Complementary and Alternative Medicine Practices and Oral and Nutritional Health

Mind–body interventions
Mind–body interventions focus on the mind’s ability to influence the body’s function and symptoms and include such approaches as hypnosis; meditation; guided imagery
Natural products
Natural products include herbal and other dietary supplements and probiotics
Manipulative and body-based methods
The manipulative and body-based category includes methods involved in the manipulation or movement of the body, such as chiropractic, osteopathy, and massage
Other CAM practices may include Alternative medical systems (homeopathy, naturopathy, traditional oriental medicine); Energy therapy (magnet, qi gong); and movement therapy
a Source National Center for Complementary and Alternative medicine (www.​nccam.​nih.​gov)

Trends in CAM Usage in the United States

CAM increased in popularity in the United States for the past few decades, and continues to be used [13, 8]. A survey conducted in 1990 by Eisenberg and colleagues is widely considered to have served as a wake-up call for healthcare professionals concerning the growing popularity of CAM in the U.S. [1]. In this landmark survey of 1,539 respondents, the researchers disclosed that one in three Americans who participated in the survey had used at least one CAM therapy during the past year and that visits to CAM providers totaled 425 million, which exceeded the number of visits to all U.S. primary care physicians that year. The majority of those who used CAM therapies for serious medical conditions also sought care from their conventional physicians, but approximately 72% did not disclose their CAM activities to these physicians. Further, most (estimated at 75%) of the expenditures associated with the use of CAM therapy were paid out-of-pocket.
When consumers were surveyed in 1997, an even greater number of participants had used a CAM modality (42% vs. 34% in 1990), out-of-pocket expenditures were similar, and the same percentage of users did not share their CAM activities with their conventional physicians [2]. A 2001 survey examined lifetime use and age at onset and found 67.6% of 2,055 respondents had used at least one CAM therapy in their lifetimes [3]. For the population as a whole, lifetime use increased with age. This study concluded that the trend for CAM therapies was strong and that there would be a continuing demand for CAM therapies for the foreseeable future. National survey results report similar findings with 38% of adults disclosing CAM use [4, 9], and 49% specifying use of a dietary supplement product [8] for reasons that include boosting energy and a general sense of well-being.
Given the prevalence of CAM use, OHCPs should be prepared to communicate with patients on their patterns of use and whether or not the CAM is intended for a systemic effect or to treat an oral health condition. In rural communities and low income or minority populations, access to dental care may be challenging and patients may turn to alternative remedies for oral conditions such as pain, bleeding gums, and xerostomia [10, 11].

Concerns About Efficacy and Safety of CAM Therapies

Among the key issues regarding CAM use that concern healthcare providers is the uncertainty over efficacy and safety of CAM practices. Many of these modalities have been used in other cultures for centuries. In the U.S., however, consumers are quick to adapt therapies that have not been validated through research. Concerns regarding natural products that may differ from those of other countries due to species, soil, water, growing conditions, or the circumstances regarding product manufacturing further complicate assurance of consistent health outcomes associated with CAM practices. The creation of NCCAM in 1998 was a major step forward in establishing the groundwork for investigating efficacy and safety of various CAM modalities in the US. The mission of NCCAM is to subject CAM practices to rigorous scientific scrutiny to identify usefulness, safety, and efficacy of CAM in health care [12]. NCCAM’s research approach includes basic and translational research as well as observational and clinical trials. Areas of interest include chronic pain, inflammation, and modalities to support health and wellness [13]. For those CAM modalities that are found to be health-promoting, the expectation is that they can be safely integrated into mainstream medicine. However, given the paucity of clinical trials of CAM on dental and oral health outcomes, clinicians should individually evaluate the risk/benefit profile and make a determination to use or not to use the CAM approach within patient care modalities. Rakel [14] describes a system of evaluating the benefit in light of the potential harm. In weighing the evidence with the harm to make an informed choice, the clinician can assess if there is evidence with no or minimal harm, then there is potential for use; conversely if there is little evidence and potential harm, the indication for use would be unfavorable. However to weigh the evidence against possible harm, the OHCP must be well versed in the CAM modality or should consult with or refer to a CAM practitioner.

