Using essential oils in the dental office is fun and useful. I started using essential oils in my general dental practice after taking a rigorous program of study. I feel it is not necessary for a dental practitioner to have a certificate of study, to include essential oils in a practice, but, must be aware of the potential safety issues and the chemical properties of the oils that are being used.
Short courses are offered that would be very helpful to get you going. Many pharmacists have a background that could assist also. I am listing the ways that I use essential oils in my own practice. There are no set parameters for their use specifically in dental offices and I have implemented these uses with the advice of aromatic advisors and am sharing them here.
While I keep over 70 different essential oils at my home for personal use, I seldom have more than four or five different bottles at the office at any one time. Keeping the selection to a minimum at the office is safer. It gives you good control on their use as they will be in the hands of staff that may not be educated of their dangers.
Aromatherapy is not synonymous with environmental fragrancing. Environmental fragrancing is enhancing the mood of a clinical setting with smells of commercial air fresheners, spices, potpourri, scented candles, baking bread or cookies, etc. Aromatherapy involves scientific use of pure essential oils to produce pharmacodynamic effects. In both cases, it must be pointed out that individuals react differently to the same odours because smell is controlled largely by the primitive limbic part of our brains and our reactions to smell is largely dependant on our memories that have been connected to that smell from past life experiences.
In recent research from Brown University, Dr. Rachel Herz reports that, "experience and not genes, determines our emotional reactions to scents." Dr. Serge Marchand, who has studied physical reactions to scent at the University of Quebec also points out that scent, when attached to memories of a positive experience, can play a role in affecting mood, pain and aid in the healing process.7
My favorite way to use essential oils in the office is by "misting" the air. I do this using a clean dark spray bottle with 40mls of distilled water and add up to 20 drops of an antiseptic oil or blend of oils. I often simply use lemon essential oil -- it is very inexpensive, antiseptic and stimulating/ uplifting. Just walk around the office spraying the mist occasionally and you are assured to get some smiles for the effort. It can be used instead of a commercial air deodorizer, and may be used in a limited number of humidifiers. (Use only in recommended cold humidifiers.)
Danielle Sade owner of Healing Fragrances School of Aromatherapy suggests a number of other nice blends for misting: "Mists of Awakenings" = Peppermint (6 drops) + Mandarin (10 drops) + Ginger (4 drops) or try "Mists of Calmness" = Lavender (10 drops) + Geranium Rose (5 drops) + Sweet Marjoram (5 drops).6 (Note: adding glycerin +/or honey to a mist makes a great skin toner, too.)
I do not use aromatic candles or oil burners in the office. Use a salt lamp for effect if you want a soft light, it is safer than using candles. I have a number of well situated electric diffusers that have very quiet fans. They are positioned behind the receptionist and in each of the operatories. I do not think that it is fair to put a particular scent in the waiting room because everyone reacts differently to scent and there is not a universally pleasant scent that I would like to impose on everyone. My receptionist enjoys the effects of a blend of fresh orange smells, which are good for anxiety (e.g. Neroli, Petitgrain and Sweet Orange), which we often complement by having a bowl of mandarin oranges on the counter and offering an orange flavoured tea (Blood Orange Tea by Tea in the Sahara).
The combination of tasting, seeing and smelling something similar has a stronger effect than just using one sense alone. The use of orange scent in a dental waiting room has actually been tested and reported.5 Stores often use orange colours and smells as they are thought to encourage spending by shoppers. Slightly different research was done using a clove (eugenol) smell in the waiting room and the effect differed according to the patients' past dental experiences.(7) I change the blend occasionally and do not allow the diffusers to be on constantly to prevent sensitization to the smell. To mix it up, I also like both Frankensence and/or Cinnamon to blend with orange.
I try to make patients aware that I am using aromatherapy when the diffusers are on. I basically use oils that I love and keep me calm and relaxed, but, you should get feedback from the patient and assistant that they are enjoying the experience as well. Everyone reacts differently to scent and they will let you know if it is offensive to them. Essential oils dissipate very quickly after the diffuser is turned off. Using too much of the same oil can lead to sensitization to the chemicals in that oil, so know what chemical groups are in the oils you use and mix them up.
