the impact of herbal medicine on clinical dentistry - sun am.pdf♦ not usually reimbursed by...

TThhee IImmppaacctt ooff HHeerrbbaall MMeeddiicciinnee oonn CClliinniiccaall DDeennttiissttrryy KKaarreenn AA.. BBaakkeerr,, MM..SS..,, RR..PPhh..

AAssssoocciiaattee PPrrooffeessssoorr DDeepptt.. OOrraall PPaatthhoollooggyy,, RRaaddiioollooggyy aanndd MMeeddiicciinnee -- UU ooff IIoowwaa CCoolllleeggee ooff DDeennttiissttrryy DDeepptt.. CClliinniiccaall aanndd AAddmmiinniissttrraattiivvee PPhhaarrmmaaccyy -- UU ooff IIoowwaa CCoolllleeggee ooff PPhhaarrmmaaccyy

II.. DDEEFFIINNIITTIIOONNSS && PPAATTIIEENNTT UUTTIILLIIZZAATTIIOONN

AAlltteerrnnaattiivvee MMeeddiicciinnee ((aass ddeeffiinneedd bbyy tthhee OOffffiiccee ooff AAlltteerrnnaattiivvee MMeeddiicciinnee ((NNIIHH))))

♦♦ TThhoossee ttrreeaattmmeennttss && hheeaalltthh ccaarree pprraaccttiicceess nnoott ttaauugghhtt wwiiddeellyy iinn mmeeddiiccaall sscchhoooollss ♦♦ NNoott ggeenneerraallllyy uusseedd iinn hhoossppiittaallss ♦♦ NNoott uussuuaallllyy rreeiimmbbuurrsseedd bbyy mmeeddiiccaall iinnssuurraannccee ccoommppaanniieess

DDeeffiinniittiioonnss ooff ppooppuullaarr aalltteerrnnaattiivvee tthheerraappiieess

♦♦ HHoolliissttiicc mmeeddiicciinnee:: AAss tthhee tteerrmm iimmpplliieess,, ddeeaallss wwiitthh aa bbeeiinngg aass aa ""wwhhoollee"" aanndd iinntteeggrraatteedd ssyysstteemm rraatthheerr tthhaann iinnddiivviidduuaall ppaarrttss aanndd aaddvvooccaatteess tthhee ssyynneerrggiissttiicc uussee ooff hheerrbbss ttoo hheeaall tthhee bbeeiinngg.. AAllssoo rreeffeerrrreedd ttoo aass aalltteerrnnaattiivvee oorr ccoommpplleemmeennttaarryy mmeeddiicciinnee,, iitt iiss ccoommppoosseedd ooff aa sseerriieess ooff ddiisscciipplliinneess iinncclluuddiinngg cchhiirroopprraaccttiiccss,, nnaattuurrooppaatthhyy,, rreefflleexxoollooggyy,, aaccuuppuunnccttuurree,, mmaassssaaggee,, aanndd tthhee ffoolllloowwiinngg..

♦♦ HHoommeeooppaatthhyy:: BBaasseedd oonn tthhee pprriinncciippllee ooff ""lliikkee ccuurreess lliikkee””----vveerryy ssmmaallll ddoosseess ooff nnaattuurraallllyy ddeerriivveedd bboottaanniiccaall,,

mmiinneerraall,, oorr aanniimmaall ccoommppoouunnddss aarree ddiilluutteedd ttoo ttrreeaatt aa ccoonnddiittiioonn.. TThhee ssaammee ssuubbssttaannccee iinn llaarrggeerr ddoosseess iinn aa hheeaalltthhyy ssuubbjjeecctt wwoouulldd ccaauussee ssyymmppttoommss ssiimmiillaarr ttoo tthhoossee ooff tthhee ddiisseeaassee bbeeiinngg ttrreeaatteedd..

♦♦ HHeerrbbaall mmeeddiicciinnee:: RReessttss oonn tthhee uussaaggee ooff pprreeppaarraattiioonnss aanndd mmeeddiiccaattiioonnss ddeerriivveedd ffrroomm bboottaanniiccaall

ccoommppoonneennttss ssuucchh aass rroooottss,, lleeaavveess,, aanndd fflloowweerrss ttoo pprroommoottee hheeaalliinngg..

