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Oral leukoplakia

Leukoplakia is a common condition (<1%) of the mouth that involves the formation of white leathery spots on the mucous membranes of the tongue and inside of the mouth. It is not a specific disease entity and is diagnosed by exclusion of diseases that may cause similar white lesions like candidiasis or lichen planus. more...

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Leukoplakia is common in adults, mostly in the 50-70 years age group. The cause in most cases is unknown, but many are related to tobacco use and chronic irritation. A small proportion of cases, particularly those involving the floor of the mouth or the undersurface of the tongue is associated with a risk of cancer.

The so-called hairy leukoplakia associated with HIV infection and other diseases of severe immune deficiency does not have risks for cancer.

The treatment of leukoplakia mainly involves avoidance of predisposing factors like smoking, tobacco and betel chewing, alcohol,and removal of chronic irritants like sharp edges of teeth. In suspicious cases, a biopsy is also taken, and surgical excision done if pre-cancerous changes or frank cancer is detected.


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Natural medicines and oral health: a look at the literature
From Townsend Letter for Doctors and Patients, 6/1/05 by Jason Barker

The Dentists have it right. In fact, one could consider them to have the preventive medical concept down to a science. We are encouraged to visit the dentist every 6 months for a professional cleaning and general checkup that may often include fluoride treatments and early detection utilizing radiographic imaging. They even give you the tools necessary (toothbrush, floss and toothpaste) for maintaining oral health at the end of your visit. Granted, some of these (and several other) treatments are criticized for their inherent toxicity, however as a model of prevention the dental profession is intent on maintaining American's oral health. And it shows--consider all of the healthy smiles we see around us each and every day ... and now think about what our mouths may have looked like not too long ago prior to regimented brushing and flossing. The point we are trying to make is, that if we cared as well as we do for the rest of our bodies as we do our teeth, the health of humanity would be infinitely improved. Think about it ... every 6 months you are scheduled to visit a physician who asks about any symptoms, performs a physical exam, does some laboratory testing, and spends some time talking to you about how you can improve some aspect of your general health. What an incredible model to follow.



Regardless, there are many ways we can maintain our dental health utilizing the vast armamentarium of natural medicines, especially when we look at some of the indigenous uses of natural substances. After all, oral hygiene involves more than toothpaste. Moreover, some of these historical approaches continue to be scientifically validated, making them all the more appealing today when we are presented with a hundred different kinds of toothpaste and X-rays every 6 months.

Co-Enzyme Q-10

Coenzyme Q-10 (CoQ10) is widely held as a treatment for periodontal disease based on some older studies. CoQ10 is found throughout the body and in higher amounts in heart, kidney, liver and pancreatic tissues. CoQ10 plays an important role in the production of adenosine triphosphate, or ATP--the body's energy currency. CoQ10 also functions as an antioxidant and in several metabolic pathways. (1) CoQ10 is manufactured by the body and is also ingested in the diet, especially from animal products. Much of the argument for using CoQ10 in the treatment of periodontal disease is based on a study that found reduced CoQ10-enzyme activity in gingival tissue (gums). (2) Furthermore, the investigators in this study also noted decreased CoQ10 activity in the subjects' leukocytes, presumably signifying systemic deficiency of this nutrient, which they proposed was a contributor to periodontitis. A small collection of studies from the mid-1970's demonstrates some effectiveness for this nutrient in gum disease, (3-5) and a more recent Japanese study (utilizing topically-applied CoQ10) found "significant improvements" in various measures of periodontal disease progression; these investigators concluded that CoQ10 is a useful treatment for periodontal disease as a singular treatment or in combination with other nonsurgical therapies. (6) These limited, yet enticing findings regarding the use of CoQ10 and periodontal disease certainly provide plausible reason for its use. It is surprising that further studies have not occurred further delineating this preventive therapy for a costly health condition.


Xylitol is an up-and-coming dietary sweetener that has gained attention because of its utility as a sugar substitute due to its negligible effects on insulin levels (7) and its apparent ability to prevent tooth decay (8) and ear infections. (9) Xylitol is more of an alcohol than a sugar and is becoming more extensively used in diabetic food products and chewing gum. Xylitol is the alcohol form of xylose, a component of hemicellulose, a plant fiber. Xylitol is found in various fruits, vegetables, cereal grains, mushrooms and farm foods such as hay straw and corncobs. In large-scale manufacturing, xylitol is derived from birch wood chips.

