Keywords
periodontal disease - type 1 diabetes mellitus - diabetes mellitus - oral health -
self-perception
Introduction
Diabetes mellitus (DM) is a metabolic disease characterized by the dysregulation of
carbohydrate metabolism. It commonly manifests as hyperglycemia due to diminished
insulin secretion, impaired insulin action, or both.[1] Type 1 diabetes mellitus (T1DM) makes up 5 to 10% of all DM cases worldwide.[2] The disease stems from cell-mediated autoimmune destruction of the pancreatic β-cells
that produce insulin. Depending on the degree of β-cell destruction, T1DM patients
can experience reduced or absence of insulin secretion, as indicated by low or negligible
levels of plasma C-peptide. The chronic hyperglycemic status can lead to long-term
damage, dysfunction, and failure of different organs in DM patients, especially the
eyes, kidneys, nerves, heart, and blood vessels.[3] Treatment modalities for T1DM include subcutaneous injections of insulin, maintenance
of a healthy diet, and regular exercise.[4]
Periodontal disease (PD) is a condition resulting from the infection and inflammation
of the tooth-supporting tissues.[5] In the early stages of the disease, gingival inflammation may cause the gingival
tissues to appear erythematous, or edematous, and potentially result in bleeding.
Worse, gingivitis can progress into periodontitis that presents as attachment loss,
alveolar bone resorption, and tooth mobility.[6] PD is one of the most common causes of tooth loss.[7] DM is associated with an increase in the prevalence, severity, and progression of
periodontitis.[8]
[9] DM patients are three times more likely to suffer from periodontitis as compared
with nondiabetics.[10] Furthermore, 10% of children with T1DM were reported to have higher rates of attachment
loss and bone loss compared with their nondiabetic peers despite having comparable
plaques score.[11] Moreover, a recent study showed that children with DM have twice the number of periodontal
sites that eventually developed into periodontitis as compared with non-DM children.[12]
The bidirectional association between DM and PD has been established in previous literature.[13]
[14] DM is known as one of the modifying factors of periodontitis that can accelerate
the progress of PD[14] as DM can impair the periodontal tissue growth and matrix formation with fibroblasts,
osteoblasts, and osteoclasts.[15]
[16] In addition, increased thickness of the gingival basement membrane in DM patients
could also impair the vasculature of the periodontal tissues.[17]
[18] It has also been postulated that DM complicates PD by tipping the balance of oral
microbiota, resulting in the dominance of periodontal pathogens.[19]
[20] However, more in-depth studies are needed to ascertain the differences in the biofilm
of diabetics and nondiabetics. The latest evidence indicated that chronic inflammation
in PD can aggravate complications of DM by worsening glycemic control.
The American Dental Association recommendation for diabetic patients is to receive
medical follow-up on a 3-monthly basis.[21] During these visits, evaluation of hemoglobin A1c (HbA1c) and reassessment of diabetes
management are recommended. However, T1DM patients with unsatisfactory glycemic control
should be arranged for more frequent follow-ups to enhance their adherence to the
treatment regime. During this quarterly visit, T1DM patients would be able to obtain
the maximum benefits from the other multidisciplinary team of specialists, thus reinforcing
good self-care practices, such as routine dental visit.[22]
[23] Apart from having known risk of PD, poor oral hygiene was observed in youngsters
with T1DM especially those with uncontrolled HbA1c, which eventually could increase
the risk of future oral disease(s).[24]
In 2020, a study by Moore et al on professional health care workers in pediatric diabetes
care teams showed that 76.2% of them were aware that periodontitis is a possible complication
of diabetes. However, in 2022 Siddiqi and Zafar recorded a contradicting finding in
which they found that the majority of medical practitioners (89%) were aware of the
bidirectional association and knew that the glycemic index of patients with DM and
suffering PDs could be improved by providing periodontal therapy.[25] However, as low as 4.8% had received training in recognizing patients who require
dental care. This study reinforced the need for further training in this area to provide
holistic care to DM patients.[26]
[27] There is an urgent need for accurate and reliable means of surveillance, detection,
and diagnosis of periodontitis among children suffering from T1DM. In addition to
that, referral to dental care professionals for appropriate and timely management
is crucial, therefore appropriate screening tools for medical professionals to initiate
referral of patients with DM is needed.[28] Hence, it is vital to establish an effective system for nondental health providers
to identify individuals in need of dental care.[29] However, with limited resources available for regular screening and timely examination
by dental practitioners, other options should be explored.