♦♦ NNaattuurrooppaatthhyy:: AAddooppttss aa nnoonn--iinnvvaassiivvee aapppprrooaacchh eemmpphhaassiizziinngg nnaattuurraall rreemmeeddiieess,, aa hheeaalltthhyy ddiieett,, aanndd eexxeerrcciissee ttoo hheeaall rraatthheerr tthhaann ssuurrggeerryy oorr ssyynntthheettiicc ddrruuggss.. NN..DD.. iiss ““DDooccttoorr ooff NNaattuurrooppaatthhyy””

CCoommmmoonn VViieewwppooiinntt AAmmoonngg TTrraaddiittiioonnaall HHeeaalltthhccaarree PPrroovviiddeerrss:: ““EEiitthheerr WWoorrtthhlleessss oorr DDaannggeerroouuss!!!!””

♦♦ UUnnttiill tthhee 11994400ss mmuucchh ooff tthhee UU..SS.. PPhhaarrmmaaccooppooeeiiaa wwaass ccoommppoosseedd ooff ddrruuggss ooff hheerrbbaall oorriiggiinn ♦♦ 2255%% ooff ccoommmmoonn RRxx ddrruuggss ccoonnttaaiinn aatt lleeaasstt oonnee aaccttiivvee iinnggrreeddiieenntt ddeerriivveedd ffrroomm ppllaannttss

aassppiirriinn,, aattrrooppiinnee,, bbeellllaaddoonnnnaa,, ccaappssaaiicciinn,, ccooccaaiinnee,, ccoollcchhiicciinnee,, ddiiggooxxiinn,, eepphheeddrriinnee,, eerrggoottaammiinnee,, ooppiiuumm,, pphhyyssoossttiiggmmiinnee,, ppiillooccaarrppiinnee,, qquuiinniiddiinnee,, ssccooppoollaammiinnee,, ttaaxxooll,, vviinnccrriissttiinnee,, vviinnbbllaassttiinnee

♦♦ 8800%% ooff tthhee wwoorrlldd’’ss ppooppuullaattiioonn ((44 bbiilllliioonn ppeeooppllee)) uussee hheerrbbaall mmeeddiicciinnee ffoorr ssoommee aassppeecctt ooff pprriimmaarryy hheeaalltthh ccaarree aaccccoorrddiinngg ttoo tthhee WWoorrlldd HHeeaalltthh OOrrggaanniizzaattiioonn…….. WWhhaatt aarree tthhee rreeaassoonnss?????? 11)) PPaattiieenntt ddiissssaattiissffaaccttiioonn wwiitthh ccoonnvveennttiioonnaall ttrreeaattmmeennttss bbeeccaauussee ooff llaacckk ooff eeffffeecctt,, aaddvveerrssee eeffffeeccttss,, oorr ppeerrcceeppttiioonnss tthhaatt ttrreeaattmmeennttss aarree ttoooo iimmppeerrssoonnaall,, hhiigghhllyy tteecchhnniiccaall,, oorr ccoossttllyy;; 22)) TThhee nneeeedd ffoorr ppeerrssoonnaall ccoonnttrrooll iiss mmeett bbeeccaauussee ppaattiieenntt bbeeccoommeess aa ““ccoo--tthheerraappiisstt””;;

3) AAlltteerrnnaattiivvee tthheerraappiieess aarree mmoorree aattttrraaccttiivvee bbeeccaauussee ppaattiieennttss vviieeww tthheemm aass mmoorree ccoommppaattiibbllee wwiitthh tthheeiirr vvaalluuee ssyysstteemmss..