Dietary Supplement Health and Education Act of 1994

Dietary supplements are considered natural products [5]. The large number of dietary supplement products available and the use of supplements by consumers may be attributed to the passage of the Dietary Supplement Health and Education Act of 1994 (DSHEA, pronounced “De-shay”). Congress passed DSHEA as an amendment to the Federal Food, Drug, and Cosmetic Act [15]. DSHEA included several provisions that set dietary supplements and dietary supplement ingredients apart from the usual regulations that apply to food and drugs. It defined “dietary supplement,” established a new framework for assuring safety, provided guidelines for the use of claims that could be made about dietary supplements and for the literature that was displayed where supplements were sold, established labeling requirements for dietary supplements, and granted the Food and Drug Administration (FDA) the authority to establish Good Manufacturing Practices (GMPs) for the production of dietary supplements.
DSHEA defined a dietary supplement as a product intended to supplement the diet that contains a vitamin, a mineral, a herb or other botanical, an amino acid, or a combination of these. Additionally, a dietary supplement is intended for ingestion in pill, capsule, tablet, or liquid form; is not represented for use as a conventional food or as the sole item of a meal or diet; and is labeled as a “dietary supplement” [15]. All dietary supplements must be labeled as such and must carry the following disclaimer: “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease” [15]. This disclaimer is mandatory for all supplements, whether or not they are effective in improving health. It conveys no judgment on the part of the FDA as to whether or not the supplement is effective for its intended purpose.
To help consumers decipher how much is known about the intended purpose of a dietary supplement, DSHEA further established regulations for product claims. There are two types of claims that are of particular help to supplement users: health claims and structure/function claims. Health claims are the “gold standard,” must make a direct linkage between a dietary ingredient and a health benefit, and have significant scientific agreement to support the claim [16]. Dietary supplements cannot claim to decrease risk of a disease unless the claim has been cleared by the FDA as a health claim [16]. An example of an approved health claim may be applied to dietary carbohydrates and dental caries; noncariogenic carbohydrate sweeteners such as sugar alcohols may claim “sucralose, the sweetener in this food, does not promote tooth decay.”
The second type of claim, the structure/function claim, and is more general, stating that a particular supplement may promote a healthier condition but the claim cannot make a direct link between the supplement and a disease [17]. These may be more commonly used as they do not require preapproval from the FDA for a manufacturer to make the claim. Structure/function claims cannot state that a supplement will prevent, treat, or cure a disease. An example of an allowable structure/function claim would be: “Soy isoflavones promote bone health” since it makes no reference to a disease state.
In contrast to drugs, dietary supplements are not subjected to premarket approval for safety and efficacy. However, DSHEA did establish current Good Manufacturing Practices (GMPs), which were phased in by 2010, and manufacturers of dietary supplements in the U.S. are required to abide by these stated practices [18]. GMPs apply to manufacturers of dietary supplements and stipulate conditions under which supplements are manufactured, packaged, and tested. Manufacturers are required to follow the regulations for clean and safe manufacturing, quality control, and accuracy in labeling. The GMPs are welcome to healthcare practitioners and consumers to add confidence in buying dietary supplements.
The main difference between how dietary supplements and drugs (both prescription and over-the-counter) are brought to market is associated with the degree of scrutiny that products are subjected to prior to being released to the market. Drugs undergo extensive safety and efficacy testing that involves numerous stages of review that eventually involves human clinical trials. This forms the basis for FDA approval of a drug’s entry into the marketplace, whereas dietary supplements do not have to undergo this level of premarket testing and approval, and hence some impure or ineffective products have been documented [19, 20].
Information on dietary supplements with adverse effects can be found on the FDA website at www.​fda.​gov. Adverse events such as increased blood pressure, heart rate, and dizziness have been associated with supplements that stimulate the central nervous system such as sources of caffeine (guarana) or ma huang (ephedra). In fact, ephedra is banned for sale in the US due to associated adverse effects of dietary supplements containing the substance [21]. In addition to safety concerns, there is often limited evidence that a particular supplement is effective for its intended purpose. However, high quality manufacturers can elect to have their products evaluated by independent testing labs. Among the more rigorous certification programs are those offered by the U.S. Pharmacopeia (www.​usp.​org) and NSF International (www.​nsf.​org).

