Addressing Childhood Diabetes in the Dental Setting

Diabetes mellitus (DM) is one of the most common chronic health conditions worldwide, and its occurrence among children continues to rise.^1–5 Type 1 (T1D) and type 2 (T2D) of this metabolic condition cause elevated blood glucose (BG) levels due to disordered insulin release, insulin resistance, or both.⁶ The most common type in childhood, T1D develops from autoimmune-initiated destruction of pancreatic beta cells, resulting in reduced insulin production and release and glucose control. Today, approximately 50 genetic markers for T1D susceptibility have been identified.^3,7–9 While susceptibility is genetic, environmental risk factors also contribute to increased DM prevalence.^3,5,8,9

Among young children, T1D affects both genders equally, but after the age of 15, it is more frequently seen in boys and men.^3,9 T1D’s peak age of onset, currently at ages 10 to 14, continues to decline.^3,4 While the prevalence of childhood T2D remains low, its risk increases with age; higher rates of T2D among children have coincided with a growth in childhood obesity. This is likely due to the insulin demands and inflammation associated with obesity that affects pancreatic beta cells.^5,9,10

A large portion of youth with diabetes lack optimal glycemic control, which may cause oral, cardiovascular, and neurological complications. Although pediatric T2D is less common, it can follow an aggressive path with increased complications when compared to T1D. As these youth become self-reliant, the involvement of the healthcare team is imperative to bridge the gap of care that can occur with early adulthood.^{1,2,4,10–12}

Glycemic Management

DM is a complex, chronic condition requiring lifelong diet management, blood glucose monitoring (BGM), and medication to maintain lower HbA1C levels and minimize complications. With the multifactorial systemic impacts of DM, a multidisciplinary care team and strong dedication to self-care are essential. Individuals with T1D maintain a desirable BG range through insulin injections or continuous subcutaneous insulin infusions, while those with pediatric T2D manage blood pressure through healthy lifestyle choices and oral medications.^13,14 Oral health professionals need to be familiar with testing recommendations, DM medications, and current device options for BGM and insulin delivery. Asking informed questions provides insight into obstacles that families face and creates teachable moments to educate patients on the oral systemic connection.¹⁵

With T1D, BG should be assessed, logged, and reviewed at least four times per day around exercise and eating schedules. These measurements guide families on trends, patterns, insulin demands, and glycemic control. When performing BGM, children should be supervised to avoid test strip contamination or inaccurate measurement interpretation.¹⁵

Technology can provide real-time continuous glucose monitoring and insulin administration through automated delivery systems such as insulin pumps. These devices are becoming the standard of care and early adoption is the treatment of choice for pediatric patients.^12,15,16 The continuous glucose monitoring systems track measurements to facilitate healthcare communication, detect trends, identify changes, send data to smart devices, and initiate alarms to minimize emergencies.^15,16 The recommended continuous glucose monitoring targets include > 70% of time in range (70 to 180 mg/dL), < 4% of time below range (< 70 mg/dL), and < 25% of time above range (>180 mg/dL).¹⁶ Youth with T1D who use a combination of real-time continuous glucose monitoring with insulin pump delivery achieve the closest to target ranges and a lower HbA1C, thereby lowering the probability of severe hypoglycemia, diabetic ketoacidosis events, and hospitalization.¹⁶ Unfortunately, socioeconomic factors can impact access to these devices, resulting in continued reliance on finger stick BGM and insulin injections for many families.¹⁵

Errors in calculations or behaviors that cause glycemic variability during childhood take their toll on oral and systemic health.^12,15 Inaccurate carbohydrate estimation is one of the most impactful errors with T1D as each error results in an inaccurate insulin dose.¹³ Inquiring about carbohydrate management strategies can give insight into the level of monitoring.^4,17 Education on the impact of cariogenic food and drink choices on oral health, balanced with a referral to a DM-focused nutrition specialist can initiate positive, long-term health impacts.¹⁰

