Review of herbal medications with the potential to cause bleeding: dental implications, and risk prediction and prevention avenues

Management of Patients Receiving Anticoagulation Therapy in Dental Practice: A Systematic Review

BACKGROUND

Anticoagulant drugs are a valuable tool for minimizing thrombotic risks in at-risk patients. The purpose of this study is to conduct a literature review highlighting the management of these drugs during daily clinical dental practice.

MATERIALS AND METHODS

We limited our search to English-language papers published between 1 January 1989, and 7 March 2024, in PubMed, Scopus and Web of Science that were relevant to our topic. In the search approach, the Boolean keywords "anticoagulant AND dentistry" were used.

RESULTS

Twenty-five clinical trials were included for final review from 623 articles obtained from the databases Web of Science (83), PubMed (382), and Scopus (158), eliminating duplicates and 79 off-topic items, resulting in 419 articles after removing 315 entries and confirming eligibility. Overall, these studies support the use of local hemostatic measures to manage the risk of bleeding in patients on anticoagulant therapy undergoing dental procedures and highlight the importance of greater education and collaboration among healthcare professionals.

CONCLUSIONS

Research and clinical investigation have improved understanding and management of dental procedures in patients undergoing anticoagulant or antiplatelet therapy. Hemostatic agents, clinical protocols, risk factors, and continuous education are essential for navigating the complexities of anticoagulant therapy, ensuring optimal outcomes and enhancing patient well-being.

Use of herbal medication in the perioperative period: Potential adverse drug interactions

Use of herbal medications and supplements has experienced immense growth over the last two decades, with retail sales in the USA exceeding $13 billion in 2021. Since the Dietary Supplement Health and Education Act (DSHEA) of 1994 reduced FDA oversight, these products have become less regulated. Data from 2012 shows 18% of U.S. adults used non-vitamin, non-mineral natural products. Prevalence varies regionally, with higher use in Western states. Among preoperative patients, the most commonly used herbal medications included garlic, ginseng, ginkgo, St. John's wort, and echinacea. However, 50-70% of surgical patients fail to disclose their use of herbal medications to their physicians, and most fail to discontinue them preoperatively. Since herbal medications can interact with anesthetic medications administered during surgery, the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA) recommend stopping herbal medications 1-2 weeks before elective surgical procedures. Potential adverse drug effects related to preoperative use of herbal medications involve the coagulation system (e.g., increasing the risk of perioperative bleeding), the cardiovascular system (e.g., arrhythmias, hypotension, hypertension), the central nervous system (e.g., sedation, confusion, seizures), pulmonary (e.g., coughing, bronchospasm), renal (e.g., diuresis) and endocrine-metabolic (e.g., hepatic dysfunction, altered metabolism of anesthetic drugs). During the preoperative evaluation, anesthesiologists should inquire about the use of herbal medications to anticipate potential adverse drug interactions during the perioperative period.

Epidural Hematoma Associated with Red Clover Use After Epidural Injection: A Case Report

An epidural hematoma is a rare but devastating complication after interventional pain procedures. The etiology is multifactorial, including anatomical variations, inherited coagulation disorders, and consumption of anticoagulants or antiplatelet substances. Specifically, in regard to platelet aggregation, the consumption of herbal medicine is often forgotten as a potential cause for coagulation profile disorders, potentially leading to an epidural hematoma. We present the case of a patient who developed an epidural hematoma after a cervical epidural block, most likely associated with daily "red clover" consumption.

Knowledge levels of doctors and nurses working in surgical clinics about nutrients and food supplements, a multicentre descriptive study

PURPOSE

The use of nutrients and food supplements is increasing worldwide. Nutrients and food supplements frequently used in the surgical period may cause complications and side effects. This study was conducted to determine the level of knowledge about sixty-one nutrients and food supplements among doctors and nurses working in surgical clinics.

DESIGN

A multicentre descriptive, quantitative, cross-sectional study.

METHODS

The study was conducted between 15 February and 31 May 2022 with a total of 410 participants, including 143 doctors and 267 nurses, working in the surgical clinics of 8 hospitals, including public, university and private hospitals, within the borders of one province in Turkey. Data were collected face-to-face using a questionnaire developed by the researchers, which included descriptive characteristics of the doctors and nurses and questions about sixty-one nutrients and food supplements.