In 2022, a study by Mohd Said from Malaysia recommended the use of validated simplified
digital periodontal health screening software for identification of PD at early stage
in dental practice.[30] This identification tool appeared simple and appropriate to be used for screening
of PDs. This showed an effort have been made to initiate the link from the general
dental practice to specialist care. Nevertheless, the initiation from the medical
practitioner has yet to be established. Hence, there is a need of questionnaires is
of detecting populations at risk of oral diseases, which can be initiated from the
medical professionals. On top of that, the accuracy and effectiveness of using a questionnaire
when compared with the clinical examination ranged from moderate to high in various
studies, thus indicating its potential to be can be administered to instil awareness,
facilitate early detection, and predict the disease.[31] Therefore, in this context, a self- self-reported perception and the clinical parameters
could contribute to the prevention and earlier diagnosis of PD, especially in individuals
requiring complex clinical care.[32]
Therefore, the use of adapted self-report measures for PD can be considered a low-cost
alternative for the early detection and prevention of PD in DM patients. It can be
beneficial for epidemiological studies and population surveillance of the periodontal
condition.[33] This study aimed to compare the self-perceived periodontal health status using a
guided questionnaire (GQ) with the clinical measurement by dental professionals among
children and adolescents with T1DM. The study also set out to determine if the GQ
is a valid tool to be used by nondental professionals to evaluate periodontal health
status.
Materials and Methods
This two-part study was a cross-sectional study conducted from October 2020 to May
2022 at two centers, Universiti Teknologi MARA (UiTM), Selangor, and the University
of Malaya (UM), Kuala Lumpur. Content validity index for item (I-CVI) and face validity
was conducted to validate the questionnaire. A reliability study of 20 participants
and intraexaminer training and calibration was performed prior to the study.
All children and adolescents below 18 years old with T1DM diagnosis at UM and UiTM
were invited to participate in the study. They must be able to communicate in English
and or Bahasa Melayu. However, those undergoing active orthodontic therapy or using
any antibiotics or medications in the last 3 months that might cause gingival alteration,
such as drug-induced gingival enlargement, were excluded.
The sample size was determined using Epi-Info StatCal software based on the total
number of the eligible T1DM patient (n = 166)[34] and the prevalence of diabetes test knowledge was 50.4% (11.6/23 × 100).[35] Considering an attrition rate of 10% with a 95% confidence level and an acceptable
margin of error of 5.6%, the final sample calculated was 118 (108 + 10%). A total
of 113 T1DM patients were recruited. The participants and their parent(s) or caregiver(s)
answered the questionnaire during their follow-ups. The questionnaire would be answered
by parents of children below 16 years old. Subsequent appointments were arranged for
the participants to undergo a dental examination.
Definition
Body Mass Index
Body mass index (BMI) was calculated as weight in kilograms divided by height in meters
squared, i.e., BMI = weight (kg)/height2 (m2). The calculated BMI was plotted on the Centers for Diseases and Prevention (CDC)
BMI-to-age chart for the respective gender[36] ([Table 1]).
Table 1
Body Mass Index classification
|
BMI classification
|
Definition
|
|
Underweight
|
<5th percentile
|
|
Normal weight
|
<85th centile
|
|
Overweigh
|
≥85th but <95th centile
|
|
Obesity
|
≥95th centile
|
Abbreviation: BMI, body mass index.
Blood Pressure
In this study, blood pressure (BP) was reported as systolic (SBP) and diastolic (DBP)
percentiles for age/sex/height. The classification is based on the individual's age
plotted against the percentile of height in SBP or DBP (mm Hg) of the respective gender.[37] The height percentile was obtained using the CDC height-for-age percentile of the
respective gender. Based on American Academy of Pediatrics, BP categories and stages
are as follows[38] ([Table 2]).