Xylitol is not fermentable by the oral microbes responsible for causing dental caries (cavities). (10) The discovery of xylitol's preventive and remineralizing effects on teeth were first elucidated in the Turku Sugar Studies in Finland, 1971-73. (11) The effects of xylitol and sucrose were compared in their abilities to prevent dental caries and for their contribution in plaque removal (xylitol chewing gum removed 47% more plaque than did sucrose chewing gum). (12) Results of these initial investigations have been replicated several times; Finnish dental professionals incorporate xylitol chewing gum as a part of the daily oral health regimen and the entire group of Nordic dental associations recommend xylitol use for dental health. (13) Not as well endorsed in the US, xylitol has not yet achieved similar recommendation status. However, it is noteworthy that the US army has created an initiative program for its dental corps encouraging the use of this sugar substitute in dental care programs. (14)

Not to be overlooked is the adjunctive, beneficial effect of xylitol on preventing middle ear infections. Xylitol was shown to inhibit the growth of Streptococcus pneumoniae and the adhesiveness of pneumococci and Haemophilus influenza to the nasopharyngeal mucosal cells. (15) Separate trials showed a preventive effect of xylitol on middle ear infections (daily dose of 8.4 to 10 grams, in divided doses) and a reduced need for antibiotic treatment for this condition. (16)

Xylitol continues to gain popularity in the US with many products containing it that advertise as "sugar free." Xylitol is also becoming incorporated into many nutraceutical products as a sweetener and for its preventive benefits. Xylitol is widely available currently, and the authors found no negative information regarding the use of this product with the exception of diarrhea as a side effect when large amounts are ingested. However, like all newly popular health products with great promise, caution is always advised until more long-term usage information becomes available. That being said, xylitol's widespread use in Nordic countries for the last 25 or so years speaks for the absence of negative health effects of this compound.

Sanguinaria canadensis (Bloodroot)

Sanguinaria may be found in some natural toothpaste preparations and other products for oral hygiene due to the herb's ability to inhibit the growth of certain bacteria. In one study sanguinarine, an alkaloid constituent of Sanguinaria was found to inhibit the growth of 98% of bacterial isolates from human dental plaque. (17) Another clinical trial that utilized a sanguinaria-containing toothpaste and oral rinse protocol over a 6-month period demonstrated a reduction in plaque and gingival inflammation in the patient population. (18) Investigators noted a plaque reduction of 57%, bleeding reduction of 45%, and a decrease in gingival inflammation by 60% in comparison to the placebo group in which plaque was reduced by 27% and inflammation by 21%, while bleeding increased by 30%. In a similar study, researchers noted another significant reduction in gingivitis symptoms in comparison to placebo after a 6-month treatment period. (19)

While seemingly an effective adjunctive treatment for gingivitis and possible other oral conditions, some concern about the safety of bloodroot has been raised. Researchers compared the precancerous potential of Sanguinaria-associated keratoses to that of other mucosal lesions in the lip and oral mucosa. (20) Their findings suggested that lesions resulting from bloodroot might be related to a precancerous condition of the mouth known as leukoplakia. Care must be taken not to ingest large amounts of the herb; small amounts may lead to fairly intense nausea and vomiting. (21)

Mangifera indica (mango)

Several plants have been used historically for care of the teeth and oral hygiene. In rural India, the mango is a commonly used plant in both urban and rural locations. Mango leaves are folded up and covered with tea dust (finely ground, dried Camellia sinensis leaves) and rubbed against the teeth. One clinical investigation of this practice investigated the antimicrobial ability of mango leaves in oral hygiene. Mango leaves were shown to inhibit 2 types of bacteria (Prevotella intermedia & Porphyromonas gingivalis) in greater proportion than those using a toothbrush. (22)

Melaleuca alternifolia (tea tree oil)

Melaleuca is well known for its antiseptic, bactericidal and antifungal effects. And while exhibiting considerably toxicity to several pathogenic bacteria and fungi, tea tree oil appears to leave normal skin flora unmolested. Applied topically, it may have negative effects including dermatitis and burning of the oral mucosa. (23) A clinical trial using tea tree oil as an oral mouthwash observed effectiveness at controlling oral bacteria and decreasing plaque development during the time of the trial. (24) Another trial using a tea tree oil-containing gel led to a reduction in gingival inflammation and bleeding scores; plaque scores were not decreased however. (25) Subjects reported no adverse effects while using the gel; this form of application may provide a less caustic effect on the mucosa.