RESULTS

The median overall success score of the doctors and nurses participating in the study regarding the use of nutrients and food supplements was 3.20 out of 100 points, the median success score of complications and side effects of nutrients and food supplements in the surgical period was 7.06 out of 33 points, the median success score for discontinuation of nutrients and food supplements prior to surgery was 0.21 out of 16 points, and the median success score for drug interactions of nutrients and food supplements was 1.70 out of 51 points. In addition, it was found that the overall success scores of doctors and nurses regarding nutrients and food supplements increased statistically significantly with increasing age and working years. The total success score of doctors and nurses who received training in nutrients and food supplements was statistically significantly higher than that of doctors and nurses who did not receive training.

CONCLUSION

In conclusion, it was found that the level of knowledge of nutrients and food supplements among doctors and nurses working in surgical clinics was less than half or even close to zero. Therefore, it is recommended that training on nutrients and food supplements should be included in the undergraduate and postgraduate education of doctors and nurses in order to prevent complications, side effects, drug interactions and patient safety related to the use of nutrients and food supplements in the surgical period.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

Effect of chamomile intake on blood coagulation tests in healthy volunteers: a randomized, placebo-controlled, crossover trial

BACKGROUND

Chamomile is consumed worldwide for enjoyment and its potentially desirable properties. Widespread patient resource websites, however, discourage preoperative chamomile intake, lest bleeding could worsen. This precaution, though, stems largely from indirect evidence in one case report. To evaluate if chamomile ingestion impacts coagulation assays via coumarin-like substances, we designed a randomized, placebo-controlled, crossover study.

MATERIALS AND METHODS

Healthy volunteers were randomized to three interventions in a cross-over-design spanning 5 weeks per subject. Interventions included 7-day consumption of chamomile tea (3 tea bags × 3 times daily = 9 tea bags daily), a chamomile extract capsule (3 times daily), or a placebo capsule (3 times daily). A 7-day washout period elapsed between intervention periods. The primary outcome was the change in prothrombin time (PT) before vs. after each intervention. Secondary outcomes included changes in the international normalized ratio (INR), activated partial thromboplastin time (aPTT), thrombin time (TT), reptilase time (RT), and fibrinogen (FG) surrounding each intervention.

RESULTS

All 12 enrolled subjects were randomized and completed the study. The primary outcome of PT change (mean ± SD) was similar across interventions (chamomile tea =  - 0.2 ± 0.4 s, extract capsule =  - 0.2 ± 0.4 s, and placebo capsule = 0.1 ± 0.5 s; p = 0.34). INR change was 0 s (p = 0.07) for each intervention. The aPTT, TT, RT, and FG, did not change significantly across interventions (p = 0.8, p = 0.08, p = 0.8, and p = 0.2 respectively).

CONCLUSIONS

Chamomile intake by tea or capsule does not prolong PT. These findings challenge the notion to avoid perioperative chamomile intake in patients not taking warfarin.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05006378; Principal Investigator: Jonathon Schwartz, M.D.; Registered August 16, 2021.

Evening primrose oil: a comprehensive review of its bioactives, extraction, analysis, oil quality, therapeutic merits, and safety

Oil crops have become increasingly farmed worldwide because of their numerous functions in foods and health. In particular, oil derived from the seeds of evening primrose (Oenothera biennis) (EPO) comprises essential fatty acids of the omega-6 (ω-6) series. It is well recognized to promote immune cells with a healthy balance and management of female ailments. The nutrients of interest in this oil are linoleic acid (LA, 70-74%) and γ-linolenic acid (GLA, 8-10%), which are polyunsaturated fatty acids (PUFA) that account for EPO's popularity as a dietary supplement. Various other chemicals in EPO function together to supply the body with PUFA, elevate normal ω-6 essential fatty acid levels, and support general health and well-being. The inclusive EPO biochemical analysis further succeeded in identifying several other components, i.e., triterpenes, phenolic acids, tocopherols, and phytosterols of potential health benefits. This comprehensive review capitalizes on EPO, the superior product of O. biennis, highlighting the interrelationship between various methods of cultivation, extraction, holistic chemical composition, sensory characters, and medicinal value. Besides the literature review, this study restates the numerous health advantages of primrose oil and possible drug-EPO interactions since a wide spectrum of drugs are administered concomitantly with EPO. Modern techniques to evaluate EPO chemical composition are addressed with emphasis on the missing gaps and future perspectives to ensure best oil quality and nutraceutical benefits.