Table 2
Blood pressure classification
|
In children aged 1–13 y old
|
|
BP classification
|
Definition
|
|
Normal
|
<90th percentile
|
|
Elevated
|
≥90th percentile to <95th percentile, or 120/80 mm Hg to <95th percentile (whichever
is lower)
|
|
Stage 1 hypertension (HTN)
|
≥95th percentile to <95th percentile + 12 mm Hg, or 130/80–139/89 mm Hg (whichever
is lower)
|
|
Stage 2 HTN
|
≥95th percentile + 12 mm Hg or ≥ 140/90 mm Hg (whichever is lower)
|
|
In children aged ≥ 13 y old
|
|
BP classification
|
Definition
|
|
Normal
|
<120/< 80 mm Hg
|
|
Elevated
|
120/< 80–129/< 80 mm Hg
|
|
Stage 1 HTN
|
130/80–139/89 mm Hg
|
|
Stage 2 HTN
|
≥140/90 mm Hg
|
Abbreviations: BP, blood pressure; HTN, hypertension.
Lipid Profile
According to the International Society for Pediatrics and Adolescent Diabetes and
the American Diabetes Association recommended low-density lipoprotein cholesterol
(LDL-C) of < 100 mg/dL (2.6 mmol/L) in youth with DM.[39]
High-density lipoprotein cholesterol (HDL-C), total cholesterol, triglycerides can
be categorized according to NHLBI 2011.[40]
Hemoglobin A1c
HbA1c is a glycoprotein formed by a direct reaction between blood glucose and hemoglobin.
It is routinely in clinical research and clinical practice to evaluate diabetes control.
For children, adolescents, and young adults ≤ 25 years old. With access to comprehensive
care, HbA1c of < 53 mmol/dL (7.0%) is recommended.[41]
Study Instrument
Guided Questionnaire
Self-reported questionnaires adopted from two recent studies were translated and validated
to be used in this study.[42]
[43] The GQ consisted of 14 items with 8 items on patients' baseline characteristics
(Part A) and 6 items on symptoms of PD (Part B). The GQ was used to screen for any
PD comorbidity among the study participants.
Clinical Examination
Simplified Basic Periodontal Examination
The simplified basic periodontal examination (sBPE) codes formed the basis of the
assessment for patients under 18 years old. The examined teeth included one tooth
from each sextant, i.e., the upper right six (tooth 16), the upper right one (tooth
11), upper left six (tooth 26), lower left six (tooth 36), lower left one (tooth 31),
and lower right six (tooth 46). The WHO 621 probe with a light probing force of 20
to 25 g was used for this assessment. The sBPE codes were as follows: 0, healthy;
1, bleeding on gentle probing; 2, calculus present and/or plaque retention factors;
3, the presence of 4- to 5-mm pocket; and 4, the presence of 6 mm or more pocket;
and *, furcation.[44]
In children between 12 and 17 years with erupted permanent teeth, the full range of
sBPE codes (0–4) was used. For children aged between 7 and 11 years with mixed dentition,
the sBPE codes 0,1, and 2 were used. In the full primary dentition, sBPE similar to
the one used for children as young as 3 years of age was performed.[45] Apart from that, plaque index (PI)[46] and gingival index (GI)[47] were also assessed.
Statistical Analysis
Data analysis was performed using the Statistical Package for the Social Sciences
Version 20.0. Association between the GQ and the clinical examination was assessed
using the Pearson chi-square test and Fisher's exact test. A p-value < 0.05 was considered statistically significant. Diagnostic tests (sensitivity,
specificity, accuracy, positive predictive value, negative predictive value, and receiving
operating characteristic curve) were performed to measure the performance of each
question with the basic periodontal examination (BPE) as the reference for the periodontal
evaluation. For this purpose, the periodontal status was dichotomized as “0” for healthy
and “1 and above” for having PD.
Results
Questionnaire I-CVI value 0.96 indicate high value of all items. And, following changes
made based on expert opinion, a good face validation could be seen. Intraexaminer
training and calibration (intraclass correlation coefficient revealed a good value
of 85%) with acceptable reliability Cronbach's α of 0.77. [Table 3] outlines the sociodemographic, clinical parameters, and oral hygiene care characteristics
of the participants. From the 113 participants, 24.8% (n = 28) presented with stage 1 hypertension, whereas another 18.6% (n = 21) had elevated BP. Despite only 6.2% of the participants being obese, as high
as 92% of them recorded uncontrolled HbA1c. Similarly, 19.5% of the participants were
found to have high LDL-C despite normal body weight.
