Dental caries experience and periodontal treatment needs of 10- to 15-year old children with type 1 diabetes mellitus

Abstract

Aim: To investigate experience of dental caries and periodontal treatment needs among children with type I diabetes mellitus. Materials and methods: A cross-sectional study design, in which experience of dental caries and the periodontal treatment needs of 70 children with type 1 diabetes were compared with those of 70 controls matched for age and gender. The diabetic children were recruited from the child care unit of the central Benghazi hospital. The decayed, missing and filled teeth (DMFT) index for dental caries experience and Community Periodontal Index of Treatment Needs (CPITN) index for periodontal treatment needs were calculated according to World Health Organisation criteria in a dental clinic by a calibrated examiner. Scores for decayed, missing and filled teeth and periodontal treatment needs were compared in bivariate analysis. Results: Two groups were compared: diabetic children and controls. Each group consisted of 70 children (45 males and 25 females) aged between 10 years and 15 years; the mean ages were 11.66 ± 1.44 years for diabetic children and 11.63 ± 1.54 years for controls. The diabetic children had higher means for the number of decayed teeth (P = 0.037) and the number of missing teeth (P = 0.028). Professional gingival scaling was the most required periodontal treatment by diabetic children (P = 0.007). There were no gender differences among study subgroups. Conclusions: The results suggest that children with type 1 diabetes are at higher risk of developing dental caries and periodontal disease. Greater efforts are required to tackle these problem and prevent complications arising from them.

INTRODUCTION

Diabetes mellitus (DM) refers to a metabolic disorder that is characterised by various disturbances in the metabolism of fat, carbohydrates and proteins. It results from reduced production of insulin hormone or decreased body response to it. There are two major types of DM. Type 1 DM occurs early in life and characterised by deficient insulin production which requires daily administration of insulin. Resistance to insulin and defect in its secretion results in type 2 DM¹.

Diabetes mellitus has several systemic signs and symptoms; the oral cavity is not an exception and many changes in oral ecosystem are reported among diabetics. These include reduction in salivary flow rate, pH and buffer capacity and an increase in the levels of glucose, magnesium and calcium². In addition, many oral health problems such as periodontal disease, tooth decay, salivary dysfunction, oral mucosal lesions and oral infections have been reported among diabetics¹.

The relationship between diabetes and oral health has been investigated extensively. A clear relationship between periodontal diseases and diabetes has been reported in the literature, and periodontal diseases are considered the sixth complication of DM3., 4.. Furthermore, the occurrence and severity of gingival inflammation and periodontal diseases are reported to be higher among children and adolescents with type 1 DM3., 5.. However, reports on the incidence of caries among diabetic children are inconsistent6., 7..

Dental caries and periodontal disease are major public health problems and the main causes of tooth loss among the Libyans during the different decades of their lives⁸. The prevalence of DM in Benghazi, the second largest city in Libya, is 14.1%, with about 6% of all cases diagnosed as type 1⁹. The average annual incidence of type 1 DM among 0–14 years old in Benghazi is 7.8/100,000¹⁰. To date, however, no study in Libya has explored experience of dental caries and periodontal treatment needs among children and adolescents with type 1 DM.

The aim of this study was to evaluate dental caries experience and periodontal treatment needs among diabetic children in Libya.

MATERIALS AND METHODS

Participants

A cross-sectional, comparative study was conducted to assess experience of dental caries and periodontal treatment needs among Libyan children with type 1 DM. A total of 70 children (45 males and 25 females) between 10 years and 15 years old (mean age 11.66 ± 1.44 years for diabetic children and 11.63 ± 1.54 years for controls) who were diagnosed with type 1 DM and 70 controls matched for age, sex and socioeconomic status were included in the study. The participants were recruited from a child care unit in the central medical hospital in Benghazi, Libya during the period between February and June 2012. The unit provides medical care and follow-up for children diagnosed with diabetes in the eastern part of the country. The inclusion criteria included diagnosis with type 1 DM, 10- to 15 year-olds and informed consent by parents or carers. Those who had had oral prophylaxis in the last 6 months or were diagnosed for any other illness that could have an effect on the occurrence of dental caries or periodontal health problems were excluded from the study. The medical information was obtained from hospital medical records, which showed that only two diabetic children out of 70 were having controlled blood glucose levels. The controls were randomly recruited from family members and classmates of the diabetic children. They were healthy and none of them had undergone oral prophylaxis in the previous 6 months.

