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Eastern Medicine Meets Dentistry: The Use of Herbal Supplements in Dentistry Today

Natalie Kaweckyj, LDARF, CDA, CDPMA, COMSA, COA, CPFDA, CRFDA, MADAA, BA

August 2020 Course - Expires December 31st, 2023

American Dental Assistants Association

Abstract

Herbs and other supplements are becoming much more common in the United States due to public dissatisfaction of soaring prescription costs the past couple of decades, combined with the interest in returning to naturally-based products, in addition to diet supplementation with powders and pills. Four in five individuals takes some form of supplementation, whether in the form of vitamins, minerals or tonic. According to the World Health Organization, it is estimated that 85% of people worldwide rely on herbal medicines for some part of their primary health care management. In addition to the supplements many of our patients are knowingly taking, some oral health products contain herbal ingredients that may cause adverse outcomes when taken with other over-the-counter or prescription medications. The dental team must be aware of oral products containing herbs and supplements and recognize potentially dangerous combinations between various herbs or supplements and drugs commonly used in dentistry today.

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Introduction

Herbs and other supplements are becoming much more common in the United States due to public dissatisfaction of soaring prescription costs the past couple of decades, combined with the interest in returning to naturally based products, in addition to diet supplementation with powders and pills. Four in five individuals takes some form of supplementation, whether in the form of vitamins, minerals or tonic. According to the World Health Organization, it is estimated that 85% of people worldwide rely on herbal medicines for some part of their primary health care management. In addition to the supplements many of our patients are knowingly taking, some oral health products contain herbal ingredients that may cause adverse outcomes when taken with other over-the-counter or prescription medications. The dental team must be aware of oral products containing herbs and supplements and recognize potentially dangerous combinations between various herbs or supplements and drugs commonly used in dentistry today.

History of Herbal Supplementation

In this course Eastern medicine refers to the practice of medicine and medical alternatives worldwide. Western medicine refers to the practice of medicine in the United States and other Western countries that has scientific data backing the drugs and techniques used. Herbal Supplementation is becoming more customary as improvements in analysis and quality control, along with advances in clinical research, show the value of herbal medicine in treating and preventing disease as well as other ailments.

In ancient times, plants were assigned curative powers based on shape or color. Phytotherapy, also sometimes referred to as phytomedicine, has been a part of both Eastern and Western medical traditions since approximately 2000 BC and uses a plant's bark, berries, flowers, leaves, roots and seeds for medicinal purposes. More than two thousand plants were thought to have medicinal properties in the ancient world. The Chinese began using ginseng at least 3000 years ago, and Native Americans used willow bark tea to reduce fever about the time most of the "civilized world" was under Roman rule. Each civilization that has chronicled its progress produced a body of knowledge addressing the use of medicinal plants. Though displaced to some degree by the rise of what is referred to as modern medicine, herbalists and herbal preparations have continued to be part of folk and Oriental medical practice. Research has found that people in various parts of the world tend to use the same or similar plants for the same purposes. The recent increase in the popularity of herbals in American and European societies does reflect a growing dissatisfaction with current traditional medical practice, or an interest in more natural or holistic modes of healthcare. This is especially true among the elderly, where use of herbal supplementation has increased dramatically.

Herbal extracts are effective because of the interaction with specific chemical receptors within the body although in many cases, scientists are not sure what specific ingredient in a particular herb works to treat a condition or illness. Whole herbs contain many ingredients, and they may work together to produce a beneficial effect. From a pharmacodynamic perspective, herbal extracts are drugs themselves. Current estimates suggest that about half of Americans take a multivitamin, with many also taking individual vitamin supplements. Approximately 20% of those in the United States take herbal supplements while one in three also takes prescription medications in combination with herbal remedies; this translates into approximately 72 million people in the United States alone. More than 700 medications that formerly required a prescription are now available over the counter in many retail venues. The potential for a dangerous interaction between prescription medications and herbal extracts is not only significant, but on the rise as new information is learned about adverse effects with certain combinations.

There are many possible explanations for the increased use and acceptance of herbal supplements as a viable alternative to modern-day medicines. It is believed that society is turning toward natural therapies because of the technological clutter in our lives. People tend to think of nature as a place of purity, simplicity and safety. The media has also played a factor in the increase in usage with the high profile recalls of various prescription medications, like the COX-2 inhibitor Vioxx and the once popular diet drug FenPhen from the 1990s. Frequent drug recalls cause society to become distrustful of proven pharmaceuticals and search for alternative ways to treat disease and infection. Some of these drug recalls occur after the drug has been in the marketplace for decades. Individuals sometimes will not take a drug because they think drugs are dangerous but will take anything that's called an herb. Many people view herbal medicines as being more mild or safer than other drugs, but some plants contain chemicals that are powerful drugs. In fact, about 40% of all prescription medicines come from plants extracts or synthesized plant compounds.

Western Conventionalism vs. Eastern Alternativism

Herbal medicines use plant or plant ingredients to improve or maintain health. The plants and plant products are called herbs, herbal remedies, herbal medicinals, medicinal herbs, medicinal plants, and phytomedicinals. Conventional prescription and over-the-counter (OTC) medications sold in the United States may be a derivative of plants, but these medications differ from herbal medications. These traditional drugs are based on an active ingredient or chemical that pharmaceutical companies synthesize when they develop the drug. Additionally, the United States Food and Drug Administration (FDA) must approve these active ingredients for use through repeated testing and clinical trials. These traditional drugs are based on a chemical that is made in a laboratory at a pharmaceutical company, even though the active ingredient may have originally come from a plant source.

