Are supplements endangering your patients?

A new patient comes to you needing a tooth extraction. As always, you ask," are you on any medications?" The patient says, "no." You pull the tooth and the next thing you know, the patient is rushing to the emergency room with bleeding that just won't stop.

What complicated this fairly simple procedure? Nutraceuticals.

Increasingly patients are treating themselves with nutraceuticals (used here to include herbs, vitamins, minerals, and other dietary supplements) under the mistaken belief that what's packaged as "natural" can't possibly do harm. "Only around 40 percent of patients will tell their health care practitioners what [nutraceuticals] they're on," says Jessica A. Alexander, M.D., a University of Texas, San Antonio clinical anesthesiologist who devotes most of her time to studying these substances.

In some cases, such alternative treatments may benefit patients' oral health. But they can also pose serious complications for dental procedures. Some prolong bleeding, others increase the risk of cardiovascular events, potentiate anesthetics, affect blood sugar regulation, or interact with a wide range of other medications.

The market for vitamins and minerals is growing at a rate of about 4 percent per year, according to Karen A. Baker, M.S., R.Ph., an associate professor in both dentistry and pharmacy at the University of Iowa, while "specialty supplements" such as fish oil and probiotics, are growing at 13 percent per year, she says. Already Americans are spending tens of billions on such substances, even though the health effects are often poorly understood.

"You should ask specific questions about supplements," Baker told an audience at the Yankee Dental Congress 33 recently held in Boston.

Querying patients

Getting patients to talk about their herbs and supplements isn’t always easy, though. Many won't understand the connection to dentistry. "It's like when you ask if people are taking birth control pills," says Baker.

When Baker has trouble getting patients to talk about the supplements they take, she hands them a copy of Dr. Alexander's brochure for patients, "What You Should Know About Herbal and Dietary Supplement Use and Anesthesia," published by the American Society of Anesthesiologists(ASA).The society can provide brochures for your patients, and a more technical version for physicians. Dr. Alexander is working on updates for both.

Beware these nutraceuticals Almost any substance taken in large enough amounts can have important effects on a patient's health -- and so pose problems in the dental chair. No article can address all the possibilities. Instead, here are a few of the most commonly used nutraceuticals and the potential effects on dental care. Kava -- used for sedation and anxiolysis -- may increase the sedative effects of barbiturates, benzodiazepines, and alcohol. Baker warns that it is also on her "dirty dozen list" because it can cause liver failure. Valerian, likewise used for sedation, may potentiate barbiturate effects and decrease symptoms of benzodiazepine withdrawal. Echinacea, which stimulates cell-mediated immunity, is blamed for allergic reactions ("it's ragweed," says Baker). It may also decrease the effectiveness of immunosuppressants, and also cause immunosuppression itself if used long term. St. John's wort, used for mood disorders, may interfere with benzodiazepines, midazolam, methadone, and other anesthetics; heart medications such as digoxin and calcium channel blockers; and other drugs. Milk thistle, which Dr. Alexander says was the top selling herb for 2007, is used in treatment of liver disease. Researchers suspect that it interacts with drugs, including lorezepam and estrogen. It may lower blood sugar. Ginseng, in addition to its effects on bleeding, may cause cardiovascular instability and interact with calcium channel blockers and digoxin. It may antagonize morphine-induced analgesics and interact with oxycodone and fentanyl. Cranberries, a common treatment for urinary tract infections and preventative for E. coli infections, is frequently taken in juice cocktails high in acid and sugar. It may interact with warfarin and enhance renal elimination of drugs. It’s contraindicated in patients with a history of calcium stones. Saw palmetto, used for benign prostate hyperplasia (BPH), may lead to cardiovascular instability, including heart attacks. Black cohosh, used for menopausal symptoms, has been linked to tachycardia, bradycardia, hypotension, and liver toxicity in addition to prolonged bleeding. Chondroitin, used (generally with glucosamine) for arthritis, may trigger allergies to shellfish or iodine, may interact with anesthetics and cyclosporine as well as other medications. Coenzyme Q10, in addition to prolonging bleeding, may also decrease blood pressure and blood sugar, and alter thyroid hormone levels. Vitamin C, in high doses, may increase the adverse effects of aspirin and acetaminophen. It has been associated with kidney stones, severe diarrhea, nausea, and gastritis. Calcium, in high doses, may cause kidney problems and potentiate digoxin toxicity. Dirty dozen. Besides kava, Baker listed 11 other supplements "no one should take," not because of their specific relationship to dentistry, but because of other dangerous effects: aristolochic acid, comfrey, androstenedione, chaparral, germander, bitter orange, extracts from animal organs or glands, lobelia, pennyroyal oil, skullcap, and yohimbe.

