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Prof. Dr. Eduardo Hebling Associate Professor Coordinator of Geriatric Dentistry Specialty Program Prof. Dr. Eduardo Hebling Associate.

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Presentation on theme: "Prof. Dr. Eduardo Hebling Associate Professor Coordinator of Geriatric Dentistry Specialty Program Prof. Dr. Eduardo Hebling Associate."— Presentation transcript:

1 Prof. Dr. Eduardo Hebling Associate Professor Coordinator of Geriatric Dentistry Specialty Program Prof. Dr. Eduardo Hebling Associate Professor Coordinator of Geriatric Dentistry Specialty Program University of Campinas Piracicaba Dental School, Brazil University of Campinas Piracicaba Dental School, Brazil 26 TH Annual Meeting of SCD Chicago – April 12, 2014

2 Alzheimer`s Disease (AD) Most common form of dementia among the elderly; Progressive degenerative brain disorder that seriously affects a person’s ability to carry out their daily life activities; Jicha & Carr, : project to reach million worldwide (affecting 1 in 85 people globally); The disease is a growing public health concern with major socioeconomic burden. Brookmeyer et al., 2007 Font: Senile plaques

3 The dementia starts slowly. First affects the parts of the brain that control the thought, the memory and the language; People with AD may have difficulty to recall recent events or names of people who know; Over the time, the symptoms worsen; There is no cure for the disease; Some drugs can help prevent the symptoms becoming worse. Alzheimer`s Disease (AD)

4 Alzheimer’s Disease (AD) Lack of compliance and cooperation for the treatment Difficulties of care Oral Sedation Dental Care Manegement Ettinger R.F., 1992

5 Oral Sedation Reliance on patient compliance; Prolonged latent period; Erratic and incomplete absorption of drugs from the gastrointestinal tract; Inability to titrate; Inability to readily lighten or deepen the level of sedation; Prolonged duration of action. Reliance on patient compliance; Prolonged latent period; Erratic and incomplete absorption of drugs from the gastrointestinal tract; Inability to titrate; Inability to readily lighten or deepen the level of sedation; Prolonged duration of action. Disadvantages Almost universal acceptability; Ease of administration; Low cost; Decreased incidence of adverse reactions; Decreased severity of adverse reactions; No needles, syringes, equipment; No specialized training requirements. Almost universal acceptability; Ease of administration; Low cost; Decreased incidence of adverse reactions; Decreased severity of adverse reactions; No needles, syringes, equipment; No specialized training requirements. Advantages

6  Benzodiazepine drug with fast onset (30-60 minutes), short duration (60 minutes), prompt rate of half-life elimination (1.5 to 2.5 hr);  Sedative, anxiolytic, anticonvulsant and muscle relaxant properties;  Low toxicity level;  Hepatic metabolized and renal elimination;  Induce a short duration amnesia;  Low cost;  Easy use (oral via, one hour before the dental treatment)  Flumazenil, a benzodiazepine antagonist drug, can be used to treat an overdose or to reverse the sedation (IV: mg/h in 5% glucose) Midazolam Maleate Girdler et al., 2002 Yuan et al., 1999

7 To determine acceptance, safety and efficacy of oral Midazolam for conscious sedation in patients with Alzheimer’s Disease undergoing dental treatment. Objective

8 Material and Methods  Case report study  Approved by Ethical Committee at University of Campinas  Informed consent was obtained from the family of all patients  Developed in dentate elderly with Alzheimer’s Disease  Living in a Brazilian long-stay institution  Total population: 450 elderly

9 Material and Methods Inclusion Criteria: - Alzheimer’s Disease  Stages 6 to 7 (Reisberg’s Scale): severe to very severe cognitive decline  ASA IV

10 Material and Methods Exclusion Criteria:  Presence of respiratory disease (e.g., asthma, cystic fibrosis, emphysema, chronic obstructive pulmonary disorder –COPD)  Hypersensitivity by Midazolam  Previous use of some drugs: - Macrolide antibiotics (e.g., Azithromycin, Clarithromycin, Erythromycin) - Ketaconazole (antifungal drug) - Itraconazole (antifungal drug) - Ritonavir (antiretroviral drug) - Amprenavir (antiretroviral drug) - Nelfinavir (antiretroviral drug) - Nefazodone (antidepressant drug) - Rifampin (antibiotic for nonviral infections, such as tuberculosis) - Carbamazepine (anticonvulsant) - Phenytoin (anticonvulsant and cardiac antiarrhythmic) Yuan R, Flockhart DA, Balian JD. Pharmacokinetic and pharmacodynamic consequences of metabolism-based drug interactions with alprazolam, midazolam, and triazolam. J Clin Pharmacol. 1999; 39(11): Absolute Contraindications May cause decreased effect of Midazolam

