If your pt is taking insulin, find out which kind of insulin they are taking. Sulfonylureas are a major class of drugs used for diabetics. Biguanides are also used. Thiaolidinediols have had some problems associated with them. Alpha-glucosidase inhibitors are newer medications used.
3% of the general population is diabetic, although this is an underestimate. Diabetes is the number one metabolic disorder in the world. Uncontrolled diabetes mellitus is a major cardiovascular risk factor. Tight control of glucose concentration has been shown to delay the onset of some complications (retinopathy, nephropathy, coronary artery disease, arterioscerosis)… the term “tight control” is argued vigorously. If you’re fasting and have a blood sugar of 90-100 mg/dL we can call this controlled, the target for control of a diabetic pt does not mean that they’re trying to get the blood glucose from 250 to 90 or 100… the goal is to get it as low as you can with proper diet and exercise. Like HTN, you don’t absolutely push to get things back to optimal normal levels. Type I diabetics, no matter how well controlled, have a significantly shorter life expectancy than those of the type II class; there is thus some other pathology going on aside from the aberration in glucose metabolism. MDs must try to manage not only hypoglycemia but damage to organ systems.

Type I is a quick onset, as opposed to Type II, which comes on in later life. Type I diabetes is treated by insulin (primary tx), diet and exercise. Type II diabetes is treated by oral hypoglycemic agents – sulfonylureas (the gold std, because of cost effectiveness), metformin (Glucophage) (very effective, able to alter insulin receptor and alter the glucose transporter), acarbose, insulin, diet, weight reduction, and exercise. Combining metformin with another drug such as sulfonylureas is effective.
Troglitazone (Rezulin) HAS BEEN WITHDRAWN due to toxicity.

All orally effective, can be used in type 1 individual as supplement to insulin. Their half-lives vary a little. They have high plasma protein binding. There is a serious issue, NSAIDs especially compete for the same binding site that sulfonylurea binds to. If you add an NSAID to a pt taking a sulfonlyurea drug they will displace the drug. The duration of action can range from a ½ to a full day. The choice between the different sulfonylurea drugs is very subtle.
Insulin is the only drug effective for diabetes type 1. The oral hypoglycemic agents are primarily designed for type 2, but some type 2 diabetics do need insulin to get under tight control (the insulin must be injected). If a pt is not controlled by the highest possible sulfonylurea dose, if they were to get into within 10% of their appropriate weight and exercise moderately (walking, swimming…) the requirement of their sulfonylurea dose decreases markedly, some pts can stop taking the drug altogether. So you ask: Why don’t all diabetics lose weight and start exercising? Its like anything else, how do you modify behavior? That discipline is called barostatic medicine.

Problems with insulin include hypoglycemia, local or systemic allergic reactions, visual disturbances, and peripheral edema. Hypoglycemia is the most important to moniter, must know the pt’s glucose level before an appt, make sure they are well controlled before beginning. Problems with sulfonylureas include hypoglycemia, gastrointestinal disturbances, hematological disturbances, flushing (especially with alcohol ingestion), contraindicated in pts with hepatic or renal insufficiency, and drug interactions. Problems with Metformin include lactic acidosis (more likely in pts with renal insufficiency in whom the drug can accumulate), and gastrointestinal problems. Problems with Acarbose include abdominal pain, diarrhea and flatulence (uh-oh… only make appointments on windy days, otherwise keep them out of your dental chair. Flatulence in the dental office is not a good practice-builder!)

Polyuria, polydipsia and unexplained weight loss in addition to casual plasma glucose concentrations greater than 200 mg/dL (casual means just a random sample regardless of the time since the last meal)…
OR, if the fasting plasma glucose is greater than 126 mg/dL (fasting is defined as no caloric intake for at least 8 hours)…
OR, if the plasma glucose is greater than 200 mg/dL at 2 hours post caloric intake, during an oral glucose tolerance test.
Recently, the criteria for diagnosing a diabetic state was changed – for fasting plasma glucose levels, the former level that defined diabetes was 140 mg/dL, NOW its 126 mg/dL.

Non-insulin dependent patient: all dental procedures can be performed, no special precautions are needed unless complications of diabetes are present. Insulin-controlled patient: Usually all dental procedures can be performed, morning appointments are usually best. Advise pt to take usual insulin dosage and normal meals on day of dental appointment; confirm when pt comes for appointment. Advise the pt to inform you or your staff if symptoms of insulin reaction occur during the dental visit and have a source of glucose (orange juice, glucola) available and give it to pt if symptoms of insulin reaction occur. Extensive surgery needed: consult with physician concerning dietary needs during postoperative period. Consider prophylactic antibiotics for pt with brittle diabetes (the opposite of tightly controlled) or one taking high doses of insulin to prevent postoperative infection. Special precautions may be needed for pt with complications of diabetes, renal disease, heart disease, etc.

