Alternative Dental Products

By Peter L. Jacobsen, PhD, DDS, and
Richard P. Cohan, AB, DDS, MS, MA

Alternative, complementary or holistic health care is a growing area of medicine and dentistry. There are a variety of dental products promoted as an "alternative" to the standard commercial dental products that most dentists recommend and most patients use. These alternative products can be categorized as standard dental product made with natural ingredients, herbal products, homeopathic products, and synthetic alternative products. The use of dental care products should be based upon sound basic science and sufficient evidence of safety and efficacy. Dental health care providers should be aware of the range of alternative dental products and be able to help their patients understand the type of support/evidence needed to determine safety and efficacy of treatment.

Article copyright 1998 Journal of the California Dental Association.
Photographs copyright of the authors.

Alternative, collaborative, complementary, integrative, natural, unconventional and holistic are terms that are used to describe medical and dental treatments that do not conform to mainstream/allopathic/western/orthodox health approaches. The multiplicity of terms is because of vast differences in practitioners' treatment approaches and is also an attempt to position such therapy in relation to standard/orthodox health practices. These terms will be used interchangeably in this paper although the reader should realize there may be subtle and, in some cases, significantly different implications when some individuals use one term in contrast to another. The diagnostic and therapeutic value of many of the treatments and medications prescribed in such alternative practices is often questioned or roundly criticized by generally accepted and widely published medical authorities, such as the American Medical Association, the American Dental Association, the Food and Drug Administration and state medical boards. However, Mark Blumenthal, an internationally respected botanical authority and executive director of the American Botanical Council has stated repeatedly that clinical studies shouldn't be a precondition to making limited claims for efficacy. If documentation is available, for example 3,000 years of anecdotal history for some herbs, then limited claims should be allowed. Blumenthal espouses the standard used by the Commission E doctrine in Germany, which is "the doctrine of reasonable certainty for efficacy and the doctrine of absolute certainty for safety."

Table 1 Systems of Medicine Western Herbal/folk Homeopathy Eastern (Chinese) Ayurveda

Unconventional medical and dental practices, which may be viewed as conventional by those who subscribe to them, and certainly are conventional in some countries, such as their country of origin, offer a wide spectrum of treatments or treatment modalities (Table 1). A workable definition of unconventional or alternative dental practice is "those therapies neither taught widely in U.S. medical schools nor generally available in U.S. hospitals."

The public's interest in alternative health care has grown dramatically in the past few years. In a 1993 article, titled "Unconventional Medicine in the United States," Dr. David Eisenberg and colleagues reported the results of a 1990 telephone survey of U.S. adults.1 Of the 1,031 individuals who completed the survey, 34 percent said they had used at least one unconventional therapy in the previous year, and one-third of those (11.2 percent) had seen providers of unconventional therapy. The latter patients made an average of 19 visits in the course of a year to such providers, mostly for the treatment of chronic illness. Dr. Eisenberg extrapolated the survey results to the U.S. population and concluded that "Americans made an estimated 425 million visits to providers of unconventional therapy vs. only 388 million visits to all primary care physicians. Based on a reported average charge of $27.60 per visit to alternative providers, Dr. Eisenberg's group estimated "expenditures associated with use of unconventional therapy in 1990 amounted to approximately $13.7 billion ($10.3 billion out of pocket), which is comparable to the $12.8 billion spent out of pocket annually for all hospitalizations in the United States. Thus, Dr. Eisenberg concluded that "both the frequency and use of unconventional therapy in the United States is far higher then previously reported."

A significant trend toward coverage of alternative care by health insurance companies is being driven by patient demand and cost differences favoring alternative care/self-care. Leading the way are insurers such as Oxford Health and Blue Cross/Blue Shield. Oxford Health surveyed its 5,500 employees and determined that 33 percent already use some form of alternative medicine, while 25 percent were interested in learning more about alternative treatments. In 1996, Oxford Health became the first health maintenance organization to offer comprehensive coverage for a range of alternative care providers without referral by a primary care physician.2

Examples of alternative health care practitioners typically include acupuncturists, chiropractors, massage therapists, yoga instructors, nutritionists, dietitians and naturopathic physicians, aromatherapists, guided imagery caregivers, and crystal therapy healers, to name a few. Knowledge about alternative medicine is slow getting into medical school curricula. Only 50 of the nation's 125 medical schools, including Harvard, Yale and Johns Hopkins, now offer courses in alternative medicine.2

The authors' interactions with their dental colleagues and their knowledge of dental school curricula reveal that alternative dental products and treatment modalities are rarely included in dental education. In part, this may be due to the fact that the trend in health care toward alternative therapeutic measures is occurring to a lesser degree in dentistry. Also, many alternative-care protagonists are squarely aligned against orthodox dentistry by being antifluoride or antimercury. A vocal minority of practitioners preach the toxic dangers of root canal fillings and the folly of periodontal surgery in salvaging teeth. Most holistic dental practitioners simply recommend alternative and natural dental products that are available through their practice, in health food stores or by mail order. Unfortunately, most of these products have little or no direct scientific basis for the specific oral health claims.

