. Researchers say there should be increased public awareness and more studies done on the health risk posed by fluoride in chewing tobacco products.
