Patients increasingly seek integrated and preventative approaches to their healthcare. In this changing health environment, oral healthcare specialists can leverage and expand their long-standing commitment to the preventative care model.
The preventative care model in dentistry focuses on education and ongoing maintenance. As processed sugary foods flood a market sated by quick fixes, dentists respond by increasing their vigilance and quality of care. Even as diabetes incidence increases and waist circumference expands, dental caries incidence has been on the decline in countries with strong standards for dental care.1,2 Thanks to education, many patients grasp the slippery slope from dental caries to periodontal disease.
To help liberate patients from the disease-care quagmire facing North Americans today, oral care specialists need to increasingly focus on the interdisciplinary connections between oral health, heart health, gastrointestinal health, etc. “The eyes are the window to the soul” is an ethereal connection often cited. In a more tangible and measurable way, the mouth is the door to the body. For thousands of years, Traditional Chinese Medicine practitioners have gleaned whole body information from the tongue and teeth. In the same way, oral care specialists, as part of an integrated health team, play a vital role in promoting whole body health through pattern recognition of imbalance.
This article focuses on applying natural therapeutics in two areas of oral care and oral surgery: infection and inflammation.
It is well established that pathogenic strains of bacteria contribute to preventable dental disease, Streptococcus mutans being the oldest studied.3 Encouraging optimal colonization of the oral microbial environment is a worthy goal in the prevention of oral pathogen overgrowth. How to best accomplish this is the subject of much current research.
The average human being is covered in 3-6 pounds of bugs, populations of micro-organisms representing at least 10 times the cell count in our bodies. These organisms make up what is often referred to as the commensal microflora. The normal flora covers every skin and mucous membrane surface in and on our bodies, although species distribution changes with location. Severity of infection on any mucous membrane accompanies an attendant imbalance in the commensal microflora. Research into probiotic supplementation is expanding rapidly, resulting in mounting evidence of benefit in the management and prevention of diseases ranging from bowel disorders including bowel cancers, infections (including H. pylori and C. difficile), allergy, UTIs, and many others.4 Probiotics have been defined as “live micro-organisms, which, when administered in adequate amounts, confer a health benefit on the host.”5
Nutraceutical companies are rushing to fill demand for encapsulated probiotics, the vast majority of which are either lactobacilli and /or bifidobacteria species. Many of the new products are derived from bovine culture sources, with a few human sources available. Whatever the source, studies must demonstrate survivability of gastric pH, adherence to mucous membranes, and persistence in the target organ for a probiotic supplement to be considered efficacious. When human data exists with relevant clinical endpoints to support these findings, the benefit becomes obvious for all to see.
Several studies suggest that probiotic consumption beneficially affects oral ecology in children. Interestingly, the route of administration does not seem to affect this outcome; probiotics swallowed through straws resulted in an equal reduction of salivary S. mutans as did slowly melting tablets.6 One randomized control trial demonstrates that these oral ecology benefits extend to prevention of dental caries in children. Lactobacillus rhamnosus GG containing milk served to the experimental group at Finnish daycares for seven months resulted in a reduction in caries risk from 40% to 36%, while the control milk group experienced an increased risk from 39% to 43%. The statistically significant difference (594 children were randomized) was across all age groups (ages 1 – 6), with the greatest effect seen among 3 and 4-year-olds.7 Given the short study period of seven months, this is powerful preventative medicine.
Lactobacilli species account for only one genus of probiotic strain research in the oral cavity. Preliminary findings indicate that Streptoccocus salivarius adheres to the oral cavity and benefits halitosis, but that colonization counts drop significantly 3 weeks post oral administration.8 This is the case with most supplemental probiotics: adherence occurs but persistence is limited.4 In order to permanently affect the balance of commensal organisms, either probiotic exposure must be continued and/or the immune system must be rebalanced.
To conclude this section on probiotics, it should be noted that probiotics compliment the use of antibiotics and can be used concurrently to help prevent yeast infections or C. difficile.9-13 As well, preliminary studies indicate the benefit of probiotics in treating or preventing surgical wound infections.14
It is likely that expanding antibiotic resistance, coupled with the growing realization of the commensal flora’s protective effect, will cause a paradigm shift in the science of antibiotics over the coming years. Stronger antibiotics will be reserved for serious active infection, while flora-balancers such as pre and probiotics will be used more often in conjunction with herbal antibiotics. Most herbal antimicrobials, with the exception of some essential oils, do not destroy the commensal flora as much as their stronger pharmaceutical counterparts. Among the thousands of herbal antimicrobials, Berberis species, garlic, and turmeric all warrant brief mention here.
