diabetes mellitus is a disease of metabolic dysregulation , primarily of carbohydrate metabolism , characterized by hyperglycemia that results from a defect in insulin secretion , impaired insulin action or both .
the chronic hyperglycemia of diabetes is associated with long - term damage , dysfunction , and failure of different organs , especially eyes , kidneys , nerves , heart , and blood vessels .
type i diabetes mellitus , which accounts for 5 - 10% of those with diabetes , is caused by cell - mediated autoimmune destruction of the insulin - producing  cells in the pancreas .
little or no insulin secretion is manifested by low or undetectable levels of plasma c - peptide .
long - term complications of diabetes include retinopathy and nephropathy , with risk of foot ulcers , amputations , and charcot 's joints .
treatment of this disease is based on subcutaneous administration of insulin , regular exercise , diet , and weight control . a link between diabetes and periodontitis in adults has been confirmed .
it is well - established that diabetes increases the prevalence , severity , and progression of periodontal disease , although , vice versa , the fact that periodontal disease may complicate the severity of diabetes by worsening the degree of glycemic control has also been proven .
periodontitis is a chronic low - grade infection induced by multiple pathogens and can result in alteration of insulin action .
chronic gram - negative periodontal infection is currently thought to increase insulin resistance , contributing to the development of metabolic imbalance .
also , the interaction of periodontal bacterial by - products with mononuclear phagocytic cells and fibroblasts is known to induce the chronic release of cytokines ( il-1 , il-6 , tnf- ) , pge2 , and crp .
several recent studies have suggested that periodontal disease is a crucial aggravating factor in the health of patients with diabetes , mainly because it maintains a chronic systemic inflammatory process , thereby , contributing to diabetic complications .
thus , it has been suggested that adequate periodontal treatment in diabetic patients may be beneficial in reducing diabetic complications .
the present study aims at assessing the prevalence of periodontal disease in type 1 diabetes mellitus patients and its association with glycemic control and diabetic complications .
a case - controlled clinical study was performed to assess the periodontal health status of type 1 diabetes mellitus ( dm 1 ) patients .
twenty - eight patients diagnosed with dm1 visiting the outpatient department of the satyam hospital and research center for their treatment , were recruited in the study .
the patients were diagnosed according to the criteria published by the american diabetes association 2011 , and they were treated with insulin , antidiabetic drugs , diet , and physical exercise recommendation , under the physician 's supervision . 

the subjects were aged between 18 and 50 yearspatients with type i diabetes mellitusdiabetes for more than three yearspatients who did not have any active infectionpatients with > 14 natural teeth present and at least five teeth with a probing pocket depth ( ppd ) of > 5 mm and a clinical attachment level ( cal ) of > 3 mmpatients who had not had any periodontal treatment in the last six months . 
 
the subjects were aged between 18 and 50 years patients with type i diabetes mellitus diabetes for more than three years patients who did not have any active infection patients with > 14 natural teeth present and at least five teeth with a probing pocket depth ( ppd ) of > 5 mm and a clinical attachment level ( cal ) of > 3 mm patients who had not had any periodontal treatment in the last six months . 

patients were excluded if they had non type i diabetespregnancy and lactationany inflammatory disease , chronic liver disease or patients receiving any treatment that could modify the study parameters , such as , antibiotics , immunosuppressants , antiepileptics , and so on . 
 