Herbal medications, sometimes referred to as botanical or alternative medications, are made from natural chemicals extracted from a plant in a specific concentration and are produced either in original form, combined with other herbal extracts, or refined. When an herbal medication is refined, the essential extract is taken out of the plant source, concentrated and then added back to make the original herbal medication more potent.

Trends in Usage of Herbal Supplements

Herbal drug purchases are highly affected by trends and the proliferation of information on the Internet.

Much of the information available on the World Wide Web about popular herbal supplements and remedies is market-driven and not supported by clinical study or research by reputable sources. Researchers from Harvard University found that most Internet sites providing information on herbal supplements are either selling herbal products or linked to a vendor who sells them. There is great concern among the medical and dental communities that consumers may be misled by unproven claims that herbal supplements cure, diagnose, prevent or treat specific ailments and diseases. Increased supplement use may also be influenced by the trend toward the addition of herbs in multivitamin products and coverage for purchase of herbal supplements under health insurance plans. Despite the fact that health claims for herbal supplements are largely untested and unproved, an industry survey conducted in 2002 by the American Association of Health Plans and Health Insurance Association of America found that approximately fifty-eight percent of medical plans pay for herbal medicines and treatments.

2020 ingredient trends to watch for in food, drinks and dietary supplements include the following:

• Adaptogens for stress - relief supplements. Ashwagandha is an ancient medicinal herb used for managing body stress relief.

• Collagen - for joint health. Tumeric is also often used for bone and joint health.

• MTCs (Medium Chain Triglycerides) - used for sustained energy, increased endurance, weight loss management, and for enhanced brain and cognitive function. MTCs are often used as a substitute for caffeine.

• Hemp CBD (cannabidiol) - oil that is harvested from mature hemp stalks and has muscle relaxant properties; non-psychoactive and successful in treating seizures.

• Magnesium - for cardiovascular health, immune system and joint health; energy production, glucose metabolism and mood support.

• Prebiotics and fiber - healthy fiber food for the healthy bacteria in your gut; early product development and growing consumer interest. Elderberry use is growing in popularity.

• Probiotics - sales of probiotic products were number 4 in 2019. Ingredient listings will have exact strain of bacteria at some point in the future.

- Melatonin - the most well-known natural sleep aid.

The most popular herbal medicines sold yearly include echinacea, thought to relieve cold symptoms; ginkgo and ginseng, sold to improve memory and alertness; and St. John's wort, which may relieve mild depression. Some herbs used to flavor food in cooking may have medical uses, such as garlic, which may reduce the risk of heart disease. Others rounding out the Top 9 herbal medicines include elderberry, used for headaches and constipation; ginger, used to relieve nausea; tumeric, used to treat chronic inflammation and anxiety; valerian, thought to induce tranquility and calm; and chamomile, used for digestive issues and respiratory infections.

Alteration of Herbs

There has been a drive for more information about product safety in response to the increased patient use of herbal supplements. Much of the information gleaned has been eye opening. Reputable research confirms that the concern by health practitioners about herbal medicines is not unsubstantiated. When herbal supplements are manufactured, their chemical form may be altered with the use of metals and pesticides, ingredients may be substituted or misidentified, and they may be mislabeled. The chemical composition of herbal supplements is unpredictable, even when produced by conscientious manufacturing firms.

The quality, purity and strength of herbal supplements can be affected by a number of factors, including the:

• Season the herb is grown - whether in the spring, summer or fall.

• Geographical source of the plant - dry and arid, vs. humid.

• Time and conditions at harvest, whether dry or rainy.

• Drying and processing procedures used for the raw material.

• Formulation and manufacturing of the final dosage form.

The greatest risk presented by the use of herbal medicine may be that there is so much that is unknown to researchers.

Regulation of Herbal Supplements

The Dietary Supplement Health and Education Act of 1994 regulates dietary supplements, which it defines as vitamins, minerals, amino acids, herbs and other botanicals, and other products that contain a dietary substance to supplement the diet. This regulation limits the regulation of herbal supplements by the Food and Drug Administration (FDA).

Of the 20,000+ herbal nutritional and dietary supplements available today, fewer than 50 have existing controlled trial documentation of efficacy. The FDA classifies herbal medicines separately from nonprescription and prescription medicines. An herbal remedy is considered a dietary supplement, a product that is taken in addition to a normal balanced diet but is not a food or drug.

Dietary supplements include products such as amino acids, herbal preparations, minerals, vitamins, and other materials whose main ingredients are plant derivatives. Millions of people take dietary supplements daily for one reason or another. Common reasons for the use of supplements include ensuring adequate nutrition, increasing energy levels, reducing stress, or relieving some condition. They often regard the supplements as wholesome substitutes for drugs. Dietary supplements are sold as pills, capsules, liquids, extracts, teas, and powders, with many supplements being based on traditional folk or herbal remedies.

