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The Impact of Herbal Medicine on Clinical Dentistry Karen A. Baker, M.S., R.Ph. Associate Professor Dept. Oral Pathology, Radiology and Medicine - U of Iowa College of Dentistry Dept. Clinical and Administrative Pharmacy - U of Iowa College of Pharmacy I. DEFINITIONS & PATIENT UTILIZATION Alternative Medicine (as defined by the Office of Alternative Medicine (NIH)) ♦ Those treatments & health care practices not taught widely in medical schools ♦ Not generally used in hospitals ♦ Not usually reimbursed by medical insurance companies Definitions of popular alternative therapies ♦ Holistic medicine: As the term implies, deals with a being as a "whole" and integrated system rather than individual parts and advocates the synergistic use of herbs to heal the being. Also referred to as alternative or complementary medicine, it is composed of a series of disciplines including chiropractics, naturopathy, reflexology, acupuncture, massage, and the following. ♦ Homeopathy: Based on the principle of "like cures like”--very small doses of naturally derived botanical, mineral, or animal compounds are diluted to treat a condition. The same substance in larger doses in a healthy subject would cause symptoms similar to those of the disease being treated. ♦ Herbal medicine: Rests on the usage of preparations and medications derived from botanical components such as roots, leaves, and flowers to promote healing. ♦ Naturopathy: Adopts a non-invasive approach emphasizing natural remedies, a healthy diet, and exercise to heal rather than surgery or synthetic drugs. N.D. is “Doctor of Naturopathy” Common Viewpoint Among Traditional Healthcare Providers: “Either Worthless or Dangerous!!” ♦ Until the 1940s much of the U.S. Pharmacopoeia was composed of drugs of herbal origin ♦ 25% of common Rx drugs contain at least one active ingredient derived from plants aspirin, atropine, belladonna, capsaicin, cocaine, colchicine, digoxin, ephedrine, ergotamine, opium, physostigmine, pilocarpine, quinidine, scopolamine, taxol, vincristine, vinblastine ♦ 80% of the world’s population (4 billion people) use herbal medicine for some aspect of primary health care according to the World Health Organization…. What are the reasons??? 1) Patient dissatisfaction with conventional treatments because of lack of effect, adverse effects, or perceptions that treatments are too impersonal, highly technical, or costly; 2) The need for personal control is met because patient becomes a “co-therapist”; 3) Alternative therapies are more attractive because patients view them as more compatible with their value systems. ♦ 70% of patients will not tell health care providers they are taking herbal products ♦ U.S. Market for dietary supplements was almost 21 billion in 2006 ♦ Top 10 herbal products account for 60% of the total herbal medicine market MOST COMMON CONDITIONS TREATED AND THE SPECIFIC OTC SUPPLEMENTS SOLD 2005 growth 1% 5% 14% 6% 4% 7% 2% 17% 8% 1% 16% 13% 12% 12% 5% 1% 5% % of total in 2005 27% 22% 6% 6% 5% 5% 5% 3% 3% 1% 1% 1% 1% 1% 86% 14% 100% Condition Specific Supps ($mil) Sports/Energy/Weight-Loss General Health Cold/Flu-Immune Joint health Anti-cancer Heart health Bone health Gastrointestinal health Diabetes Menopause Brain Mental Sexual Health Mood Insomnia Sum of top 14 Conditions Others Total Supplements 2005 5,802 4,674 1,364 1,226 1,073 1,016 986 694 532 314 264 239 220 126 18,529 2,786 21,315 US Minerals 2003 2004 2004 2005 2005 growth growth Calcium 1,046 993 1,010 -5% 2% Magnesium 161 175 202 9% 15% Chromium 106 119 125 13% 5% Zinc 80 75 79 -6% 5% Selenium 62 62 68 1% 8% Potassium 71 70 74 -1% 6% 203 209 219 3% 5% 37 34 36 -7% 5% 1,765 1,738 1,812 -2% 4% Iron Others Total II. US Vitamins MultiVitamins 2003 2004 2004 2005 2005 growth growth 3,678 3,833 4,157 4% 8% Vitamin C 770 808 836 5% 3% Vitamin E 706 654 440 -7% -33% B Vitamins 817 880 937 8% 6% Vitamin A/Carotenoids 237 248 258 5% 4% Others 449 468 536 4% 14% 6,658 6,892 7,163 4% 4% Total Specialty Supplements Melatonin Probiotics DHEA Fish/Animal Oils Plant Oils* Glucosamine/Chondroitin Bee Products CoQ10 5 HTP SAMe MSM Gelatin