Complications of toxins and fillers in facial aesthetics

Dermal filler and botulinum toxin injections are among the most performed non-invasive procedures for rejuvenation and contouring, internationally. Although most dermal fillers and approved botulinum toxins are well tolerated with a high safety profile, adverse events and/or complications can happen. Injection-related sequelae and side effects are usually rare, mild, transient, and self-limiting in nature. However, devastating and life-changing complications, such as intravascular occlusion, skin necrosis, permanent visual impairment, and stroke, have been reported. Risk reduction measures include an in-depth knowledge of anatomy, physiology, and pharmacology, correct patient selection, correct identification of clinical indications, and, fundamentally, the importance of appropriate skill and training. In this paper, some of the complications are discussed and advice on how to minimise adverse events and complications from these injectables is provided.

Friend or Foe: Factor XII Deficiency Discovered Incidentally during Management of NSTEMI

Factor XII (FXII) deficiency is a rare coagulopathy that typically goes undiagnosed due to the lack of abnormal bleeding or thrombosis. However, the accompanying prolonged activated partial thromboplastin time (aPTT) can create difficulties with maintaining therapeutic anticoagulation in the setting of acute coronary syndrome (ACS). Here, we present the case of a 52-year-old man presenting with chest pain and diagnosed with an NSTEMI but also found with a prolonged baseline aPTT ultimately secondary to FXII deficiency. Here, we discuss the diagnostic work-up of an isolated prolonged aPTT to identify possible etiologies, such as FXII deficiency, and ultimately inform ACS management.

Complications and treatment errors in root coverage procedures

Root coverage procedures have become very common in clinical dental practice. Even though these techniques are considered safe, the clinician may face several issues during the therapy due to their surgical nature. Some of these issues can be defined strictly as complications inherent to the procedure, whereas others are medical errors or treatment errors. This review will focus on describing treatment errors and complications that may arise during different phases of the root coverage therapeutic process and on how to prevent and manage them.

Potential Oral Health Benefits of Ginseng and Its Extracts

This review discusses the effects of ginseng and its extracts in the treatment of dental caries, periodontal diseases, endodontic diseases, oral cancers, oral mucosal diseases, and some other dental associations. In the meantime, bioavailability and safety application of ginseng products are discussed. All of the articles reviewed were from PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang Data, and VIP Chinese Science and Technology Periodicals Full-Text Database through November 2022, including full-text English or non-English publications. Ginseng and its extracts were shown to have beneficial effects on oral diseases, and further studies are needed to understand the mechanisms and confirm the effects in humans.

Estimation of Platelet Count and Bleeding Time of Mice Treated with Musa paradisiaca var. sapientum (L.) Kuntze Extract

Objective

The aim of this study was to estimate the platelet count and bleeding time on peripheral blood smear of mice tail wound using Musa paradisiaca var. sapientum (L.) Kuntze (ambonese banana stem extract).

Design

Randomized post-test-only control group design.

Materials and Methods

Twenty-four male mice (Mus Musculus) were randomly divided into 4 groups. A negative control group was treated with carboxymethyl cellulose (CMC), a positive control group (K+) treated aspirin 100 mg/kg body weight, group P1 treated with aspirin 100 mg/kg body weight and tranexamic acid 50 mg/kg body weight, and group P2 treated with 30% of ambonese banana stem extract (ABSE). The mean and standard deviation data of platelet counts and bleeding time were analyzed by one-way ANOVA statistical software.

Results and Discussion

Tranexamic acid had no significant effect on platelets count compared to CMC group (p = 0.871), but administration of aspirin resulted in low platelets count significantly (p = 0.003). The platelet counts of ABSE and CMC groups were not significant different (p = 0.937). Aspirin has significantly shown prolonged bleeding time than CMC, tranexamic acid, and ABSE groups. However, there was no difference between the tranexamic acid and ABSE groups (p=0.934). The bleeding time of tranexamic acid and ABSE groups was similar, although the platelet count in the ABSE group was lower than in the CMC group.

Conclusion

This study proved that ambonese banana stem extract has a potency to shorten the bleeding time in mice tail wound without interfering to platelet count.

Complementary medicine usage in surgery: a cross-sectional survey in Germany

Background

Complementary medicine (CM) is frequently used by patients, but little is known about the usage of CM in surgical patients. The study aimed to elucidate the relevance of CM in surgery.