Insulin
Corticosteroids may increase glucose levels. High doses of salicylate analgesics (aspirin et al.) and certain NSAIDs (especially Ibuprofen and Naproxen) increase hypoglycemic action.
Type 1 diabetics are at risk for leukopenia, thrombocytopenia, delayed wound healing,
increased risk of infection, hypo-hyperglycemic episodes, angioapathy, neuropathy, retinopathy, platelet hyperaggregability, periodontal disease, and gingival bleeding. Beta-blockers may mask sings of hypoglycemia. Alcohol enhances insulin action.
Oral antidiabetic agents (OAAs)
In Type 2 diabetics: glucocorticoids may increase glucose, beta-blockers may inhibit

Mild stage: hunger, weakness, tachycardia, pallor, sweating, paresthesias
Moderate stage: incoherence, uncooperativeness, belligerence, lack of judgment, poor orientation.
Severe stage: unconsciousness, tonic or clonic movements, hypotension, hypothermia, rapid thready pulse.

The Thiazolidinedione class includes Rosiglitazone (Avandia) and Pioglitazone (Actos). Given the action of metformin and the sulfonylureas, you can combine the agents for useful effects. Combination therapy with insulin and sulfonylurea may be a more appropriate and a suitable option to insulin monotherapy in subjects with non-insulin-dependent diabetes in whom primary or secondary failure of sulfonylurea developed. Approximately 50% of diabetic pts may lose adequate metabolic control using oral agents after 10 years, primarily because of relative insulin deficiency and continuing insulin resistance.

(+)sense RNA (plus-sense RNA): A virus with a single-stranded RNA genome of the same polarity ('sense') as mRNA.
(-)sense RNA (minus-sense RNA): A virus with a single-stranded RNA genome of the opposite polarity ('sense') as mRNA.
Abortive Infection: When a virus infects a cell (or host), but cannot complete the full replication cycle, i.e. a non-productive infection.
Acute Infection: Relatively brief infections, i.e. a few days to a few weeks, following which the virus is usually eliminated completely from the body by the immune system.

Combinations of drugs are at present being used in the West (compare with tuberculosis and leukaemia chemotherapy). Various cocktails, that often have to be individually adapted, are used. As first-line treatment the WHO advises a scheme with 2 nucleoside analogues in combination with an NNRTI ("highly active antiretroviral therapy" or "HAART"). Alternatively, the combination of 2 nucleoside analogues and a protease-inhibitor can be used. Zidovudine, stavudine, lamivudine, abacavir, nevirapine and efavirenz penetrate into the cerebrospinal fluid and can thereby have a preventive effect on the occurrence of AIDS dementia. Any combination treatment should, therefore, contain one of these molecules. Videx® does not penetrate very well into the cerebrospinal fluid. *

Metastatic Calcification can occur anywhere in the body in tissue which do not normally mineralise when circulating levels of Ca2+ and PO43- are increasedcan when tumours of parathyroid gland produce excess parathyroid hormone, or when excessive resorption of bone occurs (eg. tumour in bone) Dystrophic calcification occurs with normal levels of calcium and phosphate in tissues where nuclei allow mineral to precipitatesuch nuclei occurs in degenerating or necrotic tissueeg. atherosclerosis, infarcts, tumours, injured tissues Lithiasis occurs within body cavities where degenerating or necrotic cells or micro-organisms provide nuclei for mineral depositioneg. urinary tract (uroliathiasis), biliary tract (cholelithiasis) and salivary glands (sialolithiasis)stone formation is not only facilitated by but also likely to lead to:obstruction of flowinfectioninflammation and ulcerationTags: Calcification, dystrophic, Metastatic, Lithiasis