Digestive Enzymes Homeopathics Others 2003 62 174 47 183 140 761 74 258 53 92 115 58 130 460 122 2004 67 204 48 262 177 762 81 283 59 93 111 52 147 532 134 2005 2005 growth 73 10% 243 19% 50 3% 359 37% 197 11% 810 6% 91 11% 339 20% 68 15% 96 3% 107 -3% 48 -8% 166 13% 619 16% 148 10% Total 2,728 3,013 3,414 Effectiveness of Popular Vitamins and Herbal Medicines 1. Effect of Vitamin and Mineral Supplementation on Chronic Diseases a. B vitamins and Heart Disease b. Retinoids (Vitamin A) c. Vitamin D d. Antioxidants (lycopene, lutein, zeaxanthine) e. Vitamin C (ascorbic acid) f. Calcium Supplements 13% 3 2. Glucosamine Sulfate +/- Chondroitin 3. SamE or MSM 4. Coenzyme Q10 5. Fish Oils (Omega-3 Fatty Acids) -DHA/EPA doses required to reduce triglycerides and total cholesterol -Flaxseed Oil?? 6. Melatonin (Pineal Gland Hormone) 7. Probiotics (Culturelle, etc.) 8. Bee Products (Royal Jelly) 9. 5-HTP (5-Hydroxytryptophan) 10. SamE 11. MSM 12. Gelatin 13. Digestive Enzymes (Pancreatin, etc.) 14. Ginkgo Biloba 15. Garlic 16. Echinacea 17. Ginseng 18. Saw Palmetto 19. St. John’s Wort (Goat Weed) 20. Topical Zinc for the Common Cold 4 III. REGULATORY ISSUES & SAFETY A. Federal Trade Commission (FTC) ♦ OTC Drug Regulation ♦ FTC is responsible for all over-the-counter advertising ♦ Currently herbal medicines can only be marketed in the U.S. as dietary supplements ♦ Manufacturers/distributors cannot make specific health claims without FDA approval? ♦ Structure/function claims versus disease claims B. Legislation Dietary Supplements Health & Education Act (DSHEA) 1994 Congress “freed” the population to pursue self-medication with herbal and alternative products vitamins, minerals, essential fatty acids, enzymes, coenzymes, plant derived (herbs), animal-derived (glucosamine), bacteria, glandular products (adrenal extracts), hormonal (melatonin) Act limits FDA’s regulation of “dietary supplements” to superficial labeling features because the act was not fully funded. New legislative initiatives may change this very soon. C. Problems with DSHEA Products are not required to: Gain prior marketing approval by the FDA Be Monitored for identity or potency of chemicals in the supplement Be backed by company data supporting safety or efficacy Natural = Safe ??? Paradox – public is more afraid of tested drugs than of untested dietary supplements 15-20% of adults in US have used herbals within the past year according to USDHHS D. Problems with Herbals Intentional fraudulent adulteration with another active drug Accidental substitution of a more toxic species for the intended plant material Contaminants – chemicals, toxins, biologic pathogens Inappropriate amounts of chemical ⇑ or ⇓ Adverse herb-drug or herb-disease interactions Intrinsic toxicity, low margin of safety – From Drug Topics April 16, 2001 E. Testing for Active Ingredient and Labeling –Consumer Lab gives a CL approved seal -USP dietary supplement verified seal -NSF International certifies products F. Examples of Reliable Herb Companies Nature's Way, Nature's Herbs, Phytopharmica, and Frontier Herbs Large Pharmaceutical Companies – Bayer, American Home Products, Warner Lambert, Knoll G. Patient History: Screening Questions on Dental Health Questionnaire ♦ Do you regularly take dietary supplements or herbal medicines? ♦ If YES, do you regularly take any of the following: ♦ Diet or Energy supplements Echinacea Garlic ♦ Kava Valerian Vitamin E >400I.U. Fish Oil >3 grams/day St. John’s Wort Ginger Ginkgo ♦ Do you regularly use natural or herbal oral health products? ♦ Have you recently stopped taking any herbs? ♦ Have you substituted herbs for prescription or over-the-counter drugs? H. Drug Interactions with Herbal Products: Ginseng ♦ 5 Why are herb-drug interactions difficult to assess?