What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Patients undergoing dentoalveolar surgery on oral anticoagulants (n=29212). Intervention: Direct oral anticoagulants (DOACs) vs. Vitamin K antagonists (VKAs). Primary outcome: Bleeding events (RR 0.79, 95% CI 0.68-0.92, p=0.002).

What does this research mean for the field?

Direct oral anticoagulants reduce the risk of bleeding by 21% compared to vitamin K antagonists in patients undergoing dentoalveolar surgery, driven primarily by dabigatran. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

August 12, 2025Japanese Dental Science Review2 citationsOpen Access

Risk of bleeding with dentoalveolar surgery in patients taking direct oral anticoagulants or vitamin K antagonists: A systematic review and meta-analysis

KDKe Dou YSYue Shi BYBaoyi Yang

Key Result

Direct oral anticoagulants reduced the risk of bleeding by 21% compared to vitamin K antagonists in patients undergoing dentoalveolar surgery.

Study Design

Type

Meta-Analysis (n=29,212)

Structured PICO

Does uninterrupted therapy with DOACs reduce the risk of bleeding compared to VKAs in patients undergoing dentoalveolar surgery?

Population

29,212 patients undergoing dentoalveolar surgery across 29 studies

Intervention

Uninterrupted therapy with direct oral anticoagulants (DOACs)

Comparator

Uninterrupted therapy with vitamin K antagonists (VKAs) or controls

Outcome

Risk of bleedingsafety

In patients undergoing dentoalveolar surgery, uninterrupted DOAC therapy is associated with a lower bleeding risk compared to VKAs, though both have higher bleeding risk than controls.

Main Result

Effect estimate: RR 0.79 (95% CI 0.68-0.92)

p-value: p=0.002

Limitations

Approximately one-third of the included studies were retrospective analyses based on medical records, which may be subject to inherent biases.
The definition of bleeding varied across studies, potentially leading to overestimation or underestimation of bleeding outcomes.
The extent of invasiveness associated with dentoalveolar surgery varied across the included studies.
The overall quality of evidence was assessed as very low according to the GRADE framework.

Abstract

The aim of the present study was to assess and compare the bleeding risks in patients undergoing dentoalveolar surgery who were on uninterrupted therapy with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). Electronic database searches were performed in PubMed, Embase, Web of Science, and CENTRAL through 28 September 2024, following PICOS criteria. Two reviewers independently performed literature screening, data extraction, and assessed the risk of bias. Data were pooled to estimate risk ratios (RR) with 95 % confidence intervals (CI) using a fixed-effects model. Between-study heterogeneity was assessed with the Q statistic and I 2 . Subgroup analyses were conducted according to study characteristics, while sensitivity analyses were used to pinpoint potential sources of heterogeneity and evaluate the reliability of the results. 29 studies enrolled a total of 29,212 patients. Meta-analysis demonstrated a reduced risk of bleeding in patients receiving DOACs compared to those treated with VKAs (RR = 0.79, 95 % CI: 0.68–0.92, I 2 = 0 %, P = 0.002). Subgroup analysis revealed a significantly reduced risk of bleeding with dabigatran compared to VKAs (RR = 0.40, 95 % CI: 0.23–0.67, I 2 = 0 %, P = 0.0006). However, no statistically significant differences were found between rivaroxaban (RR = 1.08, 95 % CI: 0.84–1.39, I² = 38 %, P = 0.54), apixaban (RR = 0.88, 95 % CI: 0.64–1.3, I² = 0 %, P = 0.46), edoxaban (RR = 0.70, 95 % CI: 0.45–1.11, I² = 60 %, P = 0.13) and VKAs. Combined analyses indicated an increased risk of bleeding with DOACs compared to controls (RR = 3.23, 95 % CI: 2.18–4.78, I 2 = 24 %, P < 0.0001), as well as increased bleeding risk with VKAs (RR = 3.35, 95 % CI: 2.31–4.85, I 2 = 0 %, P ＜ 0.0001). Patients receiving DOACs or VKAs have an increased risk of bleeding during dentoalveolar surgery, but severe bleeding requiring hospitalization or causing irreversible damage is rare. Patients using DOACs appear to have a lower bleeding risk compared to those on VKAs. This difference is mainly observed in dabigatran etexilate, while it remains unclear in rivaroxaban, apixaban, and edoxaban. Current quality of evidence is very low, which should be interpreted with caution. Future studies with higher quality of evidence are required to strengthen the validity of these findings.

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