Evaluation of postoperative bleeding and pain following tooth extraction in patients using direct oral anticoagulants: a prospective case-control study with blinded evaluation

Abstract

Background: Patients prescribed anticoagulants, even a seemingly uncomplicated extraction can pose a significant clinical risk of protracted or substantial bleeding. The aim of this study was to evaluate postoperative bleeding, pain scores, and oral healing parameters in patients undergoing tooth extractions while continuing direct oral anticoagulant (DOAC) therapy, compared to healthy controls. Methods: A prospective, single-blind case-control study was conducted involving 211 patients receiving DOAC therapy (apixaban, dabigatran, edoxaban, rivaroxaban) and 219 healthy control participants without anticoagulant therapy. Postoperative bleeding was assessed using a five-level bleeding grade on day 7, alongside pain evaluation via the Visual Analog Scale (VAS) and clinical assessment of erythema, edema, suppuration, and bone exposure. The data were analysed using Chi-square, Kruskal-Wallis H and Mann-Whitney U tests. Significance level was considered as 0.05. Results: Minimal postoperative bleeding was observed in most patients, regardless of anticoagulation status. However, higher bleeding grades were more common in the DOAC group, particularly among rivaroxaban (grade 2–2 in 6.9% and grade 3 in 13.8%) and edoxaban (3.6% and 7.3%, respectively) takers. Pain scores were similar across groups (mean VAS: case group 4.01 ± 2.01, control group 3.95 ± 2.04; p = 0.848). Erythema/edema rates did not significantly differ between groups (p = 0.930), whereas bone exposure was more frequent in the DOAC group (p = 0.039). No significant differences in suppuration rates were found (p = 0.548). Conclusions: Continuing DOAC therapy during tooth extractions appears clinically safe when meticulous surgical techniques and local hemostatic measures are employed. Although bleeding severity may vary among different DOACs, overall outcomes remain manageable. These findings support an individualized, risk-based perioperative approach rather than routine anticoagulant discontinuation.