Alternative medicine for the dental professional.

In the early 1900s, herbal supplements were the hallmarks of the pharmaceutical industry. About 67 percent of all medicine listed in the United States Pharmacopeia (USP) was botanicals; now it is only 2 percent. For the last 25 years, more than half of modern pharmaceuticals were derived from natural sources: aspirin, caffeine, colchicine, cyclosporine, digoxin, quinine and taxol are all plant-derived pharmaceuticals.

With the rising cost of health care and a shift towards self-medication, the consumer demand for 100-percent natural products has increased dramatically. For these reasons, health care providers are seeing more patients who are using complementary and alternative medicine (CAM). Dental health care professionals need to be well informed about the various complementary and alternative medicine practices. Since most patients do not disclose the use of herbs, it is important that questions concerning any herbal or dietary supplement are part of your medical history.

So what is CAM? Complementary medicine is the use of herbal medicine along with conventional medicine, while alternative medicine is modalities used in place of conventional medicine. Instead of CAM, a better term to use is integrative medicine. Integrative medicine combines treatment from conventional medicine and alternative medicine for which there is high-quality evidence of effectiveness. CAM practice includes whole medical systems, mind-body medicine, biologically based practices, manipulation and body-based practices, and energy medicine.

The whole medicine systems include traditional Chinese medicine, Ayurvedic medicine, homeopathy and naturopathy. Mind-body medicine includes meditation, prayer and mental healing. Biologically based practices include botanicals, vitamins, animal-derived extracts, minerals, fatty acids, amino acids and proteins. Manipulation and body-based practices include chiropractic manipulation, osteopathic manipulation and massage. Energy medicine includes use of energy fields, biofield therapies and bioelectromagnetic-based therapies.

Herbal medicine is an $80 billion per year business with an annual growth of 10 to 20 percent. So with 33 percent of Americans using herbs, over one-third of the patients you see in your practice will be taking some type of herbal supplement. The World Health Organization defines herbal supplements as finished, labeled medicine products that contain active ingredients, aerial or underground parts of plants, or other plant material or combinations, whether in the crude state or as plant preparations. Legally, herbs are classified as dietary supplements that are regulated by the food service industry. Herbal manufacturers are not held to the same standards as the pharmaceutical manufacturers. Our laws do not require the herbal manufacturers to demonstrate safety, efficacy or quality of their products.

The United States Food and Drug Administration (FDA) has established good manufacturing practices (GMPs), but adherence to them is strictly voluntary. This lack of regulation is the single biggest factor affecting the reliability of herbal products on the market today. In 1994, the Dietary Supplement Health and Education Act (DSHEA) was signed into law requiring manufacturers of herbs to be responsible for proving safety. FDA is responsible for proving safety for products approved before 1994. Labs now must include a disclaimer stating, "This product is not intended to diagnose, treat, cure or prevent any disease." The use of herbal supplements is greater in Europe than in the U.S. The German government body that regulates these supplements is called Commission E. It investigates the safety and efficacy of herbal remedies and has monographs that are considered by many a definitive source of information on herbs.

The quality of herbal supplements varies from manufacturer to manufacturer. There is a wide variation in the chemical content and amount of contaminants. There are no standardized dosages since there is no standardized percentage of herbal extract. This can vary from batch to batch. Habitat, temperature and soil characteristics are some of the factors that affect the strength of its chemical components.

Because of these issues, the American Herbal Products Association (AHPA) published the Botanical Safety Handbook. This book provides data on herbs and plant-based products sold in the United States. There are four classifications:

Class 1: Herbs that can be consumed safely when used appropriately.

Class 2: Herbs with the following restrictions unless directed by an expert.

Class 2A: For external use only

Class 2B: Not to be used during pregnancy

Class 2C: Not to be used while nursing

Class 2D: Other specific use restrictions as noted.

Class 3: Herbs for which significant data exist to recommend the following labeling: "To be used only under the supervision of an expert qualified in the appropriate use of this substance." Labeling must include dosages, contraindications, potential adverse effects and drug interactions.

Class 4: Herbs with insufficient data.

Many herbs can be toxic if used incorrectly. It is estimated that 15 million Americans are at risk, so it is important to have a good herbal supplement reference. The Physician's Desk Reference does include an edition for herbal medicine.

