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Author: Kanchan Ganda, M.D.
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1. Cardiopulmonary Diseases

Cardiac:

  • Rheumatic fever (RF)
  • Rheumatic heart disease (RHD)
  • Hypertension
    • Primary
    • Secondary

Pulmonary:

  • Sinusitis
  • Asthma
  • Chronic obstructive pulmonary disease (COPD)

2. Cardiac Conditions

2.1. Rheumatic Fever

Strep throat:

The normal oral flora includes α-hemolytic strep. (S. Viridans). When a patient comes down with strep. throat, the infection is with β-hemolytic streptococcus, an invading bacterium. Symptoms of strep. throat include (1) high temp, (2) muscle aches and pains, and (3) dysphagia. You will not see watery eyes and a runny nose with a bacterial infection.

You confirm the strep. throat with a throat culture and prescribe amoxicillin, pen VK at 250/500 mg qid( four times per day) x 5 days or Azithromycin: 500mg on the first day, followed by 250mg per day for the next 4 days.

Azithromycin a macrolide is given to penicillin allergic patients.

Rheumatic fever:

This is a nonsuppurative acute inflammatory complication to a PAST UNTREATED INFECTION with Group A beta hemolytic streptococcus. Patients will give a history of having had strep. throat in the recent past. The incomplete, incorrect, or lack of treatment against the original beta hemolytic strep. infection can result in the development of RF within three to four weeks post infection. The strep. causes an Ag-Ab (antigen-antibody) inflammatory response. There are two antigens associated with the beta hemolytic strep., streptolysin O and streptolysin S. streptolysin O is strongly antigenic and antibodies formed against this Ag are called ASLO (Anti-streptolysin O). A high ASLO titer confirms RF. Acute RF will show a negative throat culture because this is a post beta hemolytic strep. inflammatory response.

2.1.1. The Major and Minor Jones Criteria

The Jones Criteria was established by Dr. Jones and they refer to the details of the areas in the body affected by the antigen-antibody reaction

To diagnose Rheumatic Fever (RF): The patient must have two major or one major plus two minor Jones criteria present.

2.1.1.1. Major Jones Criteria

Arthritis:

Major joints when affected are affected bilaterally. The joints swell, are extremely painful and resolution occurs within a few weeks. Research has shown it to be an aseptic arthritis. Recovery of one set of joints is associated with involvement of another set of joints. There is no joint deformity once recovery occurs. Because of this moving pattern of joint involvement, this kind of arthritis is frequently referred to as a fleeting arthritis. This is commonly seen in children.

Carditis:

All three layers of the heart can get involved with RF. The endocardium is the most frequently involved layer. Fibrosis of the valves can lead to stenosis (narrowing) or incompetence (widening).

With valvular stenosis, the blood will be turbulent going through the valve and will result in a heart murmur. With valvular incompetence, the blood will be regurgitated back into the heart chamber above and result in a heart murmur. MS (mitral stenosis) and MI (mitral incompetence) are common in children. AS (aortic stenosis) and AI (aortic incompetence) are common in adults. The most affected heart valve is the mitral valve. The least commonly affected heart valve is the pulmonic valve.

Premedication is required with valvular involvement.

Involvement of the myocardium is rare, but if myocarditis occurs, the patient always has to be premedicated.

Pericardial involvement occurs more frequently in children than adults. Pericardial effusion (fluid collection in the pericardial sac) is the most common form of presentation with pericardial involvement. History of pericardial involvement calls for premedication for dental visits.

Patients with a history of RF along with rheumatic heart disease, (RHD) always need to receive an antibiotic prophylaxis before dental treatment (premedication) to avoid the occurrence of bacterial endocarditis. Any invasive dental procedure causes a bacteremia. The bacteria in the blood have a tendency to attach onto damaged valves, form an infected thrombus which can dislodge into the circulation, causing a thrombosis or embolism. This process may be acute or subacute, depending on the infecting bacteria, thus giving rise to acute (ABE) or subacute bacterial endocarditis (SBE). Administration of premedication places a high level of antibiotic into the blood prior to the dental procedures to destroy any bacteria which may enter the blood stream as a result of a bacteremia and thus prevent bacterial endocarditis.

