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and recommendations to ensure a safe environment for important laboratory parameter than blood glucose levels
these patients in dental practices. The focus of dentists because blood glucose levels fluctuate throughout the day
when performing interventions in these patients still lies on (depending on the time of day, meals, stress...) .
1-3
the potential occurrence of hypo- and hyperglycemia, their
prevention, and appropriate management . Preprocedural preparation of patients with diabetes
26
mellitus for dental procedures certainly includes evaluati-
on of diabetes complications (acute and chronic) and other
Evaluation and preparation of patients comorbidities that may not necessarily be related to diabe-
with diabetes before dental interventions tes mellitus. However, it is important to keep in mind that
among other comorbidities, hypertension is present in 40-
From a dental perspective, the most important elements 50% of diabetics and may be associated with atherosclero-
of pre-procedural evaluation of patients with diabetes melli- sis, while approximately 17% of patients with diabetes have
tus (DM) include: assessing the duration of the disease and occult infections. Coronary artery disease is often present,
treatment regimen, the presence of DM complications and/ especially in young individuals (which is atypical), as well as
or other comorbidities, and reviewing laboratory tests (blo- congestive heart failure, hepatic steatosis, and others .
2
od glucose levels, glycosylated hemoglobin, and other nece-
ssary analyses) (Table 1). The extent of pre-procedural evalu- Furthermore, it is important to consider that patients
ation depends on the complexity and urgency of the dental with diabetes mellitus have an increased susceptibility to
28
intervention, estimated duration of the procedure, the time infection , particularly concerning dental surgeries. Addi-
elapsed since the last meal (and last dose of antidiabetic tionally, they experience delayed wound healing. They are
therapy), as well as the expected level of stress, which is also prone to dehydration due to osmotic diuresis in hyper-
26
largely a subjective category and depends on the patient's glycemia, leading to the development of hyperosmolality .
personality structure. However, the most important questi- Serious complications such as diabetic ketoacidosis (due to
on is whether diabetes is well controlled. For major dental ketogenesis), thromboembolism (due to increased blood
viscosity and thrombogenesis), or cerebral edema are not
Table 1. Elements of pre-procedural evaluation of patients with DM uncommon.
Elements of preoperative evaluation Pay attention to:
Regardless of the type of dental intervention being per-
Type of DM; Duration of illness formed on individuals with DM, dentists should be familiar
1. DM characteristics Treatment regimen-therapy (oral hypo-
glycemic agents, insulin, combined) with the basic characteristics of diabetes before starting
Acute (DKA, HHS, hypoglycemia) treatment. Although many authors recommend screening
2. Presence of DM complications Chronic (micro and macroangiopathies, patients at risk of diabetic complications, clear protocols for
especially DAN)
managing high-risk patients in dental offices have not been
3. Presence of other comorbidities that Hypertension and other diseases
may (but not necessarily) be associated CV, NAFLD provided. It is considered that all patients with blood glucose
with DM levels > 16 mmol/L are at risk of complications, regardless of
Glycemia and HbA1c are mandatory, and whether alarming clinical manifestations of hyperglycemia,
4. Laboratory analyses as needed: urea, creatinine, electrolytes, such as headache, sweating, dizziness, tremors, blurred
urine analysis (albumin, ketones)
vision, etc., are present . To avoid acute complications of
26
Possibility of the need for emergency tra-
5. Assessment of the airway cheal intubation, which is often difficult diabetes, it is recommended that dental procedures for pa-
in diabetics
tients with DM be performed in the morning, after breakfast
Legend: OH - Oral Hypoglycemic; DKA - Diabetic Ketoacidosis; HHS - Hyperglycemic and administration of insulin or the morning dose of oral
Hyperosmolar State; DAN - Diabetic Autonomic Neuropathy; NAFLD - Non-Alcoholic
Fatty Liver Disease. hypoglycemic agents. Additionally, it is necessary to mea-
sure blood glucose levels before and after the intervention .
8
interventions, especially surgical procedures, consultation
with an endocrinologist or anesthesiologist is mandatory .
2
The primary goals of pre-procedural assessment and Complications of diabetes mellitus
preparation of patients with DM are to avoid hyperglycemia
Complications of diabetes can be acute or chronic, with
(> 10 mmol/L), and hypoglycemia (< 3.8 mmol/L), as well acute complications being more significant from a dental
as large fluctuations in blood glucose levels and electro-
lyte loss. The American Diabetes Association (ADA) issued perspective. Acute complications of diabetes include those
associated with severe hyperglycemia: diabetic ketoacidosis
recommendations in 2014, which are still in effect today,
stating that the target glucose values for patients schedu- (DKA), hyperglycemic hyperosmolar state (HHS), combined
disorders (DKA/HHS), as well as those associated with hypo-
led for invasive diagnostic and therapeutic procedures or
surgical interventions should be as close to the physiolo- glycemia, which can vary in severity. Both hyperglycemic
and hypoglycemic complications can quickly progress to
gical range as possible, but definitely < 10 mmol/L. This is
also supported by the Canadian and Australian Diabetes coma if not promptly diagnosed and urgently prevented.
If acute complications of diabetes are present, all elective
Associations, as well as the majority of authors 2, 27 . HbA1C,
as an indicator of long-term metabolic control, is a more procedures and interventions, including elective surgeries,

REVIEW PAPER Galenika Medical Journal, 2024; 3(9):69-75. 71