Diabetes mellitus (DM) is a chronic metabolic disorder that affects multiple biochemical and cellular processes in the body, resulting in diminished immunity and heightened susceptibility to infections.1 Worldwide, nearly 7 million new cases of DM are reported annually, and it is estimated that by 2030 the number of individuals living with diabetes will reach 366 million. Among its systemic complications, DM has been consistently recognized as an important risk factor for periodontal disease2,3. Periodontitis is a chronic, microbial-associated, host-mediated inflammatory condition characterized by progressive destruction of periodontal ligament fibers, connective tissue, and alveolar bone, ultimately leading to attachment loss and tooth mobility. The relationship between DM and periodontitis is complex and bidirectional.4 Diabetes predisposes individuals to periodontal destruction through impaired neutrophil function, altered cytokine profiles, and compromised wound healing, which collectively create an environment that favors bacterial persistence within periodontal pockets. Conversely, periodontal inflammation itself can adversely influence glycaemic control.5 Gram-negative bacterial infections associated with periodontitis increase systemic inflammatory mediators, reduce insulin-mediated glucose uptake by skeletal muscle, and contribute to insulin resistance, thereby worsening glycemic regulation. Evidence shows that effective periodontal therapy can lower glycated hemoglobin (HbA1c) levels and improve metabolic control.6 Globally, numerous studies have assessed the prevalence and risk factors for periodontitis among diabetic patients. Increasing age has been significantly associated with higher prevalence of periodontal disease among individuals with diabetes, reflecting cumulative tissue damage and long-term exposure to hyperglycemia7. Sex differences have also been explored, with some studies reporting higher prevalence among males. Lifestyle factors such as smoking further exacerbate periodontal breakdown and have been strongly linked to periodontitis in diabetic populations. Elevated HbA1c levels, indicating poor glycaemic control, have also been identified as an important predictor of periodontal disease severity, highlighting the interplay between metabolic and oral health8. Periodontitis negatively impacts quality of life by causing gingival bleeding, recurrent infections, compromised mastication, aesthetic concerns, and ultimately tooth loss, affecting nutrition, comfort, confidence, and social interactions9. Growing evidence supports the two-way relationship between diabetes and periodontitis, emphasizing the need for integrated management strategies to improve both oral and systemic health outcomes. AIM To study the prevalence of periodontal disease among diabetic and non diabetic patients.

A comparative cross-sectional study was conducted from December 2024 to June 2025 among patients visiting outdoor services at ESIC MCH Alwar. A total of 180 participants (90 Type 2 diabetic and 90 non-diabetic) were selected using Simple Random Sampling method. A minimum sample of 82 diabetic participants were calculated using a 95% confidence level, 7% allowable error and α = 0.05 assuming the prevalence of periodontal disease among diabetic patient 88% (Pant BN et al.)11. After adding 10% attrition 90 diabetic participants selected for the study. Similar number (90) non diabetic participants selected as comparison group. Inclusion criteria: Individuals aged 18 years and above with at least 16 natural teeth, Diabetic study subjects who were diagnosed with T2D more than 1 year ago along with a documented HbA1c report within the previous three months were included in the study. Exclusion criteria: Edentulous subjects, subjects with any other systemic diseases such as hypertension and epilepsy which can inhibit the clinical examination, had medication history of antibiotics or steroidal and/or nonsteroidal anti‑inflammatory agents over the past 3 weeks, or on immunosuppressive chemotherapy or professional periodontal treatment during the last 6 months and pregnant or lactating women were excluded from the study. A interview based questionnaire was administered which was divided into two sections. Section (A) Includes socio-demographic details and Section (B) For Clinical examination by using WHO Oral Health Assessment Questionnaire for adults 201312 to assess the oral health status and practices among study subjects. For oral hygiene and Periodontal Index (WHO Oral Health 2013 Criteria), Oral Hygiene Index‑Simplified (OHI‑S)13 was used. Descriptive statistics of the study subjects were depicted using mean, percentages and standard deviation. Association was evaluated using Chi‑square test. Any P < 0.05 was considered significant.