♦♦ 7700%% ooff ppaattiieennttss wwiillll nnoott tteellll hheeaalltthh ccaarree pprroovviiddeerrss tthheeyy aarree ttaakkiinngg hheerrbbaall pprroodduuccttss ♦♦ UU..SS.. MMaarrkkeett ffoorr ddiieettaarryy ssuupppplleemmeennttss wwaass aallmmoosstt 2211 bbiilllliioonn iinn 22000066 ♦♦ TToopp 1100 hheerrbbaall pprroodduuccttss aaccccoouunntt ffoorr 6600%% ooff tthhee ttoottaall hheerrbbaall mmeeddiicciinnee mmaarrkkeett

MOST COMMON CONDITIONS TREATED AND THE SPECIFIC OTC SUPPLEMENTS SOLD

Condition Specific Supps ($mil) 20052005

growth% of total in 2005

Sports/Energy/Weight-Loss 5,802 1% 27%General Health 4,674 5% 22%Cold/Flu-Immune 1,364 14% 6%Joint health 1,226 6% 6%Anti-cancer 1,073 4% 5%Heart health 1,016 7% 5%Bone health 986 2% 5%Gastrointestinal health 694 17% 3%Diabetes 532 8% 3%Menopause 314 1% 1%Brain Mental 264 16% 1%Sexual Health 239 13% 1%Mood 220 12% 1%Insomnia 126 12% 1%Sum of top 14 Conditions 18,529 5% 86%Others 2,786 1% 14%Total Supplements 21,315 5% 100%

US Vitamins 2003 2004 20052004

growth2005

growth

MultiVitamins 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%

Total 6,658 6,892 7,163 4% 4%

US Minerals 2003 2004 20052004

growth2005

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%Iron 203 209 219 3% 5%Others 37 34 36 -7% 5%

Total 1,765 1,738 1,812 -2% 4%

Specialty Supplements 2003 2004 20052005

growthMelatonin 62 67 73 10%Probiotics 174 204 243 19%DHEA 47 48 50 3%Fish/Animal Oils 183 262 359 37%Plant Oils* 140 177 197 11%Glucosamine/Chondroitin 761 762 810 6%Bee Products 74 81 91 11%CoQ10 258 283 339 20%5 HTP 53 59 68 15%SAMe 92 93 96 3%MSM 115 111 107 -3%Gelatin 58 52 48 -8%Digestive Enzymes 130 147 166 13%Homeopathics 460 532 619 16%Others 122 134 148 10%Total 2,728 3,013 3,414 13%

II. 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

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

AA.. FFeeddeerraall TTrraaddee CCoommmmiissssiioonn ((FFTTCC)) ♦♦ OOTTCC DDrruugg RReegguullaattiioonn ♦♦ FFTTCC iiss rreessppoonnssiibbllee ffoorr aallll oovveerr--tthhee--ccoouunntteerr aaddvveerrttiissiinngg ♦♦ CCuurrrreennttllyy hheerrbbaall mmeeddiicciinneess ccaann oonnllyy bbee mmaarrkkeetteedd iinn tthhee UU..SS.. aass ddiieettaarryy ssuupppplleemmeennttss ♦♦ MMaannuuffaaccttuurreerrss//ddiissttrriibbuuttoorrss ccaannnnoott mmaakkee ssppeecciiffiicc hheeaalltthh ccllaaiimmss wwiitthhoouutt FFDDAA aapppprroovvaall?? ♦♦ SSttrruuccttuurree//ffuunnccttiioonn ccllaaiimmss vveerrssuuss ddiisseeaassee ccllaaiimmss

BB.. LLeeggiissllaattiioonn

DDiieettaarryy SSuupppplleemmeennttss HHeeaalltthh && EEdduuccaattiioonn AAcctt ((DDSSHHEEAA)) 11999944 CCoonnggrreessss ““ffrreeeedd”” tthhee ppooppuullaattiioonn ttoo ppuurrssuuee sseellff--mmeeddiiccaattiioonn wwiitthh hheerrbbaall aanndd aalltteerrnnaattiivvee pprroodduuccttss

vviittaammiinnss,, mmiinneerraallss,, eesssseennttiiaall ffaattttyy aacciiddss,, eennzzyymmeess,, ccooeennzzyymmeess,, ppllaanntt ddeerriivveedd ((hheerrbbss)),, aanniimmaall--ddeerriivveedd ((gglluuccoossaammiinnee)),, bbaacctteerriiaa,, ggllaanndduullaarr pprroodduuccttss ((aaddrreennaall eexxttrraaccttss)),, hhoorrmmoonnaall ((mmeellaattoonniinn))

