Paan, Gutkha and Tobacco: What They Do to Your Mouth

Most people who chew paan or gutkha know it is not good for them. What is less widely known is that the harm does not start with the tobacco. Areca nut - supari - is classified as carcinogenic to humans in its own right, by the International Agency for Research on Cancer. A plain paan with no tobacco in it is not a safe version.

That matters here because India carries one of the highest burdens of oral cancer in the world, and because these products are so ordinary - offered after a meal, sold at every corner, chewed through a working day - that they rarely feel like a risk worth acting on.

This article covers what these products do to the teeth, the gums and the lining of the mouth, what to look for in your own mouth, and what an oral cancer screening involves. It is written by Dr. Shipra Jain, BDS MDS, at Mahavirai Dental and Medical Care in Sector 48, Sohna Road, Gurugram.

What is actually in a paan or gutkha packet

The mix varies, but the components repeat:

• Areca nut (supari). The base of most preparations, and the one people most often assume is harmless. It is not.
• Slaked lime (chuna). Strongly alkaline. It raises the pH in the mouth and helps release the active compounds from the nut - and it burns the soft tissue it sits against.
• Betel leaf. The wrapper in paan.
• Tobacco. Present in gutkha, zarda, khaini and paan masala with tobacco - and absent in plain paan masala, which is why that version is often believed to be safe.
• Catechu, flavourings, sweeteners.

Two things make this combination harder on the mouth than the sum of its parts. The quid is usually held in one place - tucked in the cheek or under the lip - so the tissue at that spot is in prolonged contact with the mixture, often for hours. And it is used repeatedly through the day, so that tissue rarely gets a break.

Oral submucous fibrosis: the one to know about

This is the condition most specifically linked to areca nut, and the one most people have never heard of.

In oral submucous fibrosis, the lining of the mouth gradually loses its elasticity. Fibrous bands form in the tissue of the cheeks, and sometimes the palate and around the lips. The mouth slowly becomes stiffer, and opening it becomes progressively harder.

It tends to announce itself quietly:

• A burning sensation when eating anything spicy - often the first thing noticed
• The inside of the cheeks looking pale or blanched rather than pink
• A leathery or tight feeling to the cheek
• Difficulty opening the mouth as wide as before - noticed while eating, or at the dentist
• In later stages, difficulty with the tongue and with swallowing

Two things make it serious. The fibrosis is not reversible - treatment aims to manage symptoms and preserve mouth opening rather than restore the tissue. And it is regarded as a potentially malignant condition, meaning cancer can develop in the affected lining.

It is also, unusually among mouth conditions, one that can affect people who started young. If you chew and you have noticed your mouth opening less freely than it used to, that is worth having looked at rather than adapting around.

What tobacco adds

Where tobacco is present - gutkha, khaini, zarda, or paan with tobacco - it brings its own set of problems on top:

• Leukoplakia. White patches on the lining of the mouth that cannot be rubbed off. This is a pre-cancerous lesion: most do not become cancer, but a proportion do, and there is no way to tell by looking which is which.
• Erythroplakia. Red, velvety patches. Much less common than white patches, and considerably more likely to be significant. A red patch that has not settled needs looking at promptly.
• Delayed healing. Tobacco impairs blood supply to the gums, so extraction sockets, gum treatment and implants all heal less predictably.
• Masked gum disease. This one catches people out. Nicotine constricts the small blood vessels in the gums, so gums that are inflamed may not bleed. Bleeding is the main early warning sign of gum disease, and without it the disease progresses silently - which is why it is often more advanced by the time it is found in someone who uses tobacco.

