Chewing betel nut is a tradition extending from Southeast Asia to the Pacific. Globally, betel nut is the fourth main psychotropic substance containing a stimulant, arecoline, that has a similar effect to nicotine. In Palau, there is broad acceptance of betel nut chewing. One of the largest immigrant groups in Hawaii is the Palauans. Chewing betel nut has significant social implications that make it difficult for those who engage in this practice to separate potential oral disease from the social importance. However, little is known about the social impact of oral disease from chewing betel nut on Palauans in Hawaii.