Periodontal Disease, Matrix Metalloproteinases andChemically Modified Tetracyclines
From the Department of Periodontology, Faculty of Dentistry, University of Oslo, Oslo, Norway
Correspondence to: Svein Steinsvoll, Sagvollveien 1, 2830 Raufoss, Norway. Tel.: / 47 61191481; Fax: /4761191481; E-mail: [email protected]
Microbial Ecology in Health and Disease 2004; 16: 1 /7
Matrix metalloproteinases (MMPs) are crucial in the degradation of the main components in the extracellular matrix and thereby playimportant roles in cell migration, wound healing and tissue remodelling. MMPs have pathogenic roles in arthritis, periodontitis, hepatitis,glomerulonephritis, atherosclerosis and cancer cell invasion. MMPs are activators of pro-inflammatory mediators that occur in latent forms,such as interleukin (IL)-1b, membrane-bound tumour necrosis factor (TNF) and different MMPs. To regulate their action, MMPs aresecreted in latent, inactive pro-enzyme forms, with plasmin and other MMPs as likely activators. MMP activity is further modulated by thetissue inhibitors of metalloproteinases (TIMP-1, -2, -3 and -4), which partly control and stabilize MMPs. In normal steady-state tissues, onlylow levels of MMPs are detected intra- and extra-cellularly because MMPs are tightly regulated at the level of transcription and secretion. Ininflamed periodontal tissue, numbers of cells expressing MMPs are increased as compared with healthy gingival tissue. Recently, novel non-antimicrobial MMP-inhibitory effects of tetracyclines were discovered, and subsequently a panel of chemically modified non-antimicrobialtetracyclines (CMTs) was developed. This paper discusses these new drugs and their possible biological effects in periodontal disease.
participate in the tissue breakdown occurring in period-
Accumulation of bacteria at the dentogingival margin
induces gingival inflammation and may trigger periodontaldisease. The host generates inflammation adjacent to the
periodontal pocket as a defence against the microbial
Matrix metalloproteinases (MMPs) are crucial in the
threat. Leukocytes including plasma cells, lymphocytes,
degradation of main components in extracellular matrix
macrophages and neutrophils are known to infiltrate
and thereby play important roles in cell migration, wound
the gingival tissue (1) and have been studied in great
healing and tissue remodelling (16 /18). MMPs have
detail, but only modest attention has been given to mast
pathogenic roles in arthritis, periodontitis, hepatitis, glo-
cells (2). Yet, mast cells are important multifunctional cells
merulonephritis, atherosclerosis and cancer cell invasion
in the first line of defence against bacterial and parasitic
(16 /23). MMPs are activators of pro-inflammatory media-
infections (3 /7), and occur in numbers comparable to
tors that occur in latent forms, such as interleukin (IL)-1b,
macrophages in the inflamed periodontal lesion (8). Mast
transforming growth factor-b1 (TGF-b1), membrane-
cells can secrete a range of substances that regulate
bound tumour necrosis factor (TNF)-a and different
angiogenesis, tissue remodelling and wound healing, which
MMPs (16 /18, 24, 25). To regulate their action, MMPs
include both degradation and synthesis of tissue compo-
are secreted in latent, inactive pro-enzyme forms, with
nents (9). A recent study showed that the numbers of
plasmin and other MMPs as likely activators (16 /18).
gingival mast cells are markedly increased in the gingival
MMP activity is further modulated by the tissue inhibitors
tissue of HIV-infected persons with periodontitis as com-
of metalloproteinases (TIMP-1, -2, -3 and -4), which partly
pared with HIV counterparts (8). The increase in mast cell
control and stabilize MMPs (16 /18, 26). In normal steady-
numbers was pronounced (10-fold) even in the early
state tissues, only low levels of MMPs are detected intra-
stages of HIV infection, indicating that this could be an
and extra-cellularly because MMPs are tightly regulated at
HIV-induced effect (8). As patients with HIV infection
the level of transcription and secretion (16 /18). In inflamed
display increased susceptibility to periodontitis (10 /15),
periodontal tissue, numbers of cells expressing MMPs are
there may be a link between mast cells and periodontal
increased as compared with healthy gingival tissue (16,
breakdown. We therefore wanted to explore whether mast
27 /30). It was recently shown that gingival mast cells
cells have properties that indicate that they can directly
strongly expressed MMP-1, MMP-2 and MMP-8, and to a
# Taylor & Francis 2004. ISSN 0891-060X
Microbial Ecology in Health and Disease
Periodontitis, MMPs and CMTs
lesser degree TIMP-1/-2 (31) (Figs. 1 and 2). Higher
PERIODONTAL DISEASE AND CHEMICALLY
numbers of MMP- and TIMP-positive mast cells were
MODIFIED TETRACYCLINES (CMTS)
detected in inflamed as compared with healthy gingiva. This
Periodontal disease is the major cause of tooth loss in the
indicates that mast cells are likely to play an important role
adult population, characterized by destruction of the
in inflammation and tissue degradation in periodontal
collagen fibres and other matrix constituents of the gingiva,
periodontal ligament and alveolar bone. Although the
Fig. 2. Microphotographs of double immunostaining of mast cell tryptase (in red) with (in green) TIMP-1 (a) and TIMP-2 (b) in a gingivalbiopsy from an HIV patient with CMP. Overlapping colours (double-stained) appear in yellow. Blue colour is nuclear staining with DAPI.
