The use of complementary and integrative practices in oral health

The World Health Organization recognizes the medical practices derived from the culture of each country, as Traditional Medicine, but all over the world, there has been no consensus about the denomination of these practices. In Brazil, the Ministry of Health recognizes the use of the following, as Complementary and Integrative Practices (CIP): Acupuncture, Homeopathy, Medicinal Plants/Phytotherapy, Thermal Water/Crenotherapy, Anthroposophic Medicine. Based on the therapies recognized by the Ministry of Health, the Brazilian Federal Council of Dentistry regulated the use of CIP in oral health: Acupuncture, Homeopathy, Phytotherapy, Laser Therapy, Flower Therapy and Hypnosis. This article presents the results of a systematic review about positive and negative evidence of the use of PIC in oral health. We analyzed 91 papers published between 2000 and 2010. Laser therapy and Phytotherapy were the CIP most tested. Laser therapy studies reported more negative results, while the Phytotherapy studies reported more positive results. Papers on Flower Therapy were not included because we found no RCT about this CIP. We found more positive than negative outcomes for the use of CIP in oral health and analysis of the papers showed that only a few authors reported the clinical outcomes. Due to the holistic perspective of CIP, we believe it is possible to show more consistent results of use of these practices in oral health, provided that a broader view (beyond quantitative parameters) is incorporated from the planning to analysis of studies in this area.


Introduction
Systematic reviews in oral health are important, especially those about less studied themes, such as Complementary and Integrative Practices (CIP).The importance of producing systematic reviews in oral health is based on the idea that 'oral health is part of total health and essential to quality of life' (AL-OTAIBI et al., 2003).Moreover one of the goals of the WHO Global Oral Health Program (ORH) is to " […] translate the evidence into action programmes" (WHO, 2014, p. 1).
The World Health Organization recognizes the medical practices derived from the culture of each country, as Traditional Medicine, but all over the world, there has been no consensus about the denomination of these practices (BARROS;NUNES, 2006;PETERS et al., 2002;SOUSA et al., 2012).In Brazil, the Ministry of Health recognizes the use of the following, as Complementary and Integrative Practices (CIP): Acupuncture, Homeopathy, Medicinal Plants/Phytotherapy, Thermal Water/Crenotherapy, Anthroposophic Medicine (MINISTRY OF HEALTH -BRAZIL, 2008).Based on the therapies recognized by the Ministry of Health, the Brazilian Federal Council of Dentistry regulated the use of six CIPs in oral health: Acupuncture, Homeopathy, Phytotherapy, Laser Therapy, Flower Therapy and Hypnosis (CFO, 2008).
According to the Brazilian legislation: Acupuncture […] comprises a group of procedures which allows the necessary stimulus of specific anatomical places through the insertion of thread-like metal needles for the promotion, maintenance and recovery of health, as well as for the prevention of injuries and diseases (MINISTRY OF HEALTH -BRAZIL, 2013, p. 15).
Homeopathy is […] a complex medical system based on holistic and vital principles and the use of the natural law of healing, which was enunciated by Hippocrates in the 6th century B.C. (MINISTRY OF HEALTH -BRAZIL, 2013, p. 17).
Phytotherapy, is a […] therapeutic process characterized by the use of medicinal plants in their different pharmaceutical forms, without the use of isolated active substances, although of vegetable origin (MINISTRY OF HEALTH -BRAZIL, 2013, p. 20).
Laser Therapy, Flower Therapy and Hypnosis are not mentioned in National Policy on Integrative and Complementary Practices of the SUS (Brazilian national health system), but are officially recognized as CIP by the Brazilian Federal Council of Dentistry (CFO, 2008).
From the point of view of the Brazilian Federal Council of Dentistry, the aim of Laser therapy […] is to empower dentists in order to ensure wide and safe professional practice, respecting the limits of the professional field of expertise of the dentist".Dentists could use this practice for diagnosis and treatments in oral health (CFO, 2008, p. 6).
Flower Therapy is defined as the […] complementary practice of health and well being, considering the use of flower essences as a treatment method by focusing attention on the individual and not the disease.It may be used by anyone, of all ages; there are no contraindications, and no interactions or production of drugs.Moreover, it offers scope of prevention and humanization, respecting the limits of the professional field of expertise of the dentist (CFO, p. 3, 2008).

Hypnosis is defined as
[…] a practice endowed with methods and techniques that provide increased therapeutic efficacy in all specialties of dentistry, requires no additional resources such as drugs or instruments and can be used in the clinical setting (CFO, 2008, p. 4).
Bearing in mind these concepts the aim of this paper was to present and discuss the findings of a systematic review about clinical use of CIP in Oral Health.