ABE can occur within 7 days of the dental procedure if no pre-med. was administered. ABE is common in the elderly and in IV drug users. Organisms: Staphylococcus, viral, fungal.

SBE is the most common form and occurs frequently 2-3 weeks, and occasionally 2-3 months after the bacteremia. Organism: Strep. Viridans

Chorea:

Occurs exclusively in children. Causes involuntary, jerky movements of the body. These movements are absent when the child sleeps but are exacerbated with emotional disturbance. It affects females more frequently. The condition improves as the child grows. Stress management for these patients is extremely helpful.

Erythema marginatum:

Rare finding. This rash occurs in only 10 percent of patients. It is a doughnut-shaped (pale center, dark margins) serpegineous rash occurring on the trunk. As the rash migrates upwards from the lower trunk area, the earlier occurring rash starts to disappear. This rash, which is more frequently seen on light-skinned than dark-skinned individuals, is diagnostic of RF when present.

** The above 4 criteria are diagnostic of RF.

2.1.1.2. Minor Jones Criteria

Fever:

A moderately high fever is common.

Arthralgia:

Patient experiences recurrent joint pains but there is no joint deformity.

Pain in the right upper quadrant (RUQ) of the abdomen:

Liver enlargement/engorgement and consequent pain often seen with CHF associated with RF.

Elevated ESR:

Increased erythrocyte sedimentation rate is seen commonly and indicates acute inflammation. It measures the levels of globulin and fibrinogen in the serum. If the ESR is decreasing, it indicates that the patient is responding to the meds and the inflammation is decreasing.

Increased C-reactive protein:

C-reactive protein is a marker for beta hemolytic streptococcus. Rising titers indicate a recent presence of the organism.

Elevated ALSO titer:

Streptolysin O and Streptolysin S are two antigenic enzymes associated with the beta hemolytic streptococcus. Streptolysin O is very antigenic, giving rise to the antistreptolysin O antibodies (ALSO). Thus, rising titers of ALSO are a strong marker of RF.

EKG Changes:

Occurs only if the myocardium is involved. There can be a problem in cardiac conduction with RF.

History:

Ask the patient if he/she developed any high fever, joint swellings or pains, skin rashes, chest pains, heart murmur or needed hospitalization as a child. These symptoms and signs relate to an occurrence of rheumatic fever. In doing so, you have incorporated the Jones criteria in your questioning to elicit the history of arthritis, carditis, chorea, erythema marginatum, subcutaneous nodules, fever and laboratory findings.

2.1.1.3. Preventative Treatment

Once the patient has overcome the primary affliction of RF and successfully treated symptomatically, the future attacks of RF are prevented by regular antibiotic treatment for the next 5 years. This PREVENTS INVASION by the BETA HEMOLYTIC STREPTOCOCCUS. This is preventive treatment against future RF attacks.

  1. Penicillin: 1.2 million units Benzathine Pen G IM (intramuscularly) is given once per month for 5 years if there is no history of allergy to Penicillin.
  2. Note that the Strep. Viridans will become resistant to Penicillin during this preventive treatment period.
  3. Erythromycin / Azithromycin: Given if patient is allergic to Penicillin. For preventive treatment, ES (Erythromycin Stearate) at 250 mg qid x 5 years is given OR Azithromycin 250mg OD (per day) for 5 years. The Strep. Viridans will become resistant to ES during this preventive treatment period.

Note: When treating a dental patient, ask them if they have had RF in the past 5 years and ask if they are on preventive therapy. If so, we must find out which antibiotic they are using and prescribe our antibiotic for premedication accordingly. The continual preventive treatment destroys the beta hemolytic strep. because it is an invading bacterium. The normal flora will be resistant and we must therefore prescribe a different anti-biotic, i.e., an antibiotic from a family other than the preventive treatment drug’s family.