Single staining from the indicated field is displayed to the right for TIMP-1/TIMP-2 (in green) and mast cells (in red). (a) Left: TIMP-1-expressing mast cells below the oral gingival epithelium (yellow). Some intra-epithelial mast cells can also be seen (red cells). Right: Singleexposures show staining for TIMP-1 (TIMP-1) and mast cell tryptase (MC) separately. (b) Left: TIMP-2-expressing mast cells below thepocket epithelium (yellow). Right: Single exposures show staining for TIMP-2 (TIMP-2) and mast cell tryptase (MC) separately. Originalmagnification /4.
Fig. 1. Microphotographs of double immunostaining for mast cell tryptase (in red) with (in green) MMP-1 (a /d), MMP-2 (e, f), or MMP-8(g, h) in a biopsy from an HIV patient with chronic marginal periodontitis (CMP). Blue colour is nuclear staining with DAPI. Overlappingcolors (double-stained) appear in yellow. (a) MMP-1-producing mast cells (in yellow) subjacent to oral gingival epithelium. (b) Singleexposure of mast cell tryptase and (c) MMP-1. (d) Double exposure of (b) and (c), showing partial co-localization of MMP-1 and mast celltryptase (yellow). (e) MMP-2-producing mast cells below pocket epithelium (red cells with yellow spots). (f) Higher magnification of fieldindicated in (e). White broken lines indicate the lumen of two MMP-2-venules, and an arrow points to a probably emigrating MMP-2-cell. (g) Inflammatory cell infiltrate below the pocket epithelium, showing MMP-8 mast cells (yellow and orange cells). MMP-8 mast cellswere often found within the dense parts of inflammatory cell infiltrates. (h) MMP-8 mast cells were often seen close to blood vessels (whitebroken line /blood vessel lumen). Original magnifications: /40 (a, h), /60 (b /d), /25 (e), /100 (f), /20 (g).
Fig. 3. Potential outcomes of gingival and periodontal infection. As a first line of defence against infection, the host tries to preventmicroorganisms from colonizing the tissue (epithelial barriers, antibacterial substances in saliva). If immune exclusion is unsuccessful,microbes or their products may penetrate or invade gingival and periodontal tissues. This will induce immune elimination systems(phagocytosis, complement activation, generation of specific immune processes mediated by B and T cells). If the invading agents are clearedaway, the tissue will become healthy again. If clearance fails, chronic infection of the gingival or periodontal tissue ensues. This is a balanced(but dynamic) condition where the infection is restrained physically (encapsulation) and functionally (phagocytosis and bacterial cell lysis).
Pro- and anti-inflammatory agents are kept in balance and the disease remains non-progressive (gingivitis or quiescent periodontitis).