Many supplements, such as vitamins and minerals, provide substances that are necessary to maintain excellent health. Yet most people will get enough of these substances if they eat a balanced diet. And many dietary supplements contain naturally occurring compounds that can act like and interact with drugs. In the United States, the FDA must approve drugs after repeated testing and clinical trials. The FDA ensures that drugs are safe and are effective to treat the conditions for which they are approved. When a drug is prescribed, it has gone through three phases of rigid testing. Part of that testing is to determine the safe upper limit of the drug and the effective dose of the drug. Although many drug interactions are dose dependent, instructions for the use of herbals aren't supported by sufficient clinical trials so guidelines for dose, concentration, and therapeutic uses are at best a guess by the manufacturer. Dietary supplements can be sold without FDA approval, and thus may not be safe or effective.

Most dietary supplements are safe when taken according to directions, but there are always some exceptions. Ephedra, also called ma huang, is an herb taken to help people increase energy. Ephedra contains the natural chemical ephedrine. Ephedrine is a stimulant and is an ingredient in several prescription and OTC drugs. Use of products containing ephedra may cause serious side effects, including but not limited to irregular heart rhythms, seizures, stroke, and death. In 2004, the FDA banned all products containing ephedra. A year later, the ban was removed when a federal court ruled the FDA did not have the authority to ban ephedra as a dietary supplement. Several deaths had resulted with the use of ephedra in dietary supplement form.

Dietary supplements can also cause harmful reactions by interacting chemically with prescription drugs. Responsible manufacturers have added labels to their products warning people not to take a supplement if they are taking certain medications, but many still take the supplements in combination with their prescribed medications. People should consult a physician about possible side effects and adverse reactions before taking any dietary supplement.

Scientists continually research the safety and effectiveness of herbs and synthetic alternatives to prescription drugs. Even though herbal medicines are natural, many do cause side effects. Herbal medicines act differently in different people, based on metabolism and the body's ability to breakdown compounds. It is important to consult a doctor or pharmacist when thinking about taking them. The strength of the active ingredients in an herbal remedy may vary depending on how the plant is grown, harvested, stored, and prepared. Unwanted effects may result from an allergy, an impurity in the product, an interaction with other drugs, a misidentification of the plant, or a wrong dose. While the benefit of some herbal medicines may outweigh the risks, for some people the risks may be too high or unknown. Individuals with allergies to certain weeds and grasses should especially be advised to consult their physician.

Scientists are investigating the active ingredients, best doses, and right combinations of herbal medicines as well as the effects that other medicines or food may have on them. Research is being conducted on the many kinds of dietary supplements to determine if they are effective in treating diseases and ailments, as many currently claim. One supplement under study is made from the leaves of the ginkgo tree, which have been used as medicine for hundreds of years in China. Researchers have found that ginkgo extract may help improve short-term memory and concentration in people with Alzheimer's disease. However, the FDA prohibits companies from claiming that any dietary supplement can cure, prevent, or treat disease.

Interactions With Dental Drugs

The National Toxicology Program has recently started to examine the structure and consistency of commercial herbal preparations to identify potential health risks from contaminants or product over use. Many herbal preparations have significant pharmacological effects. The problem that arises for the dental team is the effect these herbal products have in combination with prescription medications as well as effects on the patient's general response to medication and dental treatment. The prevalent use of herbal supplements makes it essential that healthcare providers become informed about this part of a patient's personal health practices. In 2019, the 10 most commonly prescribed drugs taken by patients arriving for dental treatment included those listed in Table 1.

The above-mentioned drugs all have various side effects when taken as directed. Patients may decide to self-medicate with herbal supplements to alleviate some of the side effects. For example, patients may experience sleeplessness when taking Advair, Crestor, Synthroid, Ventolin and Vyvanse, and may take the supplements kava or valerian to help get a good night's sleep. Patients may take the supplements feverfew for headaches and ginger root for nausea associated with taking the prescribed medications Advair, Diovan, Vyvanse, Nexium, and Ventolin. Patients may also take the supplement yohimbe to alleviate xerostomia with the use of Advair, Cymbalta, Lyrica, Nexium, Ventolin and Vyvanse.

Herbal supplements can cause side effects on their own or when combined with prescribed medications. Even though the supplement may be natural and from a natural source, it may be working in the same way as the drug it imitates, with the same possible side effects. St. John's wort is an herbal supplement used to alleviate the symptoms of mild depression and causes xerostomia, just as prescribed antidepressants do. Other side effects of herbal supplements include episodes of oral ulcers, lip irritation, swelling and gingival bleeding with the use of feverfew; increased gingival bleeding with ginkgo; oral and lingual dyskinesia with the use of kava; and tongue numbness and taste changes with the use of echinacea.

Analgesics, anesthesia, anesthetics, antibiotics, and vasoconstrictors are the drugs most likely to cause a reaction when used in conjunction with herbal supplements. Other frequently used medications in dentistry include antiseptics, anti-inflammatory medications, antifungals, fluoride, muscle relaxants, pain relievers, and saliva stimulants. Again, patients may decide to self-medicate against the side effects, resulting in more opportunities for interaction. To lessen interaction potential in surgical situations, many anesthesiologists recommend discontinuing the use of herbal supplements two to three weeks before surgery. It is recommended that dentists tell their patients to stop using the herbal supplements in Table 2 prior to dental surgery of any type.

