common herbal-drug interactions is suggested. Critical patient populations are emphasized and specific herbal-drug interactions that can lead to increased bleeding, decreased blood glucose levels, and sedation changes are discussed.
This course is specifically designed for all members of the dental health care team: dentists, dental hygienists, and dental assistants.
INTRODUCTION
The use of plants for healing purposes and the knowledge required for their use (pharmacognosy) predates written human history and forms the origin of much of modern medicine. Many conventional drugs originate from plant sources; in fact, over a century ago, of the few effective drugs that were available, most were plant-based. In 1870, the U.S. Pharmacopeia listed 636 herbal entries; the new 2022 edition lists 970 herbal entries (U.S. Pharmacopeial Convention, 2022). Although some of the original herbal entries were found to be unsafe, most were replaced by pharmaceuticals derived from the original botanical medicines. Examples include aspirin (from willow bark), digoxin (from foxglove), quinine (from cinchona bark), and morphine (from the opium poppy). The development of drugs from plants continues, with drug companies being engaged in large-scale pharmacological screening of herbal substances. In the United States and Europe, however, over-the-counter natural herb products constitute a rapidly growing market, having joined prescription and over-the-counter medicines that were originally derived from herbs. Interest in herbal medicine has been facilitated by multiple factors, including the perception that pharmaceutical medications are expensive, overprescribed, and often dangerous. Alternatively, herbal medicines are often perceived as being “natural,” and therefore safe. Herbal medicines now fall into the category of complementary and alternative medicines (CAMs). Herbal supplements are receiving increasing exposure through national media, in lay journals, and more recently in the scientific press. Although the growth of the herbal medicine industry in the United States can probably not continue indefinitely at its current accelerated pace, there is little indication of any major slowing (Ekor, 2013; Euromonitor International, 2022). Therefore, many patients will continue to use herbal medications. In fact, one survey conducted in the United States found that an estimated 12.3 million adults (5.4% of the population) used alternative therapies as a substitute for costly prescription medications (Wang,
Kennedy, & Wu, 2015). According to the 2012 National Health Interview Survey, 33.2% of U.S. adults used complementary health approaches. This percentage is similar to the percentages in 2007 (35.5%) and 2002 (32.3%; National Center for Complementary and Integrative Health, 2016). In addition, a federally funded National Health Statistics 2016 report (Nahin & Barnes, 2016) revealed that Americans spend up to $60 billion per year on CAMs. With the increasing popularity of CAMs, a new issue has arisen: herbal-drug interactions, of which oral healthcare professionals (OHCPs) must be aware. A survey of patients with heart disease, diabetes, psychiatric disorders, and/or hypertension found that 79% were taking supplements concurrently with prescription medications (Graham et al., 2008). Among those with cardiac disease, 20% reported regular use of herbals. About 16% of patients with diabetes and 16% of patients with psychiatric disorders reported regular use of CAMs. The results of this survey underscore the prevalence of herbal supplement use and the potential for herbal-drug interaction (Graham et al., 2008; Asher, Corbett & Hawke 2017; Agbabiaka, Wider, Watson & Goodman, 2017). Thus, the OHCP needs to be increasingly aware not only of these products’ effects and advantageous synergies, but also of their side effects and possible or probable adverse drug reactions. After completing this basic-level course, the learner will be able to discuss the most commonly used herbal medicines in the United States. A stoplight approach to risk assessment is discussed and a general strategy to avoid the most common herbal-drug interactions is suggested. Critical patient populations are emphasized and specific herbal-drug interactions that can lead to increased bleeding, decreased blood glucose levels, and sedation changes are discussed. This course is specifically designed for all members of the dental healthcare team: dentists, dental hygienists, and dental assistants.
PREVALENCE OF USE AND RISK FOR INTERACTIONS
Although the typical North American diet has sufficient vitamins and minerals for overall health, Americans spent more than $59.9 billion on herbal supplements in 2021, and these nutraceuticals continue to be the largest-growing category of complementary and alternative medicines (CAMs) in use (NIH, 2016; Bailey, Gahche, Miller, Thomas, & Dwyer, 2013; Nutrition Business Journal, 2022). According to the National Institutes of Health (NIH), more than one third of all Americans take dietary supplements (Bailey et al., 2011; NIH, 2007), and as many as 52% to 74% of prescription drug users also take CAMs (Ghildayal, Johnson, Evans, & Kreitzer, 2016; Hanigan, Dela Cruz, Thompson, Farmer, & Medina, 2008; John et al., 2016; Nahin et al., 2009; Qato et al., 2008; Sharma, Holmes, & Sarkar, 2016). The U.S. Food and Drug Administration (FDA) defines a dietary supplement as, “a product intended to supplement the diet” that includes “a vitamin, a mineral, an herb or 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 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).
HERBAL MEDICATIONS AND DRUGS OF GREATEST CONCERN
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
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