This article originally appeared in the October 2014 issue of ASDA News and is written by Gregory Sabino, Ph.D., Stony Brook ’16. To read more from this issue of ASDA News, click here.
When seeking dental care, patients exercise autonomy and are increasingly involved in their own treatment planning. The terms “holistic” and “alternative” invoke a variety of responses from health care professionals and patients. The Holistic Dental Association believes that being a healthy person goes beyond the absence of disease. They examine treatments and agents not typically taught during dental training. There is a special focus placed on a patient’s whole well-being that goes beyond the oral cavity. They seek to provide a means to foster the innate ability to heal.
The ADA groups “holistic” and “alternative” into a category called unconventional dentistry. The ADA targets dental practices and products not validated by scientific studies. The ADA recognizes the importance of developing new products and techniques of treatment if they are evidence based. While dental fads are present in the public, there are proven compounds and methods from traditional and natural sources that improve oral health. Research has shown positive outcomes, and in some cases, similar efficacy when compared with more contemporary ingredients.
The use of chewing sticks was first recorded more than 9,000 years ago by the Babylonians. Their use continues today. The name varies depending on the culture and region, as does the plant used. In south Asia, they are called Datan. The name Miswak or Miswaki is used in the Middle East and western Africa. Typically, they are made from trees and shrubs such as Arak, Lime or Neem. The use of Miswak has shown comparable reductions in plaque and gingivitis when compared with the use of a modern tooth brush. While the ability to control plaque through mechanical forces was shown, extracts that are released from the sticks during use possess anti-microbial properties.
Benzyl isothiocyanate is a major active ingredient from the Arak tree and it is bactericidal against gram-negative bacteria and oral pathogens. However, Almas K et al. observed that extracts from Miswak where not as bactericidal as commercially available mouthwashes. The bark extracts of Prosopis africana and Vernonia amygdalina, which are used to make chewing sticks in Africa, are highly bacteriostatic to a variety of oral pathogens and help reduce plaque formation. The typical use of chewing sticks is about five times per day. Increased levels of gingival recession and tooth wear are positively correlated with their use.
Porphyromonas gingivalis is implicated in periodontal disease. The use of herbal extracts is commonplace in traditional medicines. For centuries, Kampos are used in Japan to ease the symptoms of many illnesses. Each is a standard mixture of herbs depending on the ailment. The mixtures that contain Chinese rhubarb were found to inhibit P. gingivalis in multiple ways. The active ingredient in Chinese rhubarb are anthraquinones. The Kampos and anthraquinones extracts reduced P. gingivalis adherence to oral epithelial cells, and reduced proteinase activity. The bactericidal activity of the Kampos was due to Aloe-emodin and rhein, which are specific anthraquinones. In some cases the select Kampos mixtures out-performed the extracted anthraquinones. Similar results were also observed using extracts derived from cranberries and licorice. A-type cranberry proanthocyanidins and licochalcone A are compounds that acted in synergy to prevent the formation of biofilms by P. gingivalis. In addition, these extracts dampened the macrophage response leading to reduced expression of MMP9.
Streptococcus mutans is integral to the formation of caries, and many modern mouthrinses aim to reduce levels of this oral pathogen. Studies have shown that certain foods are anti-cariogenic. Low molecular weight extracts from shiitake mushrooms reduced growth of S. mutans at twice the concentration typically found while eating the food. Polyphenols are found in a variety of vegetables and are hypothesized to be the active component of this extract. The inhibition of DNA synthesis and macromoleclar synthesis is believed to be the main mechanism behind the shiitake mushroom’s bactericidal properties. The blocking of cell division of the pathogen was similar to the quinolones and β-lactams antibiotic families.
Alternatives to fluoride containing toothpastes are common in the marketplace. Clinical studies regarding the efficacy of these products compared with conventional products are typically limited. However, the properties of the active ingredients are often researched. Chitosan is a natural polymer from chitin. It is being added to fluoride containing toothpastes due to its ability to reduce wear and erosion of enamel. Chitosan is also bactericidal to S. mutans and P. gingivalis. The use of chitosan as a gelling agent is beneficial to toothpastes because they will not require any more preservatives. The combination of Xylitol and Chitson are the main ingredients in some alternative toothpastes.
Aloe vera toothpastes and rinses are growing in popularity, and unlike the oil-pulling fad, research supports the use of Aloe vera to some extent. Aloe vera contains anthraquinones and is antimicrobial to many oral pathogens. There are conflicting data regarding the efficacy of Aloe vera when comparing it to chlorhexidine. These varying results could be due to the instability of the anthraquinoes found in Aloe vera. Aloe vera dental products have a short shelf life when compared with more conventional toothpastes and rinses. In the future, Aloe vera may pose as a positive alternative because patients to do not experience staining and increased calculus, which is typically seen with chlorhexidine use.
Alternative dentistry also includes the use of non-pharmokinetic practice. Preprocedural anxiety can contribute to the level of pain experienced during a dental treatment. It is believed that those who experienced pain in a previous dental visit have a lower threshold to pain for subsequent treatments. Therefore, hypnosis is a valuable non-pharmacological method for managing patient fear. The use of hypnosis as an alternative form of anesthesia was first used by Jean-Victor Oudet during a dental extraction in 1829. Since then, the use of hypnosis in dental procedures is debated. A 2013 case-control study by Abdeshahi SK et al. bi lateral class AI 3rd molars were extracted using 2 percent lidocaine or hypnosis. Hypnotic anesthesia was induced in the patient’s hand and then transferred to the patient’s tooth by touch. When under hypnosis, the patient experienced less operative pain and less post-operative pain than with local anesthesia. This led to a reduced use of analgesics after the extractions. The study also reported less post-operative bleeding when the patient was under hypnosis. The use of hypno-anesthesia is shown to decrease recovery times in the medical and dental surgeries.
These are just some of examples of common forms of alternative dentistry that you may encounter during your time as a dental student. Although positive in vitro data are promising, it does not always foreshadow clinical success. It is extremely important that sound clinical research supports their use before recommending any product or procedure to our patients.
~Gregory J. Sabino, Ph. D., Stony Brook ’16, 2015-16 editor-in-chief