The search was conducted in October 2024 by four independent, calibrated reviewers. Rayyan software (Rayyan Systems, Toronto, Canada) was used to screen and filter records retrieved from electronic databases.⁽¹¹⁾

This study addressed the following focused question: What is the efficacy of topical TXA powder in controlling bleeding and preventing hemorrhagic complications following dental surgery?

Clinical studies, case reports, and letters to the editor involving patients undergoing oral surgery and reporting the topical use of crushed TXA tablets were included.

Reviews, conference abstracts, editorials, in vitro studies, animal studies, and studies describing topical TXA use as ready-to-use mouthwash solutions, injectable formulations, or systemic administration rather than crushed tablets were excluded. Studies focusing on major surgical procedures, such as cardiovascular or orthopedic surgery, were also excluded.

The intervention consisted of adjunctive hemostatic measures during or after dental surgical procedures, specifically the topical application of TXA prepared from tablets. The tablets were either crushed and applied directly to the surgical site or diluted in saline, with evaluation focused on bleeding control.

The review assessed the effectiveness of powdered TXA in controlling intraoperative hemorrhage and managing postoperative bleeding, building on the established efficacy of other formulations. Application techniques were compared, including direct placement of crushed tablets, paste preparations, and aqueous dilutions. Dosage, frequency of application, and the type of oral procedure—such as biopsy, dental extraction, and periodontal surgery—were also examined to evaluate the efficacy of TXA across different clinical settings.

The search was conducted across several major electronic databases with comprehensive coverage of medical and scientific literature, including the National Library of Medicine MEDLINE/PubMed, Scopus, Embase, BVSalud, Web of Science, and the Portal de Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). Reference lists of included studies were also screened. Duplicate records identified across databases were removed using EndNote software. No restrictions were applied regarding language, publication date, or geographic region.

A comprehensive search strategy was developed to identify studies evaluating the topical or local application of TXA at surgical sites. The strategy was adapted for each database to maximize retrieval of relevant articles. Searches were performed using title, abstract, and keyword fields in all databases (Table 1S, Supplementary Material).

Two independent, blinded reviewers conducted all stages of the literature search using Rayyan software. Studies with titles and abstracts meeting the eligibility criteria were included. When titles or abstracts were unavailable or provided insufficient information, full texts were retrieved and assessed. Articles fulfilling the inclusion criteria were selected accordingly. Disagreements between reviewers were resolved through discussion with a third reviewer until consensus was achieved.

The following data were extracted from each included study: first author's surname, year of publication, country of origin, study design, sample size and study groups, type of surgical procedure, references related to TXA, method of topical TXA application, and outcomes related to bleeding control.

Quality assessment was performed independently by two reviewers, with disagreements resolved through discussion. The included studies were evaluated using validated tools to assess risk of bias. For cohort, case-control, prospective, and retrospective studies, the Newcastle-Ottawa Scale⁽¹²⁾ was applied in accordance with Cochrane Collaboration guidance for non-randomized studies. This scale evaluates three domains: participant selection, group comparability, and outcome assessment. Studies received one star for each criterion met, with higher scores indicating lower risk of bias; 7-9 stars indicated low risk, 4-6 stars moderate risk, and fewer than 4 stars high risk.

The Joanna Briggs Institute (JBI) Critical Appraisal Checklists⁽¹³⁾ were used for clinical trials and case reports. For clinical trials, the checklist assessed allocation concealment, blinding, similarity of treatment between groups, completeness of follow-up, appropriateness of statistical analysis, and clarity of outcome reporting. For case reports, the JBI checklist evaluated clarity of patient information, clinical history, diagnostic methods, treatment, outcomes, adverse events, relevance of discussion, and clinical implications. Studies meeting at least 70% of JBI criteria were classified as low risk of bias, those meeting 40%-69% as moderate risk, and those meeting less than 40% as high risk (Table 2S, Supplementary Material).

This review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. The study protocol was registered in the Open Science Framework (https://osf.io/n5mbp).

