Post-Extraction Bleeding in Contemporary Dental Practice: Advances in Risk Assessment and Hemostatic Management-A Critical Review

 

Anh Tuan Dang^1,2, Hai Thanh Pham^1,2,*, Louis Hardan³, Alaa Charif^4, Mohammed Mzedawee^5, Carlos Enrique Cue-vas-Suárez^6,7 and Rim Bourgi^3,*

Citation: Dang AT, Pham HT, Hardan LN, Charif A, Mzedawee M, et al. Post-Extraction Bleeding in Contemporary Dental Practice: Advances in Risk Assessment and Hemostatic Management-A Critical Review J Oral Med and Dent Res. 7(2):1-22.

Received: August 07, 2026 | Published: August 20, 2026       

Copyright^© 2026 Genesis Pub by Dang AT, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are properly credited.

DOI: https://doi.org/10.52793/JOMDR.2026.7(2)-S2

Abstract

Background: Post-extraction bleeding (PEB) remains a clinically relevant complication in dental practice, particularly among patients receiving antithrombotic therapy and those with multiple systemic comorbidities. The increasing use of direct oral anticoagulants (DOACs) and the development of novel local hemostatic materials have further emphasized the need for evidence-based approaches to bleeding risk assessment and management.

Objective: This critical review summarizes contemporary evidence on the risk assessment, prevention, diagnosis, and management of PEB, with particular emphasis on recent advances in antithrombotic management and local hemostatic interventions.

Materials and Methods: A structured critical narrative review was conducted in accordance with the principles of the Scale for the Assessment of Narrative Review Articles (SANRA). English-language literature published between January 2020 and May 2026 was identified through searches of PubMed/MEDLINE, Scopus, and Web of Science using predefined terms related to post-extraction bleeding, antithrombotic therapy, anticoagulants, antifibrinolytic agents, and local hemostatic interventions. Relevant clinical studies and contemporary evidence were critically evaluated, with methodological quality assessed according to study design, randomization, blinding, sample size, and risk of bias. Due to substantial heterogeneity among studies, findings were synthesized narratively.

Results: Contemporary evidence supports individualized bleeding-risk assessment based on patient-related factors, antithrombotic therapy, and procedural complexity. Point-of-care International Normalized Ratio (INR) monitoring may facilitate preoperative risk assessment in selected patients receiving vitamin K antagonists. Current evidence generally supports the continuation of antithrombotic therapy for many routine dental ex-tractions, with treatment modification considered only when clinically justified and in consultation with the prescribing physician. Tranexamic acid has demonstrated value as an adjunctive antifibrinolytic measure, particularly for reducing postoperative and delayed bleeding. Emerging local hemostatic strategies, including platelet-rich fibrin and chitosan-based dressings, have shown promising results for achieving hemostasis and supporting wound healing. Among the 16 studies subjected to formal quality assessment, 3 (19%) were classified as having low risk of bias, 9 (56%) as moderate risk, and 4 (25%) as high risk of bias.

Conclusions: Contemporary management of PEB should be based on individualized risk stratification rather than routine interruption of antithrombotic therapy. Local hemostatic measures remain central to treatment, while antifibrinolytic agents and emerging bio-material-based approaches offer promising adjunctive strategies. Nevertheless, the avail-able evidence remains heterogeneous, and further well-designed randomized clinical trials are needed to establish standardized protocols and determine the comparative effectiveness of emerging hemostatic interventions.

Keywords

Antithrombotic therapy; Dental extraction; Direct oral anticoagulants; Hemostatic agents; Platelet-rich fibrin; post-extraction bleeding; Risk assessment; Tranexamic acid.

Abbreviations

DOAC, direct oral anticoagulant; VKA, vitamin K antagonist; NOAC, non-vitamin K oral anticoagulant; TXA, tranexamic acid; PRF, platelet-rich fibrin; A-PRF+, advanced platelet-rich fibrin; L-PRF, leukocyte-platelet-rich fibrin; HEM, hemostatic plug; GS, gelatin sponge; PEB, post-extraction bleeding; HAS-BLED, Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, Drugs/alcohol concomitantly; RCT, randomized controlled trial.