Ethical considerations

This research was conducted in full accordance with the World Medical Association Declaration of Helsinki. Formal permissions were obtained from local authorities and hospital administration departments. Informed consent was obtained from parent or carers of children in both study groups, which was implied by attending dental examinations in response to a written invitation letter to participate in the study.

Examinations

All examinations were carried out at paediatric dentistry clinics at Benghazi university. All subjects were examined by one examiner who was blinded for the study groups. Experience of dental caries and periodontal treatment needs were assessed in the presence of parents or caregivers while the participant was seated on a dental chair using dental mirror, Community Periodontal Index probe and dental chair light.

Dental caries was measured according to World Health Organisation (WHO) criteria 1997¹¹ using the decayed, missing and filled teeth index (DMFT). A tooth was recorded as decayed if it had an unmistakable cavity, undermined enamel, a detectably softened floor or wall, temporary filling, coexisting filling and decay and a crown that had been destroyed by caries and only the root left. Where any doubt existed, caries was not recorded as present. The teeth were recorded as missing only if they were extracted because of dental caries.

Periodontal treatment needs were evaluated using Community Periodontal Index of Treatment Needs (CPITN), and according to WHO criteria¹¹. The teeth to be examined were: lower first molars, upper first molars, upper right central incisor and lower left central incisor. Second molar teeth were excluded to avoid scoring the deepened sulci associated with eruption as periodontal pockets in children under the age of 15 years.

Scoring and treatment criteria was defined as follows:

• •Healthy, no treatment required
• •Gingival bleeding observed during or after gentle probing; this patient requires personnel oral hygiene instruction
• •Supra-/sub-gingival calculus seen or felt during probing; this patient requires personnel oral hygiene instruction and professional scaling.

Statistical analysis

Data management and analysis was performed using the IBM SPSS Statistics software version 20.0 (IBM Corp., Armonk, NY, USA). The mean and standard deviation were used to describe participants’ age and scores for decayed, missing and filled teeth independently and the whole DMFT index. Relative percentages and numbers were used to describe sample distribution and dental treatment needs. The means for scores of decayed teeth (D), missing teeth (M), filled teeth (F) and DMFT index were compared by study group (diabetics and controls) and sex using the t-test for independent sample and the chi-square test was used to compare the relative percentage of treatment needs at the 95% confidence level.

RESULTS

Data from 70 children with type 1 DM and other 70 medically fit children serving as controls were analysed for this study, each group consisted of 70 children (45 males and 25 females aged between 10 and 15 years old).

Table 1 compares dental caries experience for both diabetic children and controls and for diabetic children according to their gender. The diabetic children have higher means for the number of decayed teeth (P = 0.037) and the number of missing teeth (P = 0.028). There are no gender differences in dental caries experience among diabetic children.

Table 1.

Mean scores (SD) for decayed (D), missing (M) and filled (F) teeth and DMFT index (n = 140)

Variables	Decayed	Missing	Filled	DMFT index
Study group
Diabetics	0.91 (1.32)	0.19 (0.57)	0.09 (0.33)	1.19 (1.74)
Non-diabetics	0.57 (1.19)	0.10 (0.35)	0.10 (0.42)	0.80 (1.46)
P	0.037*	0.028*	0.665	0.071
Sex
Male diabetics	0.84 (1.36)	0.18 (0.61)	0.07 (0.33)	1.09 (1.87)
Female diabetics	1.04 (1.24)	0.10 (0.50)	0.10 (0.33)	1.36 (1.50)
P	0.542	0.918	0.246	0.569

^*Indicates where differences were located.

Independent sample t-test was used to compare groups.

Table 2 reports dental treatment needs and shows comparison by study group and gender. Controls showed less periodontal treatment needs; just over half of them (51.4%) were found to have no signs of periodontal disease (P = 0.026). Professional gingival scaling was the most required periodontal treatment by diabetic children (42.9%), it was significantly higher than that for controls (P = 0.007). There were no statistically significant gender differences in dental caries experience or periodontal treatment needs among diabetic children.

Table 2.

Numbers (%) of participants according to their periodontal treatment needs (n = 140)

Variables	Healthy	Personal oral hygiene instruction	Professional gingival scaling
Study group
Diabetics	23 (32.9)	17 (24.2)	30 (42.9)
Non-diabetics	36 (51.4)	19 (27.2)	15 (2.4)
P	0.026*	0.699	0.007*
Sex
Male diabetics	36 (40)	25 (27.8)	29 (32.2)
Female diabetics	23 (46)	11 (22)	16 (32)
P	0.491	0.454	0.978

^*Indicates where differences were located.

A chi-square test was used to compare groups.