What it does to the teeth and gums

Before any of the above, there is straightforward mechanical and chemical damage:

• Staining that does not respond to brushing, and often not to whitening either, because it has penetrated rather than sat on the surface.
• Tooth wear. Areca nut is hard. Years of chewing it flattens and chips the biting surfaces.
• Gum recession where the quid is habitually parked, exposing root surfaces that are softer than enamel and more prone to decay and sensitivity.
• Bone loss and loose teeth, as gum disease advances unchecked.
• Decay, particularly with sweetened preparations held against the teeth for long periods.
• Persistent bad breath that does not clear with brushing or mouthwash.

Why smokeless products feel safer, and are not

There is no smoke, no smell on the clothes, nothing that looks like a cigarette. It can be used at a desk, on a commute, anywhere. That absence of the obvious signals of smoking makes it feel like a lesser thing.

But the exposure is arguably more direct: the material sits against the lining of the mouth for hours, in one place, in a way that inhaled smoke does not. And the fact that plain paan masala without tobacco is widely treated as the harmless option misses the point that the areca nut itself is the carcinogen.

Checking your own mouth

A monthly look takes two minutes. Good light, a mirror, and clean hands:

• Pull each cheek out and look at the whole inner surface, including where you park the quid
• Lift the upper lip and pull down the lower lip
• Put out your tongue and look at the top, then lift it and look underneath
• Look at the floor of the mouth and the roof
• Feel along the jawline and neck for any lump
• Note how wide you can open, so you would notice it changing

See a dentist promptly if you find:

• An ulcer or sore that has not healed in two weeks
• A white or red patch that will not rub off
• A lump or thickening anywhere in the mouth or neck
• Numbness, or a persistent burning sensation
• Difficulty opening the mouth, chewing or swallowing
• A tooth that has loosened for no obvious reason
• Bleeding with no clear cause - most often this is simply gingivitis, but persistent bleeding that has no obvious explanation should be checked

Most of these turn out to be something harmless. The reason to have them checked anyway is that the harmless and the serious look very similar early on, and early is when the difference in outcome is greatest.

What a screening involves

Less than people expect. At Mahavirai Dental and Medical Care, an oral cancer screening is part of a routine examination rather than a separate procedure.

Dr. Shipra Jain examines the soft tissues systematically - cheeks, lips, tongue including its underside, floor of the mouth, palate and throat - and feels the neck and jaw for lumps. Mouth opening is measured where fibrosis is a concern, which gives a baseline to compare against later. It takes a few minutes, and it is painless.

If something needs a closer look, it is either monitored over a defined period or referred for biopsy. Being referred is not itself alarming - it is how a definite answer is obtained rather than a guess.

If you use these products regularly, screening at every check-up is worth asking for by name, and worth mentioning the habit even if it feels awkward. It changes what your dentist looks for.

If you are trying to stop

Not a lecture - just what changes, because it is more encouraging than most people expect:

• The gums respond quickly. Blood supply improves within weeks, and gum treatment starts to work properly rather than partially.
• Healing improves, which matters if extractions, gum treatment or implants are on the horizon.
• Risk falls over time. It does not return to that of someone who never used, but it drops, and it keeps dropping.
• Some early lesions regress once the irritant is removed - though established fibrosis will not.
• Staining can be removed once it stops being replaced. A professional clean handles most of it.

Cutting down is not the same as stopping, but it is not nothing either. If quitting outright is not realistic right now, screening becomes more important, not less.

Getting your mouth checked in Gurgaon

If you chew paan, gutkha, khaini or zarda - or you have stopped but used to - a screening is a short appointment that either reassures you or finds something while it is still small. Those are the only two outcomes, and both are better than not knowing.

Mahavirai Dental and Medical Care is a dental clinic in Sector 48, Sohna Road, Gurugram, led by Dr. Shipra Jain, BDS MDS, an endodontist and implantologist. Screening is included in a routine examination, and if something needs treating - gum disease, worn or loose teeth, staining - it can be assessed at the same visit. Our article on gum disease and overall health explores the gum-health part of this assessment.

To book, get in touch or use the appointment form. If you have found something in your own mouth that worries you, say so when you book and we will see you sooner.