Table 3
Sociodemographic, clinical parameters, and oral hygiene care of participants
|
Variables
|
n
|
(%)
|
|
Sex
|
|
Male
|
56
|
(49.6)
|
|
Female
|
57
|
(50.4)
|
|
Age
|
|
< 6 y
|
16
|
(14.2)
|
|
7–12 y
|
39
|
(34.5)
|
|
13–18 y
|
58
|
(51.3)
|
|
Race
|
|
Malay
|
55
|
(48.7)
|
|
Chinese
|
27
|
(23.9)
|
|
Indian
|
30
|
(26.5)
|
|
Others
|
1
|
(0.9)
|
|
Blood pressure[38]
|
|
Normal
|
64
|
(56.6)
|
|
Elevated
|
21
|
(18.6)
|
|
Stage 1 hypertension
|
28
|
(24.8)
|
|
FBG[41]
|
|
Normal fasting glucose
|
54
|
(47.8)
|
|
Impaired fasting glucose
|
12
|
(10.6)
|
|
Diabetes fasting glucose
|
47
|
(41.6)
|
|
RBG[41]
|
|
Normal glucose tolerance
|
11
|
(9.7)
|
|
Impaired glucose tolerance
|
39
|
(34.5)
|
|
Diabetes glucose tolerance
|
63
|
(55.8)
|
|
BMI[36]
|
|
Underweight
|
11
|
(9.7)
|
|
Healthy weight
|
68
|
(60.2)
|
|
Overweight
|
27
|
(23.9)
|
|
Obesity
|
7
|
(6.2)
|
|
HbA1c[41]
|
|
Controlled
|
9
|
(8.0)
|
|
Uncontrolled
|
104
|
(92.0)
|
|
Lipid profile
|
|
TG[40]
|
|
Acceptable
|
30
|
(26.5)
|
|
Borderline
|
24
|
(21.2)
|
|
High
|
41
|
(36.3)
|
|
Missing
|
18
|
(15.9)
|
|
TC[40]
|
|
Acceptable
|
31
|
(27.4)
|
|
Borderline
|
34
|
(30.1)
|
|
High
|
30
|
(26.5)
|
|
Missing
|
18
|
(15.9)
|
|
LDL-C[39]
|
|
Acceptable
|
48
|
(42.5)
|
|
Borderline
|
25
|
(22.1)
|
|
High
|
22
|
(19.5)
|
|
Missing
|
18
|
(15.9)
|
|
HDL-C[40]
|
|
Low
|
13
|
(11.5)
|
|
Borderline
|
6
|
(5.3)
|
|
Acceptable
|
75
|
(66.4)
|
|
Missing
|
19
|
(16.8)
|
|
Duration of diabetes
|
|
< 5 y
|
66
|
(58.4)
|
|
5–10 y
|
38
|
(33.6)
|
|
> 10 y
|
9
|
(8.0)
|
|
Frequency of brushing
|
|
Morning
|
17
|
(15.0)
|
|
Morning/before going to sleep
|
72
|
(63.7)
|
|
Morning/before going to sleep and after eating food
|
22
|
(19.5)
|
|
Use flossing
|
1
|
(0.9)
|
|
Others/adjunct
|
1
|
(0.9)
|
Abbreviations: BMI, body mass index; FBG, fasting blood glucose; HbA1c, hemoglobin
A1c; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol;
RBG, random blood glucose; TC, total cholesterol; TG, triglycerides.
Further analysis revealed that 40.9 and 53.8% of participants with healthy BMI exhibited
high LDL-C and low HDL-C, respectively ([Table 4]). In addition, uncontrolled HbA1c was observed among 91.2% of participants despite
normal BMI. A higher percentage of uncontrolled HbA1c was also reported among participants
with acceptable LDL-C (87.5%), acceptable HDL-C (90.7%), and less than 5 years of
DM (90.9%). However, all these associations were not statistically significant (p > 0.05) ([Table 5]).