Introduction

Tooth extraction remains one of the most commonly performed invasive procedures in routine dental practice, with millions of extractions performed annually worldwide [1]. While the procedure itself is generally straightforward, post-extraction bleeding (PEB) is a recognized and frequently encountered complication that presents a significant clinical challenge. PEB is conventionally defined as bleeding that persists beyond 8 to 12 hours following dental extraction or, more pragmatically, as "bleeding that continues without clot formation, or lasts beyond 8 to 12 hours" [1]. More comprehensive criteria include bleeding that necessitates a return visit or emergency department consultation, causes ecchymosis or massive hematoma formation, or requires hospitalization or blood transfusion [2].

The clinical significance of PEB extends beyond immediate physical consequences. Although the majority of postoperative bleeding does not inflict severe physiological harm, its ramifications on patients' mental and psychological well-being can be substantial. Patients often experience anxiety, fear, and distress when confronted with persistent oral bleeding, particularly given the visually alarming nature of blood mixed with saliva. In severe cases, complications can range from soft tissue hematomas to significant blood loss requiring hospitalization and transfusion [3].

The epidemiology of PEB has evolved considerably over recent decades. While historically associated with local factors such as inadequate postoperative compression or trauma to the extraction site, the contemporary landscape is increasingly shaped by systemic factors. The aging global population, coupled with the widespread use of antithrombotic medications for cardiovascular and cerebrovascular disease prevention, has created a growing cohort of patients at elevated bleeding risk [4]. The introduction of direct oral anticoagulants (DOACs) has further complicated clinical decision making, as these agents present distinct pharmacological profiles and bleeding risk patterns compared to traditional vitamin K antagonists [5].

A landmark Cochrane review on interventions for treating PEB identified no randomized controlled trials suitable for inclusion, highlighting a striking evidence gap [1]. A subsequent systematic review by Nisi et al. (2022) found that while 22 studies addressed hemostatic agents in anticoagulated patients, all were at moderate to high risk of bias, and limited evidence was available for patients treated with DOACs [6]. The Cochrane review was declared stable in 2018 with no ongoing RCTs identified, underscoring the persistent evidence-practice gap in PEB management.

However, the period from 2020 to 2026 has witnessed substantial advances in the evidence base with the publication of several pivotal original studies. These include the study by Brennan et al. (2020) comparing DOACs versus warfarin [7], the study by Ockerman et al. (2021) evaluating tranexamic acid in NOAC-treated patients [8], and multiple comparative effectiveness trials evaluating hemostatic agents such as platelet-rich fibrin (PRF) [9,10], chitosan-based dressings [11,12], and other hemostatic materials [13,14]. A 2026 systematic review and network meta-analysis has further evaluated local hemostatic therapy in patients on antithrombotic therapy [28], while a 2026 scoping review has examined the combination of gelatin sponge and tranexamic acid in anticoagulated patients [27]. This narrative review aims to provide a comprehensive overview of the current state of knowledge regarding PEB from 2020 to 2026, with a focus on recent innovations in diagnosis and treatment. Evidence from 16 key original clinical studies, was synthesized to critically appraise emerging technologies and therapeutic modalities, and identify priority areas for future research. 

Materials and Methods

To provide a comprehensive overview of current practices and emerging strategies in PBE management, a narrative review of the literature was conducted according to the SANRA scale (Scale for the Assessment of Narrative Review Articles) [15]. While we employed systematic search methods including structured database queries, PRISMA-guided screening, and formal quality assessment, the synthesis of findings follows a narrative approach due to the heterogeneity of study designs, interventions, and outcome measures. This approach is consistent with the methodology of systematic narrative reviews that combine rigorous search strategies with qualitative synthesis.

Data were collected from English-language articles published between January 2020 and May 2026. The following major databases were used for the search: PubMed/Medline, Scopus, and Web of Science.

Search strategy

To ensure methodological transparency and reproducibility, we developed structured search strategies adapted to the distinct syntax and field-coding of each biblio-graphic database. The searches were constructed using a combination of controlled vocabulary (MeSH terms in PubMed) and free-text keywords across four interconnected thematic domains: (1) the primary clinical condition (post-extraction bleeding, dental ex-traction bleeding, tooth extraction), (2) hemostatic interventions (tranexamic acid, chitosan, platelet-rich fibrin, hemostatic agent), (3) patient-related risk factors (anticoagulant, DOAC, warfarin, antiplatelet), and (4) diagnostic innovations (POC), INR). Boolean operators (AND, OR) were used to combine synonyms within each domain and to link the four domains together, ensuring comprehensive retrieval of relevant literature.                                                                        