According to recent research conducted at Case Western Reserve University School of Medicine in Cleveland, Ohio, the most frequent adverse oral and dental effects of herbal medications are dysgeusia, gingival hyperplasia, intraoral hemorrhage, necrosis, oral candidiasis, oral ulceration, stomatitis, tooth discoloration, and xerostomia. The most common side effect resulting from drug interactions between drugs used in dentistry and herbal supplements is bleeding. Increased bleeding during dental surgeries can cause a variety of complications, and sometimes hospitalization. Dental surgeries include procedures such as tooth extractions, periodontal surgeries, root planing, and biopsies. Bleeding can also complicate routine procedures such as prophylaxis, exams, and restorations.

The common herbal supplements feverfew, garlic, ginkgo, and goldenseal as well as the more uncommon alfalfa, barberry, bromelain, cinnabar root, dong quai, horse chestnut, melilot, Oregon grape, and sweet woodruff have been associated with an increased risk of bleeding during dental treatment.

Increased bleeding is not the only side effect of interactions between herbal supplements and dental medicines. Herbal supplements can have an impact on cardiac function, immunity to fight infections, metabolism of drug compounds, pain thresholds, recovery time, bruising, and sedation effects. These supplements can increase or decrease the potency of prescription medications, reducing their effectiveness or leading to the accumulation of otherwise beneficial drugs to toxic levels in the body. For instance, the medicinal herb cassia cinnamon used as a painkiller reduces the effectiveness of tetracycline by up to 80%, and calming herbal supplements, such as kava kava or St. John's wort, can strengthen the effects of general and local anesthesia. Since reputable research on herbal supplements is limited, a multitude of other potentially dangerous interactions could yet be unknown.

Pharmacology: Traditional Drugs vs. Herbal Compositions

Many herbal preparations have considerable pharmacological effects. The problem for the dental team is the unintended consequences that herbal supplements can have in combination with prescription medications, as well as effects on the patient's general response to medication and dental treatment. Drug interactions with the large number of commercially available herbal products can be grouped by the mechanism of most common interactions. These fall into three major types of  reactions: blood-clotting process, drug metabolizing, and inflammatory and immune response of the body. There are also several subgroups.

Blood-clotting interactions

Many herbal supplements can affect blood clotting. Red clover hay when dried improperly creates numerous compounds that prevent blood clotting. The best known of these compounds is the coumadin group, including dicumarol and warfarin. Many plant products can act similarly to prevent coagulation. Almost all act as vitamin K analogs, blocking the fibrin-clotting cascade. Four of the most popular herbal supplements that affect blood clotting are garlic, ginger, ginkgo biloba, and ginseng. These supplements often slow down the clotting process, although the mechanism by which each of them works differs significantly. Other herbal supplements that affect the clotting process of blood include those in Table 3.

Drug metabolizing reactions

Many supplements can have drug metabolizing reactions. For instance, the most important risk for prescription drug interactions with the widely used herbal supplement St. John's wort is with the serotonin-uptake inhibitors. The mechanism by which St. John's wort, when acting as an inhibitor of MAO, exerts a beneficial effect on depression is still not fully understood. The hypericins are known to be of the chemically active species. Variations in the preparation of St. John's wort have led to unpredictable responses and irregular effects on mood elevation. St. John's wort is also known to increase sensitivity to ionizing radiation, but it is not known if this represents a risk factor for dental radiography. Hypericin in St. John's wort may be a risk factor in higher dose ionizing radiation exposure such as cancer radiotherapy. There is also a strong possibility that St. John's wort acts to oppose the effect of antihistamines, increasing the histamine levels competing for receptor binding site occupancy.

Other drug metabolizing reactions include those in Table 4, Table 5, and Table 6.

Inflammatory and immune reactions

The most familiar and most extensively used plant affecting inflammation and immune response is the American Coneflower, the Echinacea species (Table 7). These plants are part of the Native American pharmacopoeia in all areas of North America where echinacea is native. Research has shown that some effect on the immune system has been demonstrated. Some recent success in treating colds have been observed, but based on clinical studies, only a 10% risk reduction for upper respiratory infection could be attributed to echinacea. Use of echinacea to relieve colds may be of limited value, but these plants may have a useful role in regulating the inflammatory response. Since echinacea may function as an immunostimulant, use with immunosuppressants like corticosteroids and cyclosporine is contraindicated. Hepatotoxicity has been observed with echinacea and continuous use should be limited to 8 weeks or less. Echinacea should not be used with other drugs producing liver effects such as methotrexate, ketoconazole, and phenytoin. Echinacea preparations have been difficult to standardize. The pharmacologically active glycosides are not highly soluble in alcohol so methods of extraction either by water or alcohol are crucial to the efficacy of the preparation and vary the end ingredients.

Herbal Supplements Useful in Dentistry

Despite the promise of some herbal preparations and the lack of effective medicines for some dental problems, dentists are hesitant to stray from the proven drugs used every day in practice.

The herbs aloe vera, bloodroot, calendula, echinacea, goldenseal, and grapefruit seed extract are useful for treating periodontal problems, while clove oil, garlic, lemon balm, licorice and propolis are helpful for fighting toothaches. Calendula, lavender oil, and echinacea are being used to reduce inflamed gingival tissues and treat opportunistic yeast that causes thrush. Propolis, a bee product, is thought to be an antiviral and useful in treating mouth sores. Alfalfa, dandelion, horsetail and plankton can help reduce tooth decay, and yohimbe increases salivation in some patients. The berberine content of goldenseal gives it an antimicrobial effect, killing off offensive bacteria. Bloodroot is known to inhibit decay-causing bacteria.