Periodically, however, the balance may be disturbed, either by increasing strength of the attack or diminished defence by the host, andprogressive loss of gingival and periodontal tissue may occur (active or necrotizing periodontitis). CMTs reduce the MMP activity, thegeneration of inflammatory cytokines such as IL-1, IL-6 and TNF, and the subsequent release of prostaglandins.
microflora, primarily the anaerobic gram-negative micro-
pocket by mechanical debridement and can also involve the
organisms that accumulate in the gingival crevice, initiate
use of topical or systemic antibiotics as an adjunct. A novel
this inflammatory disease in the gingival tissues, the
approach currently gaining interest is the use of ‘host-
connective tissue breakdown that occurs in this disease,
modulating therapy', which attempts to supplement the
and subsequently in the deeper periodontal tissues, is
traditional antimicrobial treatment strategies with drugs
mediated by excessive levels of activated MMPs (and other
that (1) inhibit the production of inflammatory mediators,
proteases such as serine proteases and neutrophilic elas-
such as prostaglandins and pro-inflammatory cytokines, or
tase), produced by host cells (e.g. neutrophils, macrophages,
(2) block the production and activity of host-generated,
mast cells, epithelial cells, endothelial cells, fibroblasts,
tissue-destructive proteinases such as the MMPs (33).
osteoblasts, osteoclasts), overcoming the endogenous pro-
teinase inhibitor (e.g. TIMPs, a2-macroglobulin) shield (32).
mediated bone resorption, are a third category of host-
Treatment of periodontal disease has traditionally fo-
modulating drugs that are currently being explored as
cused on the reduction of bacterial ‘load' in the periodontal
adjuncts in the treatment of periodontal disease; these
Periodontitis, MMPs and CMTs
Fig. 4. Biological roles of CMTs in inflammation and wound healing. In early phases of inflammation and at low concentrations, CMTs maymodulate integrin expression on endothelial cells (1). CMTs will counteract the effects of TGF-b1 being chemotactic for mast cells,monocytes, neutrophils and fibroblasts, and enhance expression of enzymes (e.g. matrix metalloproteinases) that are important forextravasation and migration in the extracellular matrix (2). In the inflamed area, increasing levels of TGF-b1 activate and stimulate theleukocytes to secrete pro-inflammatory cytokines and growth factors (3), and to further increase expression of surface molecules such asFcgRIII for more effective phagocytosis (4). As the leukocytes are activated they alter their TGF-b1 receptor expression and becomesusceptible to deactivation and growth arrest (5). Fibroblasts that early in inflammation produce collagenases are later induced by TGF-b1 todecrease their protease production. The fibroblasts are further stimulated to increase the production of protease inhibitors such as tissueinhibitor of metalloproteinase-1 (TIMP-1), plasminogen activator inhibitor-1 (PAI-1), and to synthesize matrix molecules (6). Finally, TGF-b1 is an IgA switch factor (7). Solid lines indicate pro-inflammatory effects while dashed lines indicate anti-inflammatory and wound healingeffects. CMTs will favour a shift of the local microenvironment towards an anti-inflammatory anabolic situation with matrix and collagendeposition, partly due to lower MMP activity and increased activity of MMP inhibitors and reduced activity of inflammatory cytokines (e.g.
IL-1, IL-6, TNF) and prostaglandins.
compounds were also recently reported to exhibit MMP-
regulation of MMP expression, and the protection of
inhibitory properties (34). With regard to the second
endogenous MMP and serine proteinase inhibitors from
therapeutic strategy, Golub et al. (35) discovered that
proteolytic or oxidative inactivation (37). Numerous dis-
tetracyclines (TCs) can inhibit collagenase and other
eases may be beneficially affected by TCs and CMTs
MMPs by non-antimicrobial mechanisms, and subse-
including periodontitis, various types of arthritis, sterile
quently developed a series of chemically modified TC
corneal ulcers, aortic aneurysms and cancer invasion and
analogues (called CMT-1 /10) that lost their antimicrobial
metastasis. CMT-3 and CMT-8 were found to be the most
activity but retained (and even showed enhanced) MMP-
potent inhibitors of MMPs and bone resorption in tissue
inhibitory properties (36 /39). These TCs and CMTs are
culture (39 /41). CMT-3 has been extensively tested and
now recognized to have multiple mechanisms of action,
found to be effective as an inhibitor of cancer cell gelatinase
including the inhibition of already active MMPs, the
activity in vitro, cancer cell invasiveness in culture, and
inhibition of activation of latent pro-MMPs, the down-
cancer metastasis in rats in vivo (42, 43). CMT-8 has been
tested as a potential therapeutic agent in animal models of
ME, Strober W, Bienenstock J, McGhee JR, eds. Mucosal
bone loss because of its potent efficacy as an inhibitor of
Immunology. San Diego: Academic Press, 1999: 469 /82.