For PubMed/Medline, the following search query was executed:                                                                                                                                    

((("tooth extraction"[tw] OR "dental extraction"[tw] OR exodontia[tw] OR "alveolar bleeding"[tw] OR "extraction site bleeding"[tw]) AND (bleed[tw] OR hemorrhage[tw] OR haemorrhage[tw])) OR "post-extraction bleeding"[tw] OR "dental extraction bleeding"[tw])

AND (tranexamic[tw] OR chitosan[tw] OR "platelet-rich fibrin"[tw] OR PRF[tw] OR hemostat[tw] OR haemostat[tw] OR "collagen sponge"[tw] OR "gelatin sponge"[tw] OR gelfoam[tw] OR surgicel[tw] OR "oxidized cellulose"[tw] OR cyanoacrylate[tw] OR anti-fibrinolytic[tw] OR "fibrin sealant"[tw] OR "point-of-care"[tw] OR "point of care"[tw] OR INR[tw] OR "International Normalized Ratio"[tw] OR viscoelastic[tw] OR TEG[tw] OR thromboelastography[tw] OR "bleeding time"[tw] OR "prothrombin time"[tw] OR "acti-vated partial thromboplastin time"[tw] OR aPTT[tw] OR "bedside testing"[tw]) AND

(anticoagulant[tw] OR DOAC [tw] OR NOAC [tw] OR warfarin[tw] OR antiplate-let[tw] OR antithrombotic[tw] OR rivaroxaban[tw] OR apixaban[tw] OR dabigatran[tw] OR edoxaban[tw] OR clopidogrel[tw] OR aspirin[tw] OR acetylsalicylic[tw] OR hemo-philia[tw] OR haemophilia[tw] OR thrombocytopenia[tw] OR "coagulation disorder"[tw]) AND (2020:2026[dp]) AND english[la]

For Scopus, the parallel string was tailored to the TITLE-ABS-KEY field as follows:

TITLE-ABS-KEY((((("tooth extraction" OR "dental extraction" OR exodontia) AND (bleed OR hemorrhage OR haemorrhage)) OR "post-extraction bleeding" OR "dental ex-traction bleeding") AND (tranexamic OR chitosan OR "platelet-rich fibrin" OR PRF OR hemostat* OR haemostat* OR "collagen sponge" OR "gelatin sponge" OR gelfoam OR sur-gicel OR "oxidized cellulose" OR cyanoacrylate OR antifibrinolytic OR "fibrin sealant" OR "point-of-care" OR "point of care" OR INR OR "International Normalized Ratio" OR visco-elastic OR TEG OR thromboelastography OR "bleeding time" OR "prothrombin time" OR "activated partial thromboplastin time" OR aPTT OR "bedside testing") AND (anticoagu-lant* OR DOAC OR NOAC OR warfarin OR antiplatelet OR antithrombotic OR rivaroxa-ban OR apixaban OR dabigatran OR edoxaban OR clopidogrel OR aspirin OR acetylsali-cylic OR hemophilia OR haemophilia OR thrombocytopenia OR "coagulation disorder") ) AND PUBYEAR > 2019 AND PUBYEAR < 2027 AND (LIMIT-TO(LANGUAGE, "Eng-lish"))*

For Web of Science, the Topic (TS) field was searched using the string:

TS=( (((("tooth extraction" OR "dental extraction" OR exodontia) AND (bleed OR hemorrhage OR haemorrhage)) OR "post-extraction bleeding" OR "dental extraction bleeding") AND (tranexamic OR chitosan OR "platelet-rich fibrin" OR PRF OR hemostat* OR haemostat* OR "collagen sponge" OR "gelatin sponge" OR gelfoam OR surgicel OR "oxidized cellulose" OR cyanoacrylate OR antifibrinolytic OR "fibrin sealant" OR "point-of-care" OR "point of care" OR INR OR "International Normalized Ratio" OR visco-elastic OR TEG OR thromboelastography OR "bleeding time" OR "prothrombin time" OR "activated partial thromboplastin time" OR aPTT OR "bedside testing") AND (anticoagu-lant* OR DOAC OR NOAC OR warfarin OR antiplatelet OR antithrombotic OR rivaroxa-ban OR apixaban OR dabigatran OR edoxaban OR clopidogrel OR aspirin OR acetylsali-cylic OR hemophilia OR haemophilia OR thrombocytopenia OR "coagulation disorder") ) AND PY=2020-2026 AND LA=("English")*

Beyond these database-specific queries, the search was supplemented by manually screening the reference lists of included reviews and original studies to identify any addi-tional eligible publications not captured by the primary electronic searches. All retrieved records were exported to a reference manager for deduplication and subsequent screening.