On healthypeople.net, Christopher Hobbs, licensed acupuncturist and member of the American Herbalist Guild, stated that essential oil-bearing plants are anti-bacterial and useful in promoting blood flow to the gingiva. These would include peppermint, spearmint, and cinnamon.

Although there may be benefits to using herbal medicines in the practice of dentistry, we really do not know much about them. Holistic dentists promote the use of alternative methods to diagnose, treat, prevent or cure a wide range of disorders that traditional medicine cannot yet cure. Some holistic dentists endorse products that are formulated from natural ingredients. Although studies may exist supporting the effectiveness of individual natural ingredients, few of these natural ingredient fortified products have had their effectiveness demonstrated in the form available for purchase. With additional research, there definitely will be a niche for herbal treatments in dentistry.

Alternative Oral and Dental Care Products

A variety of products are promoted for oral and dental uses as alternatives to standard commercial products that can be purchased OTC. Herbal products use herbal extracts to yield an active ingredient. Few of these compounds have had their effectiveness demonstrated in toothpaste formulations, although some dentifrices contain polyphenols found in green tea due to the alleged antimicrobial effects. Herbal components such as chamomile, clove oil, echinacea, eucalyptus, fennel, ginger, licorice root, tincture of myrrh, nettle leaves, tea tree oil, witch hazel, and watercress are included in herbal dental products. Herbal products have also been marketed for the management of halitosis. Parsley has been known as a breath sweetener and is often included on the plate to nibble on after eating in restaurants. Licorice sweetens breath and is used to flavor herbal toothpastes and mouthwashes. Bloodroot extract, a derivative of sanguinaria canadensis, has previously been included in oral rinse and toothpaste products with evidence of safety and effectiveness, yet there are recent reports of concerns emerging with use of this extract. Appendix I provides a list of commonly used herbals used in oral health care products.

Alternative products synthetically made include manufactured compounds often resulting from essential oils such as eucalyptol, eugenol, menthol and phenol. These ingredients are phenolic compounds, some with a history of dental use (i.e. eugenol). These compounds are primarily disinfectants even though there is no evidence of intraoral disinfection when used in oral preparations. They are mainly used as topical anesthetics.

All-natural products are typically formulated from naturally made ingredients. This group includes natural dentifrices with the abrasive ingredient coming from calcium carbonate, the fluoride component from fluorspar, and the thickening element may be of seaweed origin such as guar gum. Some of these dentifrices do not contain fluoride, and beneficial claims have not been demonstrated in clinical trials.

Homeopathic remedies have also been marketed for oral care, although reports of controlled studies with homeopathic products for oral care have not been identified. For example, a product advocated for the management of halitosis includes a combination of parsley and cottonseed oil, but because this product is marketed as a dietary supplement, documented data of safety and effectiveness against halitosis is not required prior to public use. Products are often promoted on the foundation of the individual ingredients in the product and cite laboratory studies of the action of components. These cited reviews are often not based on scientific facts of the active ingredients in the form that they are used in the oral care product.

Educating the Dental Patient

Encourage your patients to always provide you with a complete medical history, including any herbal medication and conventional drugs they are taking. Some individuals who take alternative medicines are afraid the dental team will not respect their decision to take an herbal medication and will tell them to stop taking it. However, as herbal medications become more popular, many clinicians are beginning to use them in their practices. Any discussion the dental team has with a patient about herbal supplements should be conducted with caution. Patients are likely to feel an herbal supplement is of value to their health and well-being, making it difficult to give guidance without interfering with the patient's ideas or beliefs.

The dental aspects of herbal supplementation are not as diverse as those faced by the medical community. However, plant extracts affecting inflammation and bleeding are of significant interest to the dental professional. If an herbal medication could interfere with dental treatment, you may ask your patient to stop taking the medication until the treatment is complete. The dentist also may be able to prescribe a different drug for treatment, if one is available. If the conversation is initiated by observations made by the dental team members during treatment, direct inquiry is certainly justified. This is especially true of circumstances leading to unusual bleeding of the gingiva. If the patient inquires about the effects of a particular herb, it is essential the facts about herbal supplements be presented as objectively as possible to allow the patient to make an informed decision. However, the dental professional is also obliged to supply professional judgment. Based on the current understanding of the interactions and mechanisms of action of these supplements as well as the patient's medical history, a clear and reasoned recommendation can be made without producing patient confrontation or resentment. A more difficult question to answer is about the health benefits of herbal supplements. Whatever the dental professional says will either contradict or substantiate the patient's predetermined notions, making accurate knowledge crucial.

Children under the age of 15 and elderly patients seem to be more prone to the possible adverse effects and should avoid taking herbs except at the advice of their healthcare provider. Pregnant women should not take any herbal supplements because of the herb's ability to cross through the placental barrier, or even cause premature contractions. Breastfeeding women should also refrain from taking any herbal supplements to prevent the herb's effects from being passed on to the infant.

