Herbals, surgery and anesthesia don't always mix

The woman who swears by gingko biloba wonders why her mouth won't stop bleeding after wisdom tooth surgery. What she doesn't know is that the herbal remedy she takes religiously to enhance mental alertness also acts as a powerful blood thinner that inhibits clotting.

She never thought to mention gingko when her oral and maxillofacial surgeon (OMS) asked her before surgery what medicines she takes. Gingko is an herb and, therefore, harmless and not a medicine, right?

Not true. Mounting anecdotal and scientific evidence indicates that gingko and other "natural" herbal remedies, including everything from garlic tablets to green tea, can lead to unexpected, potentially harmful side effects that can interfere with surgery and anesthesia, says Pamela L. Alberto, DMD, who will speak at the American Association of Oral and Maxillofacial Surgeons' annual meeting, September 29 - October 2, 2004, in San Francisco, California.

The potential for problems are a concern for oral and maxillofacial surgeons, who routinely administer anesthesia for surgeries that include wisdom tooth extractions, dental implant placements and intricate facial reconstructive procedures, according to Dr. Alberto, who is a clinical associate professor and director of predoctoral surgery at the University of Medicine and Dentistry of New Jersey.

"OMSs, like all doctors, are caring for a growing number of patients who rely on herbal remedies as alternatives or complements to traditional treatments for medical problems," Dr. Alberto says. More than 60 million Americans over the age of 18 use at least one herb-based product on a regular basis, she notes.

"The phenomenal popularity of these substances underscores the need for OMSs to learn more about them and their potential impact on patients. Many of the patients we see are taking a slew of alternative remedies. We have to know what they're on while they're under our care," she says.

Herbals of particular concern to OMSs include those that can cause drowsiness, excessive bleeding, cardiovascular problems or that interfere with other drugs, Dr. Alberto says.

Garlic, ginseng, ginger, chamomile and gingko, among others, can cause bleeding after surgery. Valerian root and kava may interact with sedatives given by the OMS before surgery and produce excessive drowsiness. St. John's Wort, used as a mood enhancer, can interfere with the effectiveness of many heart and blood pressure medications and blood thinners. Ginseng has been associated with an increased incidence of arrhythmias (irregular heart beats). Patients who take ginseng and receive local anesthesia with epinephrine may be putting themselves at risk for cardiovascular complications. Echinacea, used widely to enhance the immune system, may inhibit wound healing and increase the risk of post-surgical infection.

To avoid these complications, "OMSs should make it standard practice to ask patients specifically about herbals and other alternative remedies when planning surgery and anesthesia care," Dr. Alberto says, adding that she takes a complete history of herbal use by the patients she treats. Consumers tend to view herbal remedies as natural, and therefore, safe from adverse effects and drug interactions, so they often don't think to tell their doctor about them, she says.

"If we know a patient is taking a supplement that could cause problems, we can ask them to stop taking it before surgery or modify the anesthesia accordingly," she says. At the same time, patients should make sure to tell their doctor about all of the substances they are taking, including herbal supplements, prescriptions and over-the-counter drugs, she says.

The fact that herbals are classified as dietary supplements, not drugs, means they are not regulated by the United States Food and Drug Administration, Dr. Alberto adds. As a result, herbals vary greatly in quality and quantity from manufacturer to manufacturer and from batch to batch, so consumers can never be sure of what they're getting.

"The big problem is that there are herbal-drug interactions. Although there are a lot of unknowns, as surgeons, it behooves us to know as much about these products as we can," she says.

The American Association of Oral and Maxillofacial Surgeons (AAOMS), the professional organization representing more than 7,000 oral and maxillofacial surgeons in the United States, supports its members' ability to practice their specialty through education, research, and advocacy. AAOMS members comply with rigorous continuing education requirements and submit to periodic office examinations, ensuring the public that all office procedures and personnel meet stringent national standards.