(see interactions table at end of handout) o Actual doses may differ from label and herbals may contain adulterants o Potency varies by crop year o Collection, storage and marketing methods promote contamination IV. Dental Impact of Herbal Supplements What are we worried about in clinical dental practice?? • Increased bleeding or effects on hemostasis • Delayed wound healing • Effects on the immune system • Sedation and other CNS effects • Interactions with dental medications A. Surgical Considerations for Patients Taking Selected Herbal Supplements______ HERB Black Cohosh USE (S) • • treatment of PMS and dysmenhorrhea alleviate menopausal symptoms PROPOSED MECHANISM OF ACTION/EFFECTS • • Chamomile • • • anxiolytic/sedative treatment of GI spasm or irritation treatment of menstrual disorders • • • DRUG INTERACTIONS active components are triterpene glycosides and formononetin (an isoflavanoid), which may have estrogenlike hormonal activity suppresses leutenizing hormone secretion in menopausal women • also contains bioflavinoids which are considered to be active apigenin competitively inhibits binding of several benzodiazepin es contains coumarin, which exerts an antispasmotic effect • caution when administered with other drugs that can reduce BP OTHER CONSIDERATIONS • • • • no reports of coagulation disorders, but effects on coagulation system have not been studied; avoid concurrent administration of (or closely monitor) warfarin may make other drugs less effective when administered concurrently • • • • may lower BP side effects are generally mild (GI, headache, weight gain, dizziness) limit use to 3 months sedative effects noted from 6oz. cup of strong tea can cause skin irritation, allergic conjunctivitis, and/or severe allergic rx. long-term consumption may have cumulative effects consider discontinuin g 2 weeks prior to surgery 6 Echinacea antiinfective • • Evening Primrose Oil • • • • treatment of PMS lowers serum cholesterol allergic/inflammatory conditions (eczema, psoriasis) autoimmune disease (MS, lupus) • • Feverfew • • prevention and treatment of migraines anti-inflammatory agent (used to treat fever, menstrual problems, arthritis) • • • enhances "nonspecific" cell immunity by enhancing release of cytokines and phagocytic activity stimulates autoimmune processes • extract contains 6080% linoleic acid and 814% - linolenic acid (an omega-6 fatty acid formed by desatruration of linoleic acid) lowers platelet aggregation • suggested to be serotonin release during aggregation of platelets; inhibits platelet aggregation antagonizes actions of autocoids and vascular agonists potentially involved in migraines and chronic inflammation antipyretic and antiplatelet effect may be due to • may counteract immunosuppr esant drugs (e.g. corticosteroid s); do not administer together • • • • may interact with anticoagulant c or antiplatelet d drugs to raise risk of bleeding use caution when administered with drugs that lower seizure threshold (e.g. phenothiazine s, tricyclics) • may interact with anticoagulant or antiplatelet drugs to raise risk of bleeding use caution when administering with drugs that raise serotonin (fluoxetine, sumatriptan, etc.) • • • • • hepatotoxic effects may be associated with prolonged use or if administered with other hepatotoyjc agents immune suppression can result from prolonged use (> 10- 14 days) side effects are generally infrequent (GI, headache) may lower seizure threshold abrupt discontinuatio n may cause rebound headache or pain with stiff joints and muscles can cause mouth sores and loss of taste do not take for > 4 months consider discontinuin g 2 weeks prior to surgery 7 phospholipase inhibitor that prevents the release of arachidonic acid, a precursor to prostaglandins and leukotrines Fish Oil Supplements (Omega-3 fatty acids) • management of severe dyslipidemia, lowers risk of coronary heart disease, lowers BP • • • Garlic • • lowers serum cholesterol lowers blood pressure • • • • possibly via effects on prostaglandins , thromboxanes and leukotrines decreases platelet aggregation, decreases thromboxane A2 and increases bleeding times incorporated in RBCs, leading to lower blood viscosity • although no drug interactions have been reported, it would be prudent to avoid anticoagulant and antiplatelet drugs active constituents are sulfur compounds and the alliinsplitting enzyme alliinase inhibits cholesterol synthesis has vasodilator and antioxidant properties effects on coagulation include inhibition of platelet aggregation, antithromboti c activity, mean plasma