Multi vitamins and mineral supplements

Another area of growing concern is the overuse of vitamins. Many people consider vitamins safe to take in any dose, but each year the media reports thousands of cases of supplement toxicity, especially in children. The potencies of these self-prescribed supplements vary widely, containing inconsequential amounts to more than 5,000% of the recommended daily intake. The patient's medical history should include questions related to dietary supplements since most patients do not inform their healthcare providers of their usage. Documentation in the patient chart of the type of supplement, amount usually taken, potential interactions, and dental implications is a necessity. Some of your patients may also be taking amino acid and folic acid supplements or herbal products considered natural. These supplements may be considered safe and advantageous but may adversely affect an existing medical condition or interact with other supplements or medications that have been prescribed. According to the American Dietetic Association, nutrient supplementation can be helpful in meeting the recommended daily allowance (RDA) for specific conditions.

• Supplementation of iron during pregnancy.

• Supplemental vitamin B12 or fortified foods may be required for strict vegans who eliminate all animal products and persons over age 50 due to the possible reduction in absorption of vitamin B12.

• Synthetic folic acid from fortified foods or a supplement for women capable of becoming pregnant and for vegans.

• Vitamin D for those with limited milk intake and sunlight exposure - especially the elderly.

• Multivitamin and mineral supplementation or fortified foods, for those following severely restricted dietary intakes and for individuals over age 50.

• Calcium for those who prefer to meet the higher recommendations with fortification or supplemental sources of calcium.

It is recommended that individuals avoid the use of beta-carotene supplements and doses greater than the recommended daily allowance for vitamins A, C and E, and folic acid to reduce the risk of cardiovascular disease or cancer. There may be no evidence of harm, but there is also inconsistent evidence of effectiveness in the prevention of chronic diseases. Research indicates that beta-carotene from fruits and vegetables helps prevent cancer and heart disease, while the beta-carotene from supplements has shown no benefits and seems to increase cancer and overall mortality in individuals who smoke.

Store brand vitamins are often identical to the name brands for a lesser cost. Expensive supplements are no better than less costly supplements. Except for vitamin E, natural vitamins are no more beneficial than synthetic vitamins. The all-natural vitamin E vitamins should only contain d-alpha-tocopherol. Folate found in food is not as well absorbed by the body as synthetic folate and therefore should be taken as a supplement. Other components in foods may aid in the absorption and utilization of some nutrients. Daily multivitamins and mineral supplements are most effective when taken with a meal because it takes the stomach longer to empty when food is present, allowing more time for the supplement to dissolve and be absorbed. Some nutrients may compete or block the action or absorption of another nutrient and may need to be taken at another time to avoid potential interactions. Chelated supplements are marketed to have superior absorption ability but are quickly broken down by the acids in the stomach and absorbed at the same rate as other supplements. Most supplements that are labeled as time release have no value to the consumer. The body does not need to maintain a constant level of vitamins as it does for some medications such as antibiotics and allergy medications.

Specialty vitamins

Listed in Table 8 are common types of specialty vitamins that consumers purchase and some important actions to consider when looking for a particular vitamin.

Megadoses of vitamins with intakes of 20 to 600 times the RDA are sometimes advocated. A megadose is defined as a dose more than 10 times greater than the RDA. A megadose of a vitamin is a misnomer because at these higher levels the vitamin is actually functioning as a drug rather than a nutrient. A well-established standard of pharmacology is that all substances are potentially deadly at large enough doses. For patients who do choose to self-prescribe supplements, low levels of nutrients that do not exceed the RDA are recommended. Amounts above 100% of the RDA should be limited to the treatment of specific situations under medical supervision.

The dental team can intervene to provide the patient with good information about herbal supplements and sufficient knowledge of available resources. Our patients need to understand that the FDA regulates herbal products as food supplements, not drugs, and that they do not have to pass the safe and stringent standards to which prescription medications are held. Herbal supplement labeling is not required to point out risks, nor does it need to guarantee the herb products are marketed in a composition or form that can be absorbed by the body. Often, these products may have other ingredients in addition to those listed on the label.

Summary

The widespread use of herbal supplements makes it crucial for the dental team to become informed on this topic. Dental patients become their own diagnosticians by self-prescribing herbal medications and dietary supplements. They use dietary supplements to help them achieve their self-care goals, which develop out of a sense of separation from the traditional healthcare system. These supplements in their opinions are an easy means to ensure good health, to treat and prevent serious illnesses, increase mental sharpness, and to treat depression. Often, medical attention is delayed when it is truly needed. Current, scientifically substantiated information along with an understanding of the patient's needs is always the best response when a patient asks for a healthcare provider's opinion. The herbal supplement issue is no longer an exception, it is now expected.

