Anticoagulant effects of phytotherapeutic drugs and their importance in surgical dental procedures

Phytotherapeutic drugs are plant-derived products with medicinal properties. They are used for treating or preventing several diseases. However, patients who use these substances and even health professionals are unaware of their negative effects. One of the most common negative effects of phytotherapeutic drugs reported in the literature is the inhibition of natural coagulation factors in the human body. Therefore, the aim of this study was to perform a brief review of the literature concerning the anticoagulant effects of phytotherapeutic drugs and their importance in surgical dental procedures. Preventive measures, clarification and monitoring of patients taking phytotherapeutic drugs are recommended before performing surgical dental procedures, in order to prevent against complications such as hemorrhage. Indexing terms: Blood coagulation factors. Phytotherapeutic drugs. Surgical dental procedures


INTRODUCTION
Alternative substances for treating or preventing several diseases have aroused the interest of the population around the world, including natural substances and phytotherapeutic drugs [1][2][3][4][5] .
Phytotherapeutic drugs are plant-derived products with medicinal properties.The literature contains several medical indications for their use, with significant positive results that include antimicrobial, anti-inflammatory and anti-oxidant effects [6][7] .Nonetheless, considering the many countries where they are produced and marketed 8 , it could be reasonably assumed that the general population may use them without a medical or dental prescription, Anticoagulant effects of phytotherapeutic drugs and their importance in surgical dental procedures as an adjuvant in capillary treatment, and for the treatment of varicose veins and hemorrhoids [18][19] .It interferes with platelet function and with the coagulation action of warfarin 5,21 and other drugs 18 .Therefore, its use must be avoided before surgical dental procedures.

Ginkgo biloba (Gingko biloba)
Gingko biloba is a substance widely used by the population around the world in the form of gel and capsules to treat vascular disorders 18 , aid cognitive development 14 , prevent dementia 12 and Alzheimer's disease 10 , and treat macular degeneration, tinnitus and erectile 10 .Its antiplatelet action has already been reported [1][2][3][4][5] , although there are controversies on this matter 22 .
The anticoagulant effects of Ginkgo biloba have been reported mainly when this substance is used in combination with allopathic drugs, such as warfarin 5 , heparin 18 , aspirin 1,11,19,23 , and ibuprofen 24 .Therefore, dentists must be attentive to patients taking Ginkgo biloba, particularly when this substance is associated with other drugs of high hemorrhagic potential, before performing surgical procedures.

Ginseng (Panax ginseng)
Panax ginseng is used for preventing against states of physical and mental fatigue 18 , for strengthening the immune system 19 , for its aphrodisiac, antidepressant and diuretic properties, and for preventing cardiovascular disorders 4 .Its interaction with warfarin has already been established 25 .However, some studies do not corroborate these findings [26][27] .Therefore, further studies are needed on this subject.
In brief, many studies have found scientific evidence regarding the antiplatelet properties or drug interactions regarding the substances addressed in this study.These properties and interactions have demonstrated the potentiation of their hemorrhagic effects.Therefore, preventive measures, clarification and monitoring of patients taking these substances are recommended before performing surgical dental procedures, in order to prevent against complications such as hemorrhage.

Collaborators
L COSME-SILVA, JR OLIVEIRA, FD MARTINHO and CH FERRARI participated in the design, organization and writing of the article.LF CUBA and RICARDO MACHADO were responsible for critical review and writing of the article.

Garlic (Allium sativum)
Allium sativum can be consumed in the form of tablets or capsules containing powder or oil, or else applied topically.Several medicinal properties have been reported, such as antimicrobial, anti-hypertensive, antithrombotic, antimutagenic and fibrinolytic effects, as well as glucose-reducing platelet activity.It is also indicated for decreasing cholesterol and treating arteriosclerosis 12 .However, its anticoagulant effect has been proven in studies that have demonstrated a reduction in platelet activity, leading to hemorrhage 4,13 .This effect may be further heightened by its combined use with allopathic medications, such as acetylsalicylic acid, warfarin and other drugs 12,[14][15] .
Therefore, it is recommended that Allium sativum be suspended at least one week before a surgical dental procedure 10 .In case of combined used with warfarin, this recommendation is even more important, because of the likelihood of high interaction 5,10 .

Chilean boldo (Peumus boldus)
Concentrated Peumus boldus solution is widely used for the treatment of digestive and liver disorders 5 .However, its possible antiplatelet effects have already been described in the literature 5,[16][17] .When Peumus boldus is used alone in high doses and/or in association with allopathic drugs, platelet dysfunctions may be even greater.Therefore, it is recommended that the use of Peumus boldus be suspended before performing surgical dental procedures 18 .

Chamomile (Matricaria recutita)
Matricaria recutita can be used as an essential oil, in capsule or liquid form.It has several medicinal properties, such as anti-inflammatory, antispasmodic [18][19] sedative and antiseptic effects.It is indicated for the treatment of flatulence, digestive disorders and nasal mucositis 19 .However, Matricaria recutita also may act on platelet function, and consequently increase the risk of hemorrhage 11,14 .Although cases of interaction with warfarin have already been reported as leading to hemorrhage 20 , this link has not yet been clearly established.Nevertheless, because of its possible antiplatelet action and probable interaction with others drugs 5,20 , its use should be suspended preventively prior to surgical dental procedures.

Indian horse chestnut (Aesculus hippocastanum)
Aesculus hippocastanum can be taken in the form of tablets, capsules, gels or creams.This substance is used