Methods

This cross-sectional, multi-center survey utilized a paper-based questionnaire consisting of 21 questions to capture CM usage and interest as well as CM communication in visceral and thoracic surgical patients being hospitalized at the corresponding departments of surgery at the University Medical Centers in Freiburg, Heidelberg und Ulm, Germany.

Results

Overall, 151 patients consented to the survey. On average, current CM usage was stated by 44% of patients. Most frequently used CM approaches were physical exercise (63%), nutritional supplements (59%) and herbal medicine (56%). Strong interest in CM counselling was stated by 51% of patients. Almost 80% of patients wanted to be treated in a holistic manner and desired for reliable information about CM as well as CM informed physicians. Only 12% of patients communicated CM usage and interest with their attending physician. Review of literature revealed similar results showing an overall CM usage of 43%, preferring nutritional supplements and herbal medicine.

Conclusion

The results of our cross-sectional study indicate a high percentage of CM users and a strong interest in CM among surgical patients. Indeed, the current communication about CM between patients and surgeons is poor. With respect to safety and quality reasons, but also to pay attention to patients’ demands, physicians should be aware of patients’ CM usage in surgery.

Trial registration

German Clinical Trial register (DRKS00015445).

Mechanisms and interactions in concomitant use of herbs and warfarin therapy: An updated review

This review is an updated and expanded version published in this journal in 2016. Warfarin pharmacotherapy is extremely complex, since in addition to being a low therapeutic index drug, it does not follow the dose-response pattern and has characteristics that predispose the occurrence of interactions, such as high binding rate to plasma proteins, metabolization by cytochrome P450 enzymes, further to acting in the complex process of blood coagulation, platelet activation, and inflammation. For these reasons, warfarin has great potential for interaction with drugs, foods, and herbal medicines. Herb-warfarin interactions, however, are still not very well studied; thus, the objective of this update is to present new information on the subject aiming to provide a scientific basis to help health professionals in the clinical management of these interactions. A literature review was performed from May to June 2021 in multiple databases and articles published in 2016 to 2021 were included. A total of 59 articles describing 114 herbal medicines were reported to interact with warfarin. Of the plants mentioned, 84% had the potential to increase warfarin effect and the risk of bleeding. Targets possibly involved in these interactions include the processes of blood coagulation, platelet activation, and inflammation, in addition to the pharmacokinetics and pharmacodynamics of warfarin. Despite these alarming numbers, however, the clinical management of interactions is known to be effective. Thus, it is important that the use of these herbal medicines be done with caution in anticoagulated patients and that studies of herb-drug interactions be encouraged in order to generate information to support the clinical management of patients.

Why is Misdiagnosis of von Willebrand Disease Still Prevalent and How Can We Overcome It? A Focus on Clinical Considerations and Recommendations

Despite von Willebrand disease (VWD) being the most common inherited bleeding disorder, its accurate diagnosis is frequently shrouded by diagnostic pitfalls. VWD is frequently under-diagnosed, over-diagnosed and misdiagnosed, leading to significant avoidable patient morbidity and health care system burden. At the heart of this dilemma lies the heterogeneity and complexity of von Willebrand factor (VWF) and associated defects, and the necessity of coalescing clinical and laboratory features to obtain an accurate diagnosis. Common pitfalls include poor clinical and scientific understanding and familiarity with VWD, incomplete clinical history and lack of routine use of standardised bleeding assessment tools (BAT), difficulty in accessing a comprehensive repertoire of laboratory tests, significant pre-analytical, analytical and post-analytical issues, and lack of expertise in laboratory testing and interpretation. Errors, resulting in under-diagnosis, over-diagnosis, and misdiagnosis of VWD, are presented and discussed. Strategies to minimise errors include better education of clinicians and laboratory staff on VWD, routine use of validated BAT, utilising a comprehensive gamut of laboratory investigations according to a standardised algorithm, and repeating testing to minimise pre-analytical errors. Recommendations on appropriate patient selection for VWD testing, how VWD should be investigated in the laboratory, and how to ensure test results are accurately interpreted in the correct clinical context are detailed.

