Prior to initiating any invasive dental treatments, blood glucose levels of patients with diabetes should be less than 200 mg/dL. Consider that the physical and emotional stress that may occur during treatment can cause blood glucose levels to rise even higher and possibly place the patient at risk for a medical emergency. In addition, uncontrolled diabetes (Table 2) can also be a factor towards increasing healing time and place the patient at risk for infection. If the patient has forgotten to take the recommended dose of their diabetes oral agent and/or insulin, this can be done and the blood glucose value retested. Caution the patient not to take more than the prescribed amount. Also, since blood glucose values will decrease with activity, the patient could walk around the office for 15 minutes and be retested. If the blood glucose level is still above 200 mg/dL, the patient should be referred to their diabetes healthcare team and the dental appointment rescheduled. Conducting noninvasive procedures, such as radiographs or an oral examination, may be warranted prior to dismissal.

Blood glucose levels tend to be more stable in the morning; therefore, morning appointments may be more beneficial for this patient. Stress reduction techniques, such as use of headphones, and short appointments may help keep blood glucose levels from rising.

The dental patient with uncontrolled hyperglycemia may require prophylactic antibiotic therapy. Systemic antibiotic therapy or topical antimicrobial therapies are accepted treatment modalities for aggressive treatment of oral infections. Recare appointments should be at least every three months to monitor wound healing and minimize periodontal infection.

Since epinephrine antagonizes the action of insulin, resulting in hyperglycemia, local anesthesia without vasoconstrictors is recommended when possible for patients with uncontrolled diabetes. Another consideration is to use glucocorticosteroids with caution since they also have the potential to raise blood glucose levels.

Dental hygiene management also includes fluoride therapy for patients with a high caries rate and recommendations to relieve xerostomia if necessary. Since a patient with uncontrolled diabetes has an exaggerated response to plaque, encouragement of meticulous oral hygiene is essential.