2.1.2. Other Conditions Indicated for Pre-medication

  • RF with Rheumatic heart disease or carditis
  • All Congenital Heart Disease (CHD) except for Ostium Secundum ASD. Atrial Septal Defects (ASD) includes ostium primum and ostium secundum defects. Ostium primum needs premedication because of the blood exchange within the atria. Ostium secundum doesn’t need premedication.
  • Prosthetic valves or prosthetic joints need premedication.
  • Systemic shunts for hydrocephalus or hemodialysis both require premedication. A shunt for hydrocephalus is required when the CSF is not able to flow freely causing increased intracranial pressure. A shunt for hemodialysis serves as a connection between the artery and vein, usually inserted in one of the arms for patients on dialysis. NEVER monitor the blood pressure or draw blood from the arm with the shunt.
  • Past histories of SBE or ABE both require premedication.
  • Myocarditis with or without a history of RF requires premedication.
  • Patients with artificial graft materials (dacron, teflon, etc.) requires premedication.
    • Note: Pacemakers, bypass surgery, defibrilators, pins, and plates do not require premedication.
  • Valvular damage caused by the diet drug Fen-Phen.
  • Mitral Valve Prolapse (MVP) with regurgitation.
  • Patients receiving cancer drugs through an infuse port or a catheter line.

2.1.3. Endocarditis Prophylaxis NOT Recommended

  • Ostium Secundum ASD
  • Surgical Repair without residual beyond six months of ASD/VSD/PDS repair
  • Coronary artery bypass surgery
  • MVP without regurgitation
  • Functional Heart murmur
  • RF without RHD
  • Cardiac pacemakers or defibrillators

2.2. Rheumatic Heart Disease (RHD)

RF can damage the heart valves. Inflammatory response associated with RF can either narrow (stenosis) or widen (incompetence/regurgitant) the valvular openings. Mitral stenosis (MS) and mitral incompetence (MI) are more common in children. AS (aortic stenosis) and aortic incompetence (AI) are more common in adults.

Altered valvular openings give rise to murmurs and these murmurs are pathological. These murmurs need to be premedicated.

2.3. Hypertension (HTN)

The patient’s blood pressure (BP) must always be recorded at the first visit. If the reading is elevated beyond the normal range (listed below) you must take another set of readings during that visit. Repeat two more readings at the next visit. If all these are elevated, then and then only can the patient be labeled as a hypertensive. This clearly shows that one does not diagnose hypertension with one elevated reading.

Emotional disturbances, smoking, isometric exercising (weight lifting), excessive caffeine consumption are some of the common physiological conditions that can alter and elevate the BP temporarily. At an office visit, factors affecting BP reading must be taken into account; therefore, if the patient presents with conditions which may cause a temporary inaccurate reading then waiting until the end of the visit may prove valuable. Proper positioning of the arm during blood pressure monitoring and appropriate cuff size are additional factors that can alter the BP readings.

There are two types of hypertension: primary (essential) and secondary. Ninety-five percent of hypertensive patients suffer from essential hypertension. Secondary hypertension, although less common, is the more dramatic of the two, right from its onset.

Essential hypertension has no known etiology. Occurs in 95% of the hypertensive patient population. It is often asymptomatic at the start of the condition and frequently affects individuals around the age of 35 to 40 years. Hence, accidental discovery at the dental office, if the blood pressure (BP) is recorded, or during a routine physical at the physician’s office, is often how this condition is diagnosed. Symptoms start occurring after the condition has been present for some time (usually years) and is the result of narrowing of the blood vessels due to underlying premature atherosclerosis. The atherosclerosis can involve the cerebral circulation, causing TIA/CVA; the coronary circulation, causing angina/ MI; the renal circulation, causing chronic renal failure; and the peripheral circulation, causing intermittent claudication, any or all circulations may be affected. In addition, the patient may have other symptoms like headaches, vision problems, fatigue, loss of energy, and postural/orthostatic hypotension. This type of HTN runs in families. The stronger the family history, the higher the chances of this HTN starting earlier in life. Also, certain races (African-Americans, Native-Americans) have a stronger family history of HTN compared to Caucasians. Smoking, excessive alcohol consumption, obesity, diabetes, sedentary lifestyle, and a diet high in salt all play a role in the development of essential HTN.

