An FDA alert that keeps on keeping on and what it says about a patient’s medication history

I have spent a good part of my more than 30-year career as a clinician, teacher, and speaker asking people What do you take? and I have concluded that “medication” may be the most narrowly interpreted word in the English language. Ask about medications, and you may get just that—the prescriptions … the things they get in little bottles from the pharmacist (well, most of them anyway). Ask about OTC drugs or dietary supplements, and you may get “just my daily stack.” Ask whether they have ordered anything from an online pharmacy for sexual dysfunction or weight loss, and you may get a look clearly suggesting you have just overstepped.

FDA safety alert

The question about that last category matters more than it used to. On August 12, 2026, the U.S. Food and Drug Administration added three more products to a safety alert that has been growing quietly since 2023.¹ The alert covers dietary supplements marketed for weight loss, most of them labeled as tejocote root—also sold as Crataegus mexicana, raíz de tejocote, or Mexican hawthorn, and some labeled as Brazil Seed. Agency testing determined that these products are adulterated: instead of the botanical named on the label, they contain yellow oleander, a poisonous plant native to Mexico and Central America.¹ The list now runs past two dozen products, sold through major online marketplaces and through standalone wellness websites.¹

Yellow oleander

Yellow oleander (Cascabela thevetia, formerly Thevetia peruviana) is not the gentle botanical its name might suggest, and it definitely has an unfortunate reputation. Its seeds contain cardiac glycosides (thevetin A and B, neriifolin, and peruvoside) that inhibit sodium-potassium ATPase much like the prescription drug digoxin,^2,3 which has long been known to cause anorexia as an early sign of toxicity.⁴ Most of what is documented about the toxicity comes from cases of acute, large-dose ingestion, where the picture resembles digitalis poisoning: conduction defects at the sinus and atrioventricular nodes, bradyarrhythmias and tachyarrhythmias, and hyperkalemia.⁵ The FDA describes neurologic, gastrointestinal, and cardiovascular effects that may be severe or even fatal.¹

The American experience is smaller, and more pointed. The report that set this whole investigation in motion came out of a New Jersey poison center in 2022, after an emergency physician called about a child of 23 months who had swallowed a tejocote-labeled weight-loss product the child’s mother had bought online for weight loss. The child was bradycardic and hypotensive. In the laboratory testing of available products that followed, nine of 10 products labeled as tejocote root turned out to contain yellow oleander instead.⁶

Two additional problems

In addition, two of the three products added in August carried a second problem. One was found to contain diclofenac, a prescription nonsteroidal anti-inflammatory drug.⁷ The other contained phenolphthalein, a laxative pulled from the US market over cancer concerns.⁸ Neither ingredient appeared anywhere on the label. The FDA notes that the selling firm has not responded to its calls or emails.¹

How this affects the dental hygiene appointment

So, what does any of this have to do with a patient’s dental hygiene appointment? Well, let’s start with that second finding, because it reaches directly into our operatories. Picture the patient who tells you truthfully (as far as they know) that they take nothing for pain and, understandably, they have no reason to believe otherwise.

Now, picture the postoperative analgesic conversation that follows, and the possibility that an NSAID recommendation by you or your dentist is landing on top of an NSAID they have been swallowing daily without knowing it. Every analgesic decision we make rests on the medication history.

The cardiac glycoside finding is a slower burn but the same lesson. A patient taking an undisclosed digoxin-like compound is a patient whose cardiovascular picture is not what their chart and medication history say it is. When the medication history is incorrect—through no fault necessarily of the patient—any decision built on it may be incorrect too.

Underneath both findings sits the structural point. Under current US law, dietary supplements are not subject to FDA premarket review or approval. The manufacturer is responsible for determining that the product is safe and that its label claims are truthful and not misleading.⁹ Enforcement comes afterward, product by product, and, as this alert demonstrates, it can take years and it does not always end in a recall. At the end of the day, the label is a marketing document. It is not an ingredient list.