patients were excluded if they had non type i diabetes pregnancy and lactation any inflammatory disease , chronic liver disease or patients receiving any treatment that could modify the study parameters , such as , antibiotics , immunosuppressants , antiepileptics , and so on .
as the control group , 20 healthy individuals , who had come for a routine dental check - up were included .
a detailed medical history was provided by the consulting physician and information like date of diagnosis , age at diagnosis , latest reading for hba1c , and existing diabetic complications were recorded .
the diagnosis of type i diabetes was assessed by the c - peptide concentration , and metabolic control was determined on the basis of the glycosylated hemoglobin value ( hba1c ) , determined by using the micromat ii hba1c assay ( biorad ) , by the affinity chromatography method .
good metabolic control was assumed to be represented by hba1c < 7% , while poor control was defined as hba1c > 7% .
periodontal examination was performed using the unc-15 ( university of north carolina ) probe ( hufriedy ) , calibrated at every millimeter , to determine the parameters .
the probing pocket depth was defined as the distance between the gingival margin and the bottom of the probeable pocket to the nearest whole millimeter .
the cal was computed by subtracting the distance from the visible cemento - enamel junction to the gingival margin from the whole probing depth .
the measurements were performed on four surfaces of each tooth ( mesiobuccal , midbuccal , distobuccal , and midpalatal / lingual ) and the extent of periodontal disease was expressed as a mean of the affected sites out of the total number of sites measured . the total number of teeth were also noted . at the end of the clinical examination each patient
was informed of the clinical findings , given oral hygiene instructions , and advised periodontal treatment , as needed .
the data was analysed using the statistical package for social science ( spss chicago usa ) version 18 .
the qualitative variables were described as frequencies and proportions , and the quantitative variables as the mean and standard deviation ( sd ) .
the student t - test was used in the bivariate analysis to compare the means .
a statistical analysis of the clinical findings was performed to detect the differences between diabetic subjects and controls , to detect the differences between diabetic subjects with different diabetes durations , and the hba1c% .
logistic regression analysis was done using the forward stepwise method for selecting variables according to the statistic likelihood ratio , in order to assess the association of the independent variables with the probability of being a diabetic patient .

 the subjects were aged between 18 and 50 yearspatients with type i diabetes mellitusdiabetes for more than three yearspatients who did not have any active infectionpatients with > 14 natural teeth present and at least five teeth with a probing pocket depth ( ppd ) of > 5 mm and a clinical attachment level ( cal ) of > 3 mmpatients who had not had any periodontal treatment in the last six months . 
 
the subjects were aged between 18 and 50 years patients with type i diabetes mellitus diabetes for more than three years patients who did not have any active infection patients with > 14 natural teeth present and at least five teeth with a probing pocket depth ( ppd ) of > 5 mm and a clinical attachment level ( cal ) of > 3 mm patients who had not had any periodontal treatment in the last six months .

 patients were excluded if they had non type i diabetespregnancy and lactationany inflammatory disease , chronic liver disease or patients receiving any treatment that could modify the study parameters , such as , antibiotics , immunosuppressants , antiepileptics , and so on . 
 
