Postoperative bleeding risk of direct oral anticoagulants after oral surgery procedures: a systematic review and meta analysis

Direct oral anticoagulants (dabigatran, rivaroxaban, apixaban and edoxaban; DOACs) have been introduced to improve safety and superior therapeutic value compared to their predecessors such as warfarin or enoxaparin. The aim of this systematic review and meta-analysis was to assess the postoperative bleeding risk of DOACs during oral surgery procedures. Systematic searches were performed in electronic databases including PubMed, Scopus, Web of Science and Cochrane Library. Thirteen studies were included in the qualitative synthesis: two retrospective case control studies, five prospective case control studies, three cross-sectional studies, two case series and a case report; while only six studies were statistically analysed. The risk ratio of postoperative bleeding in DOACs patients was significantly greater than in healthy patients (3.04; 95% confidence interval (CI) = 1.31-7.04). This is especially true for rivaroxaban (4.13; 95% CI = 1.25-13.69), and less so for dabigatran which presented a risk ratio similar to that of healthy patients (1.00; 95% CI = 0.21-4.82). However, further research is required to support these results. Both apixaban and edoxaban were excluded from statistical analysis due to the lack of clinical studies.