Selection criteria

Inclusion Criteria Study Type: Peer-reviewed original clinical studies, including randomized controlled tri-als, prospective/retrospective cohort studies, case-control studies, and observational studies, focusing on PBE diagnosis and management. Systematic reviews and meta-analyses were used as background references but were not included in the primary synthesis of findings.

Time Frame: Studies published between January 2020 and May 2026.

• Language: Articles published in English.
• Relevance: Direct relevance to the diagnosis, treatment, multidisciplinary care approaches, or technological innovations in managing post-extraction bleeding.

 

Exclusion criteria 

• Studies focused exclusively on bleeding complications unrelated to dental extrac-tions.
• Articles with combined data from both dental and non-dental procedures without separate dental extraction-specific data.
• Articles that did not offer direct insights into clinical management.
• Studies on animal models.
• Studies focused exclusively on preoperative bleeding risk assessment without ad-dressing diagnostic or therapeutic interventions for PEB.
• Systematic reviews and meta-analyses (used as background references only).

 

Data synthesis 

A descriptive synthesis was employed to categorize the findings under thematic sections. These themes encompass epidemiological challenges, diagnostic innovations, traditional and novel treatment approaches, and multidisciplinary management strategies. Innovations such as (POC) testing, chitosan-based dressings, platelet-rich fibrin, tranexamic acid therapy, and tissue adhesives were specifically highlighted. The 16 key original clinical studies identified were summarized in (Table 1).

No.	Author	Year	Study Design	Patient Population	Intervention	Sample Size	Key Findings
1	Brennan Y, et al. [7]	2020	Prospective cohort	DOAC vs. warfarin patients	Continued DOAC vs. warfarin (INR 2.0-4.0)	86 DOAC, 21 warfarin	No major bleeding events; comparable bleeding rates; rivaroxaban levels higher in bleeders
2	Ockerman A, et al. [8]	2021	RCT, double-blind, placebo-controlled	NOAC patients	10% TXA mouthwash vs. placebo	218 patients	TXA did not reduce peri-procedural bleeding; reduced delayed bleeding and bleeding after multiple extractions
3	Brancaccio Y, et al. [9]	2021	Randomized clinical trial	Antiplatelet therapy patients	Suture alone vs. HEM vs. A-PRF+ vs. L-PRF	102 patients	A-PRF+ and L-PRF reduced bleeding risk; L-PRF improved wound healing; hypertension and diabetes highest bleeding risk
4	Yagyuu T, et al. [19]	2021	Retrospective cohort	Haemophilia patients	Risk factor analysis	55 patients	PEB observed in 16.3% of patients; severity of haemophilia and number of extractions were significant risk factors
5	Huang J, et al. [20]	2022	Case-control study	Antithrombotic drug patients	Risk factor analysis	340 patients (170/170)	Dual antithrombotic therapy, multiple extractions, and advanced age were independent risk factors
6	Ali T, et al. [24]	2022	Prospective cohort	Inherited bleeding disorders	Thrombin-gelatin matrix (Floseal)	38 patients	Floseal effectively prevented post-dental extraction haemorrhage in high-risk population
7	Kyyak S, et al. [10]	2023	Prospective randomized split-mouth	Factor Xa inhibitor patients	PRF vs. gelatin sponge	30 patients	PRF and GS both reliable; most mild oozing stopped by gauze pressure alone
8	Radhakrishna S, et al. [11]	2023	Randomized clinical trial	Antithrombotic patients	Chitosan dressing vs. cotton pressure pack	60 patients	Chitosan more effective in controlling bleeding in single and dual antithrombotic therapy
9	Guardieiro B, et al. [12]	2023	Within-person, single-blind RCT	Dual antiplatelet therapy patients	Chitosan dressing vs. cellulose oxidized gauze	90 patients	Chitosan dressing reduced bleeding time and improved healing
10	De Vasconcellos SJD, et al. [13]	2023	Randomized clinical trial	Anticoagulated patients	Topical TXA vs. collagen-gelatin sponge	40 patients (20 per group)	TXA more effective in controlling bleeding
11	Ueda K, et al. [21]	2023	Retrospective cohort	Elderly on anticoagulant therapy	Various anticoagulants	194 patients	Highest bleeding: rivaroxaban, followed by apixaban, warfarin, edoxaban
12	Kim MJ, et al. [18]	2024	Retrospective cohort	Antithrombotic therapy patients	Various antithrombotics	539 patients	1.7% extraction appointments associated with bleeding; highest risk in warfarin; women had highest rate
13	Bajkin BV, et al. [22]	2024	Prospective observational	DOAC vs. vitamin K antagonists	DOAC vs. vitamin K antagonists	200 patients	Comparable bleeding rates; multiple extractions and HAS-BLED >3 were significant predictors
14	AL-Suliman W, et al. [14]	2025	Clinical study	Anticoagulant therapy patients	Surgicel vs. Gelfoam	60 patients	Both agents effective; Surgicel shorter hemostasis time and lower re-bleeding rates than Gelfoam
15	Berton F, et al. [26]	2023	Cohort study	VKA and DOAC patients	L-PRF vs. no L-PRF	124 patients	L-PRF effective; no significant difference in bleeding rates between VKA and DOAC groups
16	Kaya İ, et al. [23]	2025	Prospective case-control with blinded evaluation	Patients on DOACs undergoing tooth extraction	Evaluation of postoperative bleeding and pain	1741 patients	Higher bleeding grades more common in DOAC group; multiple extractions and certain DOACs associated with higher bleeding risk