There is great potential for herb-drug interactions (HDIs). These should be reported to Med Watch at 1-800-FDA-1088. The National Institutes of Health (NIH) has an approved Web site that provides information on herbal medicines along with current research (www.nih.gov).

Herbs can be used to treat any disease or human ailment. As health care professionals, we need to be familiar with the most common natural products used along with potential herb-drug interactions.

The top 10 natural products used in the United States are: Echinacea, Ginseng, Ginkgo biloba, Garlic, Glucosamine, St. John's wort, Peppermint, Fish oils/omega fatty acids, Ginger and Soy.

Echinacea

Echinacea (figure 1) is a perennial plant found in Missouri, Nebraska and Kansas. It is a Native American remedy. Echinacea is approved by Commission E for use for the common cold, cough, bronchitis, urinary tract infection, mouth and pharynx inflammation and wounds, and burns. Currently, researchers are experimenting with its use to stimulate the immune system in patients with AIDS. It also is used as a prophylaxis for colds and urinary tract infections. It has been found that echinacea does not prevent the common cold but will decrease its duration. (1)

[FIGURE 1 OMITTED]

The following compounds are found in the echinacea herb:

* Water-soluble immunostimulating polysaccharides

* Volatile oil

* Flavonoids 

* Alkamides

* Polyenes

The compounds found in the echinacea root are:

* Water-soluble immunostimulating polysaccharides

* Water-soluble immunostimulating glycoproteins

* Volatile oil

* Caffeic and ferulic derivatives

* Alkamides

* Polyenes

* Effective pyrrolizidine alkaloids 

Echinacea's effect is toward nonspecific cellular immunity. This herb demonstrates antibacterial, anti-inflammatory, metabolic, immune-system enhancement, infertility, wound healing, anti-neoplastic and antiseptic properties. This depends on the type of plant species. Clinical trials found that the herbal tea preparation decreased the duration of a cold when taken at early onset. (2) Other studies found the opposite; it did not reduce the symptoms' severity or duration of the common cold.

Ginseng

Panax ginseng (figure 2) has been used to treat different health problems for about 5,000 years. It has been used to increase physical endurance, decrease fatigue, improve the ability to cope with stress and also improve concentration. Triterpene saponins are the active compounds found in ginseng. The main active ingredient consists of ginsenosides, a group of steroidal saponins.

[FIGURE 2 OMITTED]

Commission E recommends using ginseng for no longer than three weeks. Ginseng does exhibit some cognitive function, anti-neoplastic, anti-oxidant, antiplatelet, hepatic and hypoglycemic effects, as well as positive effects on infertility. Because of this, ginseng has the potential to interact with many drugs, like anticoagulants, anticonvulsants, immunosuppressants, MAO inhibitors and oral anti-diabetic agents.

Clinical trials found that ginseng can reduce the risk of gastric cancer, alleviate some symptoms of fatigue, improve cognitive function and improve vascular endothelial dysfunction. Ginseng is one herb that needs to be discontinued before surgery since it will increase bleeding.

Ginkgo Biloba

Ginkgo biloba (figure 3) has been used to treat a number of illnesses. It contains the following compounds:

* Flavonoids

* Biflavonoids

* Proanthocyanidins

* Trilactonic diterpenes 

* Trilactonic sequiterpene bilabolids

[FIGURE 3 OMITTED]

Ginkgo has shown antioxidant, anti-inflammatory, vascular and cognitive-promoting effects. Ginkgo has been found to be ineffective in the treatment of drug dependency, multiple sclerosis and ulcerative colitis.

Clinical trials have shown that ginkgo can improve cognitive function, treat intermittent claudication and enhance the effectiveness of haloperidol in the treatment of schizophrenia.

Ginkgo can interact with anticoagulants, anticonvulsants, buspirone, MAO inhibitors, nicardipine, NSAIDs, selective serotonin reuptake inhibitors and diuretics. Ginkgo is another herb that needs to be discontinued before surgery due to increased bleeding.

Garlic

The medicinal parts of garlic (figure 4) are the whole fresh bulb, dried bulb and oil.