Table 2 Alternative or Complementary Dental Product Categories Natural standard products Herbal products Homeopathic products Synthetic alternative products

Currently available alternative dental products can be classified into four categories. The authors use the terms natural standard products, herbal products, homeopathic products and synthetic alternative products (Table 2) to characterize these groups.

This grouping was done by evaluating the numerous products available in health food and vitamin stores or by mail. Common treatment claims or ingredients were evaluated and groups became apparent. There is some overlap between some groups of products.

Natural Standard Products

The first group, natural standard products, is made up of traditional oral health products formulated from naturally derived components. For example, in natural toothpaste, the fluoride comes from fluorspar, a fluoride-containing mineral mined from the earth (but bicarbonate of soda or charcoal are equally good). The abrasive system, instead of being silicone or some other synthesized abrasive, is precision-ground, naturally occurring, calcium carbonate (chalk) mined from the earth. The thickener, instead of being a synthesized product such as methylcellulose, is carrageenan, a substance derived from seaweed. The sweetener, xylitol, is a relatively expensive product extracted from birch trees, as opposed to a synthesized compound, such as saccharin.

One of the best known and most widely advertised natural oral health product lines is Tom's of Maine. Close examination of its labeling shows documentation of the source for all of the ingredients in its toothpastes and mouthrinses. One of Tom's of Maine's natural toothpastes (spearmint) has received the ADA Seal of Acceptance. This acceptance is based on the anticaries efficacy of the fluoride content. There are other natural products such as First Teeth toothpaste from the Laclede Corp.; Euroteeth, a line of tooth powders from Europe; Eco-Dent's Daily Care (made from natural sea salt); and Weleda's all-natural toothpastes made with natural silica and calcium carbonate. Weleda's toothpaste also contains myrrh, used for its antiseptic, astringent, healing, anti-inflammatory and preservative properties. To the author's knowledge, none of the companies other than Tom's of Maine, have sought the ADA Seal of Acceptance for their products. Most of these natural standard products do not contain fluoride; and their therapeutic claims have not been well-substantiated, other than anecdotally. It is interesting to note that a number of products in this category combine natural inorganic components with natural organic or herbal components, such as Beehive Botanical's Propolis Toothpaste, thereby overlapping into the category discussed next.

Herbal Products

This next large class of alternative oral health products is termed herbal products. These products feature herbal sources as the main active ingredient. Echinacea, for example, is the most common herbal remedy available in the United States for infections.3 This herb is classified as a coneflower. Most preparations are derived from Echinacea angustifolia and purpurea, usually utilized as a tincture or in powder form. It is often added to toothpastes and mouthrinses as a remedy for gum problems. Myrrh and echinacea are promoted for their antimicrobial action in toothpaste formulations by the noted therapeutic herbalist David Hoffmann in his book, The Complete Illustrated Holistic Herbal Element Books.4 No modern studies have documented the efficacy of these products to treat any dental disease above and beyond the value of effective tooth brushing.

Studies during the past 15 years have focused on the polyphenols in green tea for their antibacterial and antiviral properties. In particular, Horibetal, 1991,5 and Otake and colleagues, 1991,6 have demonstrated that these polyphenolic compounds may protect teeth from caries by killing causative bacteria. Additionally, Makimura and colleagues, 1993,7 proposed that those compounds inhibit bacterial collagenase activity. And Yu and colleagues, 1995,8 reported that the polyphenols in green tea increase the acid resistance of human enamel. Though brewed green tea is considered to have these attributes, green tea is seldom added to oral health products. Another large group of oral products promoted for their antimicrobial properties contain malleleuca (tea tree) oil. These products are available in mouthwashes, toothpastes, toothpicks and lip balms. The pure oil is also available and can be applied with a toothbrush; however, it has a very pungent taste and strong aroma. Tea tree oil does have antimicrobial properties on bacterial cultures, but no studies document the efficacy of tea-tree-oil-containing dental products on oral disease. Some herbal products, such as the new Dental Herb Co. products called Tooth & Gum Tonic and Under the Gum Concentrate are promoted as anticaries and antiperiodontitis agents. The company states the products are "tissue conditioners" and "connective tissue rebuilders" that can reverse periodontal disease. There are no studies that the authors know of to support these claims. Other common herbal ingredients in oral health care products range from cariostatic agents to analgesics to antimicrobials to bleaching/scouring agents including aloe vera; aniseed bayberry; blue flag; burdock root; calendula; cayenne; chamomile; clevers; cloves; fennel; ginger; goldenseal; gotu kola; horsetail; licorice; marshmallow; myrrh; neem; peppermint; poke root; prickly ash; propolis; red sage; rosemary; strawberry and witch hazel; essential oils such as cinnamon bark, clove oil, eucalyptus, red thyme, and true lavender; and, for fetor ex ore (halitosis), fresh parsley, pulverized nettle leaves or watercress.