Salvadora persica

The miswak is a chewing stick obtained from the persica plant. A traditional form of medicine, the miswak is rooted in religious and cultural custom and its use is widespread in Middle Eastern Muslim countries. Not until recently has persica been evaluated for effectiveness. One recent trial utilized a persica mouthwash and measured its effectiveness on gingival health and pathogenic bacteria. (26) Use of persica mouthwash led to decreased levels of the cavity-causing bacterium mutans streptococci and improved indices of gingival health. Persica did not reduce dental plaque amounts, however. Another large-scale trial evaluated several aspects of oral hygiene in Saudi Arabia including effectiveness of the miswak stick in oral health, among other aspects of dental care. (27) Investigators revealed that use of the miswak stick was at least as effective as regular toothbrushing for reduction of plaque and control of gingivitis. They also noted that persica was an effective treatment and preventive medicine for periodontal disease. These results are fascinating in that yet another traditional medicine with specific health applications is validated by modern scientific scrutiny.

Combination Botanicals

Combination treatments with botanical medicines for oral health are quite common; ingredients are variable depending on practitioner and patient variables. While the mixing of various botanicals for treatment of oral conditions can be a highly successful approach, these therapies are rarely evaluated on a larger scale, and for good reason as treatment utilizing herbal medicines are typically highly individualized treatments. However, a combination of sage oil, peppermint oil, menthol, chamomile, echinacea, myrrh, clove oil and caraway oil were applied in a clinical trial with good results. (28) Investigators were able to treat gingivitis using this combination; the herbs were added to a small amount of water and rinsed three times per day. In addition, a toothpaste containing sage and peppermint oils, chamomile, echinacea purpurea, myrrh and rhatany was evaluated over a period of three and six months for its role in promoting gingival health. (29) Again, this treatment was effective in its ability to decrease plaque size, bleeding and gingival inflammation.

Diet, lifestyle and Nutrition

The link between sugar and oral health is well delineated, with the total intake of sugars being directly related to carie formation over one's lifetime. (30) Consumption of sugar affects a wide range of oral health indices in addition to the teeth. These include saliva composition, pH and quantity, and pH of plaque on the teeth. Fermentable carbohydrates provide the substrate for bacterial action, which then have the effect of lowering the pH of saliva and plaque in the oral cavity. With higher acidity, tooth demineralization occurs.

In addition to the numerous recommendations for oral health, often missing is the suggestion of nutritional status as a health indicator, as with nearly all other areas of modernized medicine. A simple study using a vitamin and plant-derived nutraceutical in periodontal disease revealed interesting findings in the realm of nutrition and oral disease. (31) Investigators supplied subjects with periodontal disease with twice a day dosing of the nutritional supplement for 60 days. Patients were evaluated for several gingival disease parameters; investigators noted a significant decrease in gingival inflammation, bleeding, and periodontal pocket depth in those taking the supplement compared to the placebo group. While the results of this study will appear to be a 'no brainer' to the readership of this magazine, it provides further proof of the necessity and validity of sound nutritional choices and or supplementation in yet another aspect of health and disease.

Individual nutrients have been studied in oral health as well; the role of vitamin C was recently evaluated in gingival disease. Those who consumed fewer than 60 milligrams of vitamin C per day (the recommended daily allowance) were found to be 1.5 times more likely to develop gingivitis than those who consumed 180 milligrams of vitamin C each day. (32)


The preventive model that dentistry utilizes should be replicated throughout the health care system. When we truly examine the preventive leanings of the dental profession, we are left wondering why the rest of the body is neglected in comparison to the biannual dental checkups that are strongly encouraged. However, we have several natural choices for maintaining our oral health in lieu of the often harsh dental treatments and screening procedures. More interesting is the continuing modern validation of traditional medicines; this is true even of dental applications. Similar to other disease processes, proper care and feeding is paramount in maintaining health, and when disease strikes, we have several choices for assisting the body in overcoming these health challenges.


1. Greenberg S, Fishman WH. Coenzyme Q10: A New Drug for Cardiovascular Disease. J Clin Pharmacol 1990;30:596-608.

2. Hansen IL, Iwamoto Y, Kishi T, Folkers K, Thompson LE. Bioenergetics in clinical medicine. IX. Gingival and leucocytic deficiencies of coenzyme Q10 in patients with periodontal disease. 1976 Aug; 14(4):729-38. Res Commun Chem Pathol Pharmacol. 1976 Aug;14(4):729-38.

3. Wilkinson EG, Arnold RM, Folkers K, et al. Bioenergetics in clinical medicine. II. Adjunctive treatment with coenzyme Q in periodontal therapy. Res Commun Chem Pathol Pharmacol 1975;12:111-23.