A Comprehensive Review on Varicose Veins: Preventive Measures and Different Treatments

The purpose of this article was to review the different preventive measures and treatments for varicose veins disease. Varicose veins are tortuous, enlarged veins that are usually found in the lower extremities damages blood vessels leading to its painful swelling cause's blood clots, affecting people over increasing prevalence with age and affects the proficiency, productivity, and life quality of a person. Prolonged standing and obesity are the major reason for varicose vein disease. The mechanisms, prevention, risk factors, complications, and treatment of varicose veins are explained in this review. Various types of treatments such as endovascular, surgical, and herbal treatments improve quality of life and reduce the secondary complications of varicose veins. Besides these methods of treatments, varicose vein disease can be prevented by doing regular yoga/exercise and consumption of several fruits and vegetables such as Grapes, blackberries, avocados, ginger, and rosemary. Typically, varicose veins can be a benign process with several problems that can influence the life quality of an individual that can lead to potentially life-threatening complications. However, there are numerous surgical, endovascular, and chemical treatments that improve quality of life and decrease secondary complications of varicose veins. Patients with varicose veins should take an antioxidant medicament from the flavonoid groups to reduce the arterial blood pressure value, risk of atherosclerosis development, prevent thrombotic incidents.Key teaching pointsChronic venous disease is a pathological state of vein circulatory systems of the lower limbsProlonged standing and obesity are the major reason for varicose vein diseaseEndovascular, surgical, and herbal treatments improve quality of life and reduce the secondary complications of varicose veinsVenoactive drugs such as flavonoids, saponins, and others have a therapeutic effect on chronic venous disordersPhlebotropic drugs are semi-synthetic substances widely used in different states of chronic venous insufficiencyFood rich in phytoconstituents are more effective in varicose veins.

Making a complex dental care tailored to the person: population health in focus of predictive, preventive and personalised (3P) medical approach

An evident underestimation of the targeted prevention of dental diseases is strongly supported by alarming epidemiologic statistics globally. For example, epidemiologists demonstrated 100% prevalence of dental caries in the Russian population followed by clinical manifestation of periodontal diseases. Inadequately provided oral health services in populations are caused by multi-factorial deficits including but not limited to low socio-economic status of affected individuals, lack of insurance in sub-populations, insufficient density of dedicated medical units. Another important aspect is the “participatory” medicine based on the active participation of population in maintaining oral health: healthcare will remain insufficient as long as the patient is not motivated and does not feel responsible for their oral health. To this end, nearly half of chronically diseased people do not comply with adequate medical services suffering from severely progressing pathologies. Noteworthy, the prominent risk factors and comorbidities linked to the severe disease course and poor outcomes in COVID-19-infected individuals, such as elderly, diabetes mellitus, hypertension and cardiovascular disease, are frequently associated with significantly altered oral microbiome profiles, systemic inflammatory processes and poor oral health. Suggested pathomechanisms consider potential preferences in the interaction between the viral particles and the host microbiota including oral cavity, the respiratory and gastrointestinal tracts. Since an aspiration of periodontopathic bacteria induces the expression of angiotensin-converting enzyme 2, the receptor for SARS-CoV-2, and production of inflammatory cytokines in the lower respiratory tract, poor oral hygiene and periodontal disease have been proposed as leading to COVID-19 aggravation. Consequently, the issue-dedicated expert recommendations are focused on the optimal oral hygiene as being crucial for improved individual outcomes and reduced morbidity under the COVID-19 pandemic condition. Current study demonstrated that age, gender, socio-economic status, quality of environment and life-style, oral hygiene quality, regularity of dental services requested, level of motivation and responsibility for own health status and corresponding behavioural patterns are the key parameters for the patient stratification considering person-tailored approach in a complex dental care in the population. Consequently, innovative screening programmes and adapted treatment schemes are crucial for the complex person-tailored dental care to improve individual outcomes and healthcare provided to the population.

Medicinal Plants and Phytochemicals Regulating Insulin Resistance and Glucose Homeostasis in Type 2 Diabetic Patients: A Clinical Review

Diabetes is a major health problem affecting more than four hundred million adults worldwide. The transition from normal glucose tolerance to type 2 diabetes (T2D) is preceded by increased Insulin resistance (IR), an independent predictor of the development of T2D in high risk (e.g. obese populations, pre-diabetes) individuals. Insulin deficiency resulting from increased IR results in progressive glucose homeostasis dysfunction. Data has shown that IR is affected by many different factors such as genetics, age, exercise, dietary nutrients, obesity, and body fat distribution. One of the most important factors is diet, which plays an essential role in addressing T2D and metabolic syndrome. Nutraceuticals and medicinal plants have been shown to have efficacy in preventing chronic diseases like cancer, non-alcoholic fatty liver disease (NAFLD), cardiovascular disease, diabetes mellitus and metabolic syndrome, likely through the anti-inflammatory properties found in nutraceuticals. However, the effect of these compounds, including traditional plant medicines, herbal formulations or their extracts on IR have not been systematically investigated. The objective of this review was to assess the reported effects of medicinal plants and bioactive natural compounds on IR. The findings confirm that most of the herbal bioactive compounds including resveratrol, garlic, curcumin, cinnamon, ginger, nuts, berberine, anthocyanin, soybean, flaxseed, vegetable oils, and soluble fibers have benefit in their efficacy for decreasing IR, fasting blood sugar (FBS), fasting insulin and HbA1c.