Malaria is not only mankind’s biggest killer, it is one of the oldest recorded Appeared in Hippocrates’ 5th century medical journals In the mid-1600s, natives of Lima, Peru were already using the bark from a local tree to treat the disease - quinine Plasmodium vivax, ovale, malariae, and falciparum are organisms capable of causing human malaria At least 2.3 billion people are at risk for the disease worldwide 300-500 million infected causing 120 million cases and at least 1.5-3 million deaths/year 90% of those killed are in Africa; 70% are children under 5 Although there are differences seen between species, the life cycles are similar Bite from female Anopheles mosquito leads to injection of the sporozoites Sporozoites rapidly enter parenchymal cells of the liver Numerous asexual progeny (merozoites) leave the liver cells and invade erythrocytes and use the hemoglobin for nutrients Detoxify the heme group in special organelles Multiply in liver cells After entry into red blood cells, differentiate into male or female gametocytes Sexual cycle begins in host but must continue in a female mosquito ‘… Two of them could whip a dog, and … four of them could hold a man down.’ Mark Twain On the mosquitoes of Louisiana, from “Life on the Mississippi” Plasmodium falciparum infections are usually the most serious of the four because the sporozoan invades blood cells of all ages and parasitized blood cells produce projections that cause adherence to the lining of blood vessels Symptoms are characteristic shaking chills, then burning fever and sweating Toxin is involved Treatment is with chloroquine Can also be given prophylactically Blocks detoxification of the heme group No effective vaccines for prevention and resistance to chloroquine is widespread and growing Between protozoan and helminthic infections worldwide, parasitic infection in association with malnutrition is the primary cause of morbidity and mortality ~15 million, or one half, of the ~30 million children (<5> ~15 million represents 1/4 of the total ~60 million adult and child deaths from all causes

Description and Symptoms
Pedunculated flesh colored papules often found on the eyelids, neck and axilla.
Diagnosis
Clinical
Pathology
Normal skin

Description and Symptoms Thin rough scaly plaques that are more easily felt than seen. Mostly seen in a photodistribution in a setting of sun damaged skin.
Diagnosis
Clinical. Biopsy can confirm.
Pathology
A very small percentage of these sun-induced lesions will degenerate into squamous cell carcinoma.

Description and Symptoms
Small red or purple papules commonly found in Caucasian patients. More frequent with age.
Diagnosis
Clinical. Biopsy is almost never needed.
Pathology
Composed of blood vessels.

Description and Symptoms
Malignant patches progressing to plaques, tumors and ulcers on the skin. Usually very slow course and delayed diagnosis (6-8 years after onset). Sezary syndrome is more aggressive and manifested by diffuse erythema.
Diagnosis
High index of clinical suspicion. Many biopsies often needed. 5-7 year delay from onset to diagnosis is typical.
Pathology

Description and Symptoms
Dangerous skin cancer that often appears as an irregular changing mole. Warning signs: A (asymmetry), B (jagged border), C (multiple colors) and D (diameter > 6mm).
Diagnosis
Clinical confirmed by biopsy.
Pathology
Risk factors include many unusual moles, positive family history, sunburns as a child.

Description and Symptoms
Common skin colored to brown macules and papules anywhere on the body. If present as an infant they are called congenital nevi. Nevi with irregular pigmentation, jagged border, asymmetry and/or large diameter are often biopsied to rule out melanoma.
Diagnosis
Clinical. Confirmed by biopsy if needed.
Pathology

Description and Symptoms
Crusted, keratotic or ulcerated tumors. Although most are low grade malignancies, some areas carry a higher risk (lip, mucosa, ears and mid face) of metastasis.
Diagnosis
Clinical confirmed by biopsy.
Pathology
Tumors induced by either sun damage, arsenic exposure or chronic wounds.

Description and Symptoms
Pearly pink cancerous plaque with telangiectases on sun damaged skin. Prone to bleeding and ulceration. Almost zero risk of metastasis. Most common malignancy.
Diagnosis
Clinical confirmed by biopsy.
Pathology
Sun damage induced skin cancer.

Description and Symptoms
Dark papules mainly on the cheeks on patients with dark skin. The actor, Morgan Freeman has many.
Diagnosis
Clinical.
Pathology
Resembles a seborrheic keratosis.

Description and Symptoms
Firm protuberant scar that extends beyond the boundary of the injury. Keloids can be itchy or painful and often occur in certain locations (chest & shoulders) and racial groups (black, asian, etc).
Diagnosis
Diagnosis is clinical and usually not difficult.
Pathology
Altered wound healing and collagen synthesis.

Description and Symptoms
Tan to brown scaly plaques that have a “stuck-on” appearance. Often occurs more with age.
Diagnosis
Clinical. Biopsy can confirm.
Pathology
Unknown etiology.

