Oral Bleeding in Dental Surgery for Patients Taking Direct Oral Anticoagulants: A Multimodal Exploration of Haemostasis, Management Strategies, and Clinical Outcomes.

Abstract

Background: The management of dental patients on Direct Oral Anticoagulants (DOACs) is challenged by conflicting evidence and the dual risks of bleeding and thromboembolism. This creates clinical uncertainty regarding optimal perioperative strategies and the efficacy of local haemostatic measures. This research aimed to provide a robust evidence base by synthesising existing literature and prospectively testing a promising haemostatic intervention. Methods: A multi-modal research programme was conducted, comprising: (1) systematic evidence syntheses and mapping of the literature; (2) a network meta-analysis (NMA) comparing 14 local haemostatic interventions; and (3) a single-centre randomised controlled trial (the DENT-DOAC trial). The trial randomised 50 patients on DOACs undergoing dental extractions to receive either adjunctive blue-violet light-emitting diode (LED) therapy or standard care (a haemostatic sponge). Co-primary outcomes were immediate bleeding time and postoperative bleeding incidence up to day seven. Results: Evidence syntheses confirmed that continuing DOACs is safe for low-risk procedures but highlighted low-certainty evidence and critical research gaps. The NMA identified blue-violet LED therapy as a highly promising intervention. The DENT-DOAC trial, however, yielded a definitive null result. There was no statistically significant difference between the LED and standard care groups for either immediate bleeding time (70.0 vs. 73.8 sec, p=0.871) or 4 postoperative bleeding incidence. Critically, 79.6% of participants had their DOAC therapy temporarily interrupted pre-operatively, contrary to guideline recommendations. Conclusion: Adjunctive blue-violet LED therapy offers no clinical benefit over meticulous standard care for achieving haemostasis in patients on DOACs. A meticulous standard-of-care approach is highly effective. Furthermore, this research reveals a critical implementation gap between evidence-based guidelines and real-world clinical practice concerning DOAC interruption, representing a significant and avoidable patient safety risk. Future work should focus on closing this implementation gap.