Material and methods
A systematic review that focuses beyond the quantitative view has been published (BARANOWSKY et al., 2009;HARDEN, 2010;SMITH et al., 2009).Considering this perspective, this systematic review was developed with the aim of finding out about the evidence produced in the field of CIP applied to oral health.Based on this we analyzed articles according to the following categories: author, year of publication and clinical outcome of RCT analyzed (statistical and/or clinical significance).This posture was adopted because we dedicated our researches to Social Sciences in Public Health and to Complementary and Integrative Practices 1 .Taking into account this perspective, the PUBMED database was chosen because we found that this database is considered one of the most important in the field of health and is accessed worldwide (BEIKI et al., 2005, HOONG, 2010;PACKER et al., 2007).
As regards the time-frame established in which to review the articles, we assumed the definition of an older study, indicating that this varies across different medical specialties, and according to the different areas of knowledge (PATSOPOULOS; IOANNIDIS, 2009).We also considered that studies published there 5-10 years ago could provide researchers with the opportunity to look at the historical context of the subject researched and suggest guidance for later research (JYI, 2005) (CFO, 2008).We use these modalities of CIP as keywords with intention of finding papers directly related to their use.All full versions of articles available online, published between 2000 and 2010, which contained the key words cited above in the title and / or abstract were included.We conducted the bibliographic search in three stages: In the first stage, our objective was to find the papers by means a general search.We adopted the terms 'alternative therapy and/or dentistry'.We then read all the abstracts found in this search.This action provided us with the insight and directions to deepen the search for papers, because we were able to identify the vocabulary and the context of articles.
In the second stage, our objective was to extend the previous search and conduct a more specific search, in which we used the terms: 'acupuncture; homeopathy; phytotherapy; hypnosis; flower therapy; laser therapy'.In the same way as the first stage, this stage contributed to providing us with the insight to carry out one more search, considering the terms adopted by the Brazilian Federal Council of Dentistry.In this second stage, we also read all the abstracts found.
In the third stage, our objective was to conduct a more specific search, directed towards the terms related the oral health and CIP.Based on reading the articles found in the previous stages, we identified 'dental' as being a term more specific to interventions in dentistry.For this reason, we preferred to adopt 'dental' rather than 'oral' as keyword.The last search was performed using the keywords: 'dental acupuncture; dental homeopathy; dental phytotherapy; dental flower therapy; dental hypnosis; dental laser therapy'.In this third stage, we also read all the abstracts of articles.
On completion of the three stages, we tabulated all the references and eliminated the duplicated articles.After this, we started the search for the complete version of these texts, and then read the full content of all these papers.
In order to identify the 'positive' and 'negative' evidence, the criteria proposed by Pittler et al. (2000) were adopted, i.e., the positive results were those showing statistically significant values (p < 0.05) in favor of the CIP studied, when compared with the control group.No statistically significant differences in the intervention between the control group and CIP, and favorable results in the control group were classified as negative evidence.Studies that did not report the significance levels precisely, were classified according to the conclusion mentioned in the article.In the case of positive and negative outcomes observed in the same study, the result was considered directly connected to the main objective mentioned in the paper.
While reading and evaluating the papers it was clear to us that there were gaps in the design of the studies analyzed, and this problem directly affects the quality of RCT outcomes.This finding allowed us to perceive that these data may offer little reliability for recommending the clinical use of CIP in oral health.In this context, we think there is great difficulty in obtaining support in the literature to prove the possibilities for action in the field of CIP.We believe that the broader view for the planning and evaluation of CIP interventions is an important and decisive factor for the recognition of the effectiveness of these practices by the scientific community and society.We were given this impression, because when reading the papers, we noted that although some studies have failed to show statistical significance, they showed important clinical outcomes (ASSAF et al., 2007;BRATEL et al., 2005;CARUSO et al., 2008;DE OLIVEIRA et al., 2007, 2008;DE SOUSA et al., 2007;LU et al., 2000;MUMMOLO et al., 2008;RIBEIRO et al., 2008;RODRIGUES et al., 2009;SASTRAVAHA et al., 2003;SCHMID-SCHWAP et al., 2006;SMITH et al., 2007;PEREIRA et al., 2010;VENEZIAN et al., 2010).We also noted that few researchers have reported this type of finding, and we think that assigning the effects of CIP to purely numerical outcomes, may be biased with regard to planning and analysis, because the field of CIP needs to be studied from a broader point of view, incorporating data that go beyond quantitative parameters.Corroborating our impressions, Verhoef (2002, p. 275) reported that the RCT "[…] do not address why the intervention works, how participants are experiencing the intervention, and/or how they give meaning to these experiences".Thus, as a way for studies to be conducted, we suggest the incorporation of information from the reports of patients and team who will conduct the experiment.We think this posture would allow information to be captured is in accordance with the principles of the CIP and similar practices that assume the same view of health.
Another obstacle observed in the papers analyzed refers to the establishment of placebo procedures and difficulties in blinding in studies on complementary and alternative treatments.Nahin andStraus (2001) andTamayo et al. (2002), cite the problem of placebo use in research on CIP.They also reported other problems, such as difficulties with randomizing and retaining patients, and in identifying appropriate placebo interventions.Baranowsky et al. (2009, p. 3) reports that "RCTs are particularly difficult to perform in many categories of complementary and alternative medicine".This occurs because "[…] an individualized approach to the patient in diagnosis and therapy is often already part of the healing process itself" (BARANOWSKY et al., 2009, p. 3).

