CDA Essentials 2017 • Volume 4 • Issue 6

26 | 2017 | Issue 6 I ssues and P eople Why are these CAMs of concern to dentists? They’re a concern primarily due to their ubiquitous nature. Dentists will undoubtedly come across patients who are taking these drugs. One therefore has to wonder: are there medications used in dentistry that could interact badly with some of the herbal medications on the market? I think there’s also a misnomer that big pharma creates products that are overpriced, and that nutraceuticals are more natural alternatives and at a price point that is more favourable for patients. That perception needs to be corrected because many might not understand that CAMs can vary significantly from batch to batch because of the lack of regulation and you may not always be getting what you paid for. Are some herbal medications particularly problematic to dentists? Let’s focus on the main categories of medications used or prescribed by dentists: antibiotics, analgesics, local anesthetics, the emergency kit medications, and sedatives in the case of patients with a high fear of dentistry. There can be interactions between antibiotics used in dentistry and certain herbal medications. There is a significant interaction between amoxicillin and acacia , for example. Acacia can reduce the absorption, and therefore the efficacy, of amoxicillin. When it comes to administrating sedatives to patients, you should make sure that they are not taking St. John’s wort or valerian because those can work synergistically with the sedative agent and could potentially put a patient into a deeper level of sedation than you intend. Individuals with cardiac problems are also a critical patient population. If a patient is on an anticoagulant or antiplatelet agent, or you think that bleeding postoperatively could be a challenge following a procedure, you should be concerned about herbal medications that start with the letter G: garlic, ginseng, green tea, gingko. All of these can affect postoperative hemostasis. How can dentists mitigate these risks? Very few herbal medications have been shown to have strong positive effects on the well-being of patients or on disease treatment outcomes. So it is far better for a patient, should you believe there is a risk for an interaction, to stop taking that herbal medication at least 24 hours prior to dental intervention. If the patient can commit to interrupting their herbal medication intake at least 24 hours prior to the appointment, then in almost all cases you can go ahead and perform surgery using the procedures and pharmaceuticals you know work best. What resources can help guide clinical decisions? What we’re looking for is non-biased, evidence-based information. Since this is a very dynamic field, I’m hesitant to suggest a textbook as this information gets updated too frequently. The resource I’m most familiar with is the Natural Medicines Comprehensive Database (naturaldatabase.therapeuticresearch.com ). This repository is easy to navigate and it’s approved by the United States Pharmacopeia. Based on all the evidence to date—even low- level evidence—it evaluates the likelihood of any given CAM to be involved in a drug interaction. The website uses a “stoplight” approach which lets you judge the scenario you are facing: a green light means that there are no potential interactions; an amber light suggests that you may want to gather more information or do additional monitoring; and a red light indicates that an interaction is probable and that you will want to avoid that combination. You can quickly check the medications you typically prescribe or use against herbal medications that patients could be taking. This tool really is easy to implement in your clinic. There are other credible websites, such as those of the American Herbalist Guild, the Herb Research Foundation, the National Institutes of Health, and the Office of Dietary Supplements. All of those resources are excellent starting points. a This interviewhasbeeneditedandcondensed. Theviewsexpressedarethoseoftheauthor anddonotnecessarilyreflecttheopinions orofficialpoliciesoftheCanadianDental Association. Watch the full interview with Dr. Donaldson at oasisdiscussions.ca/ 2017/02/02/hdi