25. Juman F.doc J Bagh College Dentistry Vol. 25(1), March 2013 Dental caries, Orthodontics, Pedodontics and Preventive Dentistry153 Dental caries, Mutans Streptococci, Lactobacilli and salivary status of type1 diabetic mellitus patients aged 18- 22 years in relation to Glycated Haemoglobin Juman D. Al- Khayoun, B.D.S., H.D.D. (1) Ban S. Diab, B.D.S., M.Sc., Ph.D. (2) ABSTRACT Background: diabetic mellitus is one of the serious systemic diseases that may cause general systemic changes, which may be reflected in the oral cavity. The aims of this study were to assess the severity of dental caries, Mutans Streptococci and Lactobacilli in addition to flow rate and pH among uncontrolled and controlled diabetic groups in comparison with non-diabetic control group. Materials and Methods: Study groups consisted of 25 uncontrolled diabetic patients (HbA1c > 7), 25 controlled diabetic patients (HbA1c ≤ 7), in addition to 25 non-diabetic healthy looking individuals. Their age was (18-22) years from both genders. The diagnosis and recording of dental caries was according to severity of dental caries lesion through the application of D1_4MFS (Manji et al, 1989) and stimulated salivary samples were collected. Salivary flow rate and pH were estimated. Viable count of mutans streptococci (on Mitis- Salivarius Bacitracin Agar) and lactobacilli (on Rogosa) was determined. Results: The mean values of caries-severity were recorded to be highest among study groups compared to the control with statistically highly significant difference (p<0.01). Lowest values of salivary pH and flow rate were among study groups compared to the control with highly significant difference (p<0.01). Concerning Mutans Streptococci and Lactobacilli were found that the mean values of them for uncontrolled diabetic group were highly significant higher than both mean values of controlled diabetic group and control group. Conclusion: Dental caries revealed higher percentage of occurrence and severity among uncontrolled diabetic group. Furthermore there was significant influence of the diabetic and the poor metabolic control on the salivary flow rat, pH, mutans streptococci and Lactobacilli that have an effect on caries occurrence and severity. Keywords: diabetic mellitus, dental caries, Glycated Haemoglobin, Mutans Streptococci, Lactobacilli. (J Bagh Coll Dentistry 2013; 25(1):153-158). INTRODUCTION Diabetes is a chronic systemic disorder of glucose metabolism. The two main types of diabetes mellitus are type 1 or insulin-dependent diabetes mellitus (IDDM) and type 2 or non- insulin-dependent diabetes mellitus (NIDDM) (1, 2). Type 1 of diabetes account for 10 to 15 % of all cases of DM (3). Glycated haemoglobin (glycosylate haemoglobin, HbA1c) is a form of haemoglobin used to identify the average plasma glucose concentration over prolonged periods of time. It is formed in a non-enzymatic pathway by haemoglobin's normal exposure to high plasmas levels of glucose, the measurement of glycosylated haemoglobin is one of the well established means of monitoring glycemic control in patients with diabetes mellitus (4). Oral manifestations associated with diabetes are in most cases restricted to the uncontrolled or poorly controlled patient. There is evidence that diabetic patients have saliva secretion different from non-diabetic subjects (5). However, the literatures contain contradictory results, Mata et al. (6), Siudikiene et al. (7) reported that both unstimulated (resting) and stimulated salivary flow rates are reduced in diabetic (1)M.Sc student Department of Pedodontic and Preventive Dentistry, College of Dentistry, University of Baghdad. (2) Assistant Professor, Department of Pedodontic and Preventive Dentistry, College of Dentistry, University of Baghdad. patients, whereas Lopez et al. (8) reported that only unstimulated salivary flow is reduced. In contrast, Swanljung et al. (9) and Edblad et al. (10) did not find any significant differences in salivary flow rates between diabetic and non-diabetic individuals. In general, the higher the flow rate, the faster the clearance and the higher the buffer capacity (11). Sakeenabi and Hiremath (12) and Gawri et al. (13) concluded that decrease salivary flow rate, salivary pH and increase the levels of both salivary mutans streptococci and lactobacilli significantly correlated with caries experience. Studies on the concentration of Streptococcus mutans and Lactobacillus in the saliva of diabetics are inconclusive. Wallengren et al. (14) demonstrated that the inheritance of some types of HLA-DR4, most prevalent in type1 diabetics, was related to low salivary IgA activity against the Streptococcus mutans lead to increase the level of these bacteria. While other studies reporting decreased, increased or equivalent levels of the