Do I need to stop apixaban (anticoagulant) for scaling and root planing?

Management of Apixaban for Scaling and Root Planing

For patients taking apixaban who require scaling and root planing, the anticoagulant should be continued without interruption as this is considered a low bleeding risk dental procedure.

Classification of Bleeding Risk

Scaling and root planing falls into the category of minor dental procedures with low bleeding risk. According to multiple guidelines, these procedures can be safely performed without interrupting anticoagulation therapy:

• The French Working Group on Perioperative Hemostasis (GIHP) classifies minor dental procedures as low bleeding risk interventions 1
• The American College of Chest Physicians (ACCP) specifically recommends continuing anticoagulation for minor dental procedures 1
• The European Heart Rhythm Association (EHRA) practical guide states that oral anticoagulation should not be interrupted for most minor procedures where bleeding is easily controllable 1

Management Algorithm for Scaling and Root Planing

Pre-Procedure Assessment:

1. Confirm the patient is on apixaban (standard dose is typically 5mg twice daily)
2. Verify that scaling and root planing is the only planned procedure
3. No additional action required regarding medication adjustment

During Procedure:

1. Implement local hemostatic measures:
   • Use of local anesthesia with vasoconstrictors
   • Application of absorbable hemostatic dressings if needed
   • Consider tranexamic acid mouth rinse before and after procedure

Post-Procedure Care:

1. Resume normal apixaban dosing schedule without interruption
2. Provide patient with instructions for managing minor bleeding:
   • Apply pressure with gauze for 15-20 minutes if bleeding occurs
   • Avoid vigorous mouth rinsing for 24 hours
   • Soft diet for 24 hours

Evidence Supporting Continuation

The EHRA practical guide explicitly states: "It is recommended not to interrupt oral anticoagulation for most minor surgical procedures and those procedures where bleeding is easily controllable" 1. Dental procedures, including scaling and root planing, fall into this category.

The ACCP guidelines similarly suggest "continuing VKAs with coadministration of an oral prohemostatic agent" for minor dental procedures rather than stopping anticoagulation 1.

Important Considerations

• Local hemostatic measures are usually sufficient to control any bleeding during and after scaling and root planing
• No bridging therapy is required as apixaban is not being interrupted 1
• Bleeding risk is minimal with proper technique and local hemostatic measures
• Thrombotic risk from interruption outweighs the bleeding risk for minor dental procedures

Potential Pitfalls to Avoid

1. Unnecessary interruption: Stopping apixaban unnecessarily increases thrombotic risk without providing significant benefit for bleeding control
2. Inadequate local hemostasis: Ensure proper local hemostatic measures are employed
3. Lack of communication: Ensure the dental provider is aware of the patient's anticoagulation status
4. Patient anxiety: Reassure patients that minor bleeding is expected and manageable

For more extensive dental procedures with higher bleeding risk, different protocols would apply, but for routine scaling and root planing, continuing apixaban without interruption is the recommended approach to balance bleeding and thrombotic risks effectively.