Recommended Websites for Additional Information

www.herbalgram.org

A website maintained by the American Botanical Council that provides information on safety, dosage, clinical studies and interactions for many herbal supplements as well as links to herbal resources.

www.consumerlab.com

The website of an independent laboratory that tests herbal products for quality, potency and purity. It provides information about safety and efficacy for particular brands.

www.cochrane.org

The website for the Cochrane Database, which includes evidence-based reviews of dietary supplements.

https://www.fda.gov/AboutFDA/CentersOffices/OC/OfficeofScientificandMedicalPrograms/NCTR/default.htm

The website of the FDA National Center for Toxicological Research.

http://vitamins-nutrition.org/vitamins-guide/index.html

Vitamins, Minerals, and Dietary Supplement Information Guide

Statement

This information is solely for informational purposes. IT IS NOT INTENDED TO PROVIDE MEDICAL ADVICE. Neither the American Dental Assistants Association, the ADAA Council on Education, or author take responsibility for any possible consequences from any treatment, procedure, exercise, dietary modification, action or application of medication which results from reading or following the information contained in this document. The publication of this information does not constitute the practice of medicine, and this information does not replace the advice of your physician or other health care provider. Before undertaking any course of treatment, the reader must seek the advice of their physician or other health care provider. Before engaging in any complementary medical technique, including the use of natural or herbal remedies, you should be aware that many of these techniques have not been evaluated in scientific studies. Use of these remedies in connection with OTC or prescription medications can cause severe adverse reactions. Often, only limited information is available about their safety and effectiveness. Each state and each discipline has its own rules about whether practitioners are required to be professionally licensed. If you plan to visit a practitioner, it is recommended that you choose one who is licensed by a recognized national organization and who abides by the organization's standards. It is always best to speak with your primary health care provider before starting any new therapeutic technique.

Glossary

Analgesic - a drug that relieves pain.

Analogs - similar in structure.

Anticoagulant therapy - the use of drugs to prevent blood clotting.

Antihistamines - a drug that opposes the action of histamine, sometimes used for allergies.

Anxiety - a vague feeling of apprehension or uneasiness.

Botanical - made from plants or flowers.

Candidiasis - infection of the skin or mucous membrane with any species of Candida.

Cascade - the continuation of a process through a series of steps, each step initiating the next step, until the final step is reached; the action may or may not become amplified as each step progresses.

Central nervous system - the brain and spinal cord.

Chelated - an addition of metal ions to a substance to enhance dissolvability.

Cirrhosis - a chronic disease of the liver marked by formation of dense connective tissue and degenerative changes in liver cells.

Coumadin - common brand name for the drug warfarin; used to prevent blood clot formation.

Dysgeusia - impairment of the gustatory sense so that normal tastes are interpreted as being unpleasant or completely different from the characteristic taste of a particular food or chemical compound.

Dyskinesia - a defect in the ability to perform voluntary movement.

Extract - the active principle of a drug obtained by distillation or chemical processes.

Fibrin - the main component of a blood clot.

Gingival hyperplasia - excessive cell growth of normal gingival tissue.

Hemorrhage - an abnormal severe internal or external discharge of blood.

Hepatotoxicity - toxicity to the liver.

Herbology - the study of herbs, health and healing through the use of herbs.

Holistic - the comprehensive and total care of the patient; in this system, all needs such as physical, emotional, spiritual, social and economic are considered and cared for.

Metabolism - the sum of all physical and chemical changes that take place in the body.

Narcotic - a drug that depresses the central nervous system.

Necrosis - the death of areas of tissue surrounded by healthy tissue.

Pharmacopoeia - a book containing formulas and information that provide a standard for the preparing and dispensing of drugs.

Phytomedicinals - plants used in medicine.

Platelets - a fragment of a megakaryocyte that plays an important role in blood coagulation, hemostasis, and blood thrombus formation.

Raynaud's disease - a vascular disease found frequently in women between 18 and 30 years of age, marked by abnormal vasoconstriction of the extremities on exposure to cold or emotional stress.

Receptor - a cell component that combines with a drug, hormone, or chemical mediator to alter the function of a cell.

Sedative - a drug that exerts a soothing or tranquilizing effect.

Stomatitis - an inflammation of the mouth.

Synthesize - to combine two or more things to produce a new, more complex compound.

Tonic - a medicine that increases strength and tone.

Ulceration - the formation of pus on a free surface, as on the skin or mucous membrane, to form an ulcer.

Xerostomia - dryness of the mouth caused by a drug or medical condition.

References

"Everywhere You Turn: Herbs!" Nutrition New Focus, May 18, 1999. Available from URL: http://www.nutritionnewsfocus.com/ Accessed Feb. 11, 2006

Academy of General Dentistry, Alternative Medicine Sept. 23, 2001

Dietary Supplement Health and Education Act of 1994, Pub L. No. 103-417; §784,108 Stat. Appendix A, 1994.

Frankos, V.H., Brusick, D.J., Johnson, E.M., Maibach, H.I., Munro, I., Squire, R.A. and other. Safety of Sanguinaria extract as used in commercial toothpaste and oral rinse products. J Can Dent Assoc 1990; 56(7 Suppl):41-7.

Herbal remedies for dental problems. Discovery Health. http://health.howstuffworks.com/wellness/natural-medicine/herbal-remedies/herbal-remedies-for-dental-problems.htm. Accessed November 22, 2013.

Hobbs, C. Herbs for dental health. Heahty.Net. http://www.healthy.net/scr/article.aspx?Id=868. Accessed November 22, 2013.

Kuftinec, M.M., Mueller-Joseph, L.J, Kopczyk, R.A. Sanguinaria toothpaste and oral rinse regimen clinical efficacy in short- and long-term trials. J Can Dent Assoc 1990; 56(7 Suppl):31- 3.

Odell, S., "Observations from the Trenches,". Holistic Dental Association. Available from URL: http://www.simwell.com/hda/observe.htm, Accessed Feb. 11, 2006.