Complementary and Alternative Medicine: Implications for Oral Health

Good oral health is an essential foundation for optimal overall health. The recognition that oral health is integral to general health is reinforced in a position of the Academy of Nutrition and Dietetics and in Healthy People 2020 [22, 23]. Additionally, the Surgeon General’s Report on Oral Health [24] underscores the fact that diseases and limitations of the oral cavity may impact general health and wellness. OHCPs are concerned with preventing disorders that affect the health of the oral cavity and preventing and alleviating symptomatic manifestations of systemic diseases. This chapter will review CAM modalities that patients may use for systemic or oral health so that the OHCP may be able to openly communicate on CAM therapies and evaluate the impact the CAM therapy may or may not have on the oral health or procedure provided to the patient.

Whole Medical Systems

Whole medical systems refer to practices or theories in healing that evolved apart from conventional Western medicine. Among the more common whole medical systems are homeopathy, natural medicine, and traditional oriental medicine, which includes acupuncture [5].


The word “homeopathy” derives from the Greek homeos, meaning similar, and pathos, meaning suffering. Homeopathy is a medical system developed in the late eighteenth century by the German physician Samuel Hahnemann and is based on the “law of similars,” which refers to the concept of “like curing like.” When a homeopathic medication (“remedy”) is administered to a healthy person, the individual will develop signs and symptoms. If an ill person with similar signs and symptoms is given the same remedy, the ill person often becomes well. The administration of a homeopathic remedy to a well person and the careful noting of all signs and symptoms is called a “proving.” One of the fundamental principles of homeopathy is that only a single remedy is administered at a time [2527].
A second principle of homeopathy is that the minimum dose is given, so that side effects are rare. The original solution is serially diluted until not even a single molecule of the original solute remains. At each dilution, the solution is shaken vigorously, a process called “dynamizing” or “succussion.” Since theoretically no solute is present in the final dilution, which is the form used as the homeopathic medication, there is concern among Western scientists that any effect represents simply a placebo effect [28]. Some scientists have suggested that the process of preparing the remedy could alter the molecular structure of water, which may be an important factor in the efficacy of the remedy. In a critical review of homeopathy, Jonas et al. reported that conclusive evidence for the effectiveness of homeopathy is lacking. While they suggest homeopathy may have value, it should not be used as an alternative when evidence-based therapies are available [29].
Oral Health Implications
Homeopathic remedies are generally considered nontoxic; to the best knowledge of this author there are no published reports on its use causing complications with dental procedures or surgery. While homeopathy cannot replace oral surgery or medication to treat oral diseases or lesions, homeopathic preparations may be adjunct treatments for dental pain or lesions [26, 27]. Oral healthcare professionals (OHCPs) should be concerned that patients may try to relieve symptoms themselves without consulting a homeopathic provider or in lieu of other conventional treatments. If a patient wished to use a homeopathic remedy, it would be prudent for the OHCP to discuss conventional treatment options and provide a referral to a qualified homeopath. In the US, www.​homeopathy.​org is a source for referrals to a credentialed homeopath.