patients were excluded if they had non type i diabetes pregnancy and lactation any inflammatory disease , chronic liver disease or patients receiving any treatment that could modify the study parameters , such as , antibiotics , immunosuppressants , antiepileptics , and so on .
as the control group , 20 healthy individuals , who had come for a routine dental check - up were included .
a detailed medical history was provided by the consulting physician and information like date of diagnosis , age at diagnosis , latest reading for hba1c , and existing diabetic complications were recorded .
the diagnosis of type i diabetes was assessed by the c - peptide concentration , and metabolic control was determined on the basis of the glycosylated hemoglobin value ( hba1c ) , determined by using the micromat ii hba1c assay ( biorad ) , by the affinity chromatography method .
good metabolic control was assumed to be represented by hba1c < 7% , while poor control was defined as hba1c > 7% .
periodontal examination was performed using the unc-15 ( university of north carolina ) probe ( hufriedy ) , calibrated at every millimeter , to determine the parameters .
the probing pocket depth was defined as the distance between the gingival margin and the bottom of the probeable pocket to the nearest whole millimeter .
the cal was computed by subtracting the distance from the visible cemento - enamel junction to the gingival margin from the whole probing depth .
the measurements were performed on four surfaces of each tooth ( mesiobuccal , midbuccal , distobuccal , and midpalatal / lingual ) and the extent of periodontal disease was expressed as a mean of the affected sites out of the total number of sites measured . the total number of teeth were also noted . at the end of the clinical examination each patient
was informed of the clinical findings , given oral hygiene instructions , and advised periodontal treatment , as needed .
the data was analysed using the statistical package for social science ( spss chicago usa ) version 18 .
the qualitative variables were described as frequencies and proportions , and the quantitative variables as the mean and standard deviation ( sd ) .
the student t - test was used in the bivariate analysis to compare the means . a p < 0.05 was considered statistically significant .
a statistical analysis of the clinical findings was performed to detect the differences between diabetic subjects and controls , to detect the differences between diabetic subjects with different diabetes durations , and the hba1c% .
logistic regression analysis was done using the forward stepwise method for selecting variables according to the statistic likelihood ratio , in order to assess the association of the independent variables with the probability of being a diabetic patient .
the study consisted of 28 ( 17 male and 11 female ) patients diagnosed with type i diabetes mellitus .
the mean age was 32.9  10.71 years , with a range of 18 - 50 years .
on grouping the patients by decades of age , most belonged to the 21 - 30 and 31 - 40 year intervals ( 45 and 30% of the total , respectively ) .
the time elapsed from the diagnosis was 4 - 15 years and they were diagnosed around the mean age of 11 years [ table 1 ] . variables associated with the two study groups the control group represented the mean age of 31  7.4 years with an age range of 18 - 50 years .
most subjects belonged to the 21 - 30 and 31 - 40 age group ( 55 and 35% , respectively ) .
there was no significant difference in the plaque index , as the oral hygiene was similar in the two groups .
significant differences were recorded in the bleeding index , pocket depth , and attachment loss [ table 2 ] .
the diabetic group presented with a mean pocket depth of 6.337  0.650 , whereas , it was 5.181  0.705 for the non - diabetics .
the gingival bleeding index was 2.708  0.390 and 1.760  0.434 in the study and control group , respectively .
the cal was greater in the diabetics 4.337  0.648 , as compared to 2.300  0.557 in the non - diabetics .
comparison of mean values of the periodontal parameters the mean glycosylated hemoglobin ( hba1c ) value among the diabetic patients was 8.84 + 1.34 table 1 .
four patients presented hba1c values < 7% , while the remaining had values > 7% .
on comparing the diabetics with poor metabolic control of the disease versus those with moderate or good control , significant differences were recorded in the probing pocket depth ( p < 0.001 ) , bleeding index ( p < 0.001 ) , and clinical attachment level ( p = 0.001 ) .
patients diagnosed with diabetes for shorter duration of time ( 4 - 7 years ) showed the bleeding index  disease severity correlation to be 1.760  0.434 as compared to those diagnosed for a greater period of time 2.728  0.384 [ table 3 ] .
relationship between the periodontal parameters and different aspects of diabetes eleven ( 55% ) patients suffered from one or more chronic complications of the disease , while nine ( 45% ) experienced no complications .
the severity , duration , and complications significantly affected the periodontal health status [ table 3 ] .
in recent decades , many studies have reported that the presence of diabetes mellitus ( dm ) increases the prevalence , severity , and progression of periodontal disease .
there is a bidirectional relationship between the two processes , where diabetes serves as a modifier of the expression of periodontal disease .
