an increased risk of adverse events (Digmann, et al., 2019; El Desoky, 2007; McLean & Le Couteur, 2004). Older adults are seven times more likely than younger individuals to experience adverse drug events that require hospitalization (Budnitz et al., 2006). Given the prevalence of medications and CAM use among consumers, potential herbal-drug interactions warrant consideration in dental practice (Donaldson & Touger- Decker, 2013; Moghadam et al., 2020). Furthermore, considering that nearly 70% of these patients do not discuss their CAM use with their primary care providers, oral healthcare professionals (OHCPs) should ask all patients about their use, particularly when prescribing medications and when considering the patients’ overall oral healthcare plan (Nutrition Business Journal, 2022).
other botanical” in the form of “a pill, capsule, tablet or liquid” (FDA, 2022). Adverse health outcomes – including those resulting from interactions among foods, herbals, and drugs – are likely to increase as Americans live longer, have more chronic conditions, and take more prescription or herbal medications (Budnitz, Lovegrove, Shehab & Richards 2011; Budnitz, Shehab, Lovegrove, Geller, Lind & Pollock, 2021; Digmann, et al., 2019). Among adults 65 years of age and older, 40% take 5 to 9 medications regularly and 18% take 10 or more (Jamsen et al., 2016; Qato, Wilder, Schumm, Gillet, & Alexander, 2016; Slone Epidemiology Center at Boston University, 2006). Age-related physiological changes, a larger number of coexisting conditions, a greater degree of frailty, and polypharmacy have all been associated with
HERBAL MEDICATIONS AND DRUGS OF GREATEST CONCERN
This approach will help to concentrate the discussion on the most common dental-related herbal-drug interactions, with a goal of defining strategies to help avoid these interactions. Table 1: Top-Selling Herbal Medications that OHCPs are Most Likely to Encounter Rank Common Name Latin Name 1 Elderberry Sambucus nigra 2 Horehound Marrubium vulgare 3 Cranberry Vaccinium macrocarpon 4 Turmeric* Curcuma longa 5 Apple cider vinegar Malus spp.** 6 Ginger Zingiber officinalis 7 Echinacea Echinacea spp. 8 Garlic Allium sativum 9 Fenugreek Trigonella foeneum- graecum 10 Wheat grass / Barley grass Triticum aestivum / Hordeum vulgare
A multitude of herbal medications are available in the United States. However, to bring the greatest value to practicing OHCPs and their teams, this course focuses on the top 20 most common herbal medications that OHCPs are likely to encounter (Table 1; Smith, T., Majid, F., Eckl, V., & Morton Reynolds, C., 2021). The data in Table 1 correspond to retail sales of herbal supplements in mainstream, natural, and direct sales channels as defined by the Nutrition Business Journal and the Chicago area-based market research firms SPINS LLC and Information Resources, Inc. (American Botanical Council, 2021). Each of these herbal medications is represented by a common name and the accompanying Latin name. Elderberry is the most common herbal medication OHCPs are likely to encounter (Smith, T., Majid, F., Eckl, V., & Morton Reynolds, C., 2021); consumers spent an estimated $275,544,691 on elder berry supplements in 2020, with annual sales doubling each year since our first edition of this module (where elderberry didn’t even make the top 10 list). Elderberry is commonly used to support immune health and as a remedy to help alleviate cold and flu symptoms, often reducing the severity and duration of colds, and the duration of the flu. No doubt that the COVID pandemic played heavily in the rise of consumer spend on this product also. Elderberry displaced horehound which was the top-selling herbal ingredient 2013 to 2019. Horehound is the primary ingredient in many throat lozenges that may contain other herbal and nonherbal ingredients. Cranberry is a type of evergreen shrub that grows in wet habitats (such as bogs or wetlands) in northeastern and northcentral parts of the United States. Orally, cranberry is used for prevention and treatment of urinary tract infections, kidney stones, neurogenic bladder, as a urinary deodorizer for people with incontinence, prevention of urinary catheter blockage, and to heal skin around urostomy stomas. Beyond these first three, Table 1 lists the complete top 20 herbal medications OHCPs are most likely to encounter, and additional high-risk herbal-drug interactions are discussed, despite their lower prevalence in the general population. Medications that are commonly used in dentistry typically fall into five drug classes: analgesics and anti-inflammatories, antibiotics, local anesthetics, sedatives, and emergency medications (Donaldson & Goodchild, 2012). There may be some additional miscellaneous medications such as antiseptics (e.g., chlorhexidine), fluoride supplements, or drugs to treat xerostomia (e.g., pilocarpine); however, it is unlikely that these drugs are part of every OHCP’s armamentarium. The drug component of the herbal-drug interactions to be reviewed, then, will focus on the drugs commonly used in dentistry (Table 2).
Saw palmetto Ashwagandha
Serenoa repens
11 12 13 14 15 16 17 18 19 20
Withania somnifera Camellia sinensis
Green Tea
Ivy Leaf Ginkgo
Hedera helix Ginkgo biloba
Cannabidiol (CBD) Cannabis sativa
Black cohosh
Actaea racemosa
Beta-sitosterol*** --
Red rice yeast
Oryza sativa
Aloe Aloe vera * Includes standardized turmeric extracts with high levels of curcumin. ** spp. = species pluralis (more than one species). *** Beta-sitosterol is a common plant sterol that can be derived from various plants. Note. Adapted from Smith, T., Majid, F., Eckl, V., & Morton Reynolds, C. (2021). Herbal Supplement Sales in US Increase by Record- Breaking 17.3% in 2020. HerbalGram 131:52- 65. Retrieved from https://www.herbalgram.org/resources/ herbalgram/issues/131/table- of-contents/hg131-mkrpt/
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