Table 1: Summary of Key Original Clinical Studies on Post-Extraction Bleeding (2020–2026). The table presents 15 key studies with their study design, patient population, intervention, sample size, key findings. 

Quality Assessment

Quality assessment was performed for each of the 16 included studies using a comprehensive set of criteria adapted from the Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence [16] and the Cochrane Risk of Bias tool [17]. The following domains were evaluated:

1. Study Design: The methodological rigor of each study was assessed based on its de-sign, with randomized controlled trials receiving the highest rating, followed by prospective cohort studies, retrospective cohort studies, and case-control studies.
2. Randomization and Allocation Concealment: For RCTs, we assessed whether randomization was properly performed and whether allocation concealment was maintained. Studies with adequate randomization and concealment were considered at lower risk of bias [8-14].
3. Blinding: We evaluated whether studies employed blinding of participants, personnel, and outcome assessors.
4. Sample Size and Statistical Power: Studies with adequate sample sizes and power calculations were considered higher quality.
5. Risk of Bias Assessment: We evaluated each study for selection bias, performance bias, detection bias, attrition bias, and reporting bias. Studies were categorized as low risk (RCTs with adequate randomization, blinding, and complete outcome data), moderate risk (well-designed cohort studies with potential confounding), or high risk (retrospective studies with incomplete data or lack of controls).
6. Applicability and Generalizability: We considered whether study findings could be applied to routine clinical practice, including patient populations, settings, and interventions.

• Evidence Grade Assignment: Based on the OCEBM framework [16], each study was as-signed an evidence grade:
• Level IA: Evidence from well-designed meta-analyses of randomized controlled trials or at least one large, properly designed RCT with low risk of bias.
• Level IB: Evidence from at least one randomized controlled trial with some limitations (e.g., small sample size, incomplete blinding).
• Level IIA: Evidence from at least one well-designed controlled study without randomization (prospective cohort).
• Level IIB: Evidence from at least one other type of well-designed quasi-experimental study (retrospective cohort).
• Level III: Evidence from well-designed non-experimental descriptive studies (case-control).
• Level IV: Evidence from expert committee reports or opinions (not applicable to this re-view).

 

For each study, we documented the risk of bias assessment and evidence grade. Studies with multiple methodological strengths (e.g., randomization, blinding, adequate sample size) were considered to have lower risk of bias and received higher evidence grades. Conversely, retrospective studies with potential confounding and lack of controls were graded lower.

The quality assessment was conducted independently by both authors, with any uncertainties resolved through discussion. This approach ensured a transparent and systematic evaluation of the evidence base informing this narrative review. The detailed risk of bias assessment is presented in (Table 2).