Table 4
Association between low-density lipoprotein cholesterol, high-density lipoprotein
cholesterol, and body mass index
|
Variables
|
Underweight
|
Healthy weight
|
Overweight
|
Obesity
|
p-Value
|
|
n
|
(%)
|
n
|
(%)
|
n
|
(%)
|
n
|
(%)
|
|
LDL-C
|
|
Acceptable
|
2
|
(4.2)
|
33
|
(68.8)
|
10
|
(20.8)
|
3
|
(6.3)
|
0.180[a]
|
|
Borderline
|
2
|
(8.0)
|
17
|
(68.0)
|
6
|
(24.0)
|
0
|
(0.0)
|
|
High
|
1
|
(4.5)
|
9
|
(40.9)
|
10
|
(45.5)
|
2
|
(9.1)
|
|
HDL-C
|
|
Low
|
0
|
(0.0)
|
7
|
(53.8)
|
4
|
(30.8)
|
2
|
(15.4)
|
0.392[a]
|
|
Borderline
|
1
|
(16.7)
|
3
|
(50.0)
|
2
|
(33.3)
|
0
|
(0.0)
|
|
Acceptable
|
4
|
(5.3)
|
48
|
(64.0)
|
20
|
(26.7)
|
3
|
(4.0)
|
Abbreviations: BMI, body mass index; HDL-C, high-density lipoprotein cholesterol;
LDL-C, low-density lipoprotein cholesterol.
a Fisher's exact test.
Table 5
Association between selected variables and hemoglobin A1c
|
Variables
|
Controlled
|
Uncontrolled
|
p-Value
|
|
n
|
(%)
|
n
|
(%)
|
|
BMI
|
|
Underweight
|
1
|
(9.1)
|
10
|
(90.9)
|
1.000[a]
|
|
Healthy weight
|
6
|
(8.8)
|
62
|
(91.2)
|
|
Overweight
|
2
|
(7.4)
|
25
|
(92.6)
|
|
Obesity
|
0
|
(0.0)
|
7
|
(100.0)
|
|
LDL-C
|
|
Acceptable
|
6
|
(12.5)
|
42
|
(87.5)
|
0.270[a]
|
|
Borderline
|
2
|
(8.0)
|
23
|
(92.0)
|
|
High
|
0
|
(0.0)
|
22
|
(100.0)
|
|
HDL-C
|
|
Low
|
1
|
(7.7)
|
12
|
(92.3)
|
1.000[a]
|
|
Borderline
|
0
|
(0.0)
|
6
|
(100.0)
|
|
Acceptable
|
7
|
(9.3)
|
68
|
(90.7)
|
|
Duration of T1DM
|
|
< 5 y
|
6
|
(9.1)
|
60
|
(90.9)
|
0.647[a]
|
|
5–10 y
|
2
|
(5.3)
|
36
|
(94.7)
|
|
> 10 y
|
1
|
(11.1)
|
8
|
(88.9)
|
Abbreviations: BMI, body mass index; HDL-C, high-density lipoprotein cholesterol;
LDL-C, low-density lipoprotein cholesterol; T1DM, type 1 diabetes mellitus.
a Fisher's exact test.
[Table 6] shows that 27.5% of participants who reported bleeding from gingiva upon brushing,
flossing, and eating were found to have BPE during the clinical examination. This
finding indicated a high sensitivity (50%) and specificity of the questionnaire (94.5%).
In addition, 90% of T1DM presented with gingival bleeding were at risk of having PD
(p < 0.001).
Table 6
Frequency of responses for periodontal health questionnaire and diagnostic tests for
each question in relation to simplified basic periodontal examination
|
Questions
|
Answer
|
n (%)
|
SS
|
SP
|
ACC
|
PPV
|
NPV
|
AUC
|
p-Value
|
|
Part A
1.Do you think you have gum disease?
|
Yes
No
|
14 (12.8)
95 (87.2)
|
16.7
|
90.9
|
54.1
|
64.3
|
52.6
|
0.538
|
0.495
|
|
2.Overall, how do you rate your teeth and gum health?
|
Good Bad
|
91 (83.5)
18 (16.5)
|
20.4
|
87.3
|
54.1
|
61.1
|
52.7
|
0.538
|
0.492
|
|
3.Have you ever had gum treatment for gum disease, such as scaling either above or
below gum?
|
Yes
No
|
19 (17.4)
90 (82.6)
|
22.2
|
87.3
|
55.0
|
63.2
|
53.3
|
0.547
|
0.393
|
|
4.Have you ever had loose teeth without injury?
|
Yes
No
|
2 (1.8)
107 (98.2)
|
1.9
|
98.2
|
50.5
|
50.0
|
50.5
|
0.500
|
0.998
|
|
5.Have you ever been told by a dental professional that you have gum disease?
|
Yes
No
|
1 (0.9)
108 (99.1)
|
0.0
|
98.2
|
49.5
|
0.00
|
50.0
|
0.491
|
0.870
|
|
6.During the past 3 mo, have you ever noticed that your gum doesn't look good?
