By Sharon Montes, MD
Before performing a tooth extraction, you ask your patient, "So, what supplements are you taking?" Her response is, "I took some homeopathic arnica to decrease bleeding and pain after this procedure, and I am taking ginkgo for my memory." Now that you have asked the question, what do you do with the answer? This article will help you manage information about botanical and nutritional supplements, facilitating wiser choices for you and your patients.
It is estimated that 53 percent of the U.S. adult population uses dietary supplements in a year.1 In the United States, use of dietary supplements has been seen as alternative or complementary to traditional medical care, and both health care providers and consumers sometimes struggle regarding how to integrate the use of supplements into therapy.
Dietary supplements are defined as products other than tobacco that include vitamins, minerals, herbs, botanicals, amino acids, and other substances or their constituents that are labeled as being dietary supplements and can be taken by mouth in the form of pill, capsule, tablet, or liquid.
A 1997 survey of 2,055 people revealed that a third of the adult population was using at least one type of alternative therapy, and less than 40 percent were sharing that information with their health care providers.2 Frequently, patients do not inform their health care providers that they are taking these remedies, and many providers do not ask patients if they are taking any supplements.
Communication about this issue is further impaired if patients maintain a view that natural herbs are all safe, effective, and better than synthetic medicines, while health care providers may view supplements as harmless and ineffective.
When the U.S. Congress passed the Dietary Supplement Health and Education Act (DSHEA) in 1994, congressional representatives received more mail from their constituents about this act than was received regarding the Vietnam War. Although the DSHEA left consumers the freedom to choose supplements unregulated by the FDA, it also left U.S. consumers and health care providers without much safety or efficacy data about many nutritional products.
The integration of supplements into health care systems varies around the world. The World Health Organization has estimated that approximately 80 percent of the world's population continues to use traditional medicines, of which a major part is botanical therapy. In addition, botanical and nutritional medicines have been integrated into conventional practices in many other countries — even receiving insurance reimbursement in some European countries.
For many years, ginkgo was the leading prescription drug in France and Germany.3 Germany has taken knowledge of traditional herbal medicine and expanded into the pharmaceutical arena. There are many phyto-medicinal companies selling patented, standardized herbal formulas as well as mono-preparations. This greater integration in the health care system has led to greater professional education and ability to counsel patients about using dietary supplements.
Supplement overview — form, standardization, and best-sellers specific to dental practice
Patients use a variety of forms of supplements — capsules, tablets, teas, decoctions (boiling plant roots/bark), tinctures, ointments, and poultices. They may obtain supplements from a variety of sources — grocery, health, and ethnic-food stores, Internet, mail-order catalogs, friends, local gardens, fields, and forests, multi-level marketers, or health practitioners.
Most western-trained health care providers prefer to work with supplements that are in capsule or tablet form and have standardized dosing. In contrast, an herbalist may prefer to use whole, dried herbs rather than powdered or cut and sifted (hammer-milled) herbs because they can guarantee purity of ingredients, and whole herbs are less likely to lose potency as quickly as powdered herbs. In addition, to promote maximum efficacy, active ingredients may best be extracted by water, glycerin, oil, or alcohol tincture. For the most part, this knowledge is integrated into the good-quality commercial preparations.
If the plant constituents responsible for or associated with a particular medicinal action have been identified, then the herbal product can be standardized to contain a guaranteed amount of a specific compound. Standardized extracts of herbs are sold in capsule and liquid extract form in the United States. The bottle of standardized herbal product usually has the word "standardized" on the label. For instance, ginkgo biloba can be standardized to 24 percent flavonglycosides. Flavonglycosides are the chemical constituents identified to increase capillary blood circulation.
While standardization of an herbal product allows for greater accuracy of dosage, it is not possible for all botanical remedies to be standardized. Ethnobotanists and phytochemists spend years researching which plant constituents have medicinal value and which do not.
It is often unclear which chemical or groups of chemicals are responsible for the observed medicinal effects. For this reason, many effective and commonly used botanical supplements are not standardized. When a product has been standardized or its process patented and researched, however, many clinicians prefer to use the form of the product that was researched. Many European pharmaceutical companies obtain patents on the way they process the plant to achieve standardization.
For nutritional supplements, purity of product or standardization of dosing is not as important a quality issue. For nutritional supplements, the most important quality is the form of the nutrient that is most bio-available.