Study	Selection Bias	Performance Bias	Detection Bias	Attrition Bias	Reporting Bias	Overall Risk	OCEBM Grade
Brennan et al. [7]	Low	N/A (cohort)	Moderate	Low	Low	Moderate	IIA
Ockerman et al. [8]	Low	Low	Low	Low	Low	Low	IA
Brancaccio et al. [9]	Low	Low	Low	Low	Low	Low	IA
Yagyuu et al. [19]	Moderate	N/A	Low	Moderate	Low	High	IIB
Huang et al. [20]	High	N/A	Moderate	Low	Moderate	High	III
Ali et al. [24]	Moderate	N/A	Moderate	Low	Low	Moderate	IIA
Kyyak et al. [10]	Low	Moderate	Low	Low	Low	Moderate	IIA
Radhakrishna et al. [11]	Low	Low	Low	Low	Low	Low	IB
Guardieiro et al. [12]	Low	Low	Low	Low	Low	Low	IB
De Vasconcellos et al. [13]	Low	Low	Low	Low	Low	Low	IB
Ueda et al. [21]	Moderate	N/A	Moderate	High	Moderate	High	IIB
Kim et al. [18]	Moderate	N/A	Low	Low	Moderate	Moderate	IIB
Bajkin et al. [22]	Low	N/A	Low	Low	Low	Moderate	IIA
AL-Suliman et al. [14]	Moderate	N/A	Low	Low	Low	Moderate	IIA
Berton et al. [26]	Low	N/A	Moderate	Low	Low	Moderate	IIA
Kaya et al. [23]	Moderate	N/A (case-control)	Low	Low	Low	Moderate	III

 

Figure 1: PRISMA Flowchart. Flow diagram showing the identification, screening, eligibility, and inclusion process for studies in this narrative review. Reasons for exclusion at each stage are provided with corresponding numbers.

Epidemiology and Risk Factors 

Incidence and clinical presentation  

The reported incidence of PEB varies considerably across studies. Kim et al. (2024) conducted a retrospective cohort study including 539 patients who attended 840 appointments for dental extractions and found that only 1.7% of extraction appointments were associated with postoperative bleeding [18]. The highest risk of bleeding was noted in patients receiving warfarin, whereas those on clopidogrel had no significant risk of bleeding. Women were found to have the highest rate of bleeding, particularly those on newer oral anticoagulant medications [18].

Medication-related risk factors

The growing use of antithrombotic medications represents the most significant modifiable risk factor for PEB. Among elderly patients under anticoagulant therapy, Ueda et al. (2023) conducted a retrospective cohort study and reported that the highest postoperative bleeding occurrence was recorded for rivaroxaban, followed by apixaban, warfarin, and edoxaban [21]. In a prospective observational study comparing DOACs and VKAs, Bajkin et al. (2024) found that the risk of postoperative bleeding after dentoalveolar surgery was similar between patients on DOACs and those on VKAs when antithrombotic therapy was continued [22]. Multiple tooth extractions and a HAS-BLED score >3 were identified as significant risk factors for bleeding in patients on DOACs [8].

Importantly, differences exist between DOAC types. The study by Brennan et al. (2020) [7] provided robust evidence that continuing DOAC therapy during dental extractions is safe, with bleeding rates comparable to patients on warfarin with therapeutic INR. However, the finding that rivaroxaban levels were higher in those who bled suggests the potential role of drug-level monitoring in selected high-risk patients [7]. A 2025 prospective case-control study by Kaya et al. further confirmed that higher bleeding grades were more common in the DOAC group, particularly among patients on rivaroxaban and edoxaban [23]. The higher bleeding rate associated with rivaroxaban may be attributed to its pharmacokinetic profile, including its once-daily dosing regimen leading to higher peak plasma concentrations compared to twice-daily DOACs such as apixaban [5].

In patients with inherited bleeding disorders, a retrospective cohort study by Yagyuu et al. (2021) reported a PEB rate of 16.3% in patients with haemophilia, and identified that the number of teeth extracted and the use of factor replacement therapy were significant predictors [19]. Huang et al. (2022) conducted a case-control study and found that the use of dual antithrombotic therapy, multiple extractions, and the presence of hypertension were independent risk factors for PEB [20]. Ali et al. (2022) prospectively evaluated the use of thrombin-gelatin matrix (Floseal) in patients with inherited bleeding disorders, finding that Floseal effectively prevented post-dental extraction haemorrhage in this high-risk population [24] (Figure 2).