[FIGURE 4 OMITTED]

The compounds found in garlic are allins fructosans and saponins. Garlic has been used as a hyperlipidemic agent, anti-hypertensive agent and anti-neoplastic agent. It was also found to enhance the immune system and inhibit platelet aggregation. Garlic has demonstrated anti-hypertensive and antimicrobial effects. It also inhibits cytochrome P450 isoenzymes, reduces cholesterol and affects platelet aggregation. Clinical trials with garlic show reduction of plaque formation in atherosclerosis and reduced risk for stomach and colon-rectal cancer; it was also effective in preventing the common cold. Garlic did not significantly reduce serum cholesterol levels, but it reduced the incidence of hypertension. Studies did not show it improving peripheral arterial disease. Garlic can inhibit platelet aggregation so it should be discontinued prior to surgery.

Glucosamine

Glucosamine (figure 5) is found in mucopolysaccharides, chitin and mucoproteins. Glucosamine sulfate is manufactured from chitin. It is used commonly with chondroitin. It needs to be used with caution in patients allergic to shellfish. Glucosamine is used to treat osteoarthritis; it may also be effective in the treatment of diabetes mellitus. High levels of glucosamine and chondroitin can lead to an increased INR leading to bleeding. It can also increase the effects of anti-diabetic agents.

[FIGURE 5 OMITTED]

St. John's Wort

St. John's wort (figure 6) is used to treat mild to moderate depression and anxiety and can be used topically as an anti-inflammatory. It has also shown antiviral activity in increased doses. St. John's wort's activity is correlated to the hypericin component of the plant mechanism. This can inhibit cortisol secretion, block catabolic hormones and increase the concentration of CNS neurotransmitters including serotonin. The anxiolytic effect may be due to benzodiazepine receptor activation.

[FIGURE 6 OMITTED]

Clinical trials show St. John's wort is as effective as tricyclic antidepressants and benzodiazepines. They also showed that, as a cream, it improved the symptoms of atopic dermatitis. St. John's wort is currently being used in European centers for treatment of depression. Patients taking it need to avoid tyramine-containing foods, since it can increase the risk of a hypertensive crisis.

St. John's wort can interact with the following drugs: amiodarone, anesthetics, anticoagulants, antidiabetic agents, barbiturates, benzodiazepines, beta-blockers, caffeine, calcium channel blockers, carbamazepine, cyclosporine, digoxin, fexofenadine, ginkgo biloba, methadone, MAO inhibitors, nortriptyline, opioids, and selective serotonin reuptake inhibitors.

Peppermint

Peppermint (figure 7) is aromatic oil with menthol as its chief component. It does contain flavonoids. Peppermint is sometimes used as an antiseptic; it has antiviral, antimicrobial, diuretic and mild sedative effects. Peppermint also has a spasmolytic effect on smooth muscle of the digestive tract. Clinical studies show it reduces abdominal symptoms of irritable bowel syndrome, (3) reduced spasms during endoscopies, (4) relieved dyspepsia and alleviates headache. Commission E has approved it for GI and bile duct complaints, irritable bowel, inflammation of oral mucosa and upper respiratory tract.

[FIGURE 7 OMITTED]

Peppermint interacts with the following drugs:

* Antacids

* [H.sub.2]-Blockers

* Proton pump inhibitors 

* Drugs metabolized by cytochrome P450 3A4 substrates

Peppermint should not be used during pregnancy and lactation. It should also not be given to children.

Fish Oils/Omega Fatty Acids

Fish oils are commonly known as omega 3 fatty acids, omega 3 oils, docosahexaenoic acid (DHA), and eicosapentaenic acid (EPA).

Fish oils are used to prevent cardiovascular disease, decrease inflammation in rheumatoid arthritis, and treat dysmenorrhea and depression or bipolar disorders. It can also increase bleeding if more than 3 grams per day is taken.

Fish oils alter major prostaglandin and leukotriene synthesis, which decreases inflammation. Some studies have shown that it may help protect the brain from cognitive problems associated with Alzheimer's disease. It may be more effective than Ritalin for treating attention deficit disorder. Other studies did not show improvement with attention deficit-hyperactivity disorders, multiple sclerosis, male fertility or asthma.

