Dou Ke, Shi Yue, Yang Baoyi, Zhao Zhiguo
Department of Stomatology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, 321 Zhongshan Road, Nanjing 210008, China.
Department of Stomatology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Heping District, Shenyang 110004, China.
Jpn Dent Sci Rev. 2025 Dec;61:188-199. doi: 10.1016/j.jdsr.2025.08.002. Epub 2025 Aug 12.
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. 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 = 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 = 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 = 24 %, P < 0.0001), as well as increased bleeding risk with VKAs (RR = 3.35, 95 % CI: 2.31-4.85, I = 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.
本研究旨在评估和比较接受牙牙槽外科手术的患者在持续使用直接口服抗凝剂（DOACs）或维生素K拮抗剂（VKAs）治疗时的出血风险。
按照PICOS标准，于2024年9月28日前在PubMed、Embase、Web of Science和CENTRAL中进行电子数据库检索。两名研究者独立进行文献筛选、数据提取并评估偏倚风险。采用固定效应模型汇总数据以估计风险比（RR）及95%置信区间（CI）。用Q统计量和I²评估研究间异质性。根据研究特征进行亚组分析，同时采用敏感性分析确定异质性的潜在来源并评估结果的可靠性。
29项研究共纳入29212例患者。荟萃分析表明，与接受VKA治疗的患者相比，接受DOACs治疗的患者出血风险降低（RR = 0.79，95% CI：0.68 - 0.92，I² = 0%，P = 0.002）。亚组分析显示，与VKA相比，达比加群的出血风险显著降低（RR = 0.40，95% CI：0.23 - 0.67，I² = 0%，P = 0.0006）。然而，利伐沙班（RR = 1.08，95% CI：0.84 - 1.39，I² = 38%，P = 0.54）、阿哌沙班（RR = 0.88，95% CI：0.64 - 1.3，I² = 0%，P = 0.46）、依度沙班（RR = 0.70，95% CI：0.45 - 1.11，I² = 60%，P = 0.13）与VKA之间未发现统计学显著差异。综合分析表明，与对照组相比，DOACs的出血风险增加（RR = 3.23，95% CI：2.18 - 4.78，I² = 24%，P ＜ 0.0001），VKA的出血风险也增加（RR = 3.35，95% CI：2.31 - 4.85，I² = 0%，P ＜ 0.0001）。
接受DOACs或VKA治疗的患者在牙牙槽外科手术期间出血风险增加，但需要住院治疗或导致不可逆损害的严重出血很少见。与使用VKA的患者相比，使用DOACs的患者出血风险似乎较低。这种差异主要在达比加群酯中观察到，而在利伐沙班、阿哌沙班和依度沙班中尚不清楚。当前证据质量非常低，应谨慎解读。需要更高质量证据的未来研究来加强这些发现的有效性。
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