Application of Salivary Biomarkers in Risk Assessment for Oral Diseases in Children With Type 1 Diabetes

This research contributes to a deeper understanding of the etiopathogenesis of periodontal and other oral diseases in children with T1D. By analyzing the composition of the salivary microbiome and detecting pathogenic and opportunistic microorganisms, the study aims to develop targeted preventive strategies. The findings could lead to personalized preventive programs, improving early diagnosis and oral health management in this vulnerable population.This study hypothesizes that children with Type 1 Diabetes (T1D) will exhibit significantly different oral health parameters compared to healthy peers. Specifically:

1. Higher KEP and KEPS index values (Klein-Palmer system) indicating increased caries incidence.
2. Higher Silness and Loe plaque index and Loe and Silness gingival index, suggesting greater plaque accumulation and gingival inflammation.
3. Lower salivary buffering capacity and pH, potentially contributing to an increased risk of oral diseases.
4. A distinct microbial profile, with a greater presence of pathogenic and opportunistic bacteria.
5. A significantly higher Candida albicans count in the saliva. These findings could provide insights into the oral health challenges faced by children with T1D and guide preventive strategies.

This study explores how saliva can help assess the risk of dental and gum problems in children with Type 1 Diabetes (T1D). Researchers will analyze saliva samples to identify specific markers that may indicate a higher chance of cavities, gum disease, and oral infections. The goal is to develop early detection and prevention methods to improve oral health care for children with T1D.

The study will include 112 children aged 6 to 18. Half of them have Type 1 Diabetes, while the other half are healthy children of the same age and gender for comparison. All participants will be selected from the Clinic for Dentistry of Vojvodina, ensuring they are not currently sick and have not taken antibiotics in the past month. Children with other serious health conditions, fixed braces, or difficulty cooperating will not be included.

Researchers will examine different factors that could affect oral health in children with T1D, including saliva acidity (pH), its ability to neutralize acids, the presence of bacteria and fungi, and the condition of teeth and gums. They expect that children with T1D will have:

1. More cavities compared to healthy children.
2. More plaque buildup on teeth and greater gum inflammation.
3. Lower saliva protection against acids, increasing the risk of dental problems.
4. A different mix of bacteria in the mouth, with more potentially harmful microbes.
5. Higher levels of the fungus Candida albicans in saliva. The findings from this study may help better understand oral health challenges in children with T1D and lead to improved prevention and treatment strategies.

Diabetes mellitus (DM) is a metabolic disorder characterized by impaired metabolism of carbohydrates, fats, and proteins. As a chronic disease, it leads to numerous systemic complications (1). Type 1 diabetes mellitus (T1DM) most commonly affects children and adolescents, although it may also occur in adults, potentially due to modern lifestyle factors (2). The incidence and prevalence of T1DM are increasing globally, posing a significant public health and economic burden. In response, preventive programs are being developed to reduce the impact of diabetes in the general population (3). Typical symptoms of T1DM in children include frequent nocturnal urination, increased thirst, unexplained weight loss, constant hunger, hyperglycemia, blurred vision, and extreme fatigue. Additional signs may include abdominal pain, shortness of breath, or vomiting (4). In younger children, T1DM is associated with a heightened risk of diabetic ketoacidosis-the most severe and life-threatening complication of T1DM-as well as a greater risk of microvascular and macrovascular complications, often resulting in hospitalization (5).

Children and adolescents with T1DM experience absolute insulin deficiency and require lifelong exogenous insulin therapy. Treatment focuses on achieving glycemic control and preventing complications through a combination of dietary management, physical activity, and insulin therapy-delivered either via intensified insulin regimens or insulin pumps. This approach also requires frequent monitoring, regular clinical check-ups, and high levels of education and engagement from both patients and their parents (3).