AAcctt lliimmiittss FFDDAA’’ss rreegguullaattiioonn ooff ““ddiieettaarryy ssuupppplleemmeennttss”” ttoo ssuuppeerrffiicciiaall llaabbeelliinngg ffeeaattuurreess bbeeccaauussee tthhee aacctt wwaass nnoott ffuullllyy ffuunnddeedd.. NNeeww lleeggiissllaattiivvee iinniittiiaattiivveess mmaayy cchhaannggee tthhiiss vveerryy ssoooonn..

CC.. PPrroobblleemmss wwiitthh DDSSHHEEAA

PPrroodduuccttss aarree nnoott rreeqquuiirreedd ttoo:: GGaaiinn pprriioorr mmaarrkkeettiinngg aapppprroovvaall bbyy tthhee FFDDAA BBee MMoonniittoorreedd ffoorr iiddeennttiittyy oorr ppootteennccyy ooff cchheemmiiccaallss iinn tthhee ssuupppplleemmeenntt BBee bbaacckkeedd bbyy ccoommppaannyy ddaattaa ssuuppppoorrttiinngg ssaaffeettyy oorr eeffffiiccaaccyy

NNaattuurraall == SSaaffee ??????

PPaarraaddooxx –– ppuubblliicc iiss mmoorree aaffrraaiidd ooff tteesstteedd ddrruuggss tthhaann ooff uunntteesstteedd ddiieettaarryy ssuupppplleemmeennttss 1155--2200%% ooff aadduullttss iinn UUSS hhaavvee uusseedd hheerrbbaallss wwiitthhiinn tthhee ppaasstt yyeeaarr aaccccoorrddiinngg ttoo UUSSDDHHHHSS

DD.. PPrroobblleemmss wwiitthh HHeerrbbaallss IInntteennttiioonnaall ffrraauudduulleenntt aadduulltteerraattiioonn wwiitthh aannootthheerr aaccttiivvee ddrruugg AAcccciiddeennttaall ssuubbssttiittuuttiioonn ooff aa mmoorree ttooxxiicc ssppeecciieess ffoorr tthhee iinntteennddeedd ppllaanntt mmaatteerriiaall CCoonnttaammiinnaannttss –– cchheemmiiccaallss,, ttooxxiinnss,, bbiioollooggiicc ppaatthhooggeennss IInnaapppprroopprriiaattee aammoouunnttss ooff cchheemmiiccaall ⇑⇑ oorr ⇓⇓ AAddvveerrssee hheerrbb--ddrruugg oorr hheerrbb--ddiisseeaassee iinntteerraaccttiioonnss IInnttrriinnssiicc ttooxxiicciittyy,, llooww mmaarrggiinn ooff ssaaffeettyy

–– FFrroomm DDrruugg TTooppiiccss AApprriill 1166,, 22000011

EE.. TTeessttiinngg ffoorr AAccttiivvee IInnggrreeddiieenntt aanndd LLaabbeelliinngg ––CCoonnssuummeerr LLaabb ggiivveess aa CCLL aapppprroovveedd sseeaall -USP dietary supplement verified seal -NSF International certifies products FF.. EExxaammpplleess ooff RReelliiaabbllee HHeerrbb CCoommppaanniieess

NNaattuurree''ss WWaayy,, NNaattuurree''ss HHeerrbbss,, PPhhyyttoopphhaarrmmiiccaa,, aanndd FFrroonnttiieerr HHeerrbbss LLaarrggee PPhhaarrmmaacceeuuttiiccaall CCoommppaanniieess –– BBaayyeerr,, AAmmeerriiccaann HHoommee PPrroodduuccttss,, WWaarrnneerr LLaammbbeerrtt,, KKnnoollll

GG.. PPaattiieenntt HHiissttoorryy:: SSccrreeeenniinngg QQuueessttiioonnss oonn DDeennttaall HHeeaalltthh QQuueessttiioonnnnaaiirree