For many years, large vitamin manufacturers sold a form of vitamin E, dl-alpha tocopheryl. This form is less expensive to manufacture than the d-alpha tocopheryl. The d-alpha form is the form found in foods that has greater affinity for the receptors in human cells. It is thought that the dl-alpha forms may prevent the action of naturally occurring vitamin E.
When assessing the quality of my patients' multivitamins, I look for the form of vitamin E listed on the label. Some of the best-quality multivitamins contain not only d-alpha tocopheryl, but also mixed tocopheryls. It has been found that the gamma and delta forms of vitamin E, found naturally in food, have different effects in the body. The gamma form plays an important role in cardiovascular health.
Frequently, health care providers who specialize in nutritional products stay most informed about the forms and products that achieve maximum clinical efficacy. For this reason, I have collaborated with local pharmacists, naturopathic physicians, and other integrative providers wherever I have established my clinical practice.
Because nutritional supplements are frequently sold in mixtures, it is difficult to track sales. In 2002, a survey was conducted of 31,044 U.S. adults. Almost 19 percent reported using natural products. The top 10 natural products used included: Echinacea (40.3%); ginseng (24.1%); ginkgo (21.1%); garlic supplements (19.9%); glucosamine (14.9%); St. John's wort (12.0%); peppermint (11.8%); fish oil/omega fatty acids (11.7%); finger supplements (10.5%); and soy supplements (9.4%).4
More recent sales data for single-preparation, botanical preparations by percentage of sales are also available. For 2005, the top 10 list of favorite single herbs by sales in the United States were: garlic (10.4%); Echinacea (8.4%); saw palmetto (7.6%); ginkgo (6.6%); cranberry (3%); soy (5.8%); ginseng-type unspecified (4.6%); black cohosh (3.9%); St. John's wort (3.6%); and milk thistle (3.3%).5 Maybe you even have some of these supplements in your kitchen or bathroom. Table 1 describes the usage and dosing for these best-selling botanical supplements.
Supplements with particular application in dental practice
Possible beneficial supplements
Clove gel: In addition to being a great cooking spice, cloves have traditionally been used for their anti-infective and topical analgesic effects. In a randomized, single-blind study, clove gel was documented to have comparable efficacy at reducing reported needle-stick pain as benzocaine 20% gel. The clove gel, which was produced by finely grinding cloves and mixing with glycerin in a 2:3 (clove: glycerin) ratio, had the advantage of being readily available and easy to produce, but the disadvantage of inducing small, aphthous-like ulcers.6
Coenzyme Q10 (CoQ10 or ubiquinone): This is a necessary cofactor for production of intracellular ATP and is found throughout the body. The cells that have greatest metabolic activity are most likely to show functional deficiency (e.g., gingival and gastric mucosa, immune system, and heart). At a general-health level, the most important use of supplemental CoQ10 is for patients taking statin medications to lower their cholesterol. The statins decrease cholesterol by blocking a liver enzyme necessary for cholesterol production. That same enzyme, found throughout the body, is used by cells to produce CoQ10. Therefore, in addition to blocking the production of cholesterol, statins also interfere with the body's production of CoQ10.7
CoQ10 deficiency has been linked with gingival disease, while adjunctive treatment is linked with significant clinical improvement. The dose used to effectively treat periodontal disease was 50 mg a day.8,9 If you were to prescribe CoQ10, it would be important to counsel your patients to use the more bioavailable, oil-based capsule at a dose of 60 mg. (It is not easily available in 50 mg strength.)
Xylitol is a five-carbon sugar found in almost all plants. It has shown greater efficacy than sorbitol in decreasing caries. It is most often found in candy or gum, and the therapeutic dose is 7 to 20 grams divided into three to five doses a day. One proposed mechanism of action is to lower plaque and salivary levels of Streptococcus mutans and lactobacilli. Some people think it increases bone density.10,11
Possible concern
Supplements that interfere with coagulation or thrombosis or have side effects localized to the oral cavity could be problematic in a dental practice. Many supplements have theoretical side effects or supplement drug interactions. In clinical practice in general, there are not absolute contraindications. (See following section about counseling special populations.) About 30,000 dietary supplements are available in the United States. About 120 of them could interact with NSAIDS, dipyridamole, or clopidogrel, and about 180 supplements could interact with warfarin.12 This becomes clinically relevant if patients are taking high doses of supplement (e.g., greater than 6,000 mg of fish oil or 400 IU of vitamin E a day) or combining many supplements. In my clinical practice, the pneumonic I use to remember the possibly clinically significant supplements is "3 Gs plus E:" garlic, ginkgo, ginger, and vitamin E all have antiplatelet action.