viscosity and • may interact with anticoagulant and antiplatelet drugs to increase risk of bleeding may potentiate antihypertensi ve drugs • • • • • • report of spontaneous epidural hematoma and postoperative bleeding may increase INR chronic or excessive doses may decrease production of Hb side effects include GI discomfort, dizziness, allergic reactions, headache, sweating, and garlic odor of breath/skin hypoglycemic hematocrit Ginger • • • prevention of nausea and vomiting digestive problems muscle pain and swelling • • • Ginkgo Biloba • • treatment of dementia symptoms or other conditions associated with cerebral or peripheral vascular insufficiency treatment of vertigo or tinnitus of vascular of involutional origin • • • • • potent agonist at the serotonin receptor exerts effect in GI tract, not in CNS multiple effects on platelet aggregation (potent inhibition of thrombaxane synthetase, prostacyclin agonist) • medicinal extracts contain 2227% flavanoid glycosides, 57% terpene lactones (ginkgofides A,B and C and bilobalide) and < 5 ppm ginkgolic acids several active constituents are potent antioxidants and freeradical scavengers inhibits agerelated decline of muscarinic cholinergic receptors and a2-adrenergic receptors ginkgolides, especially ginkgolide B, inhibit platelet activating factor,reduce thrombus • • • • may interact with anticoagulant and antiplatelet drugs to increase risk of bleeding increases calcium uptake by heart; may alter CCB drug effects • may interact with anticoagulant and antiplatelet drugs to increase risk of bleeding ginkgo toxin in Ginkgo leaf and seed may reduce effectiveness of carbamazepin e, phenytoin and phenobarbital in epileptic patients do not use with drugs that lower seizure threshold • • • • • 8 effects consider discontinuin g 2 weeks prior to surgery may increase bleeding time may effect blood glucose may effect BP consider discontinuin g 2 weeks prior to surgery several cases of spontaneous bleeding reported (subdural and subarachnoid hematomas, bleeding from iris into anterior chamber of the eye consider discontinuin g 2 weeks prior to surgery 9 formation Ginseng • • • • heighten resistance to stress enhance physical and mental performance increase stamina elevate mood • • • • • Hops • sedative-hypnotic, digestive aid • • Horse Chestnut • • reduce leg edema improve symptoms of chronic venous • active ingredients thought to be ginsenosides increases activity of CNS neurotransmitt ers by lowering their removal from neuronal synapse; increase in serotonin useful when treating anxiety and depressive disorders may potentiate activity of GABA steroidal mechanism of action has been suggested; possibility of hormone-like or hormoneinducing effects cannot be ruled out ginsenosides inhibit platelet aggregation and enhance fibrinolysis • acts as a mild depressant on higher nerve centers contains substances with estrogenic activity • main active constituent is aescin • • • may interact with anticoagulant and antiplatelet drugs to increase risk of bleeding avoid concurrent administration of hypoglycemic drugs avoid concurrent administration of MAO I • • • • • • varying effects on blood pressure hypoglycemic effect; caution in diabetics avoid in patients with manicdepressive disorders or psychosis (due to steroid effects) may potentiate action of MAO inhibitors limit use to 3 months may have additive effects with other CNS depressants drugs metabolized by the cytochrome P450 liver enzyme system • avoid in depressive states may interact with anticoagulant • side effects include nausea, insufficiency • and antiplatelet drugs to increase risk of bleeding contains coumarin constituents • • • • Kava Kava • • sedative anxiolysis • • • • active constituents are the kavalactones (kawain, dihydrokawain, methysticin, and dihydromethys ticin) kavalactones may act on central GABA and BZD binding sites; may decrease excitability of the limbic system may antagonize dopamine and inhibit MAO uptake kawain (a kavalactone) has been shown to have antiplatelet effects due to lowering platelet aggregation secondary to inhibition of cycloxygenas • • • • kavalactones potentiate effects of other CNS