♦♦ DDoo yyoouu rreegguullaarrllyy ttaakkee ddiieettaarryy ssuupppplleemmeennttss oorr hheerrbbaall mmeeddiicciinneess?? ♦♦ IIff YYEESS,, ddoo yyoouu rreegguullaarrllyy ttaakkee aannyy ooff tthhee ffoolllloowwiinngg::

♦♦ DDiieett oorr EEnneerrggyy ssuupppplleemmeennttss EEcchhiinnaacceeaa GGaarrlliicc GGiinnggeerr GGiinnkkggoo GGiinnsseenngg ♦♦ KKaavvaa SStt.. JJoohhnn’’ss WWoorrtt VVaalleerriiaann VViittaammiinn EE >>440000II..UU.. FFiisshh OOiill >>33 ggrraammss//ddaayy

♦♦ DDoo yyoouu rreegguullaarrllyy uussee nnaattuurraall oorr hheerrbbaall oorraall hheeaalltthh pprroodduuccttss?? ♦♦ HHaavvee yyoouu rreecceennttllyy ssttooppppeedd ttaakkiinngg aannyy hheerrbbss?? ♦ HHaavvee yyoouu ssuubbssttiittuutteedd hheerrbbss ffoorr pprreessccrriippttiioonn oorr oovveerr--tthhee--ccoouunntteerr ddrruuggss??

HH.. DDrruugg IInntteerraaccttiioonnss wwiitthh HHeerrbbaall PPrroodduuccttss::

5♦♦ WWhhyy aarree hheerrbb--ddrruugg iinntteerraaccttiioonnss ddiiffffiiccuulltt ttoo aasssseessss??((sseeee iinntteerraaccttiioonnss ttaabbllee aatt eenndd ooff hhaannddoouutt))

oo AAccttuuaall ddoosseess mmaayy ddiiffffeerr ffrroomm llaabbeell aanndd hheerrbbaallss mmaayy ccoonnttaaiinn aadduulltteerraannttss oo PPootteennccyy vvaarriieess bbyy ccrroopp yyeeaarr oo CCoolllleeccttiioonn,, ssttoorraaggee aanndd mmaarrkkeettiinngg mmeetthhooddss pprroommoottee ccoonnttaammiinnaattiioonn

IIVV.. DDeennttaall IImmppaacctt ooff HHeerrbbaall SSuupppplleemmeennttss 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

AA.. SSuurrggiiccaall CCoonnssiiddeerraattiioonnss ffoorr PPaattiieennttss TTaakkiinngg SSeelleecctteedd HHeerrbbaall SSuupppplleemmeennttss____________ HERB USE (S) PROPOSED

MECHANISM OF ACTION/EFFECTS

DRUG INTERACTIONS

OTHER CONSIDERATIONS

Black Cohosh

• treatment of PMS and dysmenhorrhea

• alleviate menopausal symptoms

• active components are triterpene glycosides and formononetin (an isoflavanoid), which may have estrogen-like hormonal activity

• suppresses leutenizing hormone secretion in menopausal women

• caution when administered with other drugs that can reduce BP

• may lower BP • side effects

are generally mild (GI, headache, weight gain, dizziness)

• limit use to 3 months

Chamomile • anxiolytic/sedative • treatment of GI spasm

or irritation • treatment of menstrual

disorders

• also contains bioflavinoids which are considered to be active

• apigenin competitively inhibits binding of several benzodiazepines

• contains coumarin, which exerts an antispasmotic effect

• 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

• 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 discontinuing 2 weeks prior to surgery

6Echinacea antiinfective • enhances

"nonspecific" cell immunity by enhancing release of cytokines and phagocytic activity

• stimulates autoimmune processes

• may counteract immunosuppresant drugs (e.g. corticosteroids); do not administer together

• 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)

Evening Primrose Oil

• treatment of PMS • lowers serum

cholesterol • allergic/inflammatory

conditions (eczema, psoriasis)

• autoimmune disease (MS, lupus)

• extract contains 60-80% linoleic acid and 8-14% - linolenic acid (an omega-6 fatty acid formed by desatruration of linoleic acid)

• lowers platelet aggregation

• 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. phenothiazines, tricyclics)

• side effects are generally infrequent (GI, headache)

• may lower seizure threshold

Feverfew • prevention and treatment of migraines

• anti-inflammatory agent (used to treat fever, menstrual problems, arthritis)

• 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 interact with anticoagulant or antiplatelet drugs to raise risk of bleeding

• use caution when administering with drugs that raise serotonin (fluoxetine, sumatriptan, etc.)