concentrations of these bacteria both in the saliva of diabetics and non-diabetics (7, 15). The present studies was conducted among patients with type1 diabetic mellitus aged 18-22 years in comparison to control group and determine the occurrence and severity of following variable: dental caries and its relation to physicochemical characteristic of stimulated saliva (Salivary flow rate, pH). And J Bagh College Dentistry Vol. 25(1), March 2013 Dental caries, Orthodontics, Pedodontics and Preventive Dentistry154 evaluate the quantitative distribution of Mutans Streptococci and lactobacilli in saliva and their relation to oral variable. In addition examine the relation of glycated haemoglobin(HbA1c) with dental caries, oral microorganisms and salivary variables (Salivary flow rate, pH). MATERIALS AND METHODS In the present investigation, the study group included 50 diabetic adults, with an age range of 18-22 years of both gender. They were examined at the Diabetic and Endocrinology Center, Al- Kindy Teaching Hospital in Baghdad City during the period from the first of November 2011 till the end of April 2012. They were all with confirmed diagnosis of type IDDM with minimum duration of diabetes of at least 5 years (5-10years). The samples were divided into two groups based on the HbA1c(1): 25 uncontrolled type 1 diabetes mellitus (HbA1c > 7) patients, 25 controlled type 1 diabetes mellitus (HbA1c ≤ 7) patients and non- diabetic subjects as a control group were included 25healthy students of both gender from college of dentistry / university of Baghdad who did not suffer from any systemic diseases with an age range of 18-22 years and monitored their capillary blood glucose closely prior to the study, and matching with the study group. Caries experience was recorded according to the criteria Manjie et al. (16) this allows recording decayed lesion by severity. Saliva was collected for diabetic patients at the same day of blood sample aspiration for HBA1c assessment by measuring the absorbance of the glycohemoglobin and of the total hemoglobin fraction at 415 nm in comparison with a standard glycohemoglobin preparation carried through the test procedure (Human- Biochemical, 2011, Germany). The collection of stimulated salivary samples was performed under standard condition according to Tenovuo and Lagerlöf (17). Immediately after collection of saliva, through five minutes and disappearance of the salivary foam, the salivary flow rate was expressed as ml / mins and salivary pH was measured using a portable electronic pH meter. The salivary samples were then taken to the laboratory for microbiological analysis. Saliva was homogenized by vortex mixer for two minutes. Ten fold serial dilutions were prepared using normal saline, two dilutions were selected for each microbial type and inoculated on the Mitis- Salivarius Bacitracin Agar (MSB agar) (The selective media for Mutans Streptococci) (18) and Rogosa Selective Lactobacilli agar (RSL) (19). Identification of mutans streptococci and Lactobacilli includes: Colony Morphology; gram’s stain according to Koneman et al. (20); Motility; Catalase production (20). CTA- mannitol media had been used to test the ability of Mutans Streptococci to ferment the mannitol. (21). Intra and inter calibration were performed to overcome any problem that could be faced during the research, and to ensure proper application of diagnostic criteria used in recording dental status through inter calibration. Statistical Analysis and processing of the data were carried out using SPSS version 18. Descriptive Statistics. The statistical tests that were used in ANOVA test; L.S.D. test; Student's t-test; Pearson correlation coefficients and Paired sample t-test. The level of significance was accepted at P< 0.05, and highly significance when P< 0.01. RESULTS The percentage of dental caries occurrence in the present study was 100% in diabetes mellitus patients, while in control group (non-diabetic subjects) was 88%. Results revealed that caries experience represented by DS and DMFS were highly significant differ (p<0.01) among three groups (table 1). Further investigation using L.S.D. test to DS revealed that both uncontrolled diabetic and controlled diabetic had highly significant higher DS than control group (m.d. - 25.08 and -7.72 respectively p<0.01).Furthermore the uncontrolled diabetic had highly significant higher mean value of DS than controlled diabetic group (m.d. -17.36 p<0.01). On the other hand, using L.S.D. test concerning DMFS, showed that uncontrolled diabetic had highly significant higher mean than both controlled diabetic group and control group (m.d. -19.60 and -25.80 respectively p<0.01).While data of present study showed the mean difference between controlled diabetic and control group was not