The oral cavity is frequently affected by T1DM (3). Individuals with diabetes commonly experience oral health issues such as impaired taste, periodontal disease, salivary gland dysfunction, sensory disturbances, and an increased susceptibility to dental caries and oral infections (6). The properties of saliva play a crucial role in maintaining oral health and preventing caries. Saliva protects the oral tissues, provides a defense mechanism against bacteria, fungi, and viruses (7), and regulates demineralization and remineralization processes in the cariogenic environment (8). Its buffering capacity stabilizes oral pH, thereby helping to prevent enamel demineralization (8).

Insulin deficiency in T1DM leads to both qualitative and quantitative alterations in saliva, including hyposalivation and elevated salivary glucose concentrations. These changes are associated with a higher risk of caries and periodontal disease (9). Several key factors influence the development of caries, including frequent consumption of fermentable carbohydrates, poor oral hygiene, reduced fluoride intake, and the biological characteristics of saliva (10). Studies have reported increased counts of Streptococcus mutans and Lactobacillus spp. in individuals with T1DM, particularly in those with poor metabolic control, potentially due to elevated glucose levels in saliva and gingival crevicular fluid (9,11). The relationship between T1DM and periodontal health is well established. Children with T1DM, especially those with poor glycemic control, are at increased risk of developing chronic gingivitis, which tends to worsen with age (10-12). Glycosylated hemoglobin A1c (HbA1c) is a key marker used to evaluate average blood glucose levels over the preceding two to three months. The American Diabetes Association (ADA) recommends measuring HbA1c levels three to four times per year in patients with T1DM to assess metabolic control (13). According to ADA guidelines, good metabolic control in school-aged children (6-12 years) is defined by an HbA1c level \<8%, while for adolescents and young adults (13-19 years), the target is \<7.5%.

Studies examining the oral microbiota have shown significant differences between children with T1DM and healthy children. Notably, higher counts of periodontal pathogens, S. mutans, and Lactobacillus have been documented in children with T1DM (10-12). Reports on Candida albicans are mixed: while some studies show no significant difference, others suggest higher prevalence in children with T1DM compared to healthy controls (10). These discrepancies highlight the need for further research to clarify the impact of T1DM on the oral microbiota. Previous research has linked poor metabolic control in T1DM with increased risk for oral diseases. Risk assessment has traditionally included measures of caries prevalence, salivary flow rate, buffering capacity, and bacterial counts in stimulated saliva (11). Beyond its protective role, saliva also serves as a valuable diagnostic tool for both oral and systemic diseases. Saliva collection is simple, painless, and non-invasive, making it ideal for clinical and research use (14). Identifying reliable salivary biomarkers could contribute to the prevention, diagnosis, and prognosis of oral diseases in children with T1DM (15). Mass spectrometry (MS) has emerged as a powerful technique for comprehensive salivary proteomic analysis. It enables quantitative mapping of both host and microbial proteins in saliva (16). This highly sensitive method can identify both known and novel compounds and is increasingly applied in dental and biomedical research (17,18).

The findings from this study aim to deepen our understanding of the oral microbiota in children with T1DM and its diagnostic potential in oral disease development. By identifying specific salivary biomarkers, particularly through the use of MS, it may be possible to predict and prevent oral diseases in this vulnerable population. These insights could support the development of personalized preventive and prophylactic programs, improving both oral health and overall quality of life in children with T1DM. Ultimately, this research may help pediatric dentists tailor their clinical and preventive care to reduce the risk of oral complications in children with type 1 diabetes, while also advancing the broader understanding of the relationship between T1DM and oral health.

Eligibility Criteria:
Inclusion Criteria:

* Age of subjects from 6 to 18 years, both sexes, with mixed or permanent dentition present.
* An experimental group of at least 56 subjects will be children diagnosed with DM type 1 (at least one year)
* The control group includes at least 56 subjects, healthy children, who match the tested group in gender and age, with the absence of acute diseases.

Exclusion Criteria:

* Uncooperative patient
* Associated diseases
* Unsigned informative consent from the data subject/parent/guardian
* Antibiotic use in the last few months
* Subjects with orthodontic appliances