Ginger

Ginger (figure 8) is indigenous to southeastern Asia but is cultivated in South America, India, China, Africa and the United States. The medicinal part of the plant is the root. Ginger has the following actions:

* Anti-emetic, antinausea

* Anti-inflammatory

* Antilipid

* Antiviral

* Antiplatelet

* Antipyretic 

* Antimicrobial

* Antioxidant

* Antimigraine

* Cardiotonic

[FIGURE 8 OMITTED]

Clinical trials have shown ginger to alleviate nausea and vomiting after gynecologic outpatient surgery. (5) It also decreases motion sickness and inhibits platelet aggregation. Some studies showed that it was not effective in the treatment of osteoarthritis and rheumatoid arthritis. (6) It is recommended to discontinue ginger prior to surgery.

Soy

Soy (figure 9) is found throughout the world and is commonly known as soybean. The medicinal part of the plant is the seed.

[FIGURE 9 OMITTED]

The active compounds in soy consist of phospholipids (45 percent-60 percent), fatty oils (30 percent-35 percent) and steroids as phytosterols (2 percent-5 percent). Soy has shown to have anti-neoplastic, cholesterol-lowering, cognitive function, estrogenic, and renal effects.

Soy contains a high amount of isoflavones such as genistein and daidzein. The isoflavones act as anti-estrogens and block the uptake of estrogen into the tissues in certain hormone-related cancers. It also reduces the effects of androgens on the prostate gland, but it is questionable whether soy is beneficial for prostate or breast cancer.

Epidemiological studies have found a reduction of breast, prostate and colon cancers with soy consumption. Few clinical studies are available. FDA has approved the "health claim" that soy products can reduce the risk of coronary heart disease by lowering cholesterol. The soy products must contain at least 6.25 grams of soy per serving with 25 grams of soy protein consumed per day. Also, studies have shown improved memory with soy but not attention.

Other studies have shown that soy can prevent symptoms of menopause and provide an alternative to hormone replacement therapy. Soy proteins were also shown to improve insulin resistance and glycemic control in Type 2 diabetes.

The following drugs can interact with soy:

* Estrogen

* Tamoxifen

* Thyroid agents

Soy may increase HDL cholesterol but will decrease LDL cholesterol and triglycerides.

As you can see, it is important to be familiar with the different herbal supplements and their potential herb-drug interactions. Since many of our patients are on cardiac/hypertension medications, it is important to be familiar with the cardioactive herbs (Box 1). Some of these herbs contain cardiac glycosides and have some chronotropic and inotropic effects. Patients taking these herbs must be cautioned concerning their use with their current antihypertension and cardiac drugs.

There are many herbs that affect liver metabolism (Box 2). Any patient taking ACE inhibitors, anti- asthmatics, anticoagulants, tricyclic antidepressants, glucocorticoids or oral contraceptives should avoid taking these herbs. Some of these herbs can cause hepatotoxicity due to the pyrrolizidine alkaloid found in them.

There are also herbs that alter absorption of other drugs along with the alteration of digestion and absorption (Box 3). Patients who are on MAO inhibitors must not eat foods containing tyramine. Mistletoe, night blooms, cereus and shepherd's purse all contain tyramine so your patients must be cautioned against their use. Also included are any of the sympathomimetic herbs. Any patients on MAO inhibitors or over-the-counter decongestants, or who have diabetes, hypertension, glaucoma and hyperthyroidism should avoid all sympathomimetic herbs (Box 4).

For any patients taking antihypertensive drugs, there are herbs that can potentiate their effects (Box 5). These herbs should be avoided. Patients who are on anticoagulants also need to be cautioned about herbs that increase clotting. Box 6 contains these coagulant herbs that should be avoided.

When considering performing procedures that can cause bleeding, you must make sure your patients are not taking these herbs or supplements that can increase bleeding. It is recommended to discontinue these herbs and supplements two weeks prior to the procedure (Box 7).

There are also herbs and supplements in FDA's Poison Plant Database and on the unsafe herbs list on the NIH Web site. The herbs and supplements listed on Box 8 should be avoided.