Secondary hypertension is always due to an underlying cause, e.g., renal artery stenosis, pheochromocytoma, endocrine tumors, etc. It is less common (less than 5% of the population), but is more dramatic than essential hypertension from the start. It affects patients commonly in the first and second or sixth and seventh decades of life. Removal of the underlying cause is associated with the disappearance of the hypertension.

Note: Certain drugs, when taken on a chronic basis—e.g., corticosteroids, oral contraceptives, NSAIDs—can precipitate secondary hypertension

Patients with essential HTN become symptomatic after having had elevated readings for a few years (five to ten). Premature artherosclerosis develops over time, causing narrowing of blood vessels in the major circulations of the body.

Involvement of cerebral, coronary, renal and peripheral circulations give rise to the symptoms frequently seen associated with long-standing HTN.

Involvement of the cerebral circulation can cause transient ischemic attacks (TIAs) or cerebrovascular accidents (CVAs; strokes).

Involvement of the coronary circulation can precipitate angina pectoris, myocardial infarction (MI) or CHF.

Involvement of the renal circulation can lead to chronic renal failure. This usually happens after having had 15+ years of poorly controlled HTN.

Involvement of the medium-sized arteries of the legs causes intermittent claudication.

2.3.1. Summarized findings of The Seventh Joint National Committee on detection, evaluation and treatment of high blood pressure.

Tables 1 through 4 have been adapted from The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Report. (Please note the new classification of BP readings for adults aged 18 and over.)

For the full report, please go to http://www.nhlbi.nih.gov/guidelines/hypertension/.

Table 1. Classification of Blood Pressure of Adults Aged 18 Years and Older1
Category Systolic, mmHg Diastolic, mmHg
Normal <120 <80
Prehypertension 120-139 80-89
Hypertension*
  • Stage 1
140-159 90-99
  • Stage 2
> or equal to160 > or equal to100
Defer Treatment > or equal to180 > or equal to110

1 Not taking antihypertensive drugs and not acutely ill. When systolic and diastolic pressures fall into different categories, the higher category should be selected to classify the individual’s blood pressure status. Isolated systolic hypertension is defined as a systolic blood pressure of 140 mmHg or more and a diastolic blood pressure of less than 90 mmHg and staged appropriately (e.g., 174/82 mmHg is defined as stage 2 isolated systolic hypertension. In addition to classifying stages of hypertension on the basis of average blood pressure levels, the clinician should specify presence or absence of target organ disease and additional risk factors. This specificity is important for risk classification and treatment.

* Based on the average of two or more readings taken at each of two or more visits after an initial screening.

Table 2. Components of Cardiovascular Risk Stratification in Patients with Hypertension
Major Risk Factors
  • Smoking
  • Dyslipidemia
  • Age >60 y
  • Sex (men and postmenopausal women)
  • Family history of cardiovascular disease: women <65 y or men <55 y
Target Organ Damage/Clinical Cardiovascular Disease
  • Heart diseases
    • Left ventricular hypertrophy
    • Angina or prior myocardial infarction
    • Heart failure
  • Stroke or transient ischemic attack
  • Nephropathy
  • Peripheral arterial disease
  • Retinopathy


Table 3. Recommendations for Follow-up Based on Initial Set of Blood Pressure Measurements for Adults
Initial Screening Blood Pressure, mmHg1
Systolic Diastolic Follow-up Recommended2
<120 <80 Recheck in two years
120-139 80-89 Recheck in 1 year3
140-159 90-99 Confirm within two months
160-179 100-109 Evaluate or refer to source of care within one month
> or equal to 180 > or equal to 110 Evaluate or refer to source of care immediately or within 1 week depending on clinical situation

1If the systolic and diastolic categories are different, follow recommendation for the shorter-time follow-up (e.g., 160/86 mmHg should be evaluated or referred to source of care within one month).

2Modify the scheduling of follow-up according to reliable information about past blood pressure measurements, other cardiovascular risk factors, or target-organ disease.

3Provide advice about lifestyle modifications (see Table 4).

