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ACMT Toxicology Visual Pearls: Toxic Mouth Pain

Heather A. Borek, MD |

betel nut mouthA middle-aged Asian female presents to the emergency department complaining of 2-3 days of mouth pain. She has chewed betel nut for a number of years. Which of the following is true regarding her presentation and management?

  1. Debridement should be avoided.
  2. Metronidazole is contraindicated due to the potential of a disulfiram-like reaction.
  3. Oral secretagogues should be used due to the anticholinergic effects.
  4. The patient is at increased risk of oral cancer.

Betel nut use: Acute necrotizing ulcerative gingivitis


Answer: 4
The patient is at increased risk of oral cancer

What is Betel Nut?

Chewing “betel quid”, betel nut, or areca nut is a practice encountered in Tropical Pacific, Southeast Asia, and East African regions. The betel nut consists of betel leaf, areca nut, catechu, lime, and at times tobacco. The product is used similarly to tobacco or caffeine as it has a mild euphoric and stimulatory effect and is thought to aid in digestion. The areca nut contains multiple alkaloids, the most prominent being arecoline, an acetylcholine receptor agonist producing cholinergic effects. The severity of clinical manifestations ranges from mild (such as increased salivation) to more rare but serious effects like bronchoconstriction, bronchorrhea, or bradycardia. The chewing of betel nut is associated with an increased risk of cancer of the oropharynx, liver, and uterus.1

Acute Necrotizing Ulcerative Gingivitis

Betel nut use is also associated with the development of acute necrotizing ulcerative gingivitis (ANUG), also known as “trench mouth.” ANUG is an acute bacterial infection of the periodontal tissue that can be accompanied by systemic symptoms such as fever, lymphadenopathy, and malaise. Fusobacterium, spirochetes, and other oral flora tend to be the culprit bacteria, though the infection is usually polymicrobial and often includes anaerobes.2 The infection is characterized by painful erosions of the interdental papilla that may form a pseudomembrane and spread to the oropharynx and lips. It is distinguished from chronic periodontal disease clinically by the severe pain and systemic signs.3

Immunodeficiency, poor oral care, nutritional deficiencies, and use of oral carcinogens (tobacco or Betel nut) are the most common risk factors in patients with ANUG.3 Treatment for ANUG is oral antibiotics with penicillin VK and metronidazole, amoxicillin/clavulanate, or clindamycin to cover anaerobic bacteria.2,4 Management also includes debridement by a dentist and oral rinses with chlorhexidine.

Bedside Pearls

  1. Betel nut contains arecoline that acts as an agonist at nicotinic and muscarinic receptors to produce cholinergic effects.
  2. Betel nut is an oral carcinogen and poses a risk for dental disease risk similar to tobacco.
  3. ANUG is characterized by acute presentation, severe pain, and systemic signs and symptoms.
  4. ANUG can be treated with antibiotics to cover anaerobes (such as penicillin VK plus metronidazole) as well as oral rinses and debridement.

This post was expert peer-reviewed by Dr. Bryan Judge, Dr. Louise Kao, and Dr. Ziad Kazzi.

Garg A, Chaturvedi P, Gupta P. A review of the systemic adverse effects of areca nut or betel nut. Indian J Med Paediatr Oncol. 2014;35(1):3-9. [PubMed]
Loesche W, Syed S, Laughon B, Stoll J. The bacteriology of acute necrotizing ulcerative gingivitis. J Periodontol. 1982;53(4):223-230. [PubMed]
Malek R, Gharibi A, Khlil N, Kissa J. Necrotizing Ulcerative Gingivitis. Contemp Clin Dent. 2017;8(3):496-500. [PubMed]
Rosen P, ed. Rosen’s Emergency Medicine. 9th ed. Elsevier; 2018.

Author information

Heather A. Borek, MD

Heather A. Borek, MD

Assistant Professor
Department of Emergency Medicine
Division of Medical Toxicology
University of Virginia

The post ACMT Toxicology Visual Pearls: Toxic Mouth Pain appeared first on ALiEM.

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