Position of the American Dietetic Association: Food Fortification and Dietary Supplements. Journal of the American Dietetic Association Jan. 2001, 101 (1): 115-125

Tyler, V.E. Herbal supplements. Millennium: Healthcare. American Council on Science and Health Web Site. Volume 10 Numbers 2 & 3,1998.

U.S. Preventative Service Task Force, "Routine Vitamin Supplementation to Prevent Cancer and Cardiovascular Disease: Recommendations and Rationale," Annals of Internal Medicine, July 2003; 139(1): 51-55.

www.cochrane.org, accessed March 2, 2006

www.fda.gov/nctr/ - accessed March 9, 2006

www.herbalgram.org - accessed Feb. 1, 2006

www.nccam.nih.gov - accessed March 9, 2006

Health News: One third of Americans mixing supplements with meds: study -http://www.reuters.com/article/us-medications-supplements-idUSKBN0DF15020140429 accessed April 3, 2017

https://www.drugs.com/acetaminophen_hydrocodone.html ccessed March 31, 2020

https://www.drugs.com/albuterol.html accessed March 31, 2020

https://www.drugs.com/amlodipine.html accessed March 31, 2020

https://www.drugs.com/atorvastatin.html accessed March 31, 2020

https://www.drugs.com/levothyroxine.html accessed March 31, 2020

https://www.drugs.com/lisinopril.html accessed March 31, 2020

https://www.drugs.com/metformin.html accessed March 31, 2020

https://www.drugs.com/omeprazole.html accessed March 31, 2020

https://www.drugs.com/simvastatin.html accessed March 31, 2020

https://fullscript.com/blog/2020-supplement-trends accessed March 14, 2020

https://www.nutritionaloutlook.com/weight-management-nutrition/clean-energy-demand-driving-mct-sales-growth-2020-ingredient-trends-watch-foods-drinks-and-dietary accessed March 15, 2020

https://www.nutritionaloutlook.com/herbs-botanicals/ashwagandha-going-mainstream-2020-ingredient-trends-watch-foods-drinks-and-dietary-supplements accessed March 19, 2020

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About the Author

Natalie Kaweckyj, LDARF, CDA, CDPMA, COMSA, COA, CPFDA, CRFDA, MADAA, BA

Natalie Kaweckyj is a Licensed Dental Assistant with restorative functions at Children's Dental Services in Minneapolis where she spends the majority of her time in hospital setting providing care under general anesthesia. The challenges of public health keep Natalie continually looking for solutions. She has worked academically, administratively and clinically, as well as legislatively in the 28 years as a dental assistant. As a DANB certificant, Natalie holds all 6 of DANB's credentials (the only one world-wide) as well as a BA in Biology and Psychology from Metropolitan State University.

Natalie served two terms as President of the American Dental Assistants Association (ADAA) in 2017-2018 and 2010-2011, remains active on several councils, and served as a President of the Professional Dental Assistants Educational Foundation (PDAEF). She served as a three-term president for the Minnesota Dental Assistants Association (MNDAA) and remains as the state business secretary. Natalie has been recognized with several ADAA awards, was one of the first ADAA Fellows in 1999 and became the first ADAA Master in 2004. She has published numerous continuing education courses, over 500 articles and lectures nationally and internationally on a variety of dental subjects.

Organized dentistry gave Natalie the insight early on that you can make a difference as a dental professional, and she was instrumental in seeing licensure for dental assistants come to fruition in Minnesota in 2009 as well as several expanded functions throughout the years. Natalie enjoys giving back to the community and does so with her volunteer writing contributions for a number of different organizations as well as her time with the ADAA and the Dental Peeps Network as a Senior Moderator.

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Appendix I

Appendix I

Take the Accredited CE Quiz:

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CREDITS: 3 SI
COST: $48.00
PROVIDER: American Dental Assistants Association
SOURCE: American Dental Assistants Association | August 2020

Learning Objectives:

  • Explain the evolution of supplement use.
  • Examine the rationale and trends for supplement usage by dental patients.
  • List the more common herbs used as supplements.
  • Identify which herbal supplement might be used to treat depression.
  • Name the herbal supplement that might be used to improve memory function.
  • Recall which herbal supplement might be used to prevent cardiovascular disease.
  • Discuss the factors that may impact herbal potency.
  • Understand how dietary supplements and herbal medicines are regulated.
  • Relate potential drug interactions with dental drugs.
  • Summarize possible oral complications with the use of some herbal and dietary supplements.
  • Describe the differences in pharmacology between traditional drugs and herbal medicines.
  • Recognize which herbal supplements hinder blood clotting.
  • Recite the herbal supplements that may interfere with anesthetics.
  • List the herbal supplements that may cause cardiovascular interactions.
  • Recognize which herbal supplements may cause gastrointestinal interactions.
  • Identify the herbal supplements that may interfere with inflammatory and immune responses.
  • Describe herbal supplements that may be useful in dentistry.
  • Explain the types of alternative oral and dental care products.
  • Recommend alternatives and suggestions to patients in terms of vitamin usage, ingredients in oral care products and where to look for additional information.

Disclosures:

The author reports no conflicts of interest associated with this work.

Queries for the author may be directed to jromano@aegiscomm.com.