8. Myint M, Steinsvoll S, Yuan ZN, Johne B, Helgeland K,
both bone resorption and cartilage destruction in culture,
Schenck K. Highly increased numbers of leukocytes in inflamed
and bone/cartilage-type collagenase (MMP-13) activity in
gingiva from patients with HIV infection. AIDS 2002; 16: 235 /
vitro (39, 40), as well as in other diseases such as diabetes
(38). Consistent with the animal studies, Scarpellini et al.
9. Galli SJ. Mast cells and basophils. Curr Opin Hematol 2000; 7:
(44) found that the administration of a 3-month regimen of
a regular antimicrobial dose of doxycycline to postmeno-
10. Winkler JR, Robertson PB. Periodontal disease associated with
HIV infection. Oral Surg Oral Med Oral Pathol Oral Radiol
pausal women produced shifts in serum and urine markers
Endod 1992; 73: 145 /50.
of bone resorption (e.g. hydroxyprolinuria) and bone
11. Yeung SC, Stewart GJ, Cooper DA, Sindhusake D. Progression
formation (e.g. serum alkaline phosphatase and osteocalcin)
of periodontal disease in HIV seropositive patients. J Period-
consistent with a partial normalization of the high-turnover
ontol 1993; 64: 651 /7.
bone loss seen in these osteoporotic women. As described
12. Holmstrup P, Westergaard J. Periodontal diseases in HIV-
infected patients. J Clin Periodontol 1994; 21: 270
by Cianco and Ashley (45), sub-antimicrobial (low-dose)
13. Lamster IB, Grbic JT, Bucklan RS, Mitchell-Lewis D, Rey-
regimens of doxycycline (shown to suppress MMP activity
nolds HS, Zambon JJ. Epidemiology and diagnosis of HIV-
in gingival crevicular fluid and in gingival tissues of
associated periodontal diseases. Oral Dis 1997; 3: 141 /8.
periodontitis patients), administered to humans in long-
14. Lamster IB, Grbic JT, Mitchell-Lewis D, Begg MD, Mitchell
term double-blind studies, significantly reduced the severity
A. New concepts regarding the pathogenesis of periodontaldisease in HIV infection. Ann Periodontol 1998; 3: 62
of periodontal disease, including alveolar bone loss.
15. Robinson PG. Which periodontal changes are associated with
Referring again to periodontal disease, although micro-
HIV infection? J Clin Periodontol 1998; 25: 278 /85.
bially induced and mediated by excessive activity of host-
16. Birkedal-Hansen H, Moore WG, Bodden MK, Windsor LJ,
generated MMPs and other tissue-destructive proteinases, it
Birkedal-Hansen B, DeCarlo A, et al. Matrix metalloprotei-
is now recognized that this local oral disease can be
nases: a review. Crit Rev Oral Biol Med 1993; 4: 197 /250.
exacerbated by certain systemic and environmental factors
17. Nagase H. Activation mechanisms of matrix metalloprotei-
nases. Biol Chem 1997; 378: 151 /60.
(e.g. several IL-1 gene polymorphisms, HIV infection,
18. Parsons SL, Watson SA, Brown PD, Collins HM, Steele RJ.
diabetes and smoking). Figures 3 and 4 indicate possible
Matrix metalloproteinases. Br J Surg 1997; 84: 160 /6.
biological effects of CMTs in periodontal pathogenesis.
19. Parsons SL, Watson SA, Collins HM, Griffin NR, Clarke PA,
CMTs have so far been shown to have beneficial effects in
Steele RJ. Gelatinase (MMP-2 and -9) expression in gastro-
the treatment of chronic periodontal disease. However, the
intestinal malignancy. Br J Cancer 1998; 78: 1495 /502.
20. McCawley LJ, Matrisian LM. Matrix metalloproteinases:
mainstay and gold standard in the treatment of periodontal
multifunctional contributors to tumor progression. Mol Med
disease is still mechanical debridement of the infected root
Today 2000; 6: 149 /56.
surfaces. CMTs are an important adjunct to this standard
21. Martignetti JA, Aqeel AA, Sewairi WA, Boumah CA, Kam-
treatment. Studies are needed to further uncover the
bouris M, Mayouf SA, et al. Mutation of the matrix
pathogenesis of periodontal disease and to develop new
metalloproteinase 2 gene (MMP2) causes a multicentric
drugs that help to facilitate resolution of such inflammatory
osteolysis and arthritis syndrome. Nat Genet 2001; 28: 261 /5.