Table 4. Lifestyle Modifications for Hypertension Control and/or Overall Cardiovascular Risk
  • Lose weight if overweight
  • Limit alcohol intake to no more than 1 oz/d of ethanol (24 oz of beer, 8 oz of wine, or 2 oz of 100-proof whiskey) per day or 0.5 oz of ethanol per day for women and lighter-weight people
  • Increase aerobic physical activity (30-45 min most days of the week)
  • Reduce sodium intake to no more than 100 mmol/d (2.4 g of sodium or 6 g of sodium chloride)
  • Maintain adequate dietary potassium, calcium and magnesium intake
  • Stop smoking and reduce intake of dietary saturated fat and cholesterol intake for overall cardiovascular health

2.4. Cerebral Circulation Problems

  • TIA: transient ischemic attack is associated with a temporary cerebral arterial spasm, lasting for a few seconds-minutes, often recurring , with complete cessation in 24 hours. Any or all of the following symptoms—blurred vision or loss of vision, slurred speech or loss of speech, tingling numbness in the hands and feet, decreased sensations in limbs, or paralysis of limbs, lightheadedness, and dizziness can occur. A few or all of the above findings may be seen in the patient. Once the spasm is relieved the circulation is maintained and no tissue or brain damage occurs. The patient never loses consciousness. These patients have a fifty to sixty percent chance to go on to develop a stroke/CVA in the future. When the symptoms of TIA occur in the dental setting, immediately feel the radial pulse, take BP, and observe respiration rate (commonly referred to as the vital signs). The pulse will often be rapid and “bounding” ,indicating an increase in BP. These patients must be placed in a semi-sitting position or a forty-five degree angle. This is called the reverse Trendenlenberg position. This will slow bloodflow back to the heart thus lowering the BP. The respiration rate is usually higher than the normal 14-16 breaths in this patient. It may be as high as 20-25 breaths/ min. As the patient is being stabilized by the above procedure, call for emergency help.
  • CVA: cerebrovascular accident. This is another name for a stroke. CVA is caused by obstruction to any part of the cerebral circulation due to a thrombus, embolism or aneurysm rupture. Acute cessation of the circulation to the brain occurs with CVA leading to death of the cerebral tissue beyond the obstruction.. The patient may have a sudden loss of consciousness, resulting in a coma. Hemiplegia often occurs. Hemiplegia is a loss of voluntary movements of the opposite side of the body; sensory and motor loss frequently occurs. Headache is a prominent symptom with stroke. The headache is mild to moderate with embolus/thrombus and excruciating with ruptured aneurysm. The patient invariably loses consciousness with aneurysm but not with a thrombus/embolism. Symptoms and signs are very dramatic in onset with ruptured aneurysms, and gradual (hours to days) with thrombus/embolism. Motor, sensory or combined deficits (as listed with TIA) occur. Patient is always hospitalized and can have obvious paralysis or paresis which can persist after recovery. Diabetes, smoking, high cholesterol, and HTN can precipitate stroke. When the symptoms of CVA occur in the dental setting, observe the vital signs. BP will not be dramatically increased with an intracranial hemorrhage. In these patients. they will present with a “thready” or faint pulse with taccycardia. Conclusion is that the BP has dropped. Proceed to get the patient in a horizontal position . Use a neckroll to raise the head slightly, as the intracranial pressure is increased following an aneurysmal rupture. In stroke due to thrombus/embolus, the vital signs are increased, so use a semi-sitting position.
  • Clinical Note: Never give a local anesthetic (L.A.) containing epinephrine to a patient with a history of TIA as epinephrine will worsen the vasospasm and may start a TIA during dentistry. Also, after a stroke, dental treatment is deferred for 6 months; Aspirin, Dipyridamole, or Coumadin are given to help prevent further TIAs and CVAs.