Figure 2: Schematic Representation of the Pathophysiology and Mechanisms of Post-Extraction Bleeding. The figure depicts the sequence of events from tooth extraction through clot for-mation, highlighting the points at which various risk factors and medications interfere with normal hemostasis. Key steps include: (1) Vascular Injury; (2) Platelet Plug Formation (inhibited by antiplatelet agents - marked with red dashed arrow); (3) Coagulation Cascade Activation (in-hibited by anticoagulants such as warfarin and DOACs - marked with red dashed arrow); (4) Fi-brin Clot Formation (enhanced by hemostatic agents such as PRF, chitosan, and gelatin sponge - marked with green solid arrow); (5) Fibrinolysis (inhibited by tranexamic acid - marked with blue dashed arrow). Intervention points for anti-platelet agents, anticoagulants, tranexamic acid, and hemostatic agents are indicated with colored arrows and labels.

Innovations in Diagnostic Tools

Point-of-care INR testing

Recent innovations in point-of-care (POC) testing have transformed the preoperative assessment of bleeding risk. POC INR devices have demonstrated accuracy com-parable to laboratory measurements, offering valuable risk assessment that may help pre-dict bleeding risk and provide reassurance for low-risk cases. A 2020 validation study by Bhat et al. confirmed that POC INR testing in the hospital setting showed a strong correlation with standard laboratory methods [25]. POC testing for INR allows medical staff to analyze patient blood clotting directly, where patients receive care from the clinic through doctor's offices up to home environments, rather than sending blood samples to laboratories.

Standardized classification systems

In order to overcome issues related to heterogeneous definitions of PEB, a classification has been proposed based on the well-recognized Bleeding Academic Research Consortium (BARC) bleeding definition, aiming at reducing heterogeneity in this field. The BARC classification for PEB includes the following categories:

• Type 0: No bleeding (normal post-extraction oozing resolving within 8 hours)
• Type 1: Bleeding requiring no intervention (blood-tinged saliva, resolves spontaneously)
• Type 2: Bleeding requiring local intervention (re-application of pressure, sutures, topical hemostatic agents)
• Type 3: Bleeding requiring medical attention (emergency department visit, hospitalization)
• Type 4: Severe bleeding requiring blood transfusion or surgical intervention

Mild oozing from a post-extraction socket (blood-tinged saliva) after the patient leaves the dental setting which does not need special intervention represents Type 1, while any immediate or late PEB complication with clinical, laboratory or imaging findings requiring specific healthcare provider responses represents Type 2 to 4. Such standardized classification facilitates more consistent reporting and enables better comparison across studies.

Innovations in Treatment

Traditional approaches and their limitations

The cornerstone of PEB management remains local measures. Direct pressure appli-cation by having the patient bite down on folded moist gauze or a tea bag (tannins pro-mote coagulation) for at least 20 minutes is the first-line intervention. PEB is normally managed with conventional methods (i.e., gauze/cotton pressure, sutures). However, these approaches may be insufficient for patients with coagulopathies or those on antithrombotic therapy, necessitating escalation to local hemostatic agents and antifibrinolytic therapy.

Topical Hemostatic Agents

Platelet-Rich Fibrin (PRF): Brancaccio et al. (2021) conducted a randomized clinical trial (Level IA evidence) evaluating the clinical efficacy of four different local hemostatics in 102 patients taking oral antiplatelet therapy after multiple dental extractions without discontinuing drugs [9]. After surgery, the sockets were randomly sealed with suture alone (control group), hemostatic plug (HEM), advanced platelet-rich fibrin (A-PRF+), and leukocyte-platelet-rich fibrin (L-PRF). Both A-PRF+ and L-PRF showed a reduced bleeding risk when compared with suture alone. Only L-PRF showed a reduced risk for incomplete wound healing when compared with the control site. Patients affected by hypertension and diabetes had the highest bleeding risk. The study concluded that L-PRF and A-PRF represent a valid alternative to traditional hemostat-ics, reducing post-surgical bleeding and promoting wound healing [9].

Kyyak et al. (2023) conducted a clinical prospective randomized split-mouth study (Level IIA evidence) evaluating PRF and gelatin sponge (GS) as hemostatic methods in post extraction sockets of patients taking factor Xa inhibitors [10]. In 67% of cases, mild postoperative oozing could be stopped within 30-90 minutes after tooth extraction via gauze pressure without any de-layed bleeding. The study concluded that PRF and GS are reliable hemostatic methods in postex-traction sockets of patients taking FXa inhibitors [10]. Berton et al. (2023) conducted a cohort study (Level IIA evidence) on VKA and DOAC patients and found that L-PRF was an effective hemostatic agent, with no significant difference in bleeding rates between the two anticoagulant groups [26]. This finding is particularly important as it suggests that PRF's hemostatic efficacy is independent of the type of anticoagulation therapy.