* Box 1. Cardioactive Herbs

Broom tops
Cactus Granti
  florus fruit
Coltsfoot leaf
Devil's claw
Dogbane root
Figwort
Foxglove
Fumitory
Ginger
Ginseng
Golden seal
Hawthorn
Immortal root
Kola
Lily of the valley
Linden flower
Mistletoe leaf
Motherwort
Pleurisy root
Prickly ash bark

* Box 2. Herbs Affecting Liver Metabolism

American mandrake
Balmony
Barberry
Blue Flag
Coltsfoot
Comfrey
Fringe tree
Golden seal
Hound's tongue
Life root
Oregon grape
Sage brush
Squaw weed
Wahoo (Burning bush)

* Box 3. Herbs Affecting GI Absorption

Aloe
Buckeye
Cayenne
Coffee
Ephedra
Horse chestnut
Marshmallow
Morman Tea
Senna
Uva ursi

* Box 4. Sympathomimetic Herbs

Cayenne
Ephedra
Night bloom cereus
Kola nut
Yohimbe

* Box 5. Hypotensive Herbs

Black cohosh
Coleus
Golden seal
Hawthorn
Periwinkle
Shepherd's purse

* Box 6. Coagulant Herbs

Agrimony
Golden seal
Mistletoe
Yarrow

* Box 7. Anticoagulant Herbs and
Supplements

Alfalfa
Allspice
Angelica
Bilberry
Blackhaw
Bogbean
Boldo
Buchu
Cat's claw
Chamomile
Chondroitin
Co-enzyme Q10
Evening primrose
Fenugreek
Feverfew
Flax
Garlic
Ginkgo
Ginseng
Glucosamine
Guggul
Horse chestnut
Poplar
White willow

* Box 8. Unsafe Herbs and Supplements

Aconite
Agrimony
Alfalfa
Aloe
American
  hellebore
Angelica
Arnica
Ash
Andrographis
Balsam of Peru
Butterbur
Chaparral
Coltsfoot
Comfrey
Jimson weed
Sassafras

There are many herb-drug interactions. New interactions are becoming known every day, so caution is necessary, especially when using these herbs concurrently with pharmaceuticals. That's why it is a must to have a good reference book in your office along with taking a thorough medical history on your patient. This will help to avoid any medical emergencies or complications in your dental practice.

References

(1.) Barrett BP, Brown RI, Locken K, et al. Treatment of the common cold with unrefined echinacea. Ann Internal Med 2002; 137 (12) 939-46.

(2.) Lindenmuth GF, Lindenmuth EB. The efficiency of echinacea compound herbal tea preparation on the severity and duration of upper respiratory and flue symptom: a randomized, double-blind placebo controlled study. J Alt Compl Med 2000; 6 (4): 327-33.

(3.) Dew MJ, Evans, BK, Rhodes J. Peppermint oil for irritable bowel syndrome: a multicenter trial. Br J Clin Pract 1984; 38: 394, 398.

(4.) Leicester RJ, Hunt RH. Peppermint oil to reduce colonic spasm during endoscopy. Lancet 1982; 2 (8305): 989.

(5.) Phillips S, Ruggier R, Hutchinson SE. Ginger-an antiemetic for day case surgery. Anaesthesia 1993; 48: 715-7.

(6.) Bliddal H, Rosetzsky A, Schlichtine P, et al. A randomized placebo controlled cross-over study of ginger extracts and ibuprofen in osteoarthritis. Osteoarthritis Cartilage 2000; 8: 9-12,.

(7.) PDR for herbal medicines. 3rd ed. Montvale, N.J.: Thomson PDR; 2005.

(8.) Schultz V, Rudolf H, Tyler V. Rational phytotherapy: a physician guide to herbal medicine. New York: Springer; 1998.

(9.) Wynn RL, Meiller TF, Crossley HL. Lexi-Comp's Drug Information Handbook for Dentistry. 13th ed. Hudson, Ohio: Lexi-Comp; 2007.

By Pamela L. Alberto, DMD

Pamela L. Alberto, DMD, earned her doctorate from the University of Pennsylvania, School of Dental Medicine and her specialty certificate in Oral and Maxillofacial Surgery from the University of Medicine and Dentistry of New Jersey-University Hospital. She is currently the Director of Predoctoral Surgery and a Clinical Associate Professor in the Department of Oral and Maxillofacial Surgery at New Jersey Dental School. She is a Diplomate in the American Association of Integrative Medicine. She is a fellow in the American Association of Oral and Maxillofacial Surgery, the American College of Oral and Maxillofacial Surgery and the International College of Dentistry. She is a member of the International Society of Plastics, Anesthetics and Reconstructive Surgery.