American Indian and Alaska Native (AI/AN) adults have high levels of periodontal disease, and thus research on periodontal disease was identified by our Native partners as a critical need. Obesity and associated type 2 diabetes (T2D), both factors related to increased risk of periodontal disease in adults, are increasingly common in youth, especially in AI/AN youth. Periodontal disease is largely preventable, as it is influenced by many modifiable social and behavioral risk factors. To prevent periodontal disease, it is imperative that healthy behaviors be established early in life. Adolescence is an especially vulnerable time in development, when independence is being established and habits are formed, and therefore is a critical age group to target. Adolescence is also a critical time period because type 2 diabetes (T2D) is now occurring increasingly during puberty, especially in obese youth and ethnic minority groups such as AI/AN.
However, little is known about periodontal disease in AI/AN adolescents, or about the relationship between periodontal disease and the recent rise in pediatric obesity and T2D. T2D in youth is much more commonly associated with extreme obesity, very poor dietary habits, extreme physical inactivity and medications that induce insulin resistance than in adults, as young age is otherwise typically protective against T2D. In addition, insulin resistance worsens during puberty. Therefore, data on the relationship between obesity and T2D and periodontal disease in adults cannot be extrapolated to youth, who require pediatric specific studies. In addition, executive functioning, a critical component to behavior change, is not fully developed during adolescence. Therefore, behavioral interventions developed in adults may not be effective in teens, requiring research in designing adolescent-specific interventions
The developmental project will address the following specific aims:
SA1: Assess modifiable oral health behavioral risk factors, knowledge, attitudes and executive functioning in a group of urban-dwelling AI/AN adolescents at high risk for T2D, and determine whether these factors are associated with severity of periodontal disease as assessed by attachment loss (periodontitis) and mean percent bleeding sites (gingivitis).
Primary modifiable behavioral risk factors to be examined include: frequency of brushing/flossing, frequency of professional dental cleaning, smoking, use of smokeless tobacco products, dietary intake of refined sugars, obesity (body mass index, BMI) and hyperglycemia (glucose and HbA1c). In addition, factors underlying behaviors will also be examined (oral health attitudes, knowledge and beliefs, acculturation, stress, social support, access to care and access to home dental supplies).
Hypothesis 1.1 Greater periodontitis and gingivitis in AI/AN adolescents will be associated with less frequent brushing, flossing, and professional dental cleaning, increased rates of smoking and smokeless tobacco use, greater percent of energy from carbohydrates, higher BMI, and higher glucose and HbA1c.
Hypothesis 1.2: AI/AN adolescents at risk for T2D (obesity, prediabetes) or with T2D will have more severe behavioral risk factors, (in particular greater percent of energy from refined sugars), more negative attitudes, decreased health knowledge and poorer executive function due to the disordered lifestyle associated with development of T2D.
The primary outcome will be change in brushing and flossing at 2 weeks and 2 months after the intervention, to assess changes in behaviors in response to the intervention. Secondary outcomes will be overall rating of oral health, symptoms of tooth and gum disease, perceived importance of tooth and gum health, current smoking and smokeless tobacco use. Subjects will also be asked to mail back any remaining dental floss to allow assessment of how much floss was actually used at the 2 week time point.
SA2: Based on the findings from SA1, and in partnership with the CNOHR and DIHFS Community Advisory Committees, develop a culturally-appropriate behavioral intervention focused on the psychosocial factors identified as key mechanisms influencing periodontal disease in AI/AN adolescents and develop a protocol to evaluate its effectiveness.
Results from this study will be used to identify the key psychosocial factors that influence oral health behavior and outcomes among AI/AN youth at risk for T2D and to evaluate the potential effectiveness and clinical feasibility of a motivational intervention in AI/AN youth. The findings from this pilot study will be used to design a culturally appropriate community-based “R01” intervention trial for preventing and controlling periodontal disease in AI/AN youth, when the disease process is still reversible and life-long healthy habits can be established.