A word of caution about using the ever popular lavender oils: lavender comes in several different chemotypes. High altitude lavender (Lavendula augustifolia) ($$$) is relaxing whereas lavendin (Lavendula x intermedia-usually less expensive, but, far more available) is a stimulant!! Spike lavender (Lavendula spica) is not appropriate to use in the dental office as a relaxant because of the high camphor and 1,8 cineole levels. Spike lavender can also be neurotoxic. Also, to further complicate matters, the more expensive high altitude, true lavender, is commonly adulterated with lavendin, or by adding synthetic linalool and linalyl acetate.
At the American Association of Cosmetic Dentistry conference in 2004 (in Vancouver), placing drops of lavender (type not specified) on a patient's bib was suggested as a relaxation technique. If high altitude, true lavender was being used, both the dentist and assistant could be feeling very sleepy after inhaling it throughout a lengthy procedure, which is unwise. Sometimes Petitgrain is used instead of Lavender.
NOVEL USES OF ESSENTIAL OILS IN DENTISTRY THAT I HAVE TRIED
1. Handkerchief technique: put a few drops of essential oil(s) onto a Kleenex, cotton buff or gauze square and the patient can inhale the aroma when they feel the urge. This is better technique than putting the oils on the patients' bib as the practitioner is not as affected by the scent and it is not constant.
2. Using them in combination with vinegar, Borax or Baking Soda to make your own cleaning products for outside the operatory, in the washroom, reception, on glass and mirrors. Use distilled water and clean containers/bottles.
3. Make individualized mouth rinses and tooth powders depending on the patient's need. Denture wearers may want to soak their dentures in a home made natural antifungal, disinfecting solution rather than the commercial ones. Recipes are readily available on the internet and in some of my references.
4. Make your own lip moisturizers to give to patients for use during their treatment and for take home. Same goes for novel take home giveaways e.g.scented bath salts (see 11 below), or hand lotions which are especially appreciated in holiday seasons. Soap is difficult and somewhat dangerous to make yourself (due to caustic ingredients), start with something easier.
5. I make my own essential oil scented hand cream and keep it on the reception desk for patient/staff use. If you do not use preservatives, mark an expiry date (but, it will be long gone before that date).
6. Warm, essential oil misted face wipes for cleanup after treatment are a treat. Several companies will custom make these for you or you can make them yourself. Your office can have its own "signature scent." They can be warmed in the microwave or commercially available units.
7. "Breatheasy" mixtures of essential oils can be inhaled to help alleviate respiratory tract and sinus conjestion. If you've tried them, you know how fast and effective these cineole-rich oils can be. Patients appreciate when you use them during cold and flu season. If you are making your own, you should be aware of the different types of Eucalyptus available. For example, Eucalyptus globulus. is more mucolytic than Eucalyptus radiata. If you are treating a dental patient and they are stuffed up and have difficulty breathing, dental treatment will be even more difficult to perform if you give them Eucalptus globulus. and their nose starts to run more or they experience post nasal drip. If they inhale just Eucalyptus radiata, easier breathing should be facilitated.
8. Salves and ointments for different purposes can be made fresh for individual patient's needs if the ingredients and sterile containers are kept on the premises.
9. For anxious adult patients: Try letting them inhale from a Bergamot bottle followed by a deep sniff of Frankincense. The combination of the two oils has a very balanced chemistry and sometimes can help settle down an anxious patient.
10. If a patient comes in and has a dreadful cold and you do not want to treat them, offer them a vial of your own cold remedy to put into a bowl of hot boiling water and inhale at home and reappoint them. Then they will feel it wasn't a total waste to show up for their scheduled appointment and you feel better at sending them away. Juniper, Lemongrass, Eucalyptus citradora and Frankinsence is a nice blend.9 Combinations of myrcene and oxides work well for cold and flu formulas.
