Dental Care for Diabetic Children
Diabetes is a chronic condition that has multiple repercussions on an individual’s health and well-being. Nowhere is this more evident than in a child. Children with diabetes will usually fall under type 1 diabetes mellitus, previously called insulin-dependent diabetes mellitus. This disease dramatically alters not only their way of life, self-image and body chemistry, but oral environment as well.
Diabetes and dental health
Due to the very nature of the disease, poor control of diabetes affects the functioning of salivary glands leading to a decrease in the saliva flow rate. This would make it more difficult to wash off debris from the mouth, chew food easily, lubricate the mouth during speech, and remineralize or bring minerals back to teeth. Also, the saliva loses most of its buffering capacity or the presence of natural acid blockers.
These acid blockers are essential in the prevention of caries or tooth decay. It allows the teeth to be confronted by an acid challenge but not be affected by it. If the saliva is able to neutralize acid, it can overcome potential erosion, sensitivity or caries problems. Add to this the fact that salivary pH levels go down or become more acidic in diabetic patients.
Hyperglycemia or an increase in blood glucose levels in children show a marked increase in salivary glucose levels too. This means that a change in the flora of the mouth occurs with increases seen in salivary lactobacilli and yeast counts. Our mouth is teeming with bacteria and other microbes but what is important is the unique balance that occurs day in and day out. When this delicate balance is disturbed, it opens the gate to more tooth decay and gum problems.
These gum problems may range from localized gingivitis to severe, generalized periodontitis. Unfortunately with diabetes, gum problems are usually more severe due to defects in neutrophil and immune cell function.
Thus, there is greater gingival inflammation and gingival bleeding seen in both the primary and secondary dentition. This means that even though it is quite uncommon to see any gum problems with children’s baby teeth, this is not the case in diabetic children. Ten percent even manifest with overt periodontitis. The big difference between gingivitis and periodontitis is that with periodontitis there is actual bone loss occurring. This is a red flag and is usually a sign of systemic disease.
In some cases, only the first permanent molars and permanent incisors are affected but it may also be generalized and affect all of the teeth that are present in the mouth. Since it is usually uncommon in children, diagnosis may be difficult or even overlooked.
Although there is a distinct association between control of diabetes mellitus and occurrence of these problems, it is unfortunate that even in well-controlled cases, these problems still arise. Studies are also being done to find out if the condition adversely affects developing teeth and bone. To this end, it is important to protect and strengthen teeth that are already present and those that are still growing underneath.
Detection and treatment
But how can parents know if there are problems already? Simple, look inside your child’s mouth. Check if there are any cavities present. Check if the gums are inflamed – gums that are swollen, have rolled borders, and are not well-adapted to the teeth. See if the gums are red, instead of a healthy pink hue. If the saliva is sticky and frothy instead of watery, you may expect some problems.
Also, talking to your kids may be a big help. Most of them will complain of bleeding during toothbrushing or bleeding of the gums even with slight manipulation. They may say that their gums feel fat and bulging or that there is a “weird” metallic taste in their mouth due to the oozing of blood. Others may remark on “wobbly” teeth – a feeling that their teeth are moving or swaying in the sockets. This is usually a sign of bone loss already.
Though these may seem scary or daunting to any parent, it is important to know that there are things that we can do to prevent or treat these problems. First of all, we must emphasize oral hygiene. Daily toothbrushing and flossing are still the staple of a good oral health regimen. Early and correct diagnosis is essential in starting an effective therapeutic program. This may include a periodontal exam wherein a probe is inserted into the gingival cuff of every tooth. This is not a routine procedure for children so thorough history-taking will aid in this endeavour.
If a periodontal problem is detected, local debridement may be done after medical clearance. Clearance is necessary due to the patient’s compromised immunity and slower healing capability. The child may not be able to tolerate the transient bacteremia* following an invasive dental procedure like deep cleaning and scaling.
Some may be required to take prophylactic antibiotics before the procedure. If the problem is severe and generalized, the child may even be put on systemic antibiotics. If caries are present, then all cavities must be cleaned out and filled to prevent bacteria from spreading and causing more severe consequences such as dental abscesses or facial swelling. Unfortunately, if the cavities have eaten up the tooth and extraction is indicated, this will still require medical clearance before the extraction can be done.
Of course it is best to keep the condition in check with proper diet, exercise and medical intervention to keep blood glucose levels down. However, there are easy chairside dental tests that we can do to monitor the child’s oral condition.
The plaque-check +pH test measures the pH of plaque after a sucrose challenge. This means that we will be able to determine the cariogenic (cavity-producing) potential of the plaque present in the child’s mouth. This cariogenic potential gives us an idea of the total acid produced by the bacteria in plaque. The greater the acid production, the greater the chance for cavities to be formed. This test also includes the use of a disclosing gel that colors the plaque on teeth and distinguishes between fresh plaque and mature plaque – plaque that has been on the teeth for more than 48 hours. Can you imagine having plaque that’s more than two days old? This is the kind of plaque that forms more acid and causes more cavities. Unfortunately, this is very common in children since they may not be able to brush as well. In diabetic children, this is even more so due to the fact that plaque is stickier, more adherent to teeth.
Another test is the Saliva-Check Buffer Test. This test measures the pH of resting saliva and then checks the protective properties of stimulated saliva. If the resting saliva pH is 5.5 (critical pH) or lower, demineralization occurs. This means that acid is working to slowly leach out minerals from the teeth and will surely cause white spot lesions and then cavities. White spot lesions are signs of early tooth decay and are characterized by opaqueness or a change in color and translucency of the enamel of teeth. The sides or margins become chalky-white in appearance but are easy to miss if parents are not aware and are not looking for them. Most diabetic children will have acidic saliva thus, this test may be important in monitoring that tendency. The test also checks the stimulated saliva’s ability to counteract or neutralize an acid challenge. This will allow us to know if the patient is in the low, moderate or high risk category.
Preventive tooth care
At this juncture, it is best to formulate a customized preventive regimen for the child depending on caries-risk status. This may include fluoride tablet supplementation, daily tooth mousse application, and regular fluoride varnish treatment.
Fluoride tablets are prescribed to patients where a deficiency in fluoride is seen. Since the tablets are chewed and swallowed, the effect is not only seen in erupted teeth but more importantly in developing permanent teeth. These will serve to strengthen teeth while still under the bone.
Tooth mousse is a milk derivative composed of bio-available calcium and phosphate. It is found in crème form and is easily applied to all natural teeth surfaces allowing minerals to be brought back to the teeth. Its use also promotes the stimulation of saliva thereby increasing flow and watery consistency. This is a very good adjunct to the home care regimen and has shown great clinical results plus its different flavours make it easy and thoroughly enjoyable for kids to use.
Fluoride varnish is a vehicle by which fluoride can be applied topically to the teeth but is dramatically different from the fluoride gel that regular dentists use. It contains the highest concentration of fluoride available about 25 times the amount found in toothpaste and has the specific clinical ability to adhere to teeth. Thus, it is able to stay on teeth longer without being washed off by moisture or saliva. When this procedure is done, it is best to have the child eat prior since they can’t eat, drink or gargle for two hours to maximize the effect of the fluoride varnish.
Regular dental visits of at least every three months are also crucial in preventing problems and monitoring each child’s progress.
Diabetes may be a condition wrought with many challenges but with proper care and preventive maintenance, our children’s oral health may be optimized.
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