2.5. Coronary Circulation Problems

Chest pain, although frequently thought to be due to heart disease can commonly originate from other structures too. Frequent causes of cardiac related chest pain are:

  • Classic angina pectoris: This is brought on by exertion. Exertion causes a temporary increase in the myocardial oxygen demand. The coronary arteries, usually narrowed secondary to coronary arteriosclerosis, are unable to supply the extra demand of blood flow. This causes temporary myocardial ischemia. The pain lasts for less than 5 to 10 minutes. The pain is alleviated by rest, because rest decreases the myocardial oxygen demand.
  • Angina pectoris: Progressive HTN causes narrowing of the coronary arteries. When such a patient indulges in strenuous activities, e.g., walking uphill, snow shoveling, etc., the myocardial oxygen demand goes up and the narrowed arteries are unable to provide that extra circulation to fulfill that demand. This causes the patient to experience a retrosternal discomfort/ tightness. Sweating, palpitation, raised blood pressure are prominent symptoms and signs. The patient immediately stops the activity, clenches his chest, hunches over and then gradually starts improving (cessation of activity decreases myocardial O2 demand). This discomfort never lasts for more than 10 to 15 minutes, usually lasting for 3-5 minutes. This is classic angina pectoris. Nitroglycerin, sublingual (0.3 mg SL) is used to treat an angina attack. When the patient experiences just a few angina attacks per year and they all respond to nitroglycerin, the angina is referred to as stable angina.
  • Unstable angina: This occurs when less and less activity precipitates attacks in the patient, and the frequency of attacks per year increases . The amount of nitroglycerin needed increases progressively. Unstable angina can lead to myocardial infarction at some point. With classic stable and unstable angina attacks occurring in the dental setting, all three vitals signs are elevated so a semi-sitting position is desirable in an emergency. Always check if the patient has nitroglycerine with them, ask them if they have it on them prior to the appointment and make sure they bring it with them for each and every visit.
  • Myocardial infarction (MI) is caused by an obstruction of the coronary arteries. When the myocardial ischemia is prolonged, it results in irreversible muscle damage or necrosis. The pain lasts for more than 15 minutes, is not relieved by rest, and frequently results in hospitalization. MI occurs following an actual obstruction of the coronary arteries. This results in death of the myocardium supplied by the coronaries beyond the obstruction. MI attack is associated with severe, excruciating pain in the chest lasting longer than fifteen minutes and a dropping BP (blood pressure) (note the difference between MI and angina). The pulse is rapid, thready (weak) and often irregular. The patient feels as if “a crane or an elephant is sitting on his/her chest.” The pain frequently radiates to the left arm or jaw. The patient looks very pale and is often in a shock-like state. The patient is constantly pacing because no one position gives the patient any relief. The pain usually lasts for hours. Perspiration, nausea, vomiting and abdominal bloating are commonly associated symptoms along with the chest pain. If immediate attention is rendered to the patient within 1-4 hours of onset, survival rate is almost 100%. MI attacks can occur with or without a past history of angina. With MI occurring in the dental setting, a rapid, thready pulse (indicating a lowered BP) with increased respiration due to anxiety, is observed. A horizontal position is given to the patient to stabilize the patient while others call for emergency help.
  • Clinical Note: Patients with stable angina may have a L.A. with epi, whereas unstable angina and MI patients cannot. MI patients must have dental treatment deferred for 6 months from initial attack.
  • CHF: Congestive heart failure can be precipitated by MI. The heart is unable to function adequately. Fluid in the lungs (confirmed by auscultating bilateral basilar rales) and peripheral pitting edema occur because of inadequate pumping action of the heart. Shortness of breath (SOB) on exertion and rest along with orthopnea and distended neck veins and palpitation are other associated findings with CHF.

2.6. Renal Circulation Problems

Chronic renal failure: Occurs following progressive renal damage in a patient with uncontrolled hypertension of 15 to 20 years duration. Manifestation occurs with urination output increasing (from 1 to 3 liters/ day) initially. This increase is often seen at night (nocturia) and lasts weeks to months. As the condition progresses, urine output will decrease. Renal damage is judged by the rising serum creatinine levels in the blood. Normal serum creatinine values are 0.4–1.2 mg/dL. To roughly measure renal status, take the serum creatinine value (SCV) and make it the denominator with 1 as the numerator. This fraction will give you an idea of the working capacity of the kidneys, e.g., if serum creatinine is 2.2 mg/dL, then half of the renal functioning capacity exists.