• abrupt discontinuation 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


7phospholipase 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

• 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

Garlic • lowers serum cholesterol

• lowers blood pressure

• active constituents are sulfur compounds and the alliin-splitting enzyme alliinase

• inhibits cholesterol synthesis

• has vasodilator and antioxidant properties

• effects on coagulation include inhibition of platelet aggregation, antithrombotic activity, mean plasma viscosity and

• may interact with anticoagulant and antiplatelet drugs to increase risk of bleeding

• may potentiate antihypertensive 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

8hematocrit effects


Ginger • prevention of nausea and vomiting

• digestive problems • muscle pain and

swelling

• 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)


• increases calcium uptake by heart; may alter CCB drug effects

• may increase bleeding time

• may effect blood glucose

• may effect BP • consider

discontinuing 2 weeks prior to surgery

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

• medicinal extracts contain 22-27% flavanoid glycosides, 5-7% terpene lactones (ginkgofides A,B and C and bilobalide) and < 5 ppm ginkgolic acids

• several active constituents are potent antioxidants and free-radical scavengers

• inhibits age-related decline of muscarinic cholinergic receptors and a2-adrenergic receptors

• ginkgolides, especially ginkgolide B, inhibit platelet activating factor,reduce thrombus


• ginkgo toxin in Ginkgo leaf and seed may reduce effectiveness of carbamazepine, phenytoin and phenobarbital in epileptic patients

• do not use with drugs that lower seizure threshold

• several cases of spontaneous bleeding reported (subdural and subarachnoid hematomas, bleeding from iris into anterior chamber of the eye


9formation

Ginseng • heighten resistance to stress

• enhance physical and mental performance

• increase stamina • elevate mood

• active ingredients thought to be ginsenosides

• increases activity of CNS neurotransmitters 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 hormone- inducing effects cannot be ruled out

• ginsenosides inhibit platelet aggregation and enhance fibrinolysis


• 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 manic- depressive disorders or psychosis (due to steroid effects)

• may potentiate action of MAO inhibitors


Hops • sedative-hypnotic, digestive aid

• acts as a mild depressant on higher nerve centers

• contains substances with estrogenic activity

• may have additive effects with other CNS depressants

• drugs metabolized by the cytochrome P450 liver enzyme system

• avoid in depressive states

Horse Chestnut

• reduce leg edema • improve symptoms of

chronic venous

• main active constituent is aescin

• may interact with anticoagulant

• side effects include nausea,

10insufficiency • contains

coumarin constituents

and antiplatelet drugs to increase risk of bleeding

stomach discomfort, allergic skin reactions, itching and muscle spasms

• turn urine red • can cause

kidney or liver damage

• can cause severe bleeding or bruising


Kava Kava • sedative • anxiolysis

• active constituents are the kavalactones (kawain, dihydrokawain, methysticin, and dihydromethysticin)

• 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 psychopharmacologic agents

• 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


• no evidence of potential for dependency

• consider discontinuin

11e g 1-2 weeks

prior to surgery

Passion Flower

• relaxation • sleep

• active constituents may be glycosides (harmala compounds), maltone and ethyl-maltone, and flavanoids

• chrysin (component; a flavanoid) has BZD receptor activity

• possible additive effects with other CNS depressants

• avoid MAO I

• reports of hepatotoxicity and pancreatic toxicity

• no evidence of potential for dependency

Saw Palmetto

• treatment of benign prostatic enlargement

• like finasteride (antiandrogenic activity); antiestrogenic activity

• potential additive effects with otherhormones ad

• can cause HTN and GI disturbances

St. John's Wort

• treatment of mild-moderate depression, anxiety

• 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 down-regulation of serotonin receptors and neurohormonal mechanisms

