Medicines you should tell your surgeon about before surgery

If you remember only one sentence from this article, make it this: give your surgeon a list of all your medicines, and do not stop, reduce or increase any medicine on your own. The decision about each medicine is made together by the surgeon and the doctor who prescribed it.

Why does the surgeon need to know every medicine?

MyOMS says to tell the surgeon about all medicines and supplements, even ones you think are unimportant, because they may interact with anaesthesia and with the medicines used after the operation. The same source, in its discussion of complications, writes that heavy or prolonged bleeding after an extraction is unusual, and that some medicines raise the risk. With the list in hand, the surgeon can plan your care in advance and, if needed, coordinate with your own doctor.

MedlinePlus recommends writing a list that includes prescription medicines, over-the-counter medicines, ones you take now and then, vitamins, supplements and herbal products, with the amount and how often you take them. The NHS also says to tell the pre-operative assessment nurse about all medicines, vitamins and herbal supplements, and to bring your medicines along with the list.

Which groups matter most?

Blood thinners and antiplatelet medicines

MedlinePlus names blood thinners such as warfarin, clopidogrel and apixaban, as well as anti-inflammatory pain relievers such as aspirin, ibuprofen and naproxen. This source writes that, starting about two weeks before surgery, the surgeon may give specific instructions about medicines that carry a bleeding risk, and that you should ask which of your regular medicines to take on the day of surgery. If such an instruction is needed, the surgeon and your own doctor decide it together.

Two risks are involved: bleeding during surgery, and the risk of dangerous clots if a medicine is stopped. For this reason, the decision is not yours to make. Two studies show that medicine still has no single approach:

• A prospective study in BMC Oral Health looked at patients on an oral blood thinner who were having a tooth extracted and whose medicine was not stopped during surgery. Local agents were used to control bleeding in this study. Most patients managed mild bleeding themselves, and no major bleeding needing hospital admission or a blood transfusion was reported, but some patients had bleeding that needed prompt attention. The authors noted that a break in the medicine raises the risk of a vessel being blocked by a clot.
• Another systematic review in the same journal says that minor oral surgery seems safe for patients taking these medicines, but whether to continue or stop the medicine for oral surgery is still debated and needs more research.

These two texts are not advice for you. Their message is that the decision should be made with the knowledge of both the surgeon and your own doctor. See also the after-surgery care guide.

Osteoporosis medicines, bisphosphonates and similar drugs

Bisphosphonates (oral or injected), denosumab and some anti-cancer medicines are linked to a rare complication called medication-related osteonecrosis of the jaw. A comprehensive review in Int J Implant Dent, which summarised several guidelines and position papers including the AAOMS position paper, says:

• The complication is rare, and it is seen more often in cancer patients who receive these medicines in high doses than in osteoporosis patients. In osteoporosis it has been reported very rarely.
• In a review of 3,198 bisphosphonate-related cases, about 62 percent began with a tooth extraction. Extraction is the most commonly reported local factor. Implant placement and gum disease are also on the list of factors.
• Older age, diabetes, smoking and cortisone use are among the reported factors.
• For a patient who has not yet started the medicine, it is preferable to have the mouth and teeth checked and any needed treatment done before starting, with the start time set by the prescribing doctor.
• A dentist should not decide about stopping these medicines in patients with a serious condition such as cancer, and the review writes that stopping the medicine to prevent this complication is generally not recommended.

What does this mean for you? If you take an osteoporosis medicine or a similar cancer medicine, or are about to start one, tell your surgeon before an extraction, an implant or any other surgery. Say which medicine and since when. Do not stop the medicine yourself.

Diabetes medicines and insulin

The NHS says that if you use insulin, the care team needs to know. MedlinePlus writes that keeping a condition such as diabetes under control lowers the risk of problems after surgery. Instructions for diabetes medicines on the day of surgery come only from your surgeon and your own doctor, because they relate to fasting.

Heart valve disease

If you have an artificial heart valve, a past heart valve infection or certain congenital heart conditions, say so before any mouth surgery. The ADA, drawing on heart guidelines, writes that these patients sometimes need a preventive antibiotic before dental work. That decision belongs to the surgeon and the heart specialist.

Radiotherapy to the head and neck

This one is not a medicine, but it matters just as much. The Canadian Cancer Society writes that damage to the jaw after radiotherapy, including a tooth extraction, raises the risk of osteoradionecrosis, the loss of part of the jawbone because of radiation. It can appear years later. So mention any radiotherapy, even if it was long ago, before any extraction or surgery.

Cortisone and immune-suppressing medicines

The review above lists cortisone and immune-suppressing medicines among the medicines and conditions that, together with bisphosphonates, have been linked to higher risk. So write them on your list and leave the decision about them to your doctor.

Supplements, vitamins and herbal medicines

MedlinePlus lists vitamin E alongside medicines that carry a bleeding risk, and says to include vitamins, supplements and natural remedies on your list too. “It’s natural” is not a reason to leave something out.

Smoking, alcohol and drugs

MyOMS says smoking slows healing and raises the risk of complications, and that alcohol can interact with anaesthetic medicines. MedlinePlus asks you to mention how much alcohol you drink and any drug use. The aim is not to judge you; it is anaesthetic safety.

What should you tell the surgeon at the visit?

• A list of medicines and supplements with the amount and how often you take them
• Allergies, especially to medicines and latex
• A history of bleeding and clotting
• Any problem with a previous surgery or anaesthetic
• Past illnesses and operations, and whether a new medicine is about to be started
• An artificial heart valve and any radiotherapy to the head and neck
• Smoking, alcohol and any substance you use

The first visit guide and preparing for surgery cover these in more detail.

If you remember after the visit that you did not mention something

Call the clinic promptly. MedlinePlus says that if you come down with an illness such as a cold or a fever before surgery, you should also let them know right away, because the operation may be postponed. In both cases, do not stop or add a medicine on your own.

What questions should you ask?

• Which of my medicines affect bleeding or healing?
• Will the surgeon coordinate with my own doctor, or do I need to follow up myself?
• If you give an instruction about a medicine, will you give it to me in writing?
• Which of my medicines should I take on the day of surgery?
• What sign after surgery means I should call right away? Warning signs