Detecting Type 2 Diabetes in Pediatric Populations

Obesity rates among United States children and adolescents are consistently rising, resulting in an increase in type 2 diabetes. Approximately 208,000 Americans younger than 20 are diagnosed with diabetes.¹ The World Health Organization estimates that 90% of these 208,000 have type 2 diabetes.² Children with poorly controlled glucose levels are at increased risk for periodontal disease.³ Early detection of diabetes mellitus is vital for periodontal disease prevention, and some of the first clinical signs of diabetes may be notable during routine dental examinations. Collaborative efforts between dental and medical teams can increase the likelihood of early diabetes detection, while helping to prevent oral health complications.

Periodontal disease is noted as the “sixth complication of diabetes”⁴ and evidence suggests it adversely affects health outcomes among patients with diabetes.⁵ Diabetes affects all periodontal parameters, including bleeding scores, probing depths, attachment loss and tooth loss.^6–9 Patients with diabetes are five times more likely to be partially edentulous as those without diabetes.⁷ Other oral complications related to diabetes include: candidiasis, caries, gingivitis, lichen planus, neurosensory disorders (such as burning mouth syndrome), salivary dysfunction, taste impairment and xerostomia.⁸ Periodontal destruction in children and adolescents with diabetes begins earlier than previously believed.¹⁰ Even after adjusting for oral hygiene levels, these populations experience significantly increased gingival inflammation compared with control subjects.¹¹

Periodontitis is preceded by gingivitis, which can be prevented through regular oral hygiene care.¹² Individuals with un­controlled, undiagnosed or poorly controlled type 2 diabetes are more susceptible to periodontal disease than the general population. Compared with those with adequate metabolic glycemic control, these patients may demonstrate more severe periodontitis.¹³ This is due to impaired antibacterial functions of neutrophils, wound healing, and other biologic mechanisms in which infection (such as that caused by gingivitis and periodontitis) can increase insulin resistance in peripheral tissues.¹⁴ Cianciola et al¹⁵ investigated the prevalence of periodontal disease in children with insulin-dependent diabetes mellitus (IDDM) and control subjects. Among children between the ages of 11 and 18, 9.8% of those with IDDM showed signs of periodontitis, compared to only 1.7% in the control group. In children 10 or younger, Cianciola et al¹⁵ found no evidence of periodontitis in either group; however, other research documents the presence of gingivitis associated with diabetes in children as young as 5.¹⁶

The incidence of periodontal disease in children and adolescents increases when these individuals have type 2 diabetes with periods of hyperglycemia (fasting plasma glucose of 126 mg/dL or higher).¹⁷ Patients with hyperglycemia often present with elevated blood glucose levels that contribute to tissue breakdown — regardless of whether the hyperglycemia is caused by type 1 or type 2 diabetes.¹⁷ A significant bidirectional relationship has been reported between hyperglycemia and periodontal disease, suggesting that both diseases may share common pathways.¹⁷

A two-way reciprocal relationship has been shown when the inflammatory process associated with periodontal disease releases pro-inflammatory cytokines.¹⁸ These cytokines play a key role in regulatory responses, including disrupting the ability to control insulin levels. The balance between pro-inflammatory and anti-inflammatory responses is also crucial in periodontal disease progression.¹⁸

Most oral health professionals routinely note type 2 diabetes as a risk factor for periodontitis. Obesity and diabetes in younger patients should also be used as risk factors for the development and progression of periodontal disease.¹⁹

MEDICAL HISTORY AND ASSESSMENT

Physical assessment has been defined as the “collection and analysis of systematic and oral health data in order to identify client needs;”²⁰ specifically, vital sign assessment should include temperature, pulse, respiration and blood pressure. These provide a baseline for identifying potential or undiagnosed medical conditions. One in three Americans is diagnosed with hypertension, including children,²¹ and this increase is more profound among those with an increased body mass index (BMI).²²