11  Sedation: Midazolam oral (15 mg), one hour before Material and Methods The author show no conflict of interest Guo T, Mao GF, Xia DY, Su XY, Zhao LS. Pharmacokinetics of midazolam tablet in different Chinese ethnic groups. J Clin Pharm Ther. 2001; 36(3): Romano MM, Soares MS, Pastore CA, Tornelli MJ, de Oliveira Guaré R, Adde CA. A study of effectiveness of midazolam sedation for prevention of myocardial arrthymias in endosseous implant placement. Clin Oral Implant Res. 2012; 23(4): Sjövalls S, Kanto J, Kangas L, Pakkanen A. Comparison of midazolam and flunitrazepam for night sedation. Anaesthesia 1982, 37: 924–928.

12  Sedation level: was measured by Ramsay Sedation Scale  Local anesthesia: 2% lidocaine with 1:100,000 epinephrine Material and Methods

13  Pulse oximeter: Blood pressure (mmHg) Heart rate (beats/min) Respiratory rate (breaths/min) Saturation of peripheral oxygen (SpO 2 )  Sedation and behavioral scores were recorded every minute. Material and Methods

14  Security Parameters: - Hypoxemia: SPO 2 < 90%, 15 seconds - Bradycardia: heart rate < 60 beats/min - Tachycardia: heart rate > 100 beats/min - Hypotension: decrease of 20% or more in basal systolic arterial pressure rate (BSAP) - Hypertension: increase of 20% or more in basal systolic arterial pressure rate (BSAP) Material and Methods Pedersen T, Dyrlund Pedersen B, Møller AM. Pulse oximetry for perioperative monitoring (Cochrane Review). In: The Cochrane Library. Issue 1; Jorgensen JS, Schmid ER, Konig V, Faisst K, Huch A, Huch R. Limitations of forehead pulse oximetry. J Clin Monit. 1995; 11(4):

15  Analysis of variance for repeated measures: to compare changes in variable values across time;  Neuman-Keuls post hoc test: for comparison between pairs of means where the analysis of variance results were significant (P < 0.05)  Linear regression: to determine the correlation coefficients  Results was expressed by means ± SD Statistical Analysis Material and Methods

16  A total of 65 patients (26 males and 39 females)  Mean age of 72 years  The heart and respiratory mean rates for both gender were similar and within acceptable limits Results

17  The lowest mean of saturation of peripheral oxygen (SPO 2 ) was 91 % (SD=± 1.7), ranging 91 to 97 %, within safe limits. Results Pressure of arterial oxygen (PaO 2 ) Reference Scores of Acute Respiratory Distress (ARD) < 60 mmHg Saturation of peripheral oxygen (SPO2) < 90 % Partial arterial pressure of CO 2 (PaCO 2 ) > 50 mmHg Pedersen T, Dyrlund Pedersen B, Møller AM. Pulse oximetry for perioperative monitoring (Cochrane Review). In: The Cochrane Library. Issue 1; 2007.

18  Level of sedation ranged of 2 to 5.  Only one patient showed low sedation level due to concomitant use of Lorazepam in only one session.  Time of drug action after the dental care: 40 (± 15) minutes Results

19  Local anesthesia and extractions were 90% of the treatments  Of the 195 dental care sessions: 92% were performed with total acceptance, 6% with doubtful acceptance, 2% no treatment could be performed.  No complications were registered during or after the dental care treatment. Results

20 Note: Permission of the family to display images on this patient Starting the dental care Ending the dental care After 40 minutes Ramsey Level 1 (anxious, agitated, restless ) One hour before Ramsey Level 2 (co-operative, calm, oriented) Ramsey Level 2 maintained End of sedation 01 hour

21 Oral Midazolam is a safe and effective method of sedation for dental care in elderly with Alzheimer`s Disease. Conclusion

22 Prof. Dr. Eduardo Hebling University of Campinas Piracicaba Dental School, Brazil University of Campinas Piracicaba Dental School, Brazil


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