Psychological symptoms in Chinese nurses may be associated with predisposition to chronic disease: a cross-sectional study of suboptimal health status

BACKGROUND

Suboptimal health status (SHS) is a reversible state between ideal health and illness and it can be effectively reversed by risk prediction, disease prevention, and personalized medicine under the global background of predictive, preventive, and personalized medicine (PPPM) concepts. More and more Chinese nurses have been troubled by psychological symptoms (PS). The correlation between PS and SHS is unclear in nurses. The purpose of current study is to investigate the prevalence of SHS and PS in Chinese nurses and the relationship between SHS and PS along with predisposing factors as well as to discuss the feasibility of improving health status and preventing diseases according to PPPM concepts in Chinese nurses.

METHODS

A cross-sectional study was conducted with the cluster sampling method among 9793 registered nurses in Foshan city, China. SHS was evaluated with the Suboptimal Health Status Questionnaire-25 (SHSQ-25). Meanwhile, the PS of depression and anxiety were evaluated with Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) self-assessment questionnaires. The relationship between PS and SHS in Chinese nurses was subsequently analyzed.

RESULTS

Among the 9793 participants, 6107 nurses were included in the final analysis. The prevalence of SHS in the participants was 74.21% (4532/6107) while the symptoms of depression and anxiety were 47.62% (2908/6107) and 24.59% (1502/6107) respectively. The prevalence of SHS in the participants with depression and anxiety was significantly higher than those without the symptoms of depression (83.3% vs 16.7%, P < 0.001) and anxiety (94.2% vs 5.8%, P < 0.0001). The ratio of exercise habit was significantly lower than that of non-exercise habit (68.8% vs 78.4%, P < 0.001) in SHS group.

CONCLUSIONS

There is a high prevalence of SHS and PS in Chinese nurses. PS in Chinese nurses are associated with SHS. Physical exercise is a protective factor for SHS and PS so that the exercise should be strongly recommended as a valuable preventive measure well in the agreement with PPPM philosophy. Along with SDS and SAS, SHSQ-25 should also be highly recommended and applied as a novel predictive/preventive tool for the health measures from the perspectives of PPPM in view of susceptible population and individual screening, the predisposition to chronic disease preventing, personalization of intervention, and the ideal health state restoring.

Dental students' knowledge of and attitudes towards complementary and alternative medicine in Australia - An exploratory study

OBJECTIVES

While complementary and alternative medicine (CAM) is used by more than half of Australians, its role in dentistry is rarely covered in the curricula of Australian dental schools. This study aimed to investigate dental students' knowledge of and attitudes towards CAM.

DESIGN

Australian dental students in the final two years of their study were invited to undertake a survey. These questions consisted of five clinically relevant case vignettes, for which there was only one correct answer amongst four possible options and seven self-reported perspective-based questions. Results were analysed using descriptive statistics.

RESULTS

Of the 185 students that participated, the mean correct response rate for the five clinical scenarios was 3.46 ± 0.95 (range: 0-5 out of 5). Of 185 students, 157 (85 %) answered more than half of the questions correctly. All five questions were answered correctly by 19 (10 %) students. Most (74 %) students self-reported to have little to no knowledge. More than two-thirds of dental students reported an interest in and belief in the effectiveness of CAM. A similar proportion expressed a desire for the integration of CAM content into their undergraduate curriculum.

CONCLUSIONS

Despite approximately three out of four of dental students in this study having little to no knowledge on CAM, attitudes towards CAM therapies, and the need to integrate them into the dental curriculum, were generally positive. Future research into identifying specific knowledge gaps could help to redesign improved dental curricula.

Vegetarian diet and incidence of total, ischemic, and hemorrhagic stroke in 2 cohorts in Taiwan

Objective

To determine how a vegetarian diet affects stroke incidence in 2 prospective cohorts and to explore whether the association is modified by dietary vitamin B₁₂ intake.