In both adult and pediatric patients, hypertension can increase the severity of periodontal disease and cause other adverse health effects.^23–25 Beginning at age 3, obtaining an accurate blood pressure reading is recommended by the American Academy of Pediatrics for all patients to aid in early detection of blood pressure abnormalities.²⁶ Hypertension in children and adolescents is determined by patients’ height and gender, and is presented in a percentile curve (Table 1).²⁷ Children with blood pressure readings higher than 120/80 are classified as prehypertensive. Environmental causes of hypertension include diet, exercise and the health of the expectant mother.²⁷ Genetic coding has shown several gene variants are linked to diabetes, hypertension and metabolic syndromes.²⁸ By routinely taking blood pressure readings in children and adolescents, oral health professionals can play an important role in the early detection of hypertension and related conditions.

Childhood obesity is a significant risk factor for type 2 diabetes;¹⁹ thus, clinicians should include BMI as a component of vital sign assessment due to its impact on general and oral health. In children and adolescents, BMI is categorized differently than in adults (Table 1). Patients with BMI scores ranging from the 85th to the 95th percentile may indicate an abnormality in glucose metabolism; in these cases, referral to a medical provider is recommended.²¹

PHYSICAL INDICATORS

Signs of type 2 diabetes in children and adolescents are not always listed on medical history forms. Often overlooked are physical signs and reported symptoms that can be detected during routine dental appointments, including acanthosis nigricans, skin tags, dry itchy skin, poor general skin healing and oral candidiasis.

As the obesity rates in children climb, so will the incidence of metabolic changes leading to type 2 diabetes. Skin changes are sometimes the first signs detected in a child or adolescent with undiagnosed type 2 diabetes. These changes — such as dry, irritated skin — may be observed by oral health professionals when securing the napkin around the patient’s neck.

As noted, children and adolescents who are obese or have insulin resistance frequently present with acanthosis nigricans.²⁹ Often caused by untreated hyperinsulinemia due to type 2 diabetes, this is a mucocutaneous disorder characterized by diffuse hyperpigmented areas of the skin, resulting in a velvety appearance.²⁹ The affected areas appear dark and thickened, and may be seen at the neckline, elbows, or on the back of the hand.

Skin tags are another sign of type 2 diabetes in children,³⁰ and can be observed in the neck and anterior chest area in children and adolescents with insulin sensitivity. Although harmless, skin tags may signal insulin sensitivity in an asymptomatic child or adolescent.³¹

Oral health professionals should ask patients or the parent/caregiver about dry, itchy skin or the presence of any wound that does not appear to be healing.³¹ Monitoring for the occurrence of frequent infections (including bladder infections) is also appropriate when screening for type 2 diabetes.³²

During routine oral exams, candidiasis may be observed in children and adolescents with undiagnosed type 2 diabetes. Signs and symptoms include white patches on the tongue or other areas of the mouth and throat (Figure 1). Candidiasis is common among those with poorly controlled hemoglobin A1c levels.^8,13,14,32 If blood glucose levels are not controlled, candidal colonization is likely.³³ Oral candidiasis in an obese child or adolescent should alert dental providers to the likely presence of other health problems, including diabetes. Medical consultation may be indicated.

IMPLICATIONS FOR PRACTICE

Oral health professionals are well positioned to note the oral and systemic manifestations of diabetes, and can actively contribute to early detection. A worthwhile step in addressing the increased incidence of type 2 diabetes is to modify health data collection to include signs and symptoms related to diabetes. This should include BMI calculations,²² blood pressure measurements for patients older than 3,³⁴ and inquiring about returning or persistent infections.³²

As noted, dental providers should consider signs and symptoms of type 2 diabetes while completing the visual physical assessment of the head and neck, including looking for acanthosis nigricans, skin tags and dry, itchy skin.^29–31 Oral examination should also evaluate for xerostomia, oral candidiasis or other recurring infections.^32,33 The presence of any combination of these signs and symptoms warrants referral to a medical provider.²⁰

Beyond the opportunity for early detection, perhaps the most important role oral health professionals play in caring for children and adolescents with type 2 diabetes is educating patients and parents/caregiver about the oral and systemic links.