Challenges and Comorbidities

Hypoglycemia is a common occurrence among those with DM who use insulin. The American Diabetes Association categorizes standard BG levels as low: 61 to 70, very low: 51 to 60, and dangerously low: < 50. An inability to recognize and manage hypoglycemia, known as recurrent hypoglycemia, results in decreased recognition of early signs and symptoms. Up to 25% of those with T1D may have hypoglycemia unawareness, making them six times more susceptible to severe hypoglycemic episodes. Approximately, one-third of these episodes result in seizures or coma.¹⁸

The signs and symptoms of hypoglycemia can impact the level of BGM in both positive and negative ways. The associated discomfort and fear can increase motivation to monitor BG levels closely. Unfortunately, high stress and anxiety levels, termed “hypoglycemic fear,” can impact daily activities. This fear may occur when those with T1D need assistance to correct a severe hypoglycemic episode. In response, hypoglycemic avoidance behaviors such as excessive BGM, purposely maintaining a higher BG level by withholding insulin, or over treating hypoglycemia may affect systemic health.¹⁸

DM requires a high level of care coordination, knowledge, and dedication to management, therefore many factors impact glycemic control. Negative factors include older age, challenges at school, family conflict, single parent household, higher number of children, and lower levels of education and income.¹⁷ A top reason for glycemic variability and difficulty with DM management is family dynamics, particularly conflict surrounding DM tasks.¹⁹

Positive factors include families with higher education levels in which both parents are present, and small parent-to-child ratio, but a high level of self-management with DM has the greatest impact.^4,17 Parents/caregivers of children with T1D often rank higher on “worry” assessments than adults with T1D, and mothers tend to rank higher than fathers.¹⁸ Despite their worries, parents/caregivers need to provide autonomy to build self-efficacy and perseverance to support self-care.¹⁹ High levels of resilience can be created through a cohesive, adaptive family environment. Resilience increases self-management through positive adaptive behavioral approaches, higher self-esteem, optimism, and increased self-efficacy. Self-efficacy can mitigate family challenges and psychological risk factors, but the best outcomes occur with high self-efficacy within supportive families. The risk of poor glycemic control increases with low self-efficacy and high family conflict.^4,19 Oral health professionals may recognize families with conflict, financial challenges, and DM-related stress and offer their support. Referring families to their primary care physicians and local resources can be impactful.¹⁷

Youth with T1D are three times more likely to be diagnosed with a mental health issue; nearly half may experience anxiety or depression symptoms related to “diabetes distress.”^4,20 Mental health and chronic medical conditions have a bidirectional impact. Mental health issues can obstruct adequate self-management and poor self-management can increase the risk of developing mental health issues. Stress and anxiety negatively impact sleep quality, quality of life, and glycemic levels.^4,20 Oral health professionals may recognize difficulty focusing, lethargy, or trouble maintaining adequate personal hygiene; these issues should be documented and discussed. Demonstrating empathy and asking follow-up questions can determine if families have sought mental health support. Addressing mental health needs is imperative for successful glycemic control and improved systemic health.²⁰ Patients’ primary care physicians can evaluate, individualize DM treatment, and offer resources for cognitive behavior therapy or mental healthcare support.¹⁸

Dental Appointment Recommendations

Oral health professionals can assess patients’ level of glycemic control and commitment to DM care by asking detailed questions about their last meal, BGM, medications, and/or insulin delivery system. Documenting contact information for all healthcare providers will enhance continuity of care and interprofessional communication.^10,11 Individuals with T1D are more likely than those with T2D to have a regular healthcare provider. A larger percentage of youth with T2D are from lower income households with reduced access to healthcare and DM care. Youth with T2D often have higher HbA1C levels and need more education about the severity of their condition.¹¹