Traditional Chinese Medicine and Acupuncture

Traditional Chinese medicine (TCM) is a holistic practice in which the body is viewed as being in a state of harmony and balance, both within itself and with the environment in which it lives [30, 31]. Disharmony signals disease, and the therapeutic goal is to bring the individual back into balance. The body and mind are unified, and a universal life force of chi (pronounced “chee”) is believed to flow throughout the individual along specific channels or “meridians.” Maintaining the free flow of chi is essential for health. TCM practitioners use a combination of acupressure and acupuncture, herbal remedies, and meditative exercise to achieve balance. Acupressure uses the pressure of the fingers, palm, or elbow to stimulate specific sites along the meridians, whereas acupuncture uses hair-thin needles to stimulate these sites. Acupuncture may be helpful in the treatment of chronic pain conditions by stimulating the release of natural endorphins that mitigate pain. TCM practitioners restore chi with the use of Chinese herbal medicines and acupuncture [31].
TCM practitioners are keen observers and include parameters in their examinations not typically used in the Western world. Practitioners ask many questions and observe the voice, emotions, and general demeanor of the patient. They conduct a visual examination that includes body movement, facial colors, and the tongue. TCM practitioners believe they can tell much about the health of the inner organs by observing the health of the tongue: its color, moisture, coating, fit within the oral cavity, and presence of abnormalities. They are careful listeners and also rely on smell to detect disharmony within the body. Finally, they use a touching examination to determine the person’s sensitivity to touch and to evaluate pulses, which provides insight into the state of the individual’s chi.
Oral Health Implications
Acupuncture may be used in some populations for managing periodontal disease, caries, and pain [32]. Individuals may seek acupressure or acupuncture for temporomandibular joint disorders (TMD) and myofascial pain, and to reduce the gag reflex during dental procedures [33]. Treatments provided by a licensed acupuncturist may provide pain relief without adverse effects to the patient. As an analgesic, acupuncture may be an alternative for patients with severe allergic reactions to conventional medications. The results of a systematic review and meta-analysis indicate that efficacy of acupuncture for managing TMD may be limited but that more research is needed [34]. The results of a pilot study demonstrated that trigger point acupuncture may be effective for chronic TMD myofascial pain when compared with sham acupuncture placebo [35].
Acupuncture [36, 37] and acupuncture-like nerve stimulation [38] have been used in patients with head and neck carcinoma to prevent and treat xerostomia. Meng and colleagues [36, 37] reported on the use of acupuncture to prevent xerostomia in patients undergoing radiation therapy. The researchers compared the use of acupuncture to standard care and also to sham acupuncture. In both instances, the use of acupuncture resulted in reduced xerostomia symptoms and improved quality of life among patients, compared to patients who received standard care or sham acupuncture. Similarly, Wong and colleagues [38] compared an acupuncture-like nerve stimulation to oral pilocarpine for the treatment of xerostomia. In acupuncture-like nerve stimulation, electrical stimulation is applied transcutaneously on the relevant acupuncture points, thus providing therapy to patients without the use of needles or a licensed acupuncturist. The aims of the study were to evaluate the feasibility of delivering the acupuncture-like nerve stimulation and to identify the treatment on xerostomia among patients. The results of the study suggest that acupuncture-like nerve stimulation can have positive impacts on xerostomia symptoms and that the treatment is feasible to further study in a larger population and for a longer duration of time to evaluate sustained benefits.
The use of Chinese herbs may potentially interfere with dental therapy or medications. Since these remedies are typically complex mixtures of several herbs, it can be difficult to determine which active constituents are present and how these might interact with anesthetics and other medications [39]. The Natural Medicines Comprehensive Database (www.​naturaldatabase.​com) may provide information on individual herbs, botanicals, and natural products.

Mind–Body Interventions

Mind–body medicine recognizes that the mind plays a key role in health and views the mind and the body as a unified whole that should not be treated as separate entities [48]. Psychosocial approaches using the brain, body, and behavioral strategies can influence physical function, pain control, and anxiety [41, 42, 44]. Several mind–body interventions are used to promote a state of relaxation in the body. Meditation and hypnosis may have applications to dental therapy. Meditation involves deep breathing exercises and focused attention to effect muscle relaxation. Dr. Herbert Benson introduced the concept of the “relaxation response” in the early 1970s [40]. In this approach, he brought together a number of different types of relaxation and meditation techniques, with a common outcome of a state of consciousness that reduced heart rate, blood pressure, breathing rate, brain-wave patterns, and often, pain. Mindfulness meditation derives from the Buddhist tradition and is the concept of staying in the present moment. It underlies all of the mind–body interventions and promotes a state of enhanced relaxation and insightfulness. Hypnosis is a state between sleep and wakefulness that allows for relaxation and deep concentration [4048].
Oral Health Applications
Patients may use mind–body interventions to manage fear of dental therapy or to minimize pain. Published research [45, 46, 49, 50] suggests that some individuals are helped by a combination of one or more of these approaches to control dental anxiety and pain. Nonpharmacologic approaches may be advantageous to patients; OHCPs may consider training and use of mind–body approaches as applicable.