Among 180 study participants (90 Diabetic and 90 Non-diabetic Group) majority were belonging to the 31–45-year age group in both diabetics (47 participants) and non-diabetics (44 participants), indicating that most cases occurred in middle-aged adults. Figure 1 showing that majority of 61 diabetic study subjects were male, whereas among non-diabetic study subjects, a majority of 67 subjects were male. Among them 86 and 82 participants were married in diabetic and non-dibetic group respectively. According to Clinical Characteristics of Diabetic Participants shows in table 1, duration of diabetes among participants showed that nearly half (48%) had the condition for 5–10 years, followed by 36% who had diabetes for more than 10 years, while only 16% reported a duration of less than 5 years. In terms of glycemic control, 45% of individuals had well-controlled HbA1c levels below 7%, whereas 32% demonstrated moderately controlled levels between 7–8.5%. Poor glycemic control (>8.5%) was seen in 23% of participants, indicating that almost one-fourth were at increased risk for diabetes-related complications. Variable Number Percentage Duration of Diabetes < 5 years 15 16% 5–10 years 44 48% >10 years 31 36% HbA1c Levels Controlled (<7%) 41 45% Moderately Controlled (7–8.5%) 29 32% Poor Control (>8.5%) 20 23% Table 1: Clinical Characteristics of Diabetic Participants (n = 90) Table 2 Showing Oral hygiene behaviors and practices mentioned that Oral hygiene behaviors and practices diabetics were statistically significant when compared to non-diabetics (P ≤ 0.001). A non-significant difference was observed among diabetic and non-diabetic study subjects when compared to the cleaning aids used for cleaning their teeth (P >0.05). Oral Hygiene Frequency Diabetic No. (%) Non-diabetic No. (%) χ² P value Never 3 (3.33%) 2 (2.22%) 39.448 0.000 Once a month 4 (4.44%) 1 (1.11%) 2–3 times a month 5 (5.56%) 3 (3.33%) Once a week 2 (2.22%) 5 (5.56%) 2–6 times a week 0 (0.00%) 10 (11.11%) Once a day 46 (51.11%) 66 (73.33%) Twice or more a day 30 (33.33%) 3 (3.33%) Oral Hygiene Aids Used Diabetic No. (%) Non-diabetic No. (%) χ² P value Toothbrush and toothpaste 69 (76.67%) 72 (80.00%) 7.264 0.221 Wooden toothpicks 1 (1.11%) 3 (3.33%) Plastic toothpicks 2 (2.22%) 2 (2.22%) Charcoal 0 (0.00%) 3 (3.33%) Chewstick/Miswak 14 (15.56%) 6 (6.67%) Others (specify) 4 (4.44%) 4 (4.44%) Table 2: Comparison of responses of the study subjects based on their oral hygiene behaviors Table 3 shows periodontal conditions among both groups, according to that prevalence of gingival bleeding and periodontal pocket formation among diabetic study subjects in the present study was noted as 71.11% and 64.44% respectively, whereas among the non-diabetic study subjects, periodontal pockets were seen among 43 (47.78%) study subjects. The prevalence of attachment loss among diabetic study subjects was noted as 51 (56.67%), whereas among non-diabetic study subjects, it was only 21 (23.33%). On comparison of Oral Hygiene‑Simplified Index only 4 (4.44%) among the diabetic study subjects had good score compared to non-diabetics 14 (15.56%), which is statistically significant. A statistically significant difference was found among diabetic and non-diabetic study subjects and gingival bleeding, periodontal pocket formation, and loss of attachment (P ≥ 0.05). Periodontal condition Diabetic No. (%) Non-diabetic No. (%) χ² P value Gingival bleeding Present 64 (71.11%) 40 (44.44%) 12.047 0.000* Absent 26 (28.89%) 50 (55.56%) Periodontal pocket Present 58 (64.44%) 43 (47.78%) 4.422 0.035* Absent 32 (35.56%) 47 (52.22%) Loss of attachment Present 51 (56.67%) 21 (23.33%) 14.366 0.000* Absent 39 (43.33%) 58 (64.44%) OHI-S Index Category Good 2 (2.22%) 14 (15.56%) 12.363 0.002* Fair 68 (75.56%) 66 (73.33%) Poor 20 (22.22%) 10 (11.11%) OHI-S: Oral Hygiene Index-Simplified *p-Value <0.05 consider Significant Table 3: Comparison of periodontal conditions and Oral Hygiene Index-Simplified (OHI-S) score interpretation among diabetic and non-diabetic study subjects Figure 2 Showing that the prevalence of periodontal disease differed markedly between the groups, with only 16 diabetics showing no periodontitis compared to 59 non-diabetics. Diabetics had higher rates of mild (27), moderate (39), and severe (8) periodontitis, whereas non-diabetics showed lower rates of mild (16), moderate (12), and severe (3) disease, indicating a clear association between diabetes and increased periodontal severity. Table 4 shows severity of periodontitis according to HbA1c levels and duration of disease. The distribution of periodontal disease severity according to HbA1c levels showed that participants with controlled HbA1c (<7%) mostly had mild (13) or moderate (12) periodontitis, with none exhibiting severe disease. Those with higher HbA1c levels (7–8.5% and >8.5%) had progressively more moderate and severe periodontitis, indicating a strong association between poor glycemic control and increased periodontal severity. Participants with longer disease duration had higher severity, with those having diabetes for >10 years exhibiting 9 mild, 17 moderate, and 5 severe cases. In contrast, participants with <5 years of diabetes had fewer cases of moderate (7) and severe (1) periodontitis, while those with 5–10 years had intermediate severity, indicating a clear relationship between longer diabetes duration and increased periodontal destruction, However both are statistically not significant (p-value >0.05). Category Severity of Periodontitis χ² P value Mild (27) Moderate (39) Severe (8) HbA1c Category Controlled(<7%) 13 12 0 2.383 0.304 7–8.5% 8 18 3 >8.5% 6 9 5 Duration of Diabetes < 5 years 6 7 1 0.714 0.70 5–10 years 12 15 2 >10 years 9 17 5 Table 4: Association of Periodontal Disease Severity with HbA1c Levels and duration of disease (Diabetic Group, n=74)

The age-wise distribution of participants revealed that the highest proportion belonged to the 31–45-year age group, with 47 diabetic and 44 non-diabetic individuals, indicating that middle-aged adults formed the core study population. The 46–60-year group was the next most common, comprising 23 diabetics and 28 non-diabetics, showing a substantial representation of older adults as well. Younger participants aged 18–30 years were fewer, with only 11 diabetics and 8 non-diabetics included. Also, the >60-year age group had the smallest representation, consisting of 9 diabetics and 10 non-diabetics. .Similarly,Kesavan, R.; Chaly, Preetha E.1; Reddy et al14 Among diabetics; 28.8% (144) were in the age group of 35–44, 37.6% (188) were in the group of 45–54, and 9.8% (49) were in the age group of 65–74. Among nondiabetics; 33% (165) were in the 35–44 age group, 42.6% (213) were in the age group of 45–54, and 8.2% (41) were in the group of 65–74 . The distribution of diabetes duration revealed that the largest group of participants, 48%, had diabetes for 5–10 years, highlighting a substantial population with long-standing disease. This was followed by 36% who had been diabetic for more than 10 years, indicating a significant chronic burden, while only 16% had a duration of less than 5 years. Evaluation of glycemic status showed that 45% of participants had controlled HbA1c levels below 7%, reflecting relatively good metabolic regulation in nearly half of the group. Another 32% had moderately controlled HbA1c levels between 7–8.5%, representing those with borderline glycemic management. Meanwhile, 23% exhibited poor control with HbA1c levels above 8.5%, identifying a notable proportion at higher risk for complications and more severe periodontal involvement. The assessment of oral hygiene habits among participants revealed that the majority of both diabetic and non-diabetic individuals brushed once daily, with 59 diabetics and 54 non-diabetics, while brushing twice daily was less common, reported by 31 diabetics and 36 non-diabetics. Use of interdental aids was limited, with 29 diabetics and 27 non-diabetics incorporating them into their routine, suggesting suboptimal oral hygiene practices. Similarly, mouthwash use was reported by 28 diabetics and 30 non-diabetics, indicating moderate adoption of supplementary oral care measures. Dental visits in the past year were infrequent, with only 12 diabetics and 10 non-diabetics attending, reflecting low professional dental engagement. Overall, oral hygiene behaviors were comparable between the two groups, with most participants relying primarily on basic tooth brushing.Also, Ojo KO, Odukoya OO, Ayanbadejo PO, Akinlawon D. et al15 majority of the diabetic patients 90 (81.8%) and non-diabetic respondents 92 (83.6%) used toothbrush and paste in cleaning their teeth. Nearly three quarters of diabetic group brushed once daily 80 (72.7%) compared to about half 59 (53.6%) of the non-diabetes group, and majority used toothpick in cleaning the space between their teeth 74 (67.3%) among diabetes group while 73 (66.4%) among non-diabetes group did same. The assessment of periodontal disease severity revealed a clear difference between diabetic and non-diabetic participants. Among diabetics, only 16 individuals had no periodontitis, whereas a majority of non-diabetics, 59 participants, were free of the disease. Mild periodontitis was observed in 27 diabetics compared to 16 non-diabetics, while moderate periodontitis affected 39 diabetics versus 12 non-diabetics. Severe periodontitis was relatively uncommon but still higher in diabetics, with 8 cases compared to 3 in the non-diabetic group. Overall, these findings indicate that diabetic individuals are more prone to periodontal disease across all severity levels. This highlights the significant impact of diabetes on periodontal health and the need for targeted preventive and therapeutic interventions.Similarly, de Miguel-Infante A, Martinez-Huedo MA, Mora-Zamorano E et al16 The prevalence of periodontal disease was higher among those suffering from diabetes than their non-diabetes controls (23.8% vs 19.5%; P < 0.001). Adjusted OR of periodontal disease for subjects with diabetes was 1.22 (95% CI; 1.03-1.45). The analysis of periodontal disease severity according to HbA1c levels revealed a clear relationship between glycemic control and periodontal health. Among participants with controlled HbA1c levels (<7%), most had mild (13) or moderate (12) periodontitis, and none exhibited severe disease, suggesting effective metabolic control may protect against severe periodontal destruction. In those with moderately controlled HbA1c (7–8.5%), 8 individuals had mild, 18 had moderate, and 3 had severe periodontitis, indicating an increase in disease severity with rising blood glucose levels. Participants with poorly controlled HbA1c (>8.5%) showed the highest severity, with 6 mild, 9 moderate, and 5 severe cases, highlighting the strong impact of hyperglycemia on periodontal tissue destruction. Poor glycemic regulation was closely associated with higher prevalence and severity of periodontal disease among diabetic patients. The analysis of periodontal disease severity according to the duration of diabetes demonstrated a clear trend of increasing severity with longer disease duration. Among participants with less than 5 years of diabetes, 6 had mild, 7 had moderate, and only 1 had severe periodontitis, indicating relatively limited periodontal involvement in newly diagnosed patients. Those with 5–10 years of diabetes showed an intermediate pattern, with 12 mild, 15 moderate, and 2 severe cases, reflecting progressive tissue destruction over time. Participants with more than 10 years of diabetes exhibited the highest severity, with 9 mild, 17 moderate, and 5 severe cases, highlighting the cumulative effect of prolonged hyperglycemia on periodontal tissues. Data indicate that longer exposure to diabetes significantly increases the risk and severity of periodontitis. Khader, Yousef & Albashaireh, Zakereyya et al17 The severity of periodontal disease was significantly higher in patients with diabetes > 5 years than those with duration ≤ 5 years.

The present study demonstrates a significantly higher prevalence and severity of periodontal disease among diabetic individuals compared to non-diabetic controls. Middle-aged and older adults formed the core study population, and longer duration of diabetes was strongly associated with increased periodontal destruction. Poor glycemic control, reflected by elevated HbA1c levels, was closely linked to more severe periodontitis, highlighting the impact of hyperglycemia on periodontal tissues. Oral hygiene practices were generally suboptimal but comparable between diabetic and non-diabetic participants, suggesting that diabetes itself is a major risk factor beyond oral hygiene behavior. These findings confirm the bidirectional relationship between diabetes and periodontitis, where diabetes exacerbates periodontal disease and periodontal inflammation may adversely affect glycemic control. Early screening, improved glycemic management, and targeted periodontal care are essential to reduce periodontal morbidity and improve overall health outcomes in diabetic patients.

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