|
Yes
No
|
7 (6.4)
102 (93.6)
|
11.1
|
98.2
|
55.0
|
85.7
|
52.9
|
0.546
|
0.403
|
|
7.Did you use dental floss or “other devices” for tooth cleaning in the last 7 d?
|
Yes
No
|
9 (8.3)
100 (91.7)
|
11.1
|
94.5
|
53.2
|
66.7
|
52.0
|
0.528
|
0.611
|
|
8.Did you use mouthwash or other dental rinses for “dental problems” treatment in
the last 7 d?
|
Yes
No
|
13 (11.9)
96 (88.1)
|
14.8
|
90.9
|
53.2
|
61.5
|
52.1
|
0.529
|
0.606
|
|
Part B
Do you have the following symptoms?
|
|
1. Bleeding when brushing, flossing, or eating food
|
Yes
No
|
30 (27.5)
79 (72.5)
|
50.0
|
94.5
|
72.5
|
90.0
|
65.8
|
0.723
|
<0.001
|
|
2. Swelling, red, or painful gums for no apparent reason
|
Yes
No
|
9 (8.3)
100 (91.7)
|
13.0
|
96.4
|
55.0
|
77.8
|
53.0
|
0.547
|
0.401
|
|
3. Teeth look longer, and the smile appears more “toothy”
|
Yes
No
|
3 (2.8)
106 (97.2)
|
0.0
|
94.5
|
47.7
|
0.0
|
49.1
|
0.473
|
0.623
|
|
4. Bad breath/ halitosis/foul mouth odor
|
Yes
No
|
11 (10.1)
98 (89.9)
|
14.8
|
94.5
|
55.0
|
72.7
|
53.1
|
0.547
|
0.400
|
|
5. Loosening or shifting of teeth in the affected area
|
Yes
No
|
4 (3.7)
105 (96.3)
|
3.7
|
96.4
|
50.5
|
50.0
|
50.5
|
0.500
|
0.995
|
|
6. Pus oozing between the teeth
|
Yes
No
|
0 (0.0)
109 (100.0)
|
0.0
|
100.0
|
50.5
|
0.0
|
50.5
|
0.500
|
1.000
|
Abbreviations: ACC, accuracy in percentage; AUC, area under the curve; NPV, negative
predictive value in percentage; PPV, positive predictive value in percentage; SP,
specificity in percentage; SS, sensitivity in percentage.
As presented in [Table 7], the mean PI and GI were 0.37 ± 0.31 and 0.27 ± 0.32, respectively. In other words,
48.7% of the participants had healthy periodontal status. Among 47.8% of participants
with unhealthy gingiva, 7% of them were found to have periodontitis.
Table 7
Clinical parameters of the periodontal health status of participants
|
Variables
|
n
|
(%)
|
Mean
|
Standard deviation
|
|
Index
|
|
Plaque index
|
109
|
96.5
|
0.37
|
0.31
|
|
Gingival index
|
109
|
96.5
|
0.27
|
0.32
|
|
Missing
|
4
|
3.5
|
|
|
|
Periodontal status
|
|
Healthy
|
55
|
48.7
|
|
|
|
Gingivitis
|
54
|
47.8
|
|
|
|
Missing
|
4
|
3.5
|
|
|
|
Periodontitis
|
|
Nonperiodontitis
|
105
|
92.9
|
|
|
|
Periodontitis
|
4
|
3.5
|
|
|
|
Missing
|
4
|
3.5
|
|
|
Discussion
PD is the sixth most common complication among DM patients.[48] As T1DM patients face an increased risk of PD,[49] it is vital to improve the awareness of medical professionals and patients on the
prevention and identification of oral diseases. Medical–dental coordinated care needs
to be strengthened for this purpose. The use of self-reported questionnaires can increase
T1DM patients' awareness and self-perception of oral diseases. During most medical
consultations, physicians and other nonoral health professionals often overlook the
need for oral clinical examination.[32] Hence, the use of a self-reported questionnaire can also evoke their attention to
DM patients at risk of PD. Following that, health care providers can refer the patients
to a dentist for further management to prevent oral diseases.[50]
In this study, it was found that respondents who answered “yes” to the question “Do
you have bleeding when brushing, flossing, or eating food?” were associated with a
high score of BPE compared with those who answered “no.” The sum of sensitivity plus
specificity for this item was 144%, which is considered as a “good validity.”[33] Agreed by study in Japan population, inclusion of the question on gum bleeding would
improve the predictive performance of the questionnaire as it is less confusing than
other items.[51] This finding also echoed a few other studies in which the term gum bleeding should
be used rather than gingivitis when interacting with patients [52]
[53]
[54] as not all may be familiar with the dental term of gingivitis, especially children
and adolescents. In addition, Elhassan et al (2017) also suggested that patients could
relate to bleeding better than the appearance of swollen gum.[55]
According to the Nelson's validity classification, self-reported PD (painful gums,
tooth mobility, and people's opinions whether they have gums disease) can be classified
as having moderate to high validity.[33]
[56] However, in our study, the items “Do you think you have gum disease,” “Swelling,
red, or painful gums for no apparent reason,” and “Loosening or shifting of teeth
in the affected area” were found to have low sensitivity of 16.7, 13, and 3%, respectively.