11. After purchasing a hot stone collection and playing around with the stones, I have developed a number of techniques for using them to alleviate swelling and muscle spasms. By adding appropriate essential oils to the stones' hot /cold water baths, the scent is retained in the stone when removed from the water and used on the patient. The hot stones are great for massaging the masseter and temporalis muscles, which I allow the patient to do. There are two types of stones that I use: the black lava for heating and the black speckled marine stones for cold. The marine stones can be kept in the freezer and are readily available when needed. Like the hot stones which I heat in hot water, the marine stones also retain their temperature for a moderate period of time.
Use the cold marine stones where ever you would like a cold compress or ice, the advantages being that they are smooth and do not melt. Smaller stones can be placed over the sinus areas to alleviate sinus discomfort, larger stones can be used to deliver more temperature to muscles of mastication and temporal areas for TMJ treatment and trismus. The stones are returned to hot or cold water baths when they loose their heat/cold. The stones can also be used for more traditional relaxation treatment by placing warm stones on the patient, or having them hold the hot and smooth stones in their hands during treatment. The hot stones, wrapped in a towel under the neck or lower back can also be very comforting.
All this is done in great fun and patients almost always appreciate that you are trying to be helpful in alleviating their symptoms. The stones are difficult to sterilize, placing essential oils in the water baths is a practical way to help sanitize them too. (Placing the stones in baggies when in use is the cleanest solution).
12. After long appointments, I've occasionally suggested that the patient go home and relax in a nice aromatic bath. (Good advice for the dentist and staff to take for themselves, too!) I give them a container of pre-scented Epsom or Dead Sea salts or carrier oil to put into a warm bath water to soak in. It is suggested to draw the bath and add the bath salts just as one is getting in, as aromatic essential oils dissipate quickly due to their volatile nature.6
One Christmas, the office gave out peppermint/ orange smelling bath salts that were layered in colours of white and red in vials to look like candy canes which was a big hit with patients. (You can use beet powder + water to turn the salt red.) Essential oils mix well with either salt or carrier oils allowing the hydrophobic oils to mix into the bath water. If one simply adds essential oil to bath water, they will float to the top and not mix with the water.
Danielle Sade suggests that there are four types of anxiety and blends can be created depending on the nature of the anxiety should be considered. The four types she mentions is
1. Tense anxiety -- feeling of bodily tension, muscle pain and aches;
2. Restless anxiety -- sweating, dizziness, lump in the throat, over activity of the autonomic nervous system;
3. Apprehensive anxiety -- feelings of unease, apprehension, worry, paranoia, and,
4. Repressed Anxiety -- feeling on the edge, irritable, difficulty concentrating, and insomnia. Feeling exhausted.6
Note: When there is an adverse reaction to essential oils:
Always keep in mind that the oils are hydrophobic and so wash them off with an oil, and not water! If washing it out of an eye, water or milk can be used. At a lecture, we were asked to rub a drop of oregano essential oil on our gingival. The burning sensation was immediate and so I automatically went for the glass of water on my desk, teaching me the unforgettable lesson that water can exacerbate the discomfort whereas simple table oil, olive oil or butter would have given quick relief. These oils can be dangerous, get medical attention quickly when needed. Poison units are in most large cities and should be consulted for advice.
What are essential oils and how do they differ from characteristics of the whole herb or plant?
Aromatic essential oils are hydrophobic organic materials from certain plants that are derived by steam distillation. There are only about 300 plants that produce aromatic oils which come from different parts of the plants, from tiny sacs, veins and glands. Essential oils from the bark, leaf or flower of the same plant might differ dramatically in chemical composition. You cannot assume that the herb and the essential oil will have similar properties, although sometimes they can. It is because of the low molecular weights of essential oils, that they are very volatile and can be captured during steam distillation.
The chemical properties of the essential oil molecules allow them to access receptor sites in tissues, whereas the larger molecules from the whole herb cannot access the receptor sites nor bind to them, rendering them less therapeutic. There are exceptions, as is the case with poison ivy where tiny amounts of contact with the essential oil directly from a plant can show a skin reaction, and burning the plant and inhaling the oil could be lethal.