Documenting the efficacy of these herbal products is a daunting task, even if one has access to the premier source of herbal literature in the United States, the John Uri Lloyd Library in Cincinnati, Ohio, or is adept at searching for references on the World Wide Web (see Table 3, recommended sources); or has the financial capacity to purchase hundreds of books and periodicals from sources such as the Herb Research Foundation and American Botanical Council, publishers of the HerbalGram. The efficacy of these products, when documented, is almost always based on in vitro studies of single ingredients. Few studies document the clinical efficacy of dental formulations containing combinations of these compounds. However, there are notable exceptions, such as the combination of eucalyptol, thymol menthol (found in Listerine). Sanguinaria canadensis L. (found in Viadent), is a good example of a single ingredient herbal with documented clinical efficacy.9

Another group of herbs that deserves mention is the roots of several plants that have been used as toothbrushes for centuries in various parts of the world, including licorice root, marshmallow, alfalfa and horseradish. In some cases, sections of the root are chewed for 10 to 20 minutes and become spongelike, enhancing their physical cleansing/massaging action. Some of the roots are considered to have antimicrobial properties, although confirming controlled studies are not available. Dr. Hoffmann4 suggests slicing 5-inch sections of marshmallow root, peeling the ends, boiling them together with cinnamon sticks and cloves until tender, soaking them overnight in brandy, then drying them out. Before use, he recommends soaking the ends for a short time in hot water. Since all of the ingredients are in the root, no toothpaste is necessary.4 Though evidence of the clinical efficacy of the ingredients does not exist (i.e., the claims are anecdotal), the root will remove plaque, as would any physical abrasion with a "brush." There is an extensive body of literature on herb selection and self-preparation.

There is a huge variety of Chinese herbal preparations, as well as ayurvedic herbal preparations. Ayurvedic medicine is an ancient medical tradition found most commonly in India. Chinese herb formularies contain more than 1,000 formulae for dental and gingival/periodontal problems, including toothache, gingival swellings, caries, dry mouth, halitosis, oral ulceration and various types of stained teeth. An example of a Chinese herb in one of these formulae is pearl (zenzhu), which, in a 3 percent ointment, is promoted as possessing "strong wound healing properties" when applied to oral mucositis lesions occurring secondary to chemotherapy.10 Again, controlled clinical studies of the type used to document efficacy in Western medicine, have not been reported in the Western literature.

Homeopathic Remedies

A third category of oral health products is homeopathic remedies. These are based on the medical system of homeopathy. The basis of homeopathy is the Law of Similars (from the Greek words homoios, meaning similar, and pathos, meaning suffering). According to this belief, whereas a compound in a "high" dose can cause physical, emotional or mental signs and symptoms, a "tiny" homeopathic dose of that compound can stimulate a human response to reverse the pathology. Thus, the theory of homeopathy shares some similarities with the mechanism of vaccinations and the stimulation of the immune system.
A German chemist and physician, Samuel Hahnemann, developed this "like cures like" medical approach. In 1789, Hahnemann observed that excessive amounts of cinchona bark produced symptoms virtually identical to those of malaria, whereas minuscule amounts of the same bark reversed those symptoms. An expansion of those precepts were proposed by a student of Dr. Hahnemann's, Dr. Constantine Hering, the father of American homeopathy. Hering's Law of Cures states that healing progresses from the deepest part of the body to the extremities: from the upper part of the body to the lower; from the emotional to the physical, and from the most recent maladies to the oldest.

