Bleeding Outcomes After Dental Extraction in Patients Under Direct-Acting Oral Anticoagulants vs. Vitamin K Antagonists: A Systematic Review and Meta-Analysis

Abstract

Background: The current systematic review aimed to compare bleeding outcomes in dental extraction patients receiving uninterrupted Direct-acting oral anticoagulant (DOAC) or Vitamin K antagonists (VKAs) for various systemic diseases.Methods: PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases were searched for randomized controlled trials, controlled clinical trials, prospective and retrospective cohort studies, and case control studies, conducted on adult patients undergoing dental extraction under uninterrupted DOAC or VKAs therapy and reporting bleeding outcomes. The search was conducted up to March 31, 2021. We pooled data to calculate risk ratios (RR) with 95% confidence intervals (CI) in a random-effects model.Results: Eight studies comparing 539 patients on DOAC therapy and 574 patients on VKAs were included. Meta-analysis indicated a statistically significant lower bleeding risk in patients under DOAC therapy (RR 0.68 95% CI 0.49, 0.95 I2 = 0%). However, on sensitivity analysis, the results were statistically non-significant after exclusion of any of the included studies. On pooled analysis of limited number of studies, we found no statistically significant difference in the risk of bleeding between apixaban (RR 0.85 95% CI 0.45, 1.60 I2 = 0%), rivaroxaban (RR 0.95 95% CI 0.36, 2.48 I2 = 45%), dabigatran (RR 0.49 95% CI 0.19, 1.28 I2 = 5%), edoxaban (RR 0.41 95% CI 0.13, 1.27 I2 = 0%) and VKAs.Conclusion: The results of the first review comparing bleeding outcomes after dental extraction in patients on uninterrupted DOAC or VKA therapy indicates that patients on DOAC may have a reduced risk of hemorrhage. Current evidence is of very low-quality and should be interpreted with caution. Data on individual DOAC is scarce and at this point, the difference in the risk of bleeding between these drugs cannot be elucidated. Further studies with a large sample size shall supplement our conclusion.

Edoxaban use in the context of dental procedures: analysis from the EMIT-AF/VTE database

“…The authors concluded that the accumulating data on management strategies strongly favour continuing anticoagulation before, during, and immediately after invasive dental procedures [ 6 ]. Collectively, the evidence in this review and other studies suggests similar or reduced bleeding risk during dental procedures with NOACs vs VKAs [ 6 , 7 , 14 – 16 ]. Notably, these studies generally did not describe management strategies aside from continuous anticoagulation and were not able to distinguish whether interruption patterns varied by anticoagulant [ 6 , 7 , 14 – 16 ].…”

“…Notably, these studies generally did not describe management strategies aside from continuous anticoagulation and were not able to distinguish whether interruption patterns varied by anticoagulant [ 6 , 7 , 14 – 16 ]. While most studies recommended continuing anticoagulation through dental procedures, clinical practice regarding edoxaban management varied by procedure type, and some form of interruption was common, underscoring the need for studies reporting interruption patterns and outcomes of dental procedures for individual NOACs [ 6 , 7 , 14 – 16 ].…”

“…Based on prior studies with VKAs and clinician experience with performing dental procedures without interrupting anticoagulants, continuous anticoagulation with non–vitamin K oral anticoagulants (NOACs; also known as direct oral anticoagulants) is also recommended, which is supported by head-to-head studies demonstrating similar or reduced bleeding rates with NOACs vs VKAs for dental procedures [ 5 – 7 ]. However, because of their short half-life and fast onset and offset, brief periprocedural interruption of NOAC treatment is easier than interruption of VKA therapy [ 3 ].…”

Systematic review on the effects of the discontinuation of the anticoagulant therapy and the postoperative bleeding, in patients under new oral anticoagulants after dental extraction

“…The study of Wenbing Hua et al . ( 16 ) has reported that the outcomes for bleeding was less excessive for patients taking DOACs in comparison with the group of VKAs patients and the bleeding risk was also lower. One of the limitations of the present review is that the hemostatic measures are different in the studies, which can influence the bleeding rate.…”

Local Tranexamic Acid for Preventing Hemorrhage in Anticoagulated Patients Undergoing Dental and Minor Oral Procedures: A Systematic Review and Meta-Analysis

“…However, for low-risk dental or oral procedures, both VKAs such as warfarin and DOACs may be safely continued unless the patients are on multiple medications or with renal insufficiency [ 40 ]. In the context of bleeding risk following dental procedures, there are mixed reports that DOACs are safer to use than VKAs [ 41 , 42 ], with data supporting better outcomes of post-procedural bleeding with DOACs and concomitant use of local hemostatic agents [ 43 , 44 ].…”