CONCLUSION

Unfortunately, the prevalence of type 2 diabetes and obesity continues to grow at an alarming rate, which may also increase risk for periodontal disease. In 2013, 285 million individuals were diagnosed with diabetes worldwide.¹¹ Obesity is also a global epidemic, affecting all age groups, populations and countries — regardless of socioeconomic status. Children who are obese and/or have type 2 diabetes are at increased risk for health problems.¹² As such, a new approach is needed to aid detection of these conditions. Given the oral and systemic risks, disciplines that do not traditionally focus on diabetes and obesity as a routine component of evaluation, such as oral health care, should include these assessments to ensure early diagnosis and prevent or mitigate oral complications.¹³

ACKNOWLEDGMENT

The authors would like to thank Juan F. Yepes, DDS, MD, MPH, MS, DrPH, FDS RCSEd, and Mike Fetscher for their help with this manuscript.

REFERENCES

1. American Diabetes Association. Initial Evaluation and Diabetes Management Planning. Diabetes Care. 2015;38(Supplement 1):S17–S19.
2. World Health Organization. Diabetes Fact Sheet. Available at: who.int/ media centre/factsheets/fs312/en. Accessed Accessed January 8, 2018.
3. Boyd L, Gilblin L, Chadbourne D. Bidirectional relationship between diabetes mellitus and periodontal disease: state of the evidence. Can J Dent Hyg. 2012;46(2):93–102.
4. Loe H. Periodontal disease: the sixth complication of diabetes mellitus. Diabetes Care. 1993;16:329–334.
5. Borgnakke W, Ylöstalo P, Taylor G, Genco R. Effect of periodontal disease on diabetes: systematic review of epidemiologic observational evidence. J Clin Periodontol. 2013;40:S135–S152.
6. Bridges R, Anderson J, Saxe S, Gregory K, Bridges S. Periodontal status of diabetic and non-diabetic men: effects of smoking, glycemic control, and socioeconomic factors. J Periodontol. 1996;67:1185–1192.
7. Emami E, deSouza RF, Kabawat M, Feine JS. The impact of edentulism on oral and general health. Int J Dent. 2013;2013:498305.
8. Lamster IB. Non-periodontal oral complications of diabetes mellitus. In: Lamster IB, ed. Diabetes Mellitus and Oral Health. Hoboken, NJ: John Wiley & Sons; 2014:157–190.
9. Khader Y, Dauod A, El-Qaderi S, Alkafajei A, Batayha W. Periodontal status of diabetics compared with nondiabetics: a meta-analysis. J Diabetes Complications. 2006;20:59–68.
10. Gurav AN. Management of diabolical diabetes mellitus and periodontitis nexus: are we doing enough? World J Diabetes. 2016:7:50–56.
11. Merchant AT, Oranbandid S, Jethwani W, et al. Oral care practices and A1c among youth with type 1 and type 2 diabetes. J Periodontol. 2012;83:856–863.
12. Tolle SL. Periodontal risk assessment. In: Darby M, Walsh M, eds. Dental Hygiene Theory and Practice. 4th ed. St. Louis: Elsevier; 2015:321–329.
13. Llambes F, Arias-Herrera S, Caffesse R. Relationship between diabetes and periodontal infection. World J Diabetes. 2015;6:927–935.
14. Armitage GC. Potential impact of periodontal infection on overall general health In: Darby M, Walsh M, eds. Dental Hygiene Theory and Practice. 4th ed. St. Louis: Elsevier; 2015:357–358.
15. Cianciola L, Park B, Mosovich E, Genco R. Prevalence of periodontal disease in insulin-dependent diabetes mellitus (juvenile diabetes). J Am Dent Assoc. 1982104:653–660.