I have personally observed that garlic, ginkgo, and vitamin E have clinical effects, whether increased bruising or delayed clotting, and I recommend that my patients do not combine them with NSAIDS.
Counseling patients — special populations
There are a few specific clinical situations that warrant special attention to ascertain whether a patient is taking dietary supplements in any form:
— Patients taking medications with a narrow therapeutic index, e.g., warfarin, Dilantin, digoxin, theophylline (Some plants contain coumarins or can promote increased or decreased amounts of circulating medicine.)
— Patients taking medications which depend predominately on the p450 system for metabolism (Many supplements interact with this metabolic pathway.)
— Patients who are pregnant or lactating
— Elderly patients or those with impaired liver or renal function
— Infants and small children
Many herbs are metabolized through the liver. Infants, small children, and the elderly are more sensitive to dosage issues. Many herbal practitioners do not recommend herbs for infants because their livers are immature. We recommend that people in these age groups take herbal medicines only under the direction of a practitioner educated and experienced in this area. Older adults and small children can tolerate half-strength, herbal-beverage teas occasionally. Chamomile and peppermint teas are examples of beverage teas.
Sources of further information:
Natural Medicines Comprehensive Database, (209) 472-2244
Published by the same editors of the Pharmacist's Letter, the database is available in Web or book form and has a perspective and information presentation familiar to many conventional health care providers.
American Botanical Council, Austin, Texas, (800) 373-7105
This organization is co-publisher of HerbalGram and published the English translation of the German Commission E Monographs. They sell many hard-to-obtain reference texts and organize herb study trips, and have an online subscription reference service.
Closing remarks
Dietary supplements have become an integral part of many consumers' nutritional plans. Absolute science to guide counseling is lacking. The perspectives of herbalists and pharmacists present two ends of a spectrum. Combining the experience while honoring our clients' wisdom and freedom of choice improves the clinic experience for each of us.
References
1 Radimer K, Bindewald B, Hughes J, et al. Dietary supplement use by U.S. adults: Data from the National Health and Nutrition Examination Survey, 1999-2000. Am J Epidemiol 160: 339-349, 2004.
2 Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 280: 1569-1575, 1998.
3 Murray MT. The Healing Power of Herbs. Roseville, CA, Prima Publishing. 1995.
4 Barnes PM, Powell-Griner E, McFann K, et al. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 1-19, 2004.
5 Blumenthal M, Ferrier GKL, Cavaliere C. Total Sales of Herbal Supplements in United States Show Steady Growth. HerbalGram 71: 64-66, 2006.
6 Alqareer A, Alyahya A, Andersson L. The effect of clove and benzocaine versus placebo as topical anesthetics. J Dent 34: 747-750, 2006.
7 Gaby A. The Role of Coenzyme Q10 in Clinical Medicine: Part I. Alt Med Review 1: 11-17, 1996.
8 Nakamura R, Littarru GP, Folkers K, et al. Study of CoQ10-enzymes in gingiva from patients with periodontal disease and evidence for a deficiency of coenzyme Q10. Proc Natl Acad Sci USA 71: 1456-1460, 1974.
9 Wilkinson EG, Arnold RM, Folkers K. Bioenergetics in clinical medicine. VI. adjunctive treatment of periodontal disease with coenzyme Q10. Res Commun Chem Pathol Pharmacol 14: 715-719, 1976.
10 Gales MA, Nguyen TM. Sorbitol compared with xylitol in prevention of dental caries. Ann Pharmacother 34: 98-100, 2000.
11 Makinen KK. Can the pentitol-hexitol theory explain the clinical observations made with xylitol? Med Hypotheses 54: 603-613, 2000.
12 NIH Conference on Dietary Supplements, Coagulation, and Antithrombotic Therapies. www.nhlbi.nih.gov/meetings/coagulation/index.htm.
Sharon Montes, MD, assistant professor with University of Maryland Integrative Medicine, has more than 20 years of experience practicing and teaching integrative medicine. She has specific interests in acupuncture, bio-identical hormone-replacement therapy, herbal, nutritional, and energetic therapies. Her e-mail address is [email protected].