most of these studies have emphasized on type 2 diabetes mellitus , with very few studies on the correlation and clinical features of type 1 diabetes mellitus .
thus , the present study has emphasized on the prevalence of periodontitis in type 1 diabetes mellitus ( dm1 ) and a possible association between glycemic control and the complications .
there were 28 dm1-diagnosed patients in the study and 20 healthy controls , who were demographically matched .
individuals younger than 18 years were excluded , to avoid uncertainty in the periodontal status , which could be influenced due to puberty .
the patients over 50 years were excluded to avoid the appearance of other systemic complications .
no difference was found in the two groups regarding the plaque index as they had a similar level of oral hygiene .
however , it has been shown that diabetic patients harbor more gram negative bacteria and thereby have higher plaque levels . however , bleeding index showed significantly higher values , suggesting greater susceptibility for periodontal disease .
these observations were in concordance with most of the studies on diabetes showing that diabetics show greater periodontal inflammation in response to irritation caused by plaque bacteria .
deeper pathological pockets were observed in the diabetics . this was consensus with the observations by oliver et al .
we also assessed the levels of c - peptide which ranged from 0.39 - 1.2 for the severity of type i diabetes and fasting blood glucose for the diabetic status . in the study
dm1 patients with better glycemic control ( hba1c < 7.5% ) showed significantly lower mean gi and pi and less cal compared to diabetics with poor glycemic control ( hba1c > 8) .
however , the regression analysis could not confirm a very strong correlation between metabolic control and periodontitis .
the probable reason could be that fact that only hba1c was alone used for the purpose .
it may be possible that poor glycemic control over the last 3 months was more closely correlated with gingival inflammation than connective tissue attachment loss .
measurement of glycemic control and periodontal disease represent different time frames in the patient 's life ; hba1c represents glycemic status over 3 months while periodontal parameters represent the cumulative impact of periodontal destruction over an individual 's lifetime .
therefore , hba1c measurement over 24 - 36 months and then correlation with periodontal health will give better assessment .
a correlation between the duration of diabetes and the severity of periodontal disease has been reported .
a similar correlation was also observed in our study , where longer duration of the disease affected the probing pocket depth , bleeding on probing and clinical attachment level . in the present study we observed a positive relationship between the bleeding index and the presence of periodontal pockets with complications of diabetes , as related by other authors .
the immune alterations in these patients , with subsequent increase in immune inflammatory mediator production , could be responsible for the damage observed in the periodontium , as also systemically
. the pathogenic mechanisms in type i and type ii diabetes are quite different , which may have an effect on the risk of periodontal disease as well as on other comorbidities in the two groups of patients .
persistent hyperglycemia over many years , with inherent derangement in the immune mechanism , is the inherent feature of type 1 diabetes mellitus .
periodontal disease is more prevalent and severe in type 1 diabetes mellitus patients . a greater periodontal inflammatory tendency corresponded to those individuals with poorer metabolic control , with or without complications , while longer durations of dm were associated with greater periodontal attachment loss . in the presence of similar plaque scores ,
 objective : the aim of the study was to evaluate periodontal health status in patients diagnosed with type 1 diabetes mellitus ( dm1 ) and to establish a correlation between metabolic control and periodontal health status.materials and methods : periodontal health parameters namely plaque index ( pi ) , gingival index ( gi ) , probing pocket depth ( ppd ) and clinical attachment loss ( cal ) were recorded in 28 patients diagnosed with type 1 diabetes mellitus ( dm1 ) and 20 healthy controls . 
 diabetes history was recorded based on the information provided by the physician and it included date of diagnosis , duration , age of diagnosis , latest values of glycosylated haemoglobin and existing diabetic complications . 
 statistical analysis was performed to evaluate the relationship between periodontal parameters and degree of metabolic control , the duration of the disease and the appearance of complications.results:the periodontal health in the diabetic group was compromised and they had greater bleeding index ( p < 0.001 ) , probing pocket depth ( p < 0.001 ) and clinical attachment level ( p = 0.001 ) . 
 patients diagnosed for diabetes for shorter duration of time ( 4 - 7 years ) showed bleeding index - disease severity correlation to be 1.760  0.434.conclusion:periodontal disease was more evident in type 1 diabetes mellitus patients and periodontal inflammation is greatly increased in subjects with longer disease course , poor metabolic control and diabetic complications . 
INTRODUCTION
MATERIALS AND METHODS
Inclusion criteria
Exclusion criteria
Diabetes-related parameters
Oral examination
Statistical analysis
RESULTS
DISCUSSION
CONCLUSION