DISCUSSION

The results of this study indicate that children with type 1 DM experience more dental caries than the healthy controls. Significantly higher means of the number of decayed teeth and missing teeth were reported among children with type 1 DM. The mean score for the overall DMFT index was higher among the diabetics although this difference was not statistically significant.

This study’s findings are in line with many studies that have reported higher incidence of dental caries among children with type 1 DM12., 13.. However, dental literature has shown conflicting results regarding the incidence of dental caries among people with type 1 DM⁷, with many reports finding a lower or non-significant difference in the prevalence of dental caries between diabetics and non-diabetics14., 15., 16.. This study’s findings are also consistent with the results of a literature review by Taylor et al. ¹⁷ in which most of the studies reviewed reported more tooth loss among diabetics. They also support a recent report by Patel et al. ¹⁸ who found that diabetic individuals are at higher risk of tooth loss.

Decreased salivary flow, bad oral hygiene and poor glycaemic control have been found to be highly associated with the increased incidence of dental caries among diabetic children14., 16., 19.. Poor metabolic control accounts for increasing salivary glucose levels and reducing salivary flow rate²⁰. These changes can foster the growth of cariogenic bacteria by offering the nutrients required for acid production and curbing the mechanical cleansing action of saliva, resulting in greater accumulation of dental plaque21., 22.. It can thus be suggested that the greater incidence of dental caries among diabetic children who participated in the current study can be attributed to poor metabolic control and poor oral hygiene. This suggestion can be supported by findings of a previous study in Libya in which a higher level of dental plaque was observed among children with type 1 DM²³. Furthermore, the medical records of this study’s participants showed that almost all of the diabetic children were lacking metabolic control. However, further longitudinal research on this topic needs to be undertaken before the association between dental caries and metabolic control among children with type 1 diabetes can be more clearly understood.

This research has thrown up another question in need of further investigation. The combination of findings concerning the numbers of missing teeth and filled teeth highlights issues relating to the pattern of dental service and specifically to the application of preventive dental care. While the numbers of filled teeth are nearly equal in the two study groups, the mean number of missing teeth is higher among diabetics. Tooth loss among type 1 diabetics is found to be associated with extensive periodontal disease, poor oral hygiene and dental caries²⁴. However, in the present study only teeth that were extracted because of caries were considered. In general, therefore, it seems that the option of tooth extraction is preferred over restoration of carious teeth for the diabetic children. Further research regarding the attitude and practice of dentists towards the dental care of diabetic children could help in understanding the reasons for this treatment pattern and suggest future courses of action.

This study’s findings confirm that children with type 1 DM are more likely to require periodontal treatment and are at higher risk for developing periodontal diseases. The number of diabetic children who require professional gingival scaling was higher than that for their healthy controls. Excessive calculus formation and uncontrolled diabetes were implicated in the development of periodontal pockets in diabetic individuals25., 26.. Calculus offers a niche for pathogenic bacteria at critical sites which leads to both dental caries and periodontal diseases. Regular tooth brushing and flossing can remove dental plaque and control its formation, however, once dental plaque mineralises to form calculus, professional scaling for its removal is inevitable²⁵.

The increased risk for periodontal disease among children with diabetes has been reported in dental literature26., 27.. Furthermore, periodontal destruction that starts at an early age becomes more evident during adolescence and screening programmes for early detection of people at risk should be considered routine for diabetic patients³. Unless an intervention has been made at an early stage, preventing periodontal disease and arresting its progression would not be possible, this study emphasises the need for preventive programmes targeting diabetic children and raises awareness among health-care professionals and parents about the risk of developing periodontal diseases in diabetic children.

One limitation of this study was the reliance on DMFT index criteria of dental caries, which omits the initial carious lesions and considers only actual cavitation. Dental caries is a continuous process and cavitation represents one point in time²¹. It also does not consider radiographic information that might result in underestimation of experience of dental caries. Furthermore, the inability to use radiographs for detecting unerupted teeth may subject data regarding tooth loss to recall bias by parents or guardians.

The results of the present study suggest that children with type 1 DM are at higher risk of developing dental caries and periodontal disease. These results emphasise the need to provide preventive care programmes that target diabetic children as a special oral health-care group. Further research is required to explore the impact of dental services provided and dental education curriculum on the oral health of diabetic children. Assessing of oral health-related attitude and practices of dental professionals toward diabetic children would be of great help in determining future courses of action for special care groups.

Acknowledgement

The authors are grateful to the child care unit in the central medical hospital in Benghazi, Libya for providing access to the diabetic children.

Competing interest

None declared.