Biologically Based Treatments

Natural Products (Dietary Supplements)

Dietary supplements can be conveniently divided into botanicals, which include herbs and other plant materials with potential health benefits, and nutritionals, which are essentially all other dietary supplements such as vitamins, minerals, amino acids, fatty acids, and metabolites [5, 15]. Dietary supplements of primary interest to OHCPs fall mainly into the categories of anticoagulants, anti-inflammatory agents, antimicrobial agents, immune stimulants, and analgesics. While some interactions may be based on theoretical cumulative or opposing actions of drugs and dietary supplements, a 2013 review of drugs commonly used in dentistry and dietary supplements suggests that interactions may occur with ginkgo, St. John’s wort, valerian, or evening primrose; patients using any of the medications commonly used in dentistry and taking these supplements should be advised to discontinue the use of the supplements 1–4 days prior to visits to OHCPs [51].
Botanicals (Phytotherapy)
Patients presenting for dental care may be using botanicals for the treatment of dental symptoms or for an unrelated chronic disease or for health promotion. If the dietary supplement is used for an oral problem, the OHCP should be aware and ascertain if it is in lieu of a conventional treatment. Whether for treatment of a systemic disease or for disease prevention, the practitioner should evaluate it for safety, efficacy, and potential interactions with planned procedures. Botanicals that may be of interest and concern to the OHCP are listed in Table 9.2 [52].

Table 9.2

Use and considerations regarding botanical supplements [39]
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General use(s)
Oral use(s)
Aloe vera
Mouth rinse
May cause diarrhea, malabsorption, electrolyte imbalance when ingested
Relieve diabetic neuropathy
Improve eyesight
As an astringent rinse to treat mildly inflamed mucous membranes of mouth and throat
Anti-inflammatory, reduce swelling, improve wound healing
Applied topically to treat inflammation of oral mucosa
May cause allergic reactions in individuals sensitive to members of the Asteraceae (daisy) family
Used topically for
pain relief
Topical application for pain relief for toothache, trigeminal neuralgia
Capsaicin is active compound in chili/cayenne peppers—Irritant to skin and eyes. Topical use only
Weight loss, improved strength, reduce cholesterol
Applied topically to gums may decrease risk of periodontal disease
Derived from exoskeleton of crustaceans, so should be avoided in people with shellfish allergy
Upper respiratory infections, wound healing
Locally applied as antimicrobial for oral health, inflammation of mouth
Research has not demonstrated efficacy in oral health. Do not use with immunosupressants or hepatotoxic drugs, or with AIDS, tuberculosis, or autoimmune diseases
Central nervous system stimulant
Tachycardia, hypertension, arrhythmias; reduces effectiveness of prednisone
Evening primrose oil
Premenstrual syndrome, menopause symptoms, Sjogren’s syndrome
Source of gamalinolenic and linoleic acids that may interfere with anticoagulation/antiplatelet activity
Migraine headaches, menstrual symptoms
If leaves are chewed, may cause mouth ulcers, sore tongue, swollen lips, and taste changes; may interfere with blood clotting; avoid with use of aspirin, NSAIDS; may cause allergic reactions in individuals sensitive to members of the Asteraceae (daisy) family
Cardiovascular disease
(decrease blood pressure and LDL cholesterol)
Inflammation of oral mucosa, or aqueous extract for the treatment and prevention of oral candidiasis
Additive effects with anticoagulant agents. Halitosis unless using “odorless” preparations
German chamomile
Oral mucositis
Oral rinse may prevent or treat oral mucositis associated with some forms of chemotherapy
Nov 4, 2015 | Posted by in General Dentistry | Comments Off on Complementary and Alternative Medicine Practices and Oral and Nutritional Health
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