In a sample of adolescents with type 1 diabetes being treated at a pediatric diabetes specialty clinic, we found high utilization of professional preventive dental care services, and over 90% of these adolescents had received preventive dental care instructions from a dental professional on how to floss and brush their teeth. In contrast, though, there was low knowledge about risk factors for periodontal disease. Most notably, less than half of the adolescents were aware that periodontal disease is associated with diabetes and only one-quarter knew that periodontal disease can start in childhood with bleeding gums. Despite being a group of youth at high risk for developing periodontal disease, the average toothbrushing frequency was just 9.5 times per week and nearly 42% of these adolescents did not floss. These adolescents reported that taking care of their gums was less important than taking care of their teeth and both had lower priority than taking care of their medical health. If confirmed, our findings suggest several opportunities for improving clinical dental practice in the area of health education, intervention planning, and medical-dental professional collaboration to improve the oral health outcomes for young people living with type 1 diabetes.
First, with regard to raising periodontal disease awareness and knowledge, it would appear that adolescents with type 1 diabetes are an audience of informed young people who are aware of general health and prevention concepts. For example, messages about healthy eating and physical activity were reported by a significantly higher percentage of study group adolescents when compared to national norms for preventive health advice reported by the Medical Expenditure Panel Survey [29
]. Knowledge about the oral health risks of smoking also seems high in this group of adolescents with type 1 diabetes. While we might expect more vigilance in patient education on these topics from diabetes care providers and educators, it was interesting that a greater proportion of adolescents in our study group reported significantly more preventive health advice in other topics as well. Our findings suggest, however, that most youth with diabetes may not be aware of their increased risk for periodontal disease. This is similar to the findings of Moore and colleagues, noting that many adult diabetic patients “lack(ed) important knowledge about the oral health complications of their disease” [34
]. Therefore, dental professionals should work with diabetes educators and incorporate periodontal-specific oral health messages into routine diabetes education for adolescents.
A second opportunity is to actively promote optimal oral hygiene habits for disease prevention and control through effective toothbrushing and flossing. Despite being instructed by a health professional on how to floss, the majority of the adolescents engaged in little or no flossing behavior. Youth who are self-responsible for their diabetes care should be encouraged to adopt increased dental flossing to control gingivitis and to establish healthy habits to prevent periodontitis. Relatively simple interventions may be effective, particularly when proven behavioral change techniques are used, such as supporting the development of personal behavioral intentions as described by McCaul et al., and more recently by Sniehotta et al. [26
]. Research by Syrjälä et al. has also explored the construct of self-efficacy and the theory of reasoned action in describing determinants of oral health and diabetes self-care behaviors for adults with type 1 diabetes [23
]. Self-efficacy is a person's belief in his or her ability to succeed in a particular situation. Individuals with diabetes who were confident in their ability to manage their diabetes were also more likely to adhere to oral hygiene recommendations [25
]. Though nearly all participants reported high rates of dental attendance and receiving toothbrushing and flossing instructions from dental professionals, perhaps the motivation to practice these health behaviors, particularly flossing, has not been as clearly connected with the outcomes for gingival health or the consequences of periodontal disease for diabetic patients. Promoting dental attitudes and subjective norms among diabetic children may improve the likelihood of practicing effective oral hygiene behaviors such as flossing [26
Not surprisingly, the young people who participated in our study appear to be concerned with cosmetic factors and the appearance of their teeth. Self-esteem and peer acceptance as well as family environment have been shown to influence oral hygiene behaviors with adolescents [37
]. Further study of social and psychosocial factors could provide insight into ways to motivate teens to improve brushing and flossing behaviors.
When considering the rating of dental health, it is interesting to note that this particular group of adolescents with diabetes did not rate their oral health as favorably as the general population. Perhaps children with type 1 diabetes take a more critical view of their oral health status or are less likely to rate any aspect of their health as excellent in light of their systemic health problem. However, an older survey collected for the Third National Health and Nutrition Examination Survey found that half of adolescents reported excellent or very good dental health, which is similar to our observations [39
]. Interim analysis of the clinical periodontal findings within this group is presently underway and should provide a more comprehensive picture of the oral health status and how perception compares with clinical measures.
This study has limitations. Results from a single diabetes specialty clinic may not reflect the health knowledge, attitudes, and behaviors of a typical adolescent with diabetes, although the children seen at the Barbara Davis Center are representative of children with type 1 diabetes in the region. However, adolescents in our study were more likely to have had preventive dental care in the past year than an average adolescent in the U.S. More research is needed to confirm our findings; however, there are some clinical indicators that suggest that our sample may be representative of general health behaviors in youth with diabetes. For example, our population's level of glycemic control was comparable to rates observed across large international samples of diabetic youth [40
]. The BMI scores of our population were also similar to the norms for children of this age [41
], and the self-reported rates of caries were also comparable to rates reported from the National Survey of Children's Health for this age group [27
Self-reported data also limit our ability to validate these findings. Response bias may have influenced individuals to overreport dental visit attendance and brushing or flossing behaviors. The national normative data are provided to offer context for our results. Caution should be applied when making direct comparisons between our findings and national normative data. For example, the National Survey of Children's Health obtains data via telephone interview surveys and asks parents to describe the health and dental circumstances of their children [27
]. It is likely that children and adolescents report their perceptions of oral health and the need for dental treatment based on oral signs and symptoms, and that assessment may differ from the perceptions and reports of their parents [42