Conclusion
There are various obstacles to searching, analyzing and establishing the validity and reliability of CIP outcomes in oral health.The small difference between positive and negative results characterizes the studies analyzed as weak evidence and low potential for clinical application, considering the model of evidence based dentistry.We think that a broader view in the planning and evaluation of CIP interventions is an important and decisive factor for the recognition of the effectiveness of these practices by the scientific community and society.To obtain more adequate data within the field of CIP, we suggest the incorporation of qualitative data.
The Lapacis (Laboratory of Alternative, Complementary and Integrative Practices in Health) is a theoretical and practical, oriented teaching, research and extension space.The researchers of Lapacis are graduate students that have published a variety of materials about Integrative and Complementary Practices.This Laboratory is located at the State University of Campinas -School of Medical Sciences in the Department of Health.Home Page: http://www.fcm.unicamp.br/laboratorios/lapacis/index.php.

Table 1 .
CIP distribution by author, year of publication, and positive clinical outcome.Lower gingival index levels, decreased depth of periodontal pockets after using plant-based food supplements including plants when treating periodontitis in patients receiving at-home care p Gedney, J.J.A decrease in perceived sensitivity to the intensity and discomfort of pain after using essential oils (administered nasally) made of Lavandula angustifolia and Rosmarinus officinalis at the onset of pain P Kim, K.S. Decreased need for opioid analgesics in patients who had undergone bilateral sagittal split osteotomy P Rassameemasmaung, S. 2008Decreased probing depths; decreased bleeding during probing; decreased gingival index values and decreased plaque levels with the use of a gel containing Garcinia mangostana L. P Nagata, H. 2008 Decreased probing depths; decreased values on the gingival index, decreased plaque levels with the use of chewing gum containing eucalyptus in cases of periodontitis P Rassameemasmaung, S. 2007 A decrease in volatile sulfur compounds after using mouthwashes containing G. mangostana P Takahashi, K. 2003 Slower bacterial growth and less plaque formation Continue... Acta Scientiarum.Health Sciences Maringá, v. 36, n. 2, p. 281-291, July-Dec., 2014 The use of lasers reduced the occurrence of caries because it prevented the demineralization of tooth enamel in vivo L Ozcelik, O. Low-intensity laser therapy combined with an enamel matrix protein led to a reduction in gingival recession, pain, and edema in cases of intraosseous defects L Ting, C.C.The use of lasers was efficient in removing calculus and did not cause any visible morphological alterations to the root surface L Assaf, M. Decreased occurrence of dental bacteremia after the use of a diode laser L Godoy, B.M. The irradiated samples presented higher organization of the collagen fibrils in the extracellular matrix than the non-irradiated samples.L Liu, J.F. Less resistance from children to dental treatment with the use of Er:YAG lasers in cavity preparations when compared

Table 2 .
CIP distribution by author, year of publication, and clinical negative outcome.Both control group and test group promoted statistically significant reduction in the plaque and gingival indices P Southern, E.N.The effect of chlorhexidine mouthwash (control group) was statistically superior to placebo (test group) used on dental plaque P Lauten, J.D.No statistically significant differences were found between results of the test group (herbal mouthwash) and control group (placebo mouthwash) as regards gingival index, plaque index or relative abundance of either bacterial species.
Group therapy (GT) provided more favorable results than hypnotherapy (HT) in cases of dental anxiety treatment L Mummolo, S. Both surgical and laser treatment showed a clinically appreciable validity with the Friedman's test in cases of aggressive periodontitis.L Schwarz, F. Both control group and test group (laser) promoted a significant reduction of the gingival index.Plaque index remained nearly unchanged in both groups.The mean value of bleeding on probing decreased in both groups Continue...