depressants, including opioids, barbiturates and BZDs decreases effectiveness of levodopa (due to dopamine antagonism) theoretical additive effects with other anticoagulant and antiplatelet drugs to increase risk of bleeding use caution with MAO inhibitor and other psychopharm acologic agents • • • • • • 10 stomach discomfort, allergic skin reactions, itching and muscle spasms turn urine red can cause kidney or liver damage can cause severe bleeding or bruising consider discontinuin g 2 weeks prior to surgery avoid in depression; may increase suicide risk due to its CNS depressant effects can impair motor function continuous heavy use can cause changes in blood chemistry, pulmonary hypertension, exaggerated kneecap reflex, reddened eyes, shortness of breath, weight loss and dry, flaking, discolored skin limit use to 3 months no evidence of potential for dependency consider discontinuin 11 g 1-2 weeks prior to surgery e Passion Flower • • • relaxation sleep • Saw Palmetto St. John's Wort • • treatment of benign prostatic enlargement treatment of mildmoderate depressio n, anxiety • • • • • active constituents may be glycosides (harmala compounds), maltone and ethyl-maltone, and flavanoids chrysin (component; a flavanoid) has BZD receptor activity • like finasteride (antiandrogeni c activity); antiestrogenic activity • hypericin (presumed active ingredient) shows affinity for serotonin, GABA, and BZD receptors inhibits MAO A & B (MAO inhibitor effects are thought to be minor) primary mechanism of action of hypericin is thought to be inhibition of serotonin reuptake, as well as downregulation of serotonin receptors and neurohormonal mechanisms hypericin and psuedohypericin may induce hepatic enzymes • • possible additive effects with other CNS depressants avoid MAO I • potential additive effects with otherhormone s ad • although no drug-drug or drug-food interactions have been reported, it may be prudent to avoid concomitant use with MAO inhibitor, meperidine and sympathomim etics, as well as traditional antidepressan ts • • • • • reports of hepatotoxicity and pancreatic toxicity no evidence of potential for dependency can cause HTN and GI disturbances considered an atypical antidepressa nt can cause photosensitivi ty in fairskinned people (doserelated) potentially can cause serotonin syndrome may prolong effects of anesthesia 12 Valerian • • sedative anxiolysis • • • • • • interacts and binds with GABA; valerenic acid component may inhibit breakdown of GABA, thereby enhancing activity Japanese valerian contains kessyl gycol diacetat which has BZD-like anxiolyfic effects and antidepressant effects (possibly due to blockage of MAO uptake) high concentration of glutamine in valerian extracts could explain sedative properties; glutamine is metabolized to GABA once it crosses BBB possible direct relaxing effect on smooth muscle (thought to be due to GABA present in valerian) may also weakly antagonize BZD receptors too high initial dose can cause excitability • • • may have additive effects with other CNS depressants, including barbiturates, benzodiazepin es , and opioids will likely potentiate effects from barbiturates Antabuse; there is alcohol in many of the extract products • • • • • • does not appear to affect driving ability, potentiate effects of alcohol or result in morning hangover side effects include headache and morning grogginess can cause cardiac disturbances can cause liver damage effects are not immediate (24 weeks) does not seem to cause dependence a Herbs are classified as dietary supplements and not approved by the FDA to be used as drugs. The uses, proposed mechanism of action, effects, drug interactions and other considerations are based on reports in the literature. The body of literature does not always agree on each herbs specific properties, effects and uses. b This is a very conservative recommendation for discontinuing these herbs prior to surgery, thereby allowing normal hematologic function to return. Gingko biloba is believed to be the herbal product with the most serious side effects, with several case reports in the literature of spontaneous bleeding. In two cases, the patient was also taking chronic aspirin or warfarin. c Anticoagulant drugs include warfarin, heparin and low molecular weight heparin d Antiplatelet drugs include aspirin, nonsteroidal antinflammatory agents, dipyridamole, ticlopidine, and sulfinpyrazone 13 B. DIETARY SUPPLEMENTS WITH ANTI- OR PRO-COAGULANT ACTIVITY Irreversible platelet effects: Feverfew, garlic, panax ginseng. D/C 7-10 days prior to surgery. Reversible platelet effects: Ginkgo, Vitamin E. D/C 3 days prior to surgery. 