These oils are produced as a secondary metabolism of a plant to help it survive, initiated by various types of stresses that the plant might encounter. Generally speaking, the oils that come from plants that are most challenged by nature will be the most therapeutically active. (i.e oil yields from high altitude lavender plants grown on mountain slopes with harsh climates and no pesticides will differ from the plant grown on the farm in the lush valley). The oils function to protect the plant from bacteria, fungi and viruses; attract or repel insects and other animals, and help them adapt to changes in the environment Animals cannot produce these oils, but, can benefit from using them from plant sources.
Essential oils are recognized and used in dentistry. Many commercial products use them for flavour and their antiseptic properties. Cinnamon, spearmint, peppermint, and teatree, are commonly found in toothpastes. Listerine is an essential oil mouthrinse that uses menthol, eucolyptol and thymol as active ingredients. Box's periopak, a variation of which is still in use in some dental offices uses eugenol (from clove). Zinc-oxide and eugenol is another tried and true combination still in use in some dental offices.
The list of uses is long and new research is opening different horizons. The most common uses of essential oils are outside of medicine and dentistry. They include flavorings and natural preservatives in candy, ice cream, jam, soft drinks (cola has seven essential oils), pickles, salad dressing, meat products, teas (Earl Grey is flavored with bergamot), perfumes, beauty products and household cleaning products.9 Essential oils are ubiquitous!
The choice of the type or blend of essential oils used in dentistry will be dependant on the oils' known pharmacodynamic properties. Intended uses can include: central nervous system effects (CNS sedation or stimulant; SNS stimulant); antispasmotic effects; anti inflammatory effects; analgesia and antimicrobial activities. There are many lists on which one can find confirmed properties for essential oils, for the effects just mentioned (many of the references for this article contain them).
Safety issues involving essential oils:
There are many issues to cover when dealing with safety of essential oils. You must be aware of the potential dangers that can be inherent in even some of the "safest" oils. That being said, I would not want to discourage their uses, which are very valuable to the dental profession, but, I would like to see more education and possibly controls to make sure that they are used safely and responsibly.
All popular essential oils have Material Safety Data Sheets (MSDS). The Food and Cosmetics Toxicology journals from 1973 to 1991 have valuable information from work done on rats and rabbits.2 It is because of this existing data that companies can make the "not tested on animals" claim. The results of these worldwide animal tests have been extrapolated to humans to estimate safe doses for oral and dermal doses. The LD50 represents the dose at which 50% of the test subjects died. The acute lethal dose is represented, not the chronic accumulated dose... or rather the dose that may cause organ damage or distress.
Sometimes these estimates have been grossly underestimated. For example, animal tests indicate that a probable lethal dose for Eucalyptus globulus (often used in respiratory blends and dental products), is at 34mls. In fact, the literature reports a child's death after only 5mls! Since this essential oil is sold over-the-counter and often in 10ml bottles there is a great concern for public safety for many of these products.
The scope of this article is too narrow to cover safety issues fully, but there are some topics that I would like to bring attention to:
1. Storage and dilution are both very important. Exposure to light and heat will cause the oils to oxidize and deteriorate, changing their therapeutic values and sometimes making them dangerous to use. Use smaller bottles with safety lids whenever possible and store essential oils in the fridge. Throw out any oils that smell even slightly rancid and any hydrosols after one year.
2. Essential oil exposure to operators can be an issue: vary oils used frequently to prevent yourself and staff from developing a sensitization to an oil. Very few oils can be used neat on the skin and recommending internal use should be avoided.
3. Knowledge of absorption routes and rates. There are many misconceptions with regard to absorption through skin, partly because of the aromatic massage therapy movement's popularity. The fact is, that skin absorption, especially on the palms of hands and soles of feet, is one of the least effective methods of absorption. On the other hand, inhalation can get essential oil molecules into the brain and blood almost instantaneously and mucous membrane absorption is much more rapid than topical use on skin.
4. Phototoxicity is a potential danger of a number of oils, including most citrus oils, ginger and fennel. After using these oils (even if not administered on the exposed skin), it is recommended to avoid the sun for 12-24 hours. This could be a serious issue -- a case of bergamot phototoxicity killed a woman in England who had been drinking large amounts of Earl Grey tea!!