22. Vu TH. Don't mess with the matrix. Nat Gen 2001; 28: 202 /3.
23. Wielockx B, Lannoy K, Shapiro SD, Itoh T, Itohara S,
Vandekerckhove J, et al. Inhibition of matrix metalloprotei-nases blocks lethal hepatitis and apoptosis induced by tumornecrosis factor and allows safe antitumor therapy. Nat Med
2002; 7: 1202 /8.
1. Page RC, Schroeder HE. Pathogenesis of inflammatory period-
24. Hazuda DJ, Strickler J, Kueppers F, Simon PL, Young PR.
ontal disease. A summary of current work. Lab Invest 1976; 33:
Processing of precursor interleukin 1 beta and inflammatory
disease. J Biol Chem 1990; 265: 6318 /22.
2. Zachrisson BU, Schultz-Haudt SD. A comparative histological
25. Gearing AJ, Beckett P, Christodoulou M, Churchill M,
study of clinically normal and chronically inflamed gingivae
Clements J, Davidson AH, et al. Processing of tumour necrosis
from the same individuals. Odontol Tidskr 1968; 6: 179
factor-alpha precursor by metalloproteinases. Nature 1994;
3. Echtenacher B, Mannel DN, Hultner L. Critical protective role
370: 555 /7.
of mast cells in a model of acute septic peritonitis. Nature 1996;
26. Matrisian LM, Ganser GL, Kerr LD, Pelton RW, Wood LD.
Negative regulation of gene expression by TGF-beta. Mol
4. Nilsson G, Metcalfe DD. Contemporary issues in mast cell
Reprod Dev 1992; 32: 111 /20.
biology. Allergy Asthma Proc 1996; 17: 59
27. Tonetti MS, Freiburghaus K, Lang NP, Bickel M. Detection of
5. Malaviya R, Ikeda T, Ross E, Abraham SN. Mast cell
interleukin-8 and matrix metalloproteinases transcripts in
modulation of neutrophil influx and bacterial clearance at sites
healthy and diseased gingival biopsies by RNA/PCR. J Period-
of infection through TNF-alpha. Nature 1996; 381: 77 /80.
ont Res 1993; 28: 511 /3.
6. Abraham SN, Arock M. Mast cells and basophils in innate
28. Ingman T, Sorsa T, Michaelis J, Konttinen YT. Immunohisto-
immunity. Semin Immunol 1998; 10: 373 /81.
chemical study of neutrophils- and fibroblast-type collagenases
7. Lin T-J, Befus AD. Mast cells and eosinophils in mucosal
and stromelysin-1 in adult periodontitis. Scand J Dent Res
defenses and pathogenesis. In: Ogra PL, Mestecky J, Lamm
1994; 102: 342 /9.
Periodontitis, MMPs and CMTs
29. Westerlund U, Ingman T, Lukinmaa PL, Salo T, Kjeldsen L,
multiple non-antibacterial mechanisms. Adv Dent Res 1998;
Borregaard N, Tjaderhane L, Konttinen YT, Sorsa T. Human
12: 12 /26.
neutrophils, gelatinase and associated lipocalin in adult and
38. Ryan ME, Ramamurthy NS, Golub LM. Matrix metallopro-
localized juvenile periodontitis. J Dent Res 1996; 75: 1553 /63.
teinases and their inhibition in periodontal treatment. Curr
30. Tervahartiala T, Pirila E, Ceponis A, Maisi P, Salo T, Tuter G,
Opin Periodontol 1996; 3: 85 /96.
Kallio P, Tornwall J, Srinivas R, Konttinen YT, Sorsa T. The in
39. Greenwald RA, Golub LM, Ramamurthy NS, Chowdhury M,
vivo expression of collagenolytic matrix metalloproteinases
Moak SA, Sorsa T. In vitro sensitivity of the three mammalian
(MMP-2, -8, -13, and -14) and matrilysin (MMP-7) in adult
collagenases to tetracycline inhibition: relationship to bone and
and localized juvenile periodontitis. J Dent Res 2000; 79: 1969 /
cartilage degradation. Bone 1998; 22: 33 /8.
40. Rifkin BR, Vernillo AT, Golub LM, Ramamurthy NS.
31. Næsse EP, Schreurs O, Helgeland K, Schenck K, Steinsvoll S.
Modulation of bone resorption by tetracyclines. Ann N Y
Matrix metalloproteinases and their inhibitors in gingival mast
Acad Sci 1994; 732: 165 /80.
cells in persons with and without HIV-infection. J Periodont
41. Ramamurthy NS, Golub LM, Gwinnett AJ, Salo T, Ding Y,
Res 2003; 38: 575 /82.
