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Vetting traditional Chinese medicine
COMMENTARIES
Editorials represent the opinions of the authors and not necessarily those of the American Dental Association.
COMMENTARY
Vetting traditional Chinese medicine A response to Zhou and Colleagues James Sciubba, DMD, PhD
T
he informative article, “Efficacy and Safety of Chinese Patent Medicines in the Treatment of Recurrent Aphthous Stomatitis: a Systemic Review,” by Zhou and colleagues1 in this issue represents a distillation of a large amount of research concerning the management of the common aphthous ulcer and recurrent aphthous stomatitis (RAS), which affect approximately 20% of the US population.2 The wide range of presentation and behavior extends from the typical minor aphthous ulcer of less than 1 centimeter in diameter, lasting 10 to 14 days with complete healing and without scarring over nonkeratinized mucosa, to the major form of up to several weeks in duration and often with scarring on healing. Treatment intensity is often influenced by episode frequency, ulcer location, duration, symptoms, and may include simple palliation and use of overthe-counter medications or preparations. In more severe cases, topical or systemic steroid agents may be used, with the latter requiring close monitoring. Caution must remain as it relates to widespread use of untested and existing agents and their possible relationship with the existing medication profiles given to us by our patients within our clinics and practices.
The article by Zhou and colleagues1 offers a distillation of 11 randomized clinical trials and a single clinical controlled trial in which traditional Chinese patent medicines (TCM) were used. The authors, in a thorough fashion, attempted to provide a contemporary body of evidence concerning the effectiveness of the identified medicines and their side-effect profiles, which were quite significant in many cases. Although this primary objective of the study was largely met, one may ask the legitimate question regarding the risk and benefit for this common and transitory problem in most cases. Most critically, as stated by the authors, is the question of the clinical effectiveness of the various modalities admittedly showing some benefits and if the incidence of side effects decreases, are alleviated spontaneously, or disappear with cessation of treatment. This is not the type of approach that is acceptable in the context of therapeutics, traditional or otherwise.
JADA 148(1) http://jada.ada.org
January 2017 1
COMMENTARIES
Furthermore, the conclusion of the systematic review was that the overall quality of the literature on this subject was low, with insufficient data to support the use of any intervention for first line therapy; however, TCM interventions were not part of the analysis.3 The arguments are varied but often legitimate regarding safety and efficacy of TCMs, with passionate discussions for and against the use of TCM products. Although TCM enjoys a worldwide popularity that is increasing, there are many preparations that have not been properly vetted or have had their components identified or characterized and held against the light of modern analytical methodologies.4 The investigators in this study invoke the possible role of the peripheral lymphocyte population in which altered ratios and absolute numbers of cluster of differentiation (CD) 4þ and CD8þ cell populations are altered before treatment and possibly restored to normal counts and ratios after treatment with traditional Chinese medicines as
2 JADA 148(1) http://jada.ada.org
stated in their article. This must be confirmed using immunologic methodologies, with consideration of newer possible etiologies including the role of altered innate immune function and autoinflammatory pathways. Clearly, an open mind must prevail. However, as exemplified by agents such as artemisinin, the world’s most important antimalarial drug that was isolated from an ancient Chinese medicine, we need to seriously consider all possible medical alternatives in conjunction with proper scientific and clinical rigor behind their ultimate clinical administration and therapeutic usefulness. We are pleased that the interface between Chinese traditional medicine and a Western approach to understanding the same problem will go a long way to help us deal more effectively with this common, and at times vexing, clinical issue. Caution must remain, however, as it relates to widespread use of untested and existing agents and their possible relationship with the existing medication profiles given to
January 2017
us by our patients within our clinics and practices. n http://dx.doi.org/10.1016/j.adaj.2016.11.002 Copyright ª 2017 American Dental Association. All rights reserved.
Dr. Sciubba is a consultant, The Milton J. Dance Head & Neck Center, The Greater Baltimore Medical Center, Baltimore, MD, and a professor (Ret), The Johns Hopkins School of Medicine, Baltimore, MD. Address correspondence to Dr. Sciubba at The Milton J. Dance Head & Neck Center, The Greater Baltimore Medical Center, 6569 N. Charles St., Baltimore, MD 21204, e-mail [email protected]. Disclosure. Dr. Sciubba did not report any disclosures. 1. Zhou P, Mao Q, Hua H, Liu X, Yan Z. Efficacy and safety of Chinese patent medicines in the treatment of recurrent aphthous stomatitis: a systematic review. JADA. 2017;148(1):17-25. 2. Akintoye SO, Greenberg MS. Recurrent aphthous stomatitis. Dent Clin North Am. 2014; 58(2):281-297. 3. Brocklehurst P, Tickle M, Glenny AM, et al. Systemic interventions for recurrent aphthous stomatitis (mouth ulcers). Cochrane Database Syst Rev. 2012;9:CD005411. 4. Kupferschmidt K. Dangers of Chinese medicine brought to light by DNA studies. Science. April 12, 2012. Available at: www.sciencemag.org/news/2012/04/ dangers-chinese-medicine-brought-lightdna-studies. Accessed November 11, 2016.
