Abstract
OBJECTIVE: 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). METHODS: 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. 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). CONCLUSIONS: 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.