A total of 1,127 records were identified across electronic databases: 143 from PubMed, 245 from Web of Science, 205 from BVSalud, 496 from Scopus, 25 from Periódicos CAPES, and 13 from Embase. After removal of 22 duplicates, 1,105 titles and abstracts were screened. Of these, 1,057 records provided insufficient information for eligibility assessment and were therefore excluded. Forty-eight articles met the eligibility criteria based on title and abstract and were retrieved for full-text review. Two articles were excluded at this stage for not meeting the inclusion criteria. Full-text assessment was performed for 46 articles, of which 36 were excluded for predefined reasons. Ultimately, 10 studies were included in the review.^{(4,10,14–21)} The study selection process is illustrated in figure 2.

Of the 10 included studies, three were retrospective studies, two were clinical trials, and two were prospective cohort studies. The remaining three articles comprised one case-control study, one case report, and one letter to the editor (Table 1). All included articles underwent critical appraisal to assess risk of bias (Table 2S, Supplementary Material).

Six studies used 250-mg TXA tablets,^{(4,10,14–17)} whereas three studies used 500-mg TXA tablets.^(18–20) Only one study applied TXA powder without specifying the exact concentration.⁽²¹⁾ These details are summarized in table 1.

Most studies reported the use of TXA as crushed tablets mixed with saline and applied as a paste directly to the surgical site, often in combination with gelatin or collagen hemostatic sponges.^(4,15-18,21) One study used TXA suspended in water and applied with wet cotton wool, a technique adapted for patients with hemophilia.⁽¹⁹⁾ In several studies, TXA paste mixed with saline was applied directly into the dental alveolus without the use of hemostatic sponges.^(10,14,20) These application methods are summarized in table 1.

For postoperative bleeding control, various TXA mouthwash formulations were described. Three studies recommended a TXA mouthwash prepared by dissolving one tablet in 100 mL of cold saline, used four times daily for seven postoperative days.^(15–17) Another protocol involved a mouthwash containing 500 mg of TXA used for two minutes, four times daily for four days.⁽¹⁸⁾ A different regimen recommended holding the mouthwash in the mouth for three minutes every six hours for seven days.⁽¹⁴⁾

Across the included studies, all participants had an underlying coagulation disorder. These conditions were medication-related, resulting from the use of antithrombotic agents, hereditary in origin, or associated with systemic diseases such as liver disease. Most studies involved individuals receiving antithrombotic therapy,^(15,21) including antiplatelet agents,⁽¹⁰⁾ vitamin K antagonists,^(4,14,18) or direct oral anticoagulants⁽¹⁶⁾ (Table 1). Two of the remaining studies focused on patients with hereditary bleeding disorders, namely hemophilia⁽¹⁹⁾ and Glanzmann thrombasthenia,⁽²⁰⁾ whereas one study evaluated bleeding risk in patients with liver disease⁽¹⁷⁾ (Table 1).

Among the included studies, eight focused exclusively on bleeding risk associated with dental extractions,^{(4,10,15,16,18-21)} whereas one study also evaluated periodontal therapy⁽¹⁴⁾ and another included oral biopsy.⁽¹⁷⁾ These procedures are summarized in table 1.

All studies addressed bleeding management in individuals at high risk of hemorrhage undergoing dental surgical procedures. In every case, adjunctive local hemostatic measures, including topical application of TXA tablets, were effective in controlling bleeding (Table 1). Bernardoni-Socorro et al.⁽¹⁴⁾ reported successful bleeding control in anticoagulated patients using local measures combined with TXA. Coetzee⁽¹⁹⁾ identified crushed TXA tablets as a cost-effective option in resource-limited settings. Buhatem et al.,⁽¹⁰⁾ Rocha et al.,^(4,15,16) and Lu et al.⁽²¹⁾ demonstrated that TXA, often combined with other hemostatic measures, enabled safe dental treatment without interruption of anticoagulant or antiplatelet therapy. Bhavyaa et al.⁽²⁰⁾ described the use of a TXA-soaked splint for bleeding control in a patient with Glanzmann thrombasthenia. Souza et al.⁽¹⁷⁾ showed that TXA effectively reduced bleeding complications, hospitalizations, and transfusion requirements in patients with liver disease (Table 1).