Patients often assume that dietary supplements have to comply with the same regulations as pharmaceuticals. In fact, they don’t come under the FDA's scrutiny unless the company selling the nutraceutical claims it will affect a disease.

If patients do take supplements, Baker recommends asking if these regularly include Echinacea, garlic, ginger, ginseng, kava, St. John's wort, valerian, vitamin E, or fish oil. The list corresponds to one featured in a 2001 article from the Journal of the American Medical Association (JAMA) that describes the risks each of these herbs can pose and how long before surgery they should be discontinued.

It's worth noting, however, that fads in neutraceuticals change rapidly. Dr. Alexander suggests frequently updating patient histories, with particular attention paid to the question of nutraceuticals, asking the patient, "I see you didn't check the box next to dietary supplements? Are you sure you don't use any vitamins, minerals, or herbs -- chopped, whole, in teas or tinctures?" The key is to help patients think of everything they consume regularly that might seriously affect dental procedures.

So what should you do if a patient's nutraceutical might pose a problem? "Prudence suggests discontinuation two weeks prior to any elective procedures," says Dr. Alexander.

Of course, this rather broad recommendation was formed for anesthesiologists and may not apply to patients who are just coming to you for a routine cleaning. "You have to take each case on an individual basis," acknowledges Dr. Alexander. "You’re not going to be able to tell all your patients to get off all these things for two weeks."

As a fall back, dentists can do some monitoring. Baker recommends using a blood pressure cuff (not a finger clamp) for all patients, such as one made by Omron. Dr. Alexander recommends investing in a thromboelastrogram, a machine that can measure the clotting potential of blood, and using it whenever you are concerned about the effects a nutraceutical or other drug might have on bleeding.

Bleeding

Although prolonged bleeding isn't the only effect -- or the most serious one -- that nutraceuticals can have (see sidebar), it may be the most common. Baker was recently called in to consult on the case of a retired dentist whose gums kept bleeding. The problem was that he was combining aspirin with ginkgo biloba, both of which inhibit platelet aggregation.

Ginkgo biloba is the supplement "that causes the largest number of post operative cases of bleeding in dentistry," says Baker. "People take it but they forget to tell you. So it's going to be something that comes up in your practice."

But other supplements can also increase bleeding when taken in sufficient doses, among them black cohosh, feverfew, panax ginseng, fish oil, evening primrose oil, garlic, ginger, licorice (but not anise), poplar (which contains salicylates), sweet clover (which contains courmarin), coenzyme Q10, chondroitin, St. John’s wort, soy, calcium, and vitamin E.

On the other hand, other supplements, such as alfalfa, may actually promote coagulation. In fact, it's worth mentioning to any patients taking alfalfa that it might inactivate warfarin, a drug used to prevent blood clots in some heart patients. (Soy -- despite having anticoagulant effects of its own -- may also interfere with warfarin metabolism.)

Dental products pro and con

Concerned about synthetic ingredients in dental products, many patients are looking for alternatives. That has created a market for companies selling "natural" versions that are of dubious value. Among those ingredients without good scientific evidence for their effectiveness are loturbark, myrrh, neem, tulsi, peelu and propolis, Baker says.