Berberis species have been shown efficacious in naturopathic practices for several gram positive and gram negative microbes, as well as yeast infections. Several Berberis species contain an inhibitor of the multi drug resistance pump (MDR), which means that the berberine alkaloid, normally extruded by MDRs, remains active and eludes the microbial defense system.15 This is one mechanism by which Berberis species achieve immunity from bacterial resistance. From a holistic perspective, this makes perfect sense; the whole plant evolves the necessary biochemical machinery each year to survive new microbial threats, thus conferring current bug wisdom to humans upon ingestion.
Garlic is a known antimicrobial agent and its effects on the oral flora have been studied in vitro and in vivo. Thirty patients used a garlic solution mouthwash for five weeks and found inhibition of salivary S. mutans, which continued two weeks after the end of the mouthwash period. This, in spite of the commonly reported adverse events: unpleasant taste and halitosis.16 This finding applies to multi-drug resistant S. mutans as well.17
As one of the world’s most studied spices, turmeric’s effect on S. mutans has also been examined. When applied to slides prepared with S. mutans biofilms, Javanese turmeric demonstrated similar bactericidal and acid inhibitory effects to chlorohexidine, at 1/20th the dose. In addition to its strong bactericidal activity and inhibitory effects on acidogenesis, Javanese turmeric also alters the microstructure of S. mutans biofilm, leading the study authors to conclude that it may be a good therapy for the prevention of dental caries.18
Dental Health
What links dental caries, periodontal disease and bugs? Two factors: what we ingest, inhale and inject; and how we respond to acute infection. The latter is beyond the scope of this article. As for the external environmental component, let’s focus on whole foods.
In a pioneering effort to understand the connections between diet and dental health, American dentist Weston A. Price wrote Nutritional and Physical Degeneration in 1939. In it he summarizes findings from his visits among pre-industrial peoples, suggesting profound links between optimal dental health and traditional whole foods diets. Although his research can be seen to suffer from observer biases and a lack of anthropological rigour, his broad conclusions are experiencing a philosophical renaissance in response to the rising cost of disease-care. More information can be found online, hosted by the Weston A. Price Foundation.
The main villain in the modern diet for oral health is the over-consumption of simple sugars, which leads to in vivo fermentation into acid by-products. By contrast, external fermentation of food products confers probiotic benefit upon ingestion. Today, consumption of homemade fermented foods (yogurt, kefir, sauerkraut, pickles, tempeh, natto, kombucha, etc.) is a lost practice among many North Americans. By encouraging patients to buy fermented foods, and ferment their own foods, oral care specialists can help prevent many diseases of the mouth, teeth and body.
Saving the hottest topic for last, homeopathic Arnica montana may be a good, inexpensive treatment in post-oral surgery management. Although specific studies on oral surgery and Arnica are scarce, other surgical studies suggest benefit, although the results are mixed. Given the importance of the placebo group effect in patient care and the harmless profile of homeopathic Arnica (diluted to 30CH or 200K), studies are warranted to assess its effect on post oral surgery healing time, pain, bruising and edema.
In one study of 736 dental implants in 437 patients, patients took homeopathic Arnica for three days post-op or nimesulide for two days, without antibiotics. The 96.2% implant survival rate achieved matched high rates published while following various antibiotic regimes.19 Although the evidence is inconclusive with respect to Arnica accelerating healing, two studies find benefit for its use post surgery. One RCT found a smaller area of ecchymosis on postoperative days 1, 5, 7, and 10 with Arnica montana vs. placebo as measured by a reproducible computer model.20 Another RCT of 190 patients undergoing tonsillectomy resulted in a statistically significant reduction in pain scoring with homeopathic Arnica use.21 Based on these preliminary findings, and the incredible safety profile of homeopathic medicine in general, it is likely that oral surgeons might discover benefit, however small, in patient satisfaction and general healing parameters with the use of homeopathic Arnica.
In conclusion, oral care specialists are uniquely poised to implement safe and effective natural medicine therapies to compliment their current practice guidelines. Oral care specialists appreciate the connection between what goes into the mouth and the state of internal health. Sharing their understanding for preventative and integrative care models will ensure continued dental patient satisfaction well into the 21st Century. OH
Dr. Condliffe owns the Awen Health Centre in Vancouver, BC, where he practices as a naturopathic doctor. In addition to his own clinical work, he supervises naturopathic interns at the Boucher Institute of Naturopathic Medicine and teaches at the Canadian School of Natural Nutrition. He can be reached at www.awenhealth.ca.
Oral Health welcomes this original article.
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