Paediatric type 1 diabetes mellitus: Multidisciplinary approach needed

Send your letters to the Editor, British Dental Journal, 64 Wimpole Street, London, W1G 8YS. bdj@bda.org. Priority will be given to letters less than 500 words long. Authors must sign the letter, which may be edited for reasons of space.

Sir, an eight-year-old female was referred to the department of paediatric dentistry complaining of swollen, bleeding gums and mobile lower incisors, first noted by her GDP.

On clinical examination, the gingivae surrounding the lower incisors was erythematous (Fig. 1) and there was grade II mobility of 31 with grade I mobility of the 42, 41, 32. Radiographic investigation showed periodontal bone loss between 41 and 31, just greater than half the root lengths. There was crestal bone loss between the other lower incisors and widening of the remaining periodontal ligaments of all four lower incisors periapically (Fig. 2).

Figure 1

Pre-operative photograph

Figure 2

Periapical radiograph

The patient also had caries affecting a number of her primary teeth. Blood tests were completed to explore any underlying systemic condition. Results were normal or negative apart from her random blood glucose which was elevated at 15.9 mmol/L. The patient's general medical practitioner was urgently contacted who reviewed her and sent her to hospital. She was diagnosed with type 1 diabetes mellitus and began an insulin regime.

Once her glycaemic control had improved, following liaison with her paediatrician, dental treatment was completed during early morning appointments following breakfast and insulin injection. This included a programme of prevention, supra and subgingival scaling of the lower anterior teeth, extractions and restoration of her carious primary teeth under local anaesthetic. Her gingival condition significantly improved (Fig. 3) and the family are now adapting well to the patient's newly diagnosed condition.

Figure 3

Post-operative photograph

We would like to stress that in the paediatric patient, any unexplained gingival swelling, bleeding and/or mobility of the teeth requires further investigation and could be a sign of an undiagnosed systemic condition.

The GDP may be the first clinician in contact with these patients and needs to have an awareness of associated oral manifestations of disease, whilst referring promptly if required. Prior to and following diagnosis of diabetes in paediatric patients, an effective multidisciplinary approach to medical and dental management is required for holistic patient care.