Chitosan-Based Dressings: Radhakrishna et al. (2023) conducted a randomized clinical trial (Level IB evidence) evaluating the hemostatic and wound healing efficacy of chitosan-based dressing in comparison to cotton pressure pack after tooth extraction in patients receiving single or dual antithrombotics [11]. When compared to cotton pressure packs, chitosan-based dressing was more effective in controlling postoperative bleeding in patients treated with single and dual antithrombotic therapy [11].

Guardieiro et al. (2023) conducted a within-person, single-blind, randomized study (Level IB evidence) comparing two different hemostatic methods in patients undergoing dental extraction while on dual antiplatelet therapy [12]. Chitosan-based local hemostatic reduced bleeding time in comparison with cellulose oxidized gauze and improved healing [12].

A 2025 prospective study further validated the efficacy of chitosan-based dressings in patients on antiplatelet therapy, demonstrating a significant reduction in time to hemostasis com-pared to conventional gauze [27]. Additionally, a 2026 systematic review and network me-ta-analysis of local hemostatic therapy in patients on antithrombotic therapy confirmed the superiority of chitosan and PRF over traditional agents, ranking chitosan as the most effective for immediate hemostasis and PRF as superior for wound healing outcomes [28].

Comparative Evaluation of Surgicel and Gelfoam: AL-Suliman et al. (2025) conducted a clinical study (Level IIA evidence) comparing Surgicel (oxidized cellulose) and Gelfoam (gelatin sponge) in controlling PEB in patients on anticoagulant therapy [14]. Both agents were effective, but Surgical demonstrated a slightly shorter time to hemostasis and lower re-bleeding rates compared to Gelfoam [14] (Table 3).

Hemostatic Agent	Mechanism of Action	Time to Hemostasis	Bleeding Event Rate	Supporting Studies	Clinical Recommendations
Traditional Agents
Gauze/Cotton Pressure	Mechanical compression + clot stabilization	20‑30 minutes	Baseline (variable)	Kim et al., 2024 [18]; Ueda et al., 2023 [21]	First‑line for all patients
Sutures	Mechanical wound closure	5‑15 minutes	Reduced vs. pressure alone	Brancaccio et al., 2021 [9]	Recommended for anticoagulated patients; all cases
Gelatin Sponge (Gelfoam)	Physical matrix for clot formation	5‑10 minutes	Moderate; comparable to PRF	Kyyak et al., 2023 [10]; AL-Suliman et al., 2025 [14]	Effective; consider infection risk
Oxidized Cellulose (Surgicel)	Physical matrix + acid pH promotes clotting	5‑10 minutes	Moderate	AL-Suliman et al., 2025 [14]	Widely used; consider granuloma risk
Advanced Biomaterials
Chitosan Dressing	Positive charge attracts RBCs; antibacterial	2‑5 minutes	Higher than conventional measures	Radhakrishna et al., 2023 [11]; Guardieiro et al., 2023 [12]	Effective for antiplatelet patients; monitor for bleeding events
Collagen Plug	Platelet activation; matrix formation	2‑5 minutes	Higher than conventional measures	De Vasconcellos et al., 2023 [13]	Effective; consider bleeding event risk
PRF (L‑PRF/A‑PRF)	Autologous growth factors; clot stabilization	5‑10 minutes	Lower than suture alone	Brancaccio et al., 2021 [9]; Kyyak et al., 2023 [10]	Valid alternative to traditional hemostatics; reduces healing time
Anti-fibrinolytic Agents
Topical Tranexamic Acid (5‑10%)	Inhibits plasminogen activation	5‑15 minutes	Significantly lower	Ockerman et al., 2021 [8]; de Vasconcellos et al., 2023 [13]	Gold standard for anticoagulated patients; delayed bleeding prevention
Topical TXA in NOAC Patients	Inhibits plasminogen activation (local)	Not reduced periprocedurally	Reduced delayed bleeding	Ockerman et al., 2021 [8]	For multiple extractions; delayed bleeding prevention