5. Chemistry of the individual oils -- know that the lighter monoterpene oils (e.g. lemon) will evaporate much faster than heavier more complex aromatic oils such as the phenols (e.g. clove). Monoterpenes will also be eliminated quicker in the body and burden the liver and kidneys less. Some of the oils require the body to work much harder at breaking them down (often decreasing p450 enzyme availability in the liver and skin) and sometimes necessitating a second pass before elimination, and therefore are active for longer durations. Often it is the metabolites produced to eliminate the oils which are the most dangerous.
6. Medical History -- Patients with medical histories of liver or kidney disease, on blood thinners (some oils are blood thinners e.g. eugenol), clotting disorders, high blood pressure medication, asthma, epilepsy, psychoses, on antiprostoglandins or are pregnant need special consideration.
7. Children, the elderly and medically compromised individuals -- if you feel confident using the oils with these individuals, a good rule of thumb is to at least half the dose. If there are infants under two or pets near by, avoid them completely!
8. Oral use of essential oils requires good knowledge of potential dangers.
9. Essential oil/drug interactions: Essential oils are drug absorption enhancers. If a patient is wearing a medicinal patch avoid use of the oils especially in the area of the patch. Essential oils can also increase the bioactivity of other chemicals and keep them in the body longer. Menthol from peppermint is known to increase the bioactivity of nicotine and might lead to higher risk of developing cancer. (e.g. note the dangers of menthol cigarettes or the common habit of having a peppermint to freshen breath after smoking).
There are many other known interactions of drugs and essential oils including fennel and Ciprofloxacin; essential oils and chemotherapy medications; and the contraceptive pill. Grapefuit oil may affect carbamazepine, estrogen, statin drugs and calcium channel blockers although it is considered safe for external use.1
Never Use These Essential Oils: The use of these oils is out of the scope of use in dental practice and far too dangerous.
* Almond, bitter (unrectified)
* Armoise, Artemisia arborescens
* Basil (high estragole type)
* Birch (sweet)
* Buchu (B.crenulata)
* Cade (unrectified)
* Camphor (brown or yellow)
* Cinnamon bark (note: other parts of the plant are safer e.g.leaf)
* Elecampane Fig Leaf
* Melaleuca bracteata
* Ravensara anisata
* Sage (Dalmation)
Oils that could cause significant damage to mucous membranes: Birch, Camphour, Cassia, Cinnamon bark, Clove, Eucalyptus, Ginger, Juniper, Peppermint, Spearmint, Pepper, Pimento, Rosemary, Sage, Savory, Tansy, Thyme.
Oils that could cause significant damage if applied neat to skin: Birch, Boldo, Camphour, Cassia, Cinnamon bark, Clove, Ginger, Juniper, Peppermint, Spearmint, Pepper, Pimento, Thyme.
HISTORY OF ESSENTIAL OILS
Since early days, man has recognized that he could capitalize on the protective benefits of these organic compounds that could only be produced by plants. Ayurvedic medicine literature from 2000 BCE clearly states that they were used. Cedarwood, frankincense, myrrh and cinnamon were popular with the Egyptians. Holy oil formulas and incense have not changed much in religious practice since 1240 BCE according to the scriptures. Fifteen century Europe saw the introduction of chemistry to medicine and steam distillation became widely recognized as the best way the produce the oils. Around 1500 the production of perfume began in Grasse, France, using the aromatic essential oils. By 1900, chemical science was maturing and more and more oils were analyzed. Then came the ability to synthesis molecules in the laboratory and a main focus in pharmacology was focused on reproducing molecules in the oils that were thought to be of therapeutic value in medicine.9
Essential oils vs.commercial drugs:
Historically, essential oils and plants have had a big influence on the drugs in our armamentarium. The production of Aspirin by Dr. Bayer (ASA) has origins in Salicylic Acid which was originally discovered by observing native indians who used Willow bark to treat pain and fever. The chemicals were isolated and synthetically reproduced, but, it took years before the actual anti-inflammatory mechanism was discovered and reported.4 More and more, the active ingredients in essential oils were available as synthetic chemicals, sometimes leading to other compounds and sometimes becoming popular drugs.