Sorsa T. In vivo and in vitro inhibition of matrix metallopro-
32. Birkedal-Hansen H. Role of cytokines and inflammatory
teinases including MMP-13 by several chemically modified
mediators in tissue destruction. J Periodont Res 1993; 28:
tetracyclines (CMTs). In: Davidovitch Z, Mah J, eds. Biological
Mechanisms of Tooth Eruption, Reabsorption and Replace-
33. Golub LM, Wollf M, Roberts S, Lee H, Leung M, Payonk GS.
ment by Implants. Boston: Harvard Soc Adv Orthodont, 1998:
Treating periodontal diseases by blocking tissue-destructive
enzymes. J Am Dental Assoc 1994; 125: 163 /9.
42. Lokeshwar BL, Seltzer MG, Dudak SM, Bloch LN, Golub
34. Teronen O, Konttinen YT, Lindquist C, Salo T, Ingman T,
LM. Inhibition of tumor growth and metastasis by oral
Lauhio A, Ding Y, Santivirta S, Valleala H, Sorsa T. Inhibition
administration of a non-antimicrobial tetracycline analog
of matrix metalloproteinase-1 by dichloromethylene bispho-
(CMT-3), and doxycycline in a metastatic prostate cancer
sphonate (clodronate). Calcif Tissue Int 1997; 61: 59 /61.
model. Int J Cancer 2002; 98: 297 /309.
35. Golub LM, Lee HM, Nemiroff A, McNamara TF, Kaplan R,
43. Seftor REB, Seftor EA, De Larco JE, Kleiner DE, Leferson J,
Ramamurthy NS. Minocycline reduces gingival collagenolytic
Stetler-Stevenson WG, McNamara TF, Golub LM, Hendrix
activity during diabetes: preliminary observations and a
MJC. Chemically-modified tetracyclines inhibit human mela-
proposed new mechanism of action. J Periodont Res 1983;
noma cell invasion and metastasis. Clin Exp Metastasis 1998;
18: 516 /26.
16: 217 /25.
36. Golub LM, Ramamurthy NS, McNamara TF, Greenwald RA,
44. Scarpellini F, Scarpellini L, Andreassi S, Cosmi EV. Doxycy-
Rifkin BR. Tetracyclines inhibit connective tissue breakdown:
cline may inhibit postmenopausal bone damage: preliminary
new therapeutic implications for an old family of drugs. Crit
observations. Ann N Y Acad Sci 1994; 732: 493 /4.
Rev Oral Biol Med 1991; 2: 297 /322.
45. Cianco S, Ashley R. Safety and efficacy of sub-antimicrobial
37. Golub LM, Lee HM, Ryan ME, Giannobile WV, Payne J,
dose doxycycline therapy in patients with adult periodontitis.
Sorsa T. Tetracylines inhibit connective tissue breakdown by
Adv Dent Res 1998; 12: 27 /31.
Framework for Continuous Palliative Sedation Therapy in Canada Dean MM1, Cellarius V2, Henry B3, Oneschuk D4, and Librach L5 Preamble Sedation is a commonly used procedure in many medical disciplines including palliative care. It is indicated for a variety of reasons and the type of sedation varies considerably. For example, intentional temporary sedation is sometimes used for procedures (chest-tube insertion, endoscopy, etc.) or insomnia whereas at other times sedation is unintentional (sometimes called secondary or consequential sedation) such as when sedation occurs as a side-effect of a drug being used to control a symptom. Thus the topic of sedation in palliative care practice is vast and complex. To develop this framework the authors reviewed the international literature and palliative sedation policies and protocols from within and without Canada. Recommendations from the first draft were presented at two workshops to full-time and part-time palliative care physicians and to family physicians and a subsequent draft based on feedback from the workshops was then sent to selected inter-professional reviewers across Canada. Their feedback was incorporated into the next draft and this was sent to members of the Canadian Society of Palliative Care Physicians (CSPCP) who were then surveyed for their level of agreement with the recommendations. There was a 29.3% response with over 70% agreement with all but three of the recommendations. This final document addresses planned sedation for management of intolerable and refractory symptoms. It does not address emergency sedation e.g. for an acutely agitated and delirious patient.
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