Chronic renal failure causes the diastolic pressure to rise. Hypertension, elevated cholesterol and triglycerides, gout or diabetes could lead to kidney problems. With a SCV of 2.0 mg/dl or greater, a L.A. with epi. are contraindicated. Aspirin, and NSAIDS should not be administered to patients with s. creatinine that is above the normal range, even if the elevation is 0.1mg/dL beyond normal!. The only antibiotic which may be safely used is erythromycin or azithromycin, as they are cleared by the liver. The rest of the antibiotics, like penicillin, cephalosporins, vancomycin, etc. are cleared through the kidney and are, therefore contraindicated. Regular dose clindamycin can be used as long as the patient is not on dialysis. Once the patient develops ESRD (end stage renal disease), dialysis begins and then you can only use low dose clindamycin in that patient.

2.7. Peripheral Circulation Problems Intermittent Claudication:

Due to atherosclerotic involvement of the medium-sized arteries of the legs; it causes the patient to experience excruciating pain in the calves when the patient walks uphill or briskly. He/she has to stop the activity to feel comfortable. Smoking excessively can also independently lead to intermittent claudication. These patients should not receive a L.A. with epi, and are considered ASA (American Society of Anesthesiologist) III patients.

2.8. Postural (Orthostatic) Hypotension:

Presents as a feeling of light-headedness or dizziness when getting up very suddenly from a lying down position. Occurs commonly in the elderly patient due to sluggish, erect vasoconstrictive effect and consequently slower cerebral perfusion. This symptomatology may also occur in a lean, petite individual or in a patient with BP readings at low normal levels. These patients during the episode present with normal respiration and a normal or slightly increased pulse. Certain medications—anti-hypertensives, anti-depressants, anti-Parkinson drugs—can cause postural hypotension too. Long standing diabetes associated with autonomic neuropathy can also precipitate postural hypotension. The patient experiences mild tachycardia with a drop in BP on standing up suddenly. As the patient collapses and becomes horizontal, the circulation to the brain is maintained and he/she is back to normal.

Clinical Note: These patients must be treated in a horizontal position in the dental chair, and must be slowly raised to a semi-seating and standing position upon completion of a procedure.

2.9. Prinz-Metal's Angina:

Also called coronary artery spasm angina. This type of angina is not associated with premature artherosclerosis. It occurs more commonly in women than men (classic angina occurs more commonly in men than women) and is precipitated frequently at rest or upon emotional outburst due to coronary artery vasospasm (classic angina is precipitated by exercise). The signs and symptoms are similar to classic, stable angina. Niphedipine, a calcium channel blocker (relaxes smooth muscles), is used to treat this angina.

Clinical Note: Patients who are being treated with Niphedipine may experience gingival hyperplasia as a side effect. When treatment is changed to another drug, it may take 6-12 months for the hyperplasia to subside

3. Pulmonary Conditions

3.1. Sinusitis (The Nose and Sinuses)

Viral infections and allergies involving the frontal, ethmoidal, or maxillary sinuses frequently give rise to nasal discharge, fever, headaches, postnasal drip, nasal congestion, watery eyes, sneezing, an itchy sensation in the eyes, nose and throat. All sinus infections (viral or bacterial) cause excruciating headaches and facial pain when the patient leans forward. Bacterial infections of the sinuses will not be associated with watery eyes and runny nose. Applying mild pressure on the sinuses will cause the patient to experience tenderness if the sinuses are inflamed.

If the sinuses are inflamed, the patient will complain of localized facial pain, tenderness over the sinuses, and fever.

Clincal Note: If the above-mentioned symptoms are related to environmental factors or due to changes in the seasons, allergy is the most frequent cause. Certain drugs may predispose to nasal stuffiness, e.g., alcohol, reserpine, and guanethidine (these are antihypertensive agents).

Epistaxis refers to bleeding from the nose. Local causes may be trauma, foreign body, inflammation or overdrying of the nasal mucosa. Bleeding disorders may also be the cause of epistaxis. Uncontrolled hypertension can manifest as epistaxis.