Glycemic management can be evaluated by inquiring about the most recent medical visit, recent glucose and HbA1C measurements, BGM frequency, and the last glycemic episode and/or hospitalization. The American Diabetes Association recommends maintaining HbA1C levels below 7.5% for children, and below 7% for adolescents nearing adulthood.¹⁵ With age, HbA1C can be negatively impacted as youth take on increased self-care responsibilities.^4,17 Children who have established relationships with their healthcare providers transition better to the adult medical system than those with fewer visits.²⁰ Reinforcing the need for regular medical appointments at dental visits can strengthen these relationships and continuity of care into adulthood.¹¹

The macrovascular and microvascular impacts of DM can affect oral and systemic health.⁹ Oral health professionals need to be attentive to the signs and symptoms of poor glycemic control and DM comorbidities.^7,10 Due to high prevalence of neuropathy with DM that often goes undiagnosed, oral health professionals may recognize intolerance of the supine position and increased risk of orthostatic hypotension. Patients may experience dizziness when lying back or when leaving the chair.²

Due to an increased risk of oral complications and infection, oral health professionals should initiate prevention strategies and diligently screen for xerostomia, caries, periodontal changes, and oral lesions.¹⁴ The genetic variants associated with T1D contribute to increased caries risk, even when glycemic control is effective.⁷ Because DM can decrease salivary function, lower buffering capacity, and increase saliva viscosity, oral health professionals should evaluate saliva quality and quantity as well as recommend products or techniques to reduce dryness.^7,10

Oral flora changes related to DM may lead to higher levels of pathogenic bacteria, especially with poor glycemic control. The bidirectional association between gingival inflammation and DM is well documented.¹⁰ Higher levels of periodontal pathogens increase the risk of chronic gingivitis and attachment loss; this risk increases with age and time since diagnosis.^10,14 Pediatric patients with DM are three times more likely to develop periodontal diseases than those without DM, and those with poor glycemic control are at the highest risk.¹⁰

Strong plaque control methods are necessary to counteract the increased caries and periodontal risks. Anticariogenic and antimicrobial oral self-care products as well as those that promote acid buffering should be included in patients’ oral hygiene regimens.⁷ Brushing should be recommended two to three times daily with a fluoride toothpaste. If the patient is at high risk for caries, daily use of 5,000 ppm prescription toothpaste, fluoride mouthrinse, and fluoride treatments three to four times per year may be recommended.¹⁰

During a dental appointment, rapidly changing glycemic levels can result in a medical emergency. As the stress of a dental visit can increase hypoglycemia risk, assessing BG at the appointment is prudent. Morning appointments at a time shortly after a meal may help reduce the risk of hypoglycemia.¹⁰

Early signs of hypoglycemia include headaches, changes in mood, dizziness and shakiness, sleepiness or fatigue, weakness, and sweating. If untreated, the patient can experience confusion, seizures, loss of consciousness, and, in an extreme situation, death.^10,18 Glucose measuring devices are approved by the United States Food and Drug Administration, but accuracy varies. Interstitial glucose is measured by continuous glucose monitors rather than BG, so the lag time of up to 40 minutes can indicate a false high or low if BG is rapidly changing.

Oral health professionals must recognize the signs of an glycemic event to identify when to initiate emergency medical care.¹⁵ If hypoglycemic and conscious, > 15 mg of carbohydrates, such as fruit juice, soda, or glucose, should be administered every 15 minutes until the blood glucose exceeds 60 mg/dL. If loss of consciousness occurs, contact emergency assistance and administer glucose gel intraorally or dextrose intravenously. While very rare in pediatric patients, a diabetic ketoacidosis event due to hyperglycemia requires immediate transport to the hospital. Blood glucose should be assessed and uncontrolled DM should be managed prior to extensive treatment to improve outcomes and reduce the risk of glycemic emergency.¹⁰

Conclusion

Due to the complexity of DM management, oral health professionals play a contributing role within the healthcare team in supporting youth with DM and their families. With the strong association between DM and oral disease, oral health professionals must be educated about the oral systemic risks and recognize the signs of poor glycemic control.

References

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From Dimensions of Dental Hygiene. September/October 2025; 23(5):40-45.