Editorials represent the opinions of the authors and not necessarily those of the American Dental Association.
COMMENTARY
Vetting traditional Chinese medicine A response to Zhou and Colleagues James Sciubba, DMD, PhD
T
he informative article, “Efficacy and Safety of Chinese Patent Medicines in the Treatment of Recurrent Aphthous Stomatitis: a Systemic Review,” by Zhou and colleagues1 in this issue represents a distillation of a large amount of research concerning the management of the common aphthous ulcer and recurrent aphthous stomatitis (RAS), which affect approximately 20% of the US population.2 The wide range of presentation and behavior extends from the typical minor aphthous ulcer of less than 1 centimeter in diameter, lasting 10 to 14 days with complete healing and without scarring over nonkeratinized mucosa, to the major form of up to several weeks in duration and often with scarring on healing. Treatment intensity is often influenced by episode frequency, ulcer location, duration, symptoms, and may include simple palliation and use of overthe-counter medications or preparations. In more severe cases, topical or systemic steroid agents may be used, with the latter requiring close monitoring. Caution must remain as it relates to widespread use of untested and existing agents and their possible relationship with the existing medication profiles given to us by our patients within our clinics and practices.
The article by Zhou and colleagues1 offers a distillation of 11 randomized clinical trials and a single clinical controlled trial in which traditional Chinese patent medicines (TCM) were used. The authors, in a thorough fashion, attempted to provide a contemporary body of evidence concerning the effectiveness of the identified medicines and their side-effect profiles, which were quite significant in many cases. Although this primary objective of the study was largely met, one may ask the legitimate question regarding the risk and benefit for this common and transitory problem in most cases. Most critically, as stated by the authors, is the question of the clinical effectiveness of the various modalities admittedly showing some benefits and if the incidence of side effects decreases, are alleviated spontaneously, or disappear with cessation of treatment. This is not the type of approach that is acceptable in the context of therapeutics, traditional or otherwise.
JADA 148(1) http://jada.ada.org
January 2017 1
COMMENTARIES
Furthermore, the conclusion of the systematic review was that the overall quality of the literature on this subject was low, with insufficient data to support the use of any intervention for first line therapy; however, TCM interventions were not part of the analysis.3 The arguments are varied but often legitimate regarding safety and efficacy of TCMs, with passionate discussions for and against the use of TCM products. Although TCM enjoys a worldwide popularity that is increasing, there are many preparations that have not been properly vetted or have had their components identified or characterized and held against the light of modern analytical methodologies.4 The investigators in this study invoke the possible role of the peripheral lymphocyte population in which altered ratios and absolute numbers of cluster of differentiation (CD) 4þ and CD8þ cell populations are altered before treatment and possibly restored to normal counts and ratios after treatment with traditional Chinese medicines as
2 JADA 148(1) http://jada.ada.org
stated in their article. This must be confirmed using immunologic methodologies, with consideration of newer possible etiologies including the role of altered innate immune function and autoinflammatory pathways. Clearly, an open mind must prevail. However, as exemplified by agents such as artemisinin, the world’s most important antimalarial drug that was isolated from an ancient Chinese medicine, we need to seriously consider all possible medical alternatives in conjunction with proper scientific and clinical rigor behind their ultimate clinical administration and therapeutic usefulness. We are pleased that the interface between Chinese traditional medicine and a Western approach to understanding the same problem will go a long way to help us deal more effectively with this common, and at times vexing, clinical issue. Caution must remain, however, as it relates to widespread use of untested and existing agents and their possible relationship with the existing medication profiles given to
January 2017
us by our patients within our clinics and practices. n http://dx.doi.org/10.1016/j.adaj.2016.11.002 Copyright ª 2017 American Dental Association. All rights reserved.
Dr. Sciubba is a consultant, The Milton J. Dance Head & Neck Center, The Greater Baltimore Medical Center, Baltimore, MD, and a professor (Ret), The Johns Hopkins School of Medicine, Baltimore, MD. Address correspondence to Dr. Sciubba at The Milton J. Dance Head & Neck Center, The Greater Baltimore Medical Center, 6569 N. Charles St., Baltimore, MD 21204, e-mail [email protected]. Disclosure. Dr. Sciubba did not report any disclosures. 1. Zhou P, Mao Q, Hua H, Liu X, Yan Z. Efficacy and safety of Chinese patent medicines in the treatment of recurrent aphthous stomatitis: a systematic review. JADA. 2017;148(1):17-25. 2. Akintoye SO, Greenberg MS. Recurrent aphthous stomatitis. Dent Clin North Am. 2014; 58(2):281-297. 3. Brocklehurst P, Tickle M, Glenny AM, et al. Systemic interventions for recurrent aphthous stomatitis (mouth ulcers). Cochrane Database Syst Rev. 2012;9:CD005411. 4. Kupferschmidt K. Dangers of Chinese medicine brought to light by DNA studies. Science. April 12, 2012. Available at: www.sciencemag.org/news/2012/04/ dangers-chinese-medicine-brought-lightdna-studies. Accessed November 11, 2016.