The Role of Dietary Supplements in Post-Surgical Bleeding

In the United States, the use of Dietary supplement in adults aged 20 and older has increased in the last 2 decades. The percentage of population taking at least one dietary supplement increased from 42% in 1988 to 1994 to 53% in 2003 to 2006, with women (compared to men) more likely to consume one or more dietary supplements and multivitamins.

Globally, the supplement market is valued at $82 billion, with the US contributing approximately $23 billion. The most popular supplements are vitamin D, followed by omega 3, coenzyme Q10, multivitamins, probiotics, B vitamins (B1 through B12), magnesium, curcumin, vitamin C, calcium, and protein/nutrition powders/drinks. For herbal and botanical supplements, green tea is the most used, followed by cranberry, garlic, ginseng, echincaea, ginkgo biloba, turmeric and milk thistle.

The growing popularity of dietary supplements has led to increased scrutiny, which has called into question the safety of these products. Bleeding has been one of the complications associated with the use of dietary supplements.

A recent study estimated 23,005 emergency-department visits in 1 year attributed to adverse events related to the use of dietary supplements, with 65,9% involving single herbal or complementary nutritional product and 31.8% involving a single micronutrient product. A weight-loss product was implicated in 25.5% of emergency-department visits and an energy product in 10.0%. The principal adverse events were palpitations, chest pain, or tachycardia (71,8%). The mean age of the patients receiving treatment was 32 years old and 28% of the visits involved people from 20 to 34 years of age.

Other complications included interaction with prescription medications and between different dietary supplements. In dentistry, special attention has to be taken in patients who are taking anticoagulants and cytochrome in addition to specific micronutrients such as vitamin D, vitamin E, vitamin K, calcium, fluoride, iron, magnesium, selenium, and zinc, and herbal-nutrient formulations such as cranberries, saw palmetto, garlic, ginko biloba, ginseng, ginger, valerian and Echinacea. These augment the effects of anticoagulants and inhibit drugs that are absorbed by cytochrome P450 enzymes.

For surgeons and their patients, intraoperative and postoperative bleeding are undesirable complications of periodontal and/or oral surgery. Any dietary supplement that contributes to bleeding should be identified and avoided whenever possible.

There is a paucity of literature regarding implant surgery, extraction, orthodontic surgery, or endodontic surgery and dietary supplements. However, a review of periodontal therapy reports some studies are exploring the use of the anti-inflammatory characteristics of certain dietary supplements to gain a better result post therapy and suggests taking supplements of vitamins and minerals, particularly vitamin C, may contribute to improvement of periodontal health.
In addition, food and herbal supplements are reviewed that may increase the risk for operative and postoperative bleeding.
In many cases, many dietary supplement users base their decisions on inadequate information from advertisements or take counsel from nonmedical figures, despite the paucity or absence of clinical guidance and little or no information about interactions or side effects.

All dentists should exercise as much precaution as possible to avoid complications. Therefore, dentists should take a thorough medical and medication history at every appointment. A complete history should include the exact dosages and frequencies of ingestion of vitamins, minerals, and herbs that the patient reports.
Cases with a bleeding complication following second-stage implant abutment insertion surgery, illustrates possible etiology and importance of dietary supplements and glucosamine on potential postsurgical problems. Patients taking a combination of multivitamins, iron, branched-chained amino-acid powder, glutamine, glucosamine, zinc, vitamin C, and vitamin E, clinicians need to be aware of any dietary supplements and dosages the patient takes prior to surgical procedures to prevent excessive bleeding.

Recommendations to stop these supplements prior to surgery similar to those given to patients on any anticoagulant (eg, aspirin, warfarin, rivaroxaban, dabigatran etexilate mesylate) should be discussed with patients undergoing periodontal and implant surgery.

Source: Compendium magazine of continuing Education in Dentistry (November/December 2016. Volume 37. Number 10.