14 V. TWELVE DIETARY SUPPLEMENTS NO ONE SHOULD TAKE!!! Name Dangers (Also known as) DEFINITELY HAZARDOUS Documented organ failure and known carcinogenic properties Aristolochic acid (Aristolochia, birthwort, snakeroot, Potent human carcinogen; snakeweed, sangree root, sangrel, serpentary, serpentaria; kidney failure, sometimes asarum canadense, wild ginger). Can be an ingredient in requiring transplant; deaths Chinese herbal products labeled fang ji, mu tong, ma dou reported. ling, and mu xiang. Can be an unlabeled substitute for other herbs, including akebia, asarum, clematis, cocculus, stephania, and vladimiria species. Regulatory actions FDA warning to consumers and industry and import alert, in April 2001. Banned in 7 European countries and Egypt, Japan, and Venezuela. VERY LIKELY HAZARDOUS Banned in other countries, FDA warning, or adverse effects in studies Comfrey (Symphytum officinale, ass ear, black root, Abnormal liver function or FDA advised industry to remove from blackwort, bruisewort, consolidae radix, consound, gum damage, often irreversible; market in July 2001. plant, healing herb, knitback, knitbone, salsify, slippery deaths reported. root, symphytum radix, wallwort) Androstenedione (4-androstene-3, 17-dione, andro, androstene) Increased cancer risk, decrease in HDL cholesterol. FDA warned 23 companies to stop manufacturing, marketing, and distributing in March 2004. Banned by athletic associations. Chaparral (Larrea divaricata, creosote bush, greasewood, Abnormal liver function or FDA warning to consumers in December hediondilla, jarilla, larreastat) damage, often irreversible; 1992. deaths reported. Germander (Teucrium chamaedrys, wall germander, wild Abnormal liver function or Banned in France and Germany. germander) damage, often irreversible; deaths reported. 15 Kava (Piper methysticum, ava, awa, gea, gi, intoxicating Abnormal liver function or FDA warning to consumers in March pepper, kao, kavain, kawa-pfeffer, kew, long pepper, damage, occasionally 2002. Banned in Canada, Germany, malohu, maluk, meruk, milik, rauschpfeffer, sakau, tonga, irreversible; deaths reported. Singapore, South Africa, and Switzerland. wurzelstock, yagona, yangona) LIKELY HAZARDOUS Adverse-event reports or theoretical risks Bitter orange (Citrus aurantium, green orange, kijitsu, High blood pressure; neroli oil, Seville orange, shangzhou zhiqiao, sour orange, increased risk of heart zhi oiao, zhi xhi) arrythmias, heart attack, stroke. Organ/glandular extracts(brain/adrenal/pituitary/ placenta/other gland “substance” or “concentrate”) Theoretical risk of mad cow disease, particularly from brain extracts. None FDA banned high-risk bovine materials from older cows in foods and supplements in January 2004. (High-risk parts from cows under 30 months still permitted.) Banned in France and Switzerland. Lobelia (Lobelia inflata, asthma weed, bladderpod, Breathing difficulty, rapid Banned in Bangladesh and Italy. emetic herb, gagroot, lobelie, indian tobacco, pukeweed, heartbeat, low blood vomit wort, wild tobacco) pressure, diarrhea, dizziness, tremors; possible deaths reported. Pennyroyal oil(Hedeoma pulegioides, lurk-in-the-ditch, mosquito plant, piliolerial, pudding grass, pulegium, runby-the-ground, squaw balm, squawmint, stinking balm, tickweed) Liver and kidney failure, None nerve damage, convulsions, abdominal tenderness, burning of the throat; deaths reported. Scullcap (Scutellaria lateriflora, blue pimpernel, helmet flower, hoodwort, mad weed, mad-dog herb, mad-dog weed, quaker bonnet, scutelluria, skullcap) Abnormal liver function or None damage. Yohimbe (Pausinystalia yohimbe, johimbi, yohimbehe, yohimbine) Change in blood pressure, None