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7. Hassinger W, Sauer G, Cordes U, et al. The effects of equal caloric amounts of xylitol, sucrose and starch on insulin requirements and blood glucose levels in insulin-dependent diabetics. Diabetologia 1981;21:37-40.

8. Trahan L. Xylitol: a review of its action on mutans streptococci and dental plaque--its clinical significance. Int Dent J 1995;45(1 Suppl 1):77-92 [review].

9. Kontiokari T, Uhari M, Koskela M. Antiadhesive effects of xylitol on otopathogenic bacteria. J Antimicrob Chemother 1998;41:563-5.

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13. Honkala S, Honkala E, Tynjala J, Kannas L. Use of xylitol chewing gum among Finnish schoolchildren. Acta Odontol Scand. 1999 Dec;57(6):306-9.

14. Richter P, Chaffin J. Army's "look for xylitol first" program. Dent Assist. 2004 Mar-Apr;73(2):38-40.

15. Kontiokari T, Uhari M, Koskela M. Effect of xylitol on growth of nasopharyngeal bacteria in vitro. Antimicrob Agents Chemother 1995;39:1820-3.

16. Uhari M, Tapiainen T, Kontiokari T. Xylitol in preventing acute otitis media. Vaccine. 2000 Dec 8:19 Suppl 1:S144-7.

17. Dzink JL. Socransky SS. Comparative in vitro activity of sanguinarine against oral microbial isolates. Antimicrob Agents Chemother 1985;27(4):663-5.

18. Hannah JJ, Johnson JD, Kuftinec MM. Long-term clinical evaluation of toothpaste and oral rinse containing sanguinaria extract in controlling plaque, gingival inflammation, and sulcular bleeding during orthodontic treatment. Am J Orthod Dentofacial Orthop 1989;96(3):199-207.

19. Harper DS, Mueller LJ, Fine JB, et al. Clinical efficacy of a dentifrice and oral rinse containing sanguinaria extract and zinc chloride during 6 months of use. J Periodontol 1990;61(6):352-8.

20. Eversole LR, Eversole GM, Kopick J. Sanguinaria-associated oral leukoplakia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:455-64.

21. McGuffin M, Hobbs C, Upton R, Goldberg A (eds). American Herbal Products Association's Botanical Safety Handbook. Boca Raton, FL: CRC Press, 1997.

22. Bairy I, Reeja S, Siddharth, Rao PS, Bhat M, Shivananda PG. Evaluation of antibacterial activity of Mangifera indica on anaerobic dental microglora based on in vivo studies. Indian J Pathol Microbiol. 2002 Jul;45(3):307-10.

23. Jandourek A, Vaishampayan JK, Vazquez JA. Efficacy of melaleuca oral solution for the treatment of fluconazole refractory oral candidiasis in AIDS patients. AIDS 1998;12:1033-7.

24. Saxer UP, Stauble A, Szabo SH, Menghini G. Effect of mouthwashing with tea tree oil on plaque and inflammation. Schweiz Monatsschr Zahnmed. 2003;113(9):985-96.

25. Soukoulis S, Hirsch R. The effects of a tea tree oil-containing gel on plaque and chronic gingivitis. Aust Dent J. 2004 Jun;49(2):78-83.

26. Khalessi AM, Pack AR, Thomson WM, Tompkins GR. An in vivo study of the plaque control efficacy of Persica: a commercially available herbal mouthwash containing extracts of Salvadora persica. Int Dent J. 2004 Oct;54(5):279-83.

27. al-Otaibi M. The miswak (chewing stick) and oral health. Studies on oral hygiene practices of urban Saudi Arabians. Swed Dent J Suppl. 2004;(167):2-75.

28. Serfaty R, Itic J. Comparative trial with natural herbal mouthwash versus chlorhexidine in gingivitis. J Clin Dentistry 1988;1:A34.

29. Yamnkell S, Emling RC. Two-month evaluation of Parodontax dentifrice. J Clin Dentistry 1988;1:A41.

30. Touger-Decker R, van Loveren C. Sugars and dental caries. Am J Clin Nutr. 2003 Oct;78(4):881S-892S.

31. Munoz CA, Kiger RD, Stephens JA, Kim J, Wilson AC. Effects of a nutritional supplement on periodontal status. Compend Contin Educ Dent. 2001 May;22(5):425-8, 430, 432 passim; quiz 440.

32. Nishida, M. Dietary Vitamin C and the Risk for Periodontal Disease. Journal of Periodontology 2000, Vol. 71, No. 8, Pages 1215-1223

by Jason Barker, ND and Chris Meletis, ND

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