Balancing Bleeding and Thrombosis in Dental Management of Patients on Novel Oral Anticoagulants: A Narrative Evidence Synthesis

This narrative review explored the perioperative hemostatic challenges posed by novel oral anticoagulants (NOACs) in dental practice, synthesizing evidence on strategies to equilibrate bleeding and thrombotic risks during oral surgical interventions. A structured literature search across major databases, supplemented by manual searching of guidelines and conference proceedings from inception up to October 2025, prioritized high-quality trials, cohorts, and consensus documents while excluding isolated case reports. Pharmacokinetic variability among agents, such as rapid renal clearance of dabigatran versus mixed hepatic-biliary pathways for factor Xa inhibitors, guides precise timing of dose omission, with renal function emerging as a critical modifier. Risk stratification integrates thrombotic propensity via clinical scoring with procedural bleeding potential and classifies interventions from low (supragingival scaling) to high (extensive flap surgery). Evidence robustly supports uninterrupted anticoagulation for minor procedures when paired with local hemostatics; topical tranexamic acid, absorbable matrices, and primary closure effectively contain postoperative oozing. Moderate- to high-risk surgeries benefit from trough-timed interruptions, typically one skipped dose for twice-daily agents and two for once-daily, combined with minimally invasive techniques including flapless implantology, piezoelectric osteotomy, and laser coagulation. Reversal agents, including idarucizumab for dabigatran and andexanet alfa for apixaban, edoxaban, and rivaroxaban, remain emergency-only tools because of their logistical and prothrombotic constraints. Multidisciplinary preoperative consultation refines decisions in complex cases. Despite consistent observational safety signals, randomized dental-specific data are limited, bleeding definitions are heterogeneous, and the long-term thrombotic consequences of brief pauses are underexplored. Real-world confounders, such as renal decline, polypharmacy, and inflammation, are underrepresented. Nonetheless, this narrative review enables safe continuation in most scenarios, minimizing morbidity through pharmacokinetic awareness, local hemostatic rigor, and surgical conservatism. Future prospective registries with standardized outcomes are essential to validate interruption thresholds and adjunctive modalities in this expanding anticoagulation population.