heart arrythmias, respiratory depression, heart attack; deaths reported. According to product labels. Sources: Natural Medicines Comprehensive Database 2004 and Consumers Union's medical and research consultants. VI. Advice For the Patient ♦ If it seems too good to be true it probably is! “Scientific Breakthrough” “Miraculous Cure” “Exclusive Product” “Secret Ingredient” “Ancient Remedy” How to Spot False Claims Medical Conspiracy to Suppress Product 16 Undocumented Case Histories Claiming Amazing Results Product Available from Only One Source Money-Back Guarantee Weight Loss is Easy and Fast Key Issues For Consumers “Natural” is not synonymous with “Safe” Lack of standardization may result in great variation among products Never use in pregnant women, the elderly, or in young children Consumers must protect themselves in the current regulatory environment VII. “Natural” Oral Health Products: Help or Hype? A. Common “Alternative” Ingredients -Loturbark, Neem, Tulsi, Myrrh -Peelu (Miswak Chewing Stick) -Melaleuca (Australian Tea Tree Oil) -Propolis (Bee Product) -Essential Oils -Coenzyme Q10 (Ubiquinone) -Green Tea Extract -Antioxidants -Vitamin C (Ascorbic Acid) -Aloe Vera - 17 B. Common Alternative Dental Products Product/Manufacturer Claims “Active Ingredients” Auromere (www.auromere.com) Invigorates/purifies Neem, Peelu, 24 herbal extracts Dabur (Nature Care) Astringent/cleaning Tulsi, Loturbark, essential oils DentiCare Tooth Polish (Melaleuca, Inc.) Benefits bleeding gums Melaleuca, propolis, myrrh Dentaforce (Bioforce) Astringent/stimulant Echinacea, rosemary, essential oils - Eco-Dent (Eco-Dent 888.Eco.Dent) Hardens enamel w/o F BS, tartaric acid, CaCo3, myrrh Cool Mint (Nature’s Gate) Antiseptic/ “free” calcium Sage, vitamin C, Calcium Carrot Pwd. Herbal TP and Gum Therapy (Woodstock 800.615.6895) Prevent cavities/fight gingivitis MFP, aloe vera, echinacea, golden seal, bloodroot, calendula, propolis Homeodent (Boiron-Borneman) No-mint,no effect on homeopathy Calendula, plantain, witch hazel Jason Toothpaste (www.jasonnatural.com) Best Tasting Natural Toothpaste! CoQ10, Aloe Vera, Sea Salt, Melaleuca, Gum support/perio protection Perilla Seed Extract MouthFx (www.mouthrx.com) 97% effective in 41 countries 100% natural essential oils Nutribiotic Dental Gel (www.nutribiotic.com/dentalgel) Supports teeth and gums Grapefruit Seed Extract, Zinc citrate, sanguinaria, aloe vera, stevia Parodontax (Madaus) To treat periodontal disease Rhatany, chamomille, myrrh, echinacea, Peelu (Peelu Products) Miswak/Siwak chewing stick Peelu fiber, natural sorbo fruit juice Propolis TP (Beehive Botanicals) Protects hive, benefits mankind Propolis, xylitol, flavoring oils Rembrandt “Naturals” (Den-Mat) Antioxidant, vit. C, Calcium Freshening/Invigorating/Soothing Tea Tree Oil TP (Desert Essence) Especially good for gingivitis/perio Melaleuca, propolis, ginger Tea Tree TP (Thursday Plantation) Healthy gums, decrease tartar 0.4% melaleuca, chlorophyllin-copper Tom’s of Maine (Tom’s of Maine) No dyes, preservatives, sweetners MFP, CaCo3, silica, zinc for TC Tooth and Gum Paste (Dental Herb Company 800.747.4372) Substantive, no SLS, “natural fluoride source” from tea Echinacea, green tea, essential oils No Fluoride which is toxic VIII. Herbal and Nutritional Drug Product References Natural Medicines Comprehensive Database -“Gold Standard” for objectivity and comprehensive information -patient handout option very useful and database can be searched by disease state -updated daily and fully referenced with abstracts available for review -priced at $75/year at www.naturaldatabase.com Nutrition Action Health Letter -10 issues per year. Subscribe at www.cspinet.org - -nonprofit “food police” address dietary supplement controversies -price $24/year or $42/24 months, to order fax 202.265.4954, Useful Websites -www.quackwatch.com -www.consumerlab.com -analytical reports on specific products -www.americanbotanicalsociety.com or www.herbalgram.org (Mark Blumenthal) -www.nccam.nih.gov/health/ -www.ific.org/publications/other/driupdateom.cfm. -www.mskcc.org/mskcc/html/11570.cfm. -www.asahq.org-“Herbals and Anesthesia” brochure for sale