The uncomfortable part

Here is the uncomfortable part. Put two brown capsules on a counter—one genuine tejocote root, one yellow oleander—and hand them to any pharmacist, dentist, or dental hygienist in the country and ask them to decide which one is which. Those health-care professionals would probably say that the FDA needed a laboratory to tell the capsules apart, and, clearly in the absence of any testing equipment, that their decision would be no better than one they would have obtained using a coin. That is not a knock on anybody’s training. It is a fact about what a capsule can hide, and it is exactly why the question matters more than our own judgment does.

What we should be asking our patients

Now, put a patient in the same situation, and the gravity of the situation becomes much more obvious. Which brings us back to the only tool that reliably works, and it is not a mass spectrometer. It is the medication history. For supplements, though, that first question needs better bait. “Any vitamins or supplements?” produces “no” with impressive consistency. Try instead: “Anything for weight loss, anything for energy, anything for improved mood or clearer thinking, anything you ordered online, anything a friend swears by, anything in the cabinet that did not come from your regular pharmacy?” To be clear, I don’t believe patients are withholding disclosure of their use of these products to deceive us. They are leaving them out because somewhere along the way they decided a supplement is not a medication.

You and I are not going to identify yellow oleander in an operatory. But what we can do is hear the answer that arrives and write it down. “Patient denies the use of supplements” or “Patient reports using an online weight-loss supplement, product name unknown” is worth considerably more to the next clinician than a health history with a tidy column of checked boxes with “no” as the response, or perhaps worse, no notation that the question was ever asked at all.

The 3 most important questions

The three most important questions of any dental appointment are: What do you take? Why do you take it? Did you take it today?

Also by the author:

• Will kratom become our kryptonite? Why this “herbal supplement” deserves a dental hygienist’s closer look
• The biohacking of nicotine
• Why patient self-medication with dietary supplements matters to dental hygienists

Author’s note: This article is intended for informational and educational purposes only. It does not constitute medical, dental, or pharmaceutical advice, does not establish a standard of care, and is not a continuing education activity; no continuing education credit is offered or implied. Decisions regarding an individual patient should be made by that patient’s treating clinicians in consultation with the patient’s physician of record.

Editor’s note: This article first appeared in RDH eVillage newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe.

References

1. FDA issues warning about certain products containing toxic yellow oleander. U.S. Food & Drug Administration. Updated August 12, 2026. https://www.fda.gov/food/alerts-advisories-safety-information/fda-issues-warning-about-certain-products-containing-toxic-yellow-oleander
2. Rajapakse S. Management of yellow oleander poisoning. Clin Toxicol (Phila). 2009;47(3):206-212. doi:10.1080/15563650902824001
3. Thevetia peruviana (Pers.). Poisons Information Monograph 527. International Programme on Chemical Safety. https://www.inchem.org/documents/pims/plant/thevetia.htm
4. LANOXIN (digoxin) tablets — full prescribing information. DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d91e3646-4c63-4512-ab22-db39c085c4dc
5. Eddleston M, Ariaratnam CA, Sjöström L, et al. Acute yellow oleander (Thevetia peruviana) poisoning: cardiac arrhythmias, electrolyte disturbances, and serum cardiac glycoside concentrations on presentation to hospital. Heart. 2000;83(3):301-306. doi:10.1136/heart.83.3.301
6. Berland N, Kababick J, Santos C, Calello DP. Notes from the field: online weight loss supplements labeled as Tejocote (Crataegus mexicana) root, substituted with yellow oleander (Cascabela thevetia) — United States, 2022. MMWR Morb Mortal Wkly Rep. 2023;72(37):1016-1017. doi:10.15585/mmwr.mm7237a3
7. DMagic Plus may be harmful due to hidden ingredients. U.S. Food and Drug Administration. August 12, 2026. https://www.fda.gov/drugs/medication-health-fraud-notifications/dmagic-plus-may-be-harmful-due-hidden-ingredients
8. MAGI may be harmful due to hidden ingredients. U.S. Food and Drug Administration. August 12, 2026. https://www.fda.gov/drugs/medication-health-fraud-notifications/b-magi-may-be-harmful-due-hidden-ingredients
9. Dietary supplements for weight loss: health professional fact sheet. National Institutes of Health, Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/WeightLoss-HealthProfessional/