16. Oh TJ, Eber R, Wang HL. Periodontal diseases in the child and adolescent. J Clin Periodontol. 2002;29:400–410.
17. Chiu S, Lai H, Yen A, et al. Temporal sequence of the bidirectional relationship between hyperglycemia and periodontal disease: a community-based study of 5,885 Taiwanese aged 35–44 years (KCIS No. 32). Acta Diabetol. 2015;52:123–131.
18. Akram Z, Abduljabbar T, Abu Hassan M, et al. Cytokine profile in chronic periodontitis patients with and without obesity: a systematic review and meta-analysis. Dis Markers. 2016;2016:4801418.
19. Eckel R, Kahn S, Ferrannini E, et al. Obesity and type 2 diabetes: what can be unified and what needs to be individualized? Diabetes Care. 2011;34:1424–1430.
20. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice. Available at: adha.org/resources-docs/2016-Revised-Standardsfor-Clinical-Dental-Hygiene-Practice.pdf. Accessed January 8, 2018.
21. Morandi A, Maffeis C. Predictors of metabolic risk in childhood obesity. Horm Res Paediatr. 2014;82:3–11.
22. Dumont D, Baker L, George E, Sutton N. Diabetes and BMI: health equity through early intervention on dysglycemia, and how providers can help. R I Med J. 2016;99:33–36.
23. S. Centers for Disease Control and Prevention. High Blood Pressure Fact Sheet Data & Statistics. Available at: cdc.gov/dhdsp/data_statistics/ fact_sheets/fs_bloodpressure.htm. Accessed January 8, 2018.
24. Paizan MLM, Vilela-Martin JF. Is there an association between periodontitis and hypertension? Curr Cardiol Rev. 2014; 10:355–361.
25. Bassareo PP, Mercuro G. Pediatric hypertension: an update on a burning problem. World J Cardiol. 2014;6:253–259.
26. Moyer V. Screening for Primary Hypertension in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159:613–619.
27. Banker A, Bell C, Gupta-Malhotra M, Samuels J. Blood pressure percentile charts to identify high or low blood pressure in children. BMC Pediatr. 2016;16:16–98.
28. de Oliveira S, da Cunha Nascimento D, Tibana R, et al. Elevated glycated hemoglobin levels impair blood pressure in children and adolescents with type 1 diabetes mellitus. Diabetol Metab Syndr. 2016;8:4.
29. Kutlubay Z, Engin B, Bairamov O, Tüzün Y. Acanthosis nigricans: A fold (intertriginous) dermatosis. Clin Dermatol. 2015;33:466–470.
30. Tabák A, Herder C, Rathmann W, Brunner E, Kivimäki M. Prediabetes: a high-risk state for diabetes development. Lancet. 2012;379:2279–2290.
31. Bustan R, Wasim D, Yderstraede K, Bygum A. Specific skin signs as a cutaneous marker of diabetes mellitus and the prediabetic state — a systematic review. Dan Med J. 2017;64:A5316.
32. Yeshitela B, Gebre-Selassie S, Feleke Y. Asymptomatic bacteriuria and symptomatic urinary tract infections (UTI) in patients with diabetes mellitus in Tikur Anbessa Specialized University Hospital, Addis Ababa, Ethiopia. Ethiop Med J. 2012;50:239–249.
33. Shenoy M, Puranik R, Vanaki S, Puranik S, Shetty P, Shenoy R. A comparative study of oral candidal species carriage in patients with type1 and type2 diabetes mellitus. J Oral Maxillofac Pathol. 201418:60.
34. Hansen M, Gunn P, Kaelber D. Underdiagnosis of Hypertension in Children and Adolescents. JAMA. 2007;298:874.

The authors have no commercial conflicts of interest to disclose.

FEATURED IMAGE BY ANETTA_R/ISTOCK/GETTY IMAGES PLUS

From Decisions in Dentistry. February 2018;4(2):39-42.