The reason probably due to this set of questionnaire has good predictive ability for
periodontitis, especially in the severe cases rather than gingivitis alone, as only
3.5% patients in our study presented with periodontitis.[51] Supported by one study where the prevalence of periodontitis is high, the predictive
performance of similar self-reported questions presented reported to be more accurate.[57]
In this study, the questionnaire on the perception of oral health for participants
aged less than 16 years old (72.6%) was answered by their parents or caregiver. With
a low sensitivity (18.7%) and high specificity (86%), it can be regarded as having
parents may have good perception of the child's oral health rather than poor perception.
This finding agrees with previous studies in which parental perception of their children's
oral status was found to be superior to the clinical findings.[58]
[59]
[60]
[61] In addition, parental perceptions of oral health are often dependent on clinical
conditions with recognizable symptoms, such as dental caries with toothache rather
than other less obvious oral conditions such as gum problems, malocclusion, or dental
trauma.[62] Similarly, in an earlier study by Cyrino et al (2011), the patient's perception
of health was found to be better than the actual presentation of the disease.[63] The remaining 27.4% of the questionnaire answered by 16- and17-year-olds showed
slightly higher sensitivity (27.3%) and specificity (100%). More studies reported
that younger individuals may not be able to identify PD.[32]
[64] However, contradicting to the statement, adult age more than 60 were less likely
to report gingival bleeding symptom correctly compared with less than 40 years old,
which probably due to more serious manifestation occur rather than gingival bleeding.[65]
According to a new classification of PD, 3.5% or four patients in this study had periodontitis.[66] All four participants answered “yes” for gum bleeding even though only three of
them claimed that they have gum disease. One of them with an advanced stage (stage
III) of gum disease answered “yes” to people's opinions on whether they have gum disease.
The individual also answered “yes” for bad gum condition, painful swollen gums, and
tooth mobility. This means that, our findings agree that more value was seen pertaining
to self-reported PD if severe stage periodontitis was encountered.[67] Thus, this questionnaire would be able to exclude healthy individuals from periodontal
clinical examination at a cheaper cost and would be an alternative of gold standard
periodontal examination in cost-limited epidemiology survey.[68] More importantly, this can expedite the early diagnosis and treatment of PD.
The HbA1c of most participants showed uncontrolled T1DM as many of them did not achieve
the target HbA1c of < 53 mmol/mol (<7.0%) for children and adolescents who have access
to comprehensive care.[41] In this study, almost half of the patients were diagnosed with gingivitis (47.8%).
However, there was no significant association between HbA1c and gingivitis (p = 0.271). In contrast, a significant correlation was detected between PI and sBPE
(p < 0.00). This shows that periodontal condition was more associated with the presence
of visible plaque rather than the underlying metabolic status. According to a recent
study, HbA1c in children and adolescent has a low correlation with the gingival condition
compared with adult DM patients.[69]
Even though the prevalence of T1DM in children and adolescents is increasing,[70] we faced certain challenges in recruiting eligible patients during the pandemic
in view of limited follow-up appointments available during the lockdown period. Furthermore,
more than 10 patients or their parents declined to participate.
Conclusion
This study concluded that the GQ has a high potential to be used in identifying T1DM
children at a greater risk for PD and in need of an oral examination. It can be adopted
as a tool for nondental health care providers to screen for PD before making appropriate
dental referrals for the patients. In the long term this will ensure a seamless and
coordinated care pathway for DM patients requiring dental care