Homeopathy was practiced widely in the United States from the 1830s to the late 1920s. The founding of the American Institute of Homeopathy (1844) preceded that of the American Medical Association by three years. There were 22 homeopathic medical schools and nearly 100 homeopathic hospitals in the United States by the year 1900, counting among their adherents such notable figures as Nelson D. Rockefeller, Mark Twain and Thomas Edison.11 A survey of the medical literature from 1966 to 1990 revealed that 81 out of 107 controlled clinical studies demonstrated the effectiveness of homeopathic medical regimens for a wide variety of medical problems.12

A variety of homeopathic product manufacturers, including manufacturers of dental products, note that their products are FDA-accepted. Indeed, they are recognized as drugs; and they are regulated as to their manufacture, labeling and dispensing. Homeopathic products became FDA-accepted when the FDA was formed in 1936. Few studies have been done since 1936 to document the efficacy of ingredients used in homeopathic oral health products. A textbook on dental homeopathy titled A Textbook of Dental Homeopathy for Dental Surgeons, Homeopathists and General Medical Practitioners by Dr. Collin B. Lessell,13 outlines the use of certain preparations for oral problems, such as mercurius vivus for tender bleeding gingiva and excessive salivation. The Board of Homeopathic Dentistry offers courses and a qualifying examination, and many members of the International Academy of Oral Medicine and Toxicology hold to these tenets.

There are a variety of product lines and approaches to treating oral diseases with homeopathic medicines, the oldest in America being Boericke & Tafel (established 1835), which makes more than 2,000 homeopathics. A new dental product line marketed enthusiastically to dentists through a multitiered marketing system is Orarex. These are homeopathy-based products from the Rexall Drug Co. There are a variety of other oral products containing homeopathic ingredients that are sold in health food stores. A group of homeopathics called "flower essences" are marketed over the counter. The best known of these is the Bach Flower Essences. Few controlled clinical trials have been conducted utilizing currently available homeopathic dental products to analyze their effect on oral disease.

Synthetic Alternative Products

The last category of alternative dental products is titled synthetic alternative products. These alternative dental products are made up of synthesized compounds, often derived from naturally occurring volatile essential oils. Examples include phenolic compounds such as thymol (from red thyme), eucalyptol, eugenol, menthol and phenol. They are promoted primarily as disinfectants. Phenol, per se, is an FDA-accepted product for "numbing oral mucosal surfaces," and has been employed empirically in numerous mouthwashes;14 however the authors could find no documentation of its intraoral disinfecting efficacy. Therasol is a product whose active ingredient (C31G, a combination of N, N-alkyl dimethyl glycine and Ng N-dimethyl amino oxide) is natural but not derived from a volatile oil. The product is promoted as a treatment for periodontal disease. No in vitro human studies of product use are available to document its efficacy.

Table 4 Stipulations of the Dietary Supplement and Health Education Act of 1994 No efficacy test required Proof of safety not necessary No manufacturing standards required Claims must be substantiated (but manufacturer does not have to reveal evidence) FDA approval for claims not needed

The above four categories make up the principle groupings of all alternative oral health care products within the scope of this paper. Some products may contain ingredients from several groups. As noted, most products have little to no research documenting their efficacy. When research is done, it most commonly shows that the active ingredient, when placed in a petri dish with the target organism, can kill that organism. One extrapolation that the company promoting the product urges the dental practitioner and consumer to make is that the target organism is the cause of a particular oral disease and that the manufactured product, containing the active ingredient, utilized as directed, will kill the target organism in the oral cavity and therefore resolve an oral disease. The reliability of such extrapolations is notoriously poor at best. Many problems can occur, including degradation of the active ingredient during manufacturing or storage, and an inability of the product to reach the site of action. Another extrapolation the user is forced to make is that the peculiar combination of ingredients have a synergy of action. Controlled clinical trials using these products in the oral cavity compared to an inactive product provide the best evidence of efficacy and safety. Such studies on almost all alternative oral health products and their purported active ingredients do not exist.

The natural product market is growing rapidly,2 and it is estimated that 16 percent of the population use herbs. Such natural and herbal therapies are widely accepted in Europe, and the botanical herbs industry has grown by 15 percent during the past several years. In the United States, the Dietary Supplement and Health Education Act of 199415 (Table 4) has spurred growth in the herbal industry, in part because these products do not need as rigorous FDA approval as prescription drugs.

Some authors have characterized the natural products category of compounds, including oral health products, as nutraceuticals (Table 5). Nutraceuticals are defined as naturally derived substances offering preventative or curative health/medical benefits. Nutraceuticals can be subdivided into cosmoceuticals (natural beauty aids), phytopharmaceuticals, (plant-derived products used as prescription and nonprescription drugs), functional food ingredients (nutrient-rich concentrations used as food additives) and dietary supplements (standardized botanical extracts, tinctures, powders or tablet/capsule preparations.) These products are usually manufactured and sold in accordance with the Dietary Supplement and Health Education Act. No matter what the bold print on the label claims, the fine print on the labeling should note that the product is considered a dietary supplement and that no therapeutic claims are made or implied. The literature about the product, which is distributed separately can make structure/function claims that are truthful, not misleading and do not purport to cure, treat or mitigate disease. The literature should note that the claims have not been evaluated by the FDA.