Some oral care ingredients can be harmful, says Baker. For example, vitamin C, whatever its benefits in food, doesn't belong in toothpaste, she says. "What you get is acid demineralization. Vitamin C's 2.7 pH is about like that of Coca-Cola."

Other supplements that have benefits when taken orally -- such as coenzyme Q10 and antioxidants in general -- are just a waste of money because they don’t work topically, says Baker.

Baker also listed a handful of alternative oral care ingredients with potential benefits:

• Melaleuca (tea tree oil) does seem to have some antimicrobial effects.
• Essential oils can reduce bleeding.
• Green tea extract might have mild anti-inflammatory and anti-bacterial effects.
• Aloe vera may enhance the healing of oral ulcerations (though it probably won’t help with gingivitis.)

The labels on some "natural" products boast about the things they don’t have. On the top of the list of unwanted ingredients is sodium lauryl sulfate. This common foaming agent in toothpaste may cause canker sores (regardless of the fact that it's made from "natural" coconut oil).

But it's hard to avoid, even in many alternative toothpaste brands such as Tom's of Maine. Baker came up with a short list of toothpastes that are truly free of sodium lauryl sulfate: Biotene, CloSYS (which also doesn't contain fluoride), Rembrandt, Squigle, TheraBreath and Sensodyne ProNamel. But read the labels closely since some of these brands also make products with sodium lauryl sulfate.

What to recommend

While some patients may not want to talk about their supplements, others may ask your advice. When that happens, says Baker, "Don't scoff. Stay involved and direct them toward some of the more rational products." After all, it's just as nonsensical to say that all herbs and supplements are bad as it is to say that all of them are good.

The supplement Baker endorses most enthusiastically is fish oil, which she says at a dosage of one to four grams per day can "reduce trigycerides 20 percent to 50 percent." (The product should include a combined EPA/DHA total of 1,000 milligrams per day.) Fish oil may also reduce symptoms of attention deficit-hyperactivity disorder (ADHD) and bipolar disorder.

It can increase bleeding as well. But "the biggest problem is the burping," says Baker. "You're working face to face people and you don't want to have that happen." To combat the burping, tell patients to refrigerate or freeze their fish oil before taking it.

The lactobacillus bacterium is likely effective for rotaviral diarrhea and -- of particular note to dentists -- antibiotic-associated diarrhea, Baker says. (In case anyone asks, she adds, yogurt every day can reduce risk of vaginal infections -- eaten, not applied vaginally.) When shopping for lactobacillus, Baker points out, the organism has to arrive alive, otherwise "you're just swallowing millions of carcasses." One way to find products with verified live cultures is to consult Consumer Lab.

Baker also endorsed B vitamins for cardiac disease, glucosamine for arthritis (including TMJ arthritis), and zinc for the common cold. Tumeric "looks like a pretty good anti-inflammatory" while melatonin may stop cluster headaches.

Dentists should also know about capsaicin, the active ingredient in hot peppers, which, surprisingly, can be an effective treatment for burning mouth or burning tongue.

If these - or any other nutraceuticals - cause a problem for one of your patients, you can help protect others by reporting it to the FDA.

Where to get more information

The following organizations provide mostly free information:

Consumer Lab tests supplements to see whether they contain what their labels claim they contain.

International Food Information Council gives recommended dietary intakes.

National Council on Complementary and Alternative Medicine, a branch of the National Institutes of Health (NIH), conducts research on alternative medicine and includes information about supplements.

Center for Science in the Public Interest addresses controversies over supplements and other nutrition issues.

Medline Plus, an office of the National Library of Medicine, (also part of the NIH) compiles information on many nutraceuticals.

The Food and Drug Administration issues warnings about nutraceuticals implicated in health problems.

The following organizations charge for their information:

Natural Medicines Comprehensive Database gives comprehensive information on supplements.

American Botanical Council tracks news and research on herbs.