Definition of a Virus
Viruses are segments of nucleic acid enclosed in a protein coat. Properties of Viruses Small size: range ~0.02 - 0.3 micrometers Various morphologies
polyhedralhelicalsphericalfilamentouscomplex Obligate intracellular parasites Lack membranes and a means to generate energyLack metabolism
Lack ribosomes and a mechanism for their own protein synthesisDo not grow in sizeViruses can only reproduce inside of a host cell. Structure of Viruses The viral genome is DNA or RNA.Most bacterial viruses contain double-stranded DNA.HIV is a retrovirus (an RNA virus) Classification of Viruses

Viruses contain only RNA or only DNA, but never both.
They are obligate intracellular parasites and they replicate by producing subunits and then assembling within their host cells.
WE finally have several anti-viral agents today after much research.
Viruses, like chlamydia do not have the necessary metabolic machinery to replicate outside of a cell.

Unapparent infections—have no symptoms.
Acute infections--
localized

RNA is labile and transient. --Most RNA viruses replicate in the cytoplasm. Influenza viruses and retroviruses replicate in the nucleus.
--Cells cannot replicate RNA, all RNA viruses must encode a RNA-dependent RNA polymerase. Retroviruses encode a reverse transcriptase.
--The genome structure determines the mechanism of transcription and replication.
--RNA viruses are prone to mutations because they lack proof-reading machinery.

Condyloma acuminatum: is a benign squamous papillomatous lesion (wart-like, verrucous lesion) that commonly occurs on or around the external genitalia (vulva, perineum and vagina) but also on the cervix (rarely).
The lesions are sexually transmitted and induced by HPV, mostly types 6 and 11.
Cervical cancer: intraepithelial and invasive squamous cell neoplasia is one of the most common tumours in women.
Epidemiology of increased risk for cervical cancer and precancerous dysplasia is:

Causative organism: Chikungunya virus
Alternative names: Buggy Creek virus
Properties: Family: Togaviridae Genus: Alphavirus A positive-sense, single-stranded RNA virus,Chikungunya virus is highly infective and disabling but is not transmissible between people.
It would most likely be dispensed as an aerosol or by the release of infected mosquitos. The disabling joint pain and fever, the lack of a suitable animal reservoir in Western countries and its lack of lethality make it a very "clean" weapon that could be used against key civilian installations.

Virus: enteric: 40, 41, 38; respiratory
Type: DS-DNA, linear
Capsid: Icosahedral
Virion: Naked
Antigen:H, penton
Treatment: Live vaccine available for Military
Comments:
Upper respiratory, gastroenteritis,
pharyngoconjuctivitis, military recruits, pinkeye.Tags: adenovirus, pink eye

Group: Group IV ((+)ssRNA)
Family: Flaviviridae
Genus: Flavivirus
Species: Dengue virus
Dengue (DF) and dengue hemorrhagic fever (DHF) are caused by one of four closely related, but antigenically distinct, virus serotypes (DEN-1, DEN-2, DEN-3, and DEN-4), of the genus Flavivirus.Infection with one serotype does not protect a person against infection with another.Aedes aegypti, a domestic, day-biting mosquito that prefers to feed on humans, is the most common Aedes species.(Unlike the mosquitoes that cause malaria, dengue mosquitoes bite during the day.)Dengue viruses occur in most tropical areas of the world.Dengue is most common in cities but can be found in rural areas.Incubation Period: averages 4 to 6 days, with a range of 3 to 14 days.

Virus: B-19
Type: SS-DNA, linear
Capsid: Icosahedral
Virion: Naked
Antigen:
Treatment: Self Limited
Comments:
Erythema infectiosum (fifth disease), slapped cheek, aplastic crisis in sickle cell,
spring.
Tags: parvo virus, fifth disease

Culture (gold standard) - examine for cytopathic effect (CPE) - takes a few days to two weeks a. Can add red cells to check for hemagglutinins
b. 100% specificity (for showing a virus is there, not specific ID), poor sensitivity
c. Without antigen detection (shell vial technique) can only make presumptive ID of virus

The term “drug abuse” is defined by the National Institute on Drug Abuse as: “the non-medical use of a substance for any of the following reasons – psychic effect, dependence, or suicide attempt/gesture”. The term “non-medical” generally refers to the use of prescription drugs in a manner inconsistent with accepted medical practice.
Important Terms and Concepts:
self-administration – the end result of drug-seeking behavior; animal models
tolerance – can be stated two ways: the effect of a specific dosage decreases with repeated administration, or a higher dosage is needed to produce the same effect with repeated administration.