While essential oils have always played a part in pharmacology, they are not reproducible in synthetic form as they sometimes contain a hundred different molecules and the composition in the plant varies with so many harvesting factors such as time of day, climate and altitude. Chemotypes of essential oils vary from batch to batch whereas drugs are consistent. With drugs you are assured of the amount of any active ingredient. There are so many chemicals in each essential oil, gas chromatography and mass spectrometry are necessary to assay every batch of oil to yield estimates of the identifiable chemical components.
Sometimes a chemical is isolated from the natural plant and used in the production of a drug. The drug Tamiflu (used for Avian flu) is made from an isolate of star anise. Although star anise is readily available, the drug is not, as the process is complicated and expensive.
It is largely the molecular chemistry of the essential oil molecules that allow them to be biologically active in the body and attribute their individual therapeutic uses and liken them to other drugs. For starters, most drugs weigh in, in the range of 100MW (molecular weight) units to 1000MW units. Essential oil molecule weights are typically from the smaller ones like limonene (C10H16) at 136MW units, as in many citrus oils to the heavier sclareol (C20H362) at 308 MW units, as in the oil, Clary Sage. For comparison, the estrogen molecule weighs in at about 360MW units.
Molecular size is important as it allows access to the receptor sites and potential to react. Other features such as electrical charge, lipophylicity, 3-D shape of the molecule and polarity also play roles in receptor binding. Commercial drugs will tend to target certain receptor sites to accomplish their intended purpose, whereas, when an essential oil circulates in the body, because of the number of different chemicals in the mix, often other receptors other than just the target receptors will become bound.
To further complicate the aforementioned, certain drugs will act differently, depending on the organ the receptor is in e.g. Tamoxifen is a drug that binds to estrogen receptors. It is an agonist of estrogen receptors in bone and the uterus, but an antagonist to receptors in the breast. Care must be taken as essential oil molecules may act in a similar fashion. For example, clove bud or eugenol essential oil is a mucous membrane irritant, and anaesthetic externally, but acts as an anti-inflammatory inside the body.4
There is a growing interest in incorporating complementary therapies in the dental field and aromatherapy is certainly one of the more popular ones. There is a body of evidence-based research that validates some of the claims of therapeutic values of the oils and many very credible institutions continue to add to this data bank. Because "natural" does not always mean "safe," and in the interest of public protection, I urge dentists to be well informed of the safety and suitability of their choices of essential oils and modes of administration.
Dr. Goodman is an editorial board member for Oral Health journal. She can be reached for consultation on dental aromatherapy at firstname.lastname@example.org or www.mitzvahspa.com
Oral Health welcomes this original article
BIBLIOGRAPHY, REFERENCES AND RECOMMENDED READING:
1. Essential Oil Resource Consultants, Harris, Bob and Riannon; excerps from Aromatic Pharmacology; March 2006.
2. Lis-Balchin, Maria; Aromatherapy Science, A guide for healthcare professionals, Pharmaceutical Press, 2006.
3. Battaglia, Salvatore, The Complete Guide to Aromatherapy, Second edition; The International Center of Holistic Aromatherapy, 2003.
4. Blaine Andrusek, An excerpt from the Aromatherapy Workshop; Safety and Precautions Relative to Therapeutic Uses of Essential Oils, 2006.
5. Lehrner J, Eckersberger C, Walla P, Potsch, Deecke ; Ambient odor of a dental waiting room reduces anxiety and improves mood in female patients; University of Vienna.
6. Danielle Sade, Your Health Source magazine; June 2006-pge 7 and July 2006-pge 15.
7. Focus journal, ODHA, January 2007, Vol11.number 2, page 5; "The Power of scents in a clinical setting;" www.odha.on.ca
8. Essential Oil Resource Consultants; abstract; Aromatherapy Database off E.O.R. web page.
9. Danielle Sade, Practitioner's Guide to Essential Oils; Introduction and History of Essential Oils and their Therapeutic Uses; Vol.1, Edition 1, 2006.
10. Tisserand, Robert and Balacs, Tony; Essential Oil Safety; A guide for healthcare prefessionals.