The dietary act also states that no efficacy testing is necessary and that proof of safety is not necessary for these products. There are no required manufacturing standards; however, the industry is rapidly promulgating a "Good Manufacturing Practices" doctrine. The dietary act also states that the claims must be substantiated, but it notes that manufacturers do not have to reveal the evidence for this substantiation. Furthermore, it notes that the FDA approval for claims is not required.15 A new product that is a good example within this category is Breath Assure. It is a combination of parsley oil and cottonseed oil and is designed to control halitosis. Close reading of the packaging will note that it is classified as a dietary supplement. The manufacturers note that they do not know the mechanism of action of the product; and, though they have studies documenting its efficacy, they are not available for scrutiny16 (personal communication to one of the authors).

Conclusion

Alternative, natural dental products continue to proliferate rapidly. Dentists and dental hygienists should be knowledgeable about these traditional and emerging, preventative and therapeutic products because a large number of patients use them or intend to do so. These patients may rely on dental professionals for sound advice in this area. There are a number of efficacious products available. As noted above, some products made with all natural ingredients by Tom's of Maine, spearmint and cinnamint toothpastes, have received the ADA Seal of Acceptance, and more may follow. At the same time, numerous natural dental products are available with no research supporting their efficacy. The decision regarding their use must be made by patients and/or their dental health providers and should be based on their oral health needs and the availability of scientific documentation as to their safety, at least, as well as their efficacy.

There is growing interest in alternative medicine and dentistry and the use of alternative dental products. Dentists and hygienists should have some knowledge about these products. This will enhance their credibility as knowledgeable and empathic health care providers.

Authors

Peter L. Jacobsen, PhD, DDS, is a director of the Oral Medicine Clinic and director of Oral Diagnosis and Treatment Planning at the University of the Pacific Dental School.

Richard P. Cohan, AB, DDS, MS, MA, is director of the International Dental Sutdies Oral Diagnosis and Treatment Planning course and former head of Oral Diagnosis and Treatment Planning at UOP.

References

1.  Eisenberg DM, Kessler RC et al. Unconventional medicine in the United States. N Engl J Med 328:246-52, 1993.

2.  Nutrition Business Journal, Consumers lead way towards integrated health care. Nutrition Business International 2(6):1-24.

3.  Foster S, Echinacea - Echinacea Nature's Immune Enhancer. Healing Arts Press, Rochester, Vt, 1991.

4.  Hoffmann D, The Complete Illustrated Holistic Herbal Element Books, 1996

5.  Horiba N, Maekawa Y et al. A pilot study of Japanese green tea as a medicament: antibacterial and bactericidal effects. J Endo 17(3):122-4, 1991.

6.  Otake S, Makimura M et al, Anticaries effects of polyphenolic compounds from Japanese green tea. Carie Res 25(6):438-43.

7.  Makimura M, Hirasawa M et al, Inhibitory effect of tea catechins on collagenase activity. J Periodontol 64(7):630-6, 1993.

8.  Yu H, Oho T et al, Anticariogenic effects of green tea. Fukuoka-Igaku-Zasshi 83(4):174-80, 1992.

9.  Lawrence Review of Natural Products: Bloodroot (Sanguinaria) 1-2. July, 1992.

10.  Leung A and Foster S, Encyclopedia of Common Natural Ingredients, 2nd ed. John Wiley & Sons Inc, 1996.

11.  Alternative Medicine. The Burton Goldberg Group, Future Medicine Publishing, 1994.

12.  Kleignen J, Clinical trials of homeopathy. Brit Med J 302:316-23, 1991.

13.  A Textbook of Dental Homeopathy for Dental Surgeons, Homeopathists and General Medical Practitioners. The CW Daniel Co Ltd, London, 1995.

14.  American Dental Association, Accepted Dental Therapeutics. Chicago, Ill, 1979, pp 229-32.

15.  Israelson L, Summary of the Dietary Supplement Health and Education Act of 1994. In Quarterly Review of Natural Medicine. Natural Product Research Consultants Inc, Seattle, WA 98104.

16.  Personal communication with the authors.

To request a printed copy of this article, please contact/ Peter L. Jacobsen, PhD, DDS, UOP School of Dentistry, 2155 Webster St., San Francisco, CA 94115.