Methods

Participants without stroke in the Tzu Chi Health Study (cohort 1, n = 5,050, recruited in 2007–2009) and the Tzu Chi Vegetarian Study (cohort 2, n = 8,302, recruited in 2005) were followed until the end of 2014. Diet was assessed through food frequency questionnaires in both cohorts at baseline. Stroke events and baseline comorbidities were identified through the National Health Insurance Research Database. A subgroup of 1,528 participants in cohort 1 were assessed for serum homocysteine, vitamin B₁₂, and folate. Associations between vegetarian diet and stroke incidences were estimated by Cox regression with age as time scale, adjusted for sex, education, smoking, alcohol, physical activities, body mass index (only in cohort 1), hypertension, diabetes, dyslipidemia, and ischemic heart diseases.

Results

Vegetarians had lower serum vitamin B₁₂ and higher folate and homocysteine than nonvegetarians. In cohort 1, 54 events occurred in 30,797 person-years follow-up. Vegetarians (vs nonvegetarians) experienced lower risk of ischemic stroke (hazard ratio [HR], 0.26; 95% confidence interval [CI], 0.08–0.88). In cohort 2, 121 events occurred in 76,797 person-years follow-up. Vegetarians (vs nonvegetarians) experienced lower risk of overall stroke (HR, 0.52; 95% CI, 0.33–0.82), ischemic stroke (HR, 0.41; 95% CI, 0.19–0.88), and hemorrhagic stroke (HR, 034; 95% CI, 0.12–1.00). Our explorative analysis showed that vitamin B₁₂ intake may modify the association between vegetarian diet and overall stroke (p interaction = 0.046).

Conclusion

Taiwanese vegetarian diet is associated with a lower risk of ischemic and hemorrhagic strokes.

A review of drugs that contribute to bleeding risk in general dental practice

The risk of postoperative bleeding is a daily concern for many general dental practitioners. A thorough medical and medication history must be taken to consider all risk factors, particularly drugs, that contribute to bleeding risk. While the risk from drugs such as aspirin, warfarin and clopidogrel are well known, the extent to which new antiplatelet agents and direct oral anticoagulants affect bleeding risk is less well understood. In addition, there are drugs other than antithrombotics, such as antidepressants and complementary medicines that also impair haemostasis. The aim of this paper is to provide dentists with an updated overview of the drugs commonly encountered in general dental practice that can contribute to a patient's postoperative bleeding risk.

Are drug-related dental management cautions in Lexicomp Online for Dentistry evidence-based? A systematic review of the literature

OBJECTIVES

Drug reference databases provide information on potential drug-related medical complications in a dental patient. It is important that database entries and recommendations are supported by evidence-based original studies focused on drug-related dental management complications. The aim of this study was to review and identify database drug categories associated with evidence-based drug-related medical complications during dental treatment.

DATA SOURCES

Relevant publications on adverse drug reactions and dental management complications were thoroughly reviewed from the literature published between July 1975 and July 2019.

METHOD AND MATERIALS

The drug reference database "Lexicomp Online for Dentistry" was reviewed to identify medications associated with the highest propensity to trigger drug-related dental management complications, and these were correlated with published original studies in PubMed, Embase, and Scopus databases that associated drug actions with dental treatment complications.

RESULTS

Fifty-four publications (1.2% of all full-text articles) reported original studies that directly tested drug associations with dental management complications. The cautions in the drug reference database on drug-related dental treatment mainly focused on local anesthetic precaution (P < .001), xerostomia (P < .001), bleeding (P < .001), and a combination of xerostomia and bleeding (P < .001). Antipsychotics/antidepressants were mostly associated with local anesthetic complications (80.95%), xerostomia (81.93%), and a combination of xerostomia and bleeding (22.89%). Bleeding complication was associated with anticoagulants (80.00%) and cancer chemotherapeutic agents (59.21%).

CONCLUSIONS

Similarities exist within and across different drug categories in the database entries on drug-related medical complications in a dental patient. There were a relatively limited number of publications that directly tested the association between drug-related medical complications and dental therapies.

CLINICAL RELEVANCE

The most common drug cautions during dental treatment reported in Lexicomp Online for Dentistry were limited to drug-drug interactions with local anesthetic actions, excessive bleeding, xerostomia, or a combination of any of these. These recommendations were supported by limited evidence-based studies.