• hypericin and psuedohypericin may induce hepatic enzymes

• although no drug-drug or drug-food interactions have been reported, it may be prudent to avoid concomitant use with MAO inhibitor, meperidine and sympathomimetics, as well as traditional antidepressants

• considered an atypical antidepressant

• can cause photosensitivity in fair- skinned people (dose-related)

• potentially can cause serotonin syndrome

• may prolong effects of anesthesia

12Valerian • 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, benzodiazepines , 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 (2-4 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 (Also known as)

Dangers Regulatory actions

DEFINITELY HAZARDOUS Documented organ failure and known carcinogenic properties Aristolochic acid (Aristolochia, birthwort, snakeroot, snakeweed, sangree root, sangrel, serpentary, serpentaria; asarum canadense, wild ginger). Can be an ingredient in Chinese herbal products labeled fang ji, mu tong, ma dou ling, and mu xiang. Can be an unlabeled substitute for other herbs, including akebia, asarum, clematis, cocculus, stephania, and vladimiria species.

Potent human carcinogen; kidney failure, sometimes requiring transplant; deaths reported.

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, blackwort, bruisewort, consolidae radix, consound, gum plant, healing herb, knitback, knitbone, salsify, slippery root, symphytum radix, wallwort)

Abnormal liver function or damage, often irreversible; deaths reported.

FDA advised industry to remove from market in July 2001.

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, hediondilla, jarilla, larreastat)


FDA warning to consumers in December 1992.

Germander (Teucrium chamaedrys, wall germander, wild germander)


Banned in France and Germany.

15Kava (Piper methysticum, ava, awa, gea, gi, intoxicating pepper, kao, kavain, kawa-pfeffer, kew, long pepper, malohu, maluk, meruk, milik, rauschpfeffer, sakau, tonga, wurzelstock, yagona, yangona)

Abnormal liver function or damage, occasionally irreversible; deaths reported.

FDA warning to consumers in March 2002. Banned in Canada, Germany, Singapore, South Africa, and Switzerland.

LIKELY HAZARDOUS Adverse-event reports or theoretical risks Bitter orange (Citrus aurantium, green orange, kijitsu, neroli oil, Seville orange, shangzhou zhiqiao, sour orange, zhi oiao, zhi xhi)

High blood pressure; increased risk of heart arrythmias, heart attack, stroke.

None

Organ/glandular extracts(brain/adrenal/pituitary/ placenta/other gland “substance” or “concentrate”)

Theoretical risk of mad cow disease, particularly from brain extracts.

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, emetic herb, gagroot, lobelie, indian tobacco, pukeweed, vomit wort, wild tobacco)

Breathing difficulty, rapid heartbeat, low blood pressure, diarrhea, dizziness, tremors; possible deaths reported.

Banned in Bangladesh and Italy.

Pennyroyal oil(Hedeoma pulegioides, lurk-in-the-ditch, mosquito plant, piliolerial, pudding grass, pulegium, run-by-the-ground, squaw balm, squawmint, stinking balm, tickweed)

Liver and kidney failure, nerve damage, convulsions, abdominal tenderness, burning of the throat; deaths reported.

None

Scullcap (Scutellaria lateriflora, blue pimpernel, helmet flower, hoodwort, mad weed, mad-dog herb, mad-dog weed, quaker bonnet, scutelluria, skullcap)

Abnormal liver function or damage.

None

Yohimbe (Pausinystalia yohimbe, johimbi, yohimbehe, yohimbine)

Change in blood pressure, heart arrythmias, respiratory depression, heart attack; deaths reported.

None

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“Scientific Breakthrough” “Miraculous Cure” “Exclusive Product” “Secret Ingredient” “Ancient Remedy” How to Spot False Claims Medical Conspiracy to Suppress Product

According to product labels. Sources: Natural Medicines Comprehensive Database 2004 and Consumers Union's medical and research consultants.

16Undocumented 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.jason-natural.com)

Best Tasting Natural Toothpaste!

Gum support/perio protection

CoQ10, Aloe Vera, Sea Salt, Melaleuca,

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

No Fluoride which is toxic

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

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