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Researchers have known for many decades that adult diabetes patients tend to have more serious gum problems and periodontal disease than the general population. Studies also have suggested that treating periodontal disease in adults with diabetes helps them better control their blood sugar. But until recently, investigators have not studied the connection between younger people with diabetes and periodontal disease, which causes bone loss near the teeth.

Now, the National Institutes of Health has awarded a $2 million, five-year grant to researchers at the School of Dental and Oral Surgery and the Naomi Berrie Diabetes Center to define the connection between periodontal disease and primarily Type 1 diabetes in children and adolescents. The grant's goals are to identify and understand the first changes in the gums connected with diabetes, to prevent the oral complications of diabetes as these youngsters age, and to determine how the gum changes are related to other diabetes complications, such as kidney and eye disease. The grant is the first large study to assess periodontal disease as a complication of diabetes in youngsters.

"We want to study the earliest development of periodontal disease in children and adolescents to determine the relationship of these changes to the onset of other complications of diabetes," says Dr. Ira B. Lamster, dean of the School of Dental and Oral Surgery and principal investigator for the grant. Patients with diabetes have high levels of blood sugar, which attaches to proteins in the bloodstream. In the gums, the sugar and protein combination induces an exaggerated inflammatory response, which exacerbates a periodontal infection and makes bone loss inside the gums more severe in a diabetic person.

The NIH grant is multi-pronged: It will support an immediate evaluation of the oral cavity of children and adolescents with and without diabetes; a longitudinal study that will follow the diabetes patients over time; a pathogenesis component to study underlying mechanisms that cause the clinical symptoms; and a training component to teach physicians, physician assistants, and nurses about periodontal disease and its relationship to diabetes in children and adolescents.

The researchers plan to recruit 360 children and adolescents with diabetes through the diabetes center and another 360 youngsters who do not have diabetes from the dental school's pediatric dentistry clinic, all between the ages of 6 and 18. By first comparing the mouths and health of youngsters with diabetes with those without the disease in a one-time examination, the investigators will get a snapshot of the difference between a healthy youngster's mouth and the mouth of a youngster with diabetes with respect to periodontal and other oral diseases.

The investigators will then follow for at least four years 160 of the 13- to 18-year-olds with diabetes to assess periodontal disease progression. The researchers will track the patients over time with standard blood chemistry, urine, and eye tests to evaluate blood sugar control and development of other diabetes complications.

Investigators will test the teens for periodontal disease using sensitive clinical measures and biochemical methods, including a saliva assay, developed by Dr. Lamster and patented by Columbia, that measures the inflammatory response in a patient's mouth. The assay is more efficient than the traditional method of assessing the tooth at the gumline and looking at X-rays because it can be administered more quickly and assesses the state of the entire mouth, Dr. Lamster says. The researchers will analyze gum tissue, saliva, and blood samples to see how periodontal disease begins and if it affects other parts of the mouth and the bloodstream. If periodontal disease is detected, the investigators will refer the teens for treatment.

The researchers expect to apply what they learn to design a clinical trial that will evaluate the effect of periodontal therapy (likely to be the combination of antibiotics and cleansing of infected gum tissue) on blood sugar control. Some evidence suggests that periodontal treatment can help improve blood sugar control.

The educational component is still in the planning stages, Dr. Lamster says. But the team is considering developing an informational CD-ROM about the relationship between periodontal disease and diabetes in children and teens.

Dr. Lamster's research team includes Dr. Evanthia Lalla, assistant professor of dentistry in the dental school; Dr. Robin S. Goland, Irving Associate Professor of Medicine in P&S and co-director of the diabetes center; Dr. Holly Schachner, assistant professor of clinical pediatrics in P&S; Dr. Ayxa Calero-Breckheimer, assistant professor of clinical educational psychology in the Center for Education Research and Evaluation; and Dr. Melissa Begg, associate professor of clinical biostatistics in the Mailman School of Public Health.

Periodontal disease is sometimes seen as the "forgotten complication" in diabetes although it may be the earliest complication that can be spotted by a doctor, says Dr. Schachner, assistant director for pediatric diabetes in the diabetes center, who will be enrolling the children in the study and assessing their diabetes. "Hopefully this study will give new insight into the connection between periodontal disease and diabetes and help us control both earlier," she says.

The National Institute of Dental and Craniofacial Research of the National Institutes of Health is supporting this research.