significant (p>0.05 ). Salivary flow rate and pH among study and control groups are shown in Table 2. Results revealed that salivary flow rate and pH were highly significant differ (F-value 160.03 and 183.94 respectively p<0.01) among three groups. Further investigation using L.S.D. test concerning salivary flow rate revealed that the mean value in uncontrolled diabetic group was highly significant lower than mean values in both controlled diabetic group and control group (m.d. 0.36, 1.77 respectively p<0.01), and the mean value of salivary flow rate among controlled diabetic group was highly significant lower than salivary flow rate in control group (m.d. 1.41 p<0.01). The same picture was found concerning salivary pH the mean value among uncontrolled diabetic group was highly significant lower than mean values in both controlled diabetic and control groups (m.d. 1.22, 2.14 respectively p<0.01), as J Bagh College Dentistry Vol. 25(1), March 2013 Dental caries, Orthodontics, Pedodontics and Preventive Dentistry155 well as the mean value of salivary pH in controlled diabetic group was highly significant lower than mean value of salivary pH in control group (m.d. 0.91 p<0.01). The viable count (CFU/ml) of salivary Mutans Streptococci and lactobacilli were highly significant differ (F-value 24.74 and 124.947 respectively p<0.01) among three groups. Table 3. The highest CFU/ml of salivary Mutans Streptococci and lactobacilli values were represented in the saliva of the uncontrolled diabetic group followed by the controlled diabetic group then the control group. Table 4 showed the correlation coefficients of salivary flow rate with caries experience for study and control groups. Analysis among uncontrolled diabetic group revealed that the relation between salivary flow rate and Ds was significant in negative direction (r= -0.423 p<0.05). Table 5 illustrates that the correlations were highly significant in negative direction between salivary pH and DMFS and DS (r=-0.655 and -0.663 respectively p<0.01). However among control group the relation between pH and DMFS was highly significant in negative direction (r = - 0.820 p<0.01). Table 6 revealed that among uncontrolled diabetic group the salivary mutans streptococci correlate positively with caries experience including DMFS, DS and these relations were highly significant for DMFS and DS (r = 0.741 and 0.838, respectively p< 0.01). A significant positive relations were also found among controlled diabetic group concerning DS and DMFS(r = 0.429, and 0.432 respectively p< 0.05). The same finding found concerning control group but the highly significant relation was found concerning DS and DMFS(r = 0.566 and 0.652 respectively p< 0.01). Correlation coefficients of salivary Lactobacilli in relation to dental caries are seen in table 7. This table revealed that among uncontrolled diabetic patient the salivary Lactobacilli correlate positively with caries experience including DMFS, DS and these relations were highly significant for DS and DMFS (r = 0.777 and 0.718 respectively p< 0.01). Among controlled diabetic group the salivary Lactobacilli correlate positively with DMFS, DS and these relations were highly significant for DS and DMFS (r = 0.534, 0.524 respectively p<0.01) The same finding was reported among control group as the salivary Lactobacilli correlate positively with caries experience and the correlation was significant concerning DS(r = 0.472 p<0.05). Table 8 illustrates that among uncontrolled diabetic group the HbA1c was positively correlated with caries experience represented by DMFS, DS and these relations were highly significant(r=0.586 and 0.574 respectively p<0.01). DISCUSSION Researchers in the dental field have suggested that oral diseases (periodontal disease and dental caries) should be included among the complications of diabetes (22, 23). Most evidently, not all diabetic patients are at equal risk for oral diseases, and more attention has recently been paid to possible diabetes-related risk factors to identify subjects who are more prone to dental caries. The study groups selected aged 18-22 years, as at these ages the type 1 diabetes mellitus are predominate. However, in the present study it was difficult to have relatives patients as a control group, so, most of individuals among control group were from the students of college of dentistry, this could partly explained the differences in the severity of caries among study groups and control group. Since those students relatively differs from study subjects in their socioeconomic and behavior which play a role in the oral hygiene. Data of the present study showed that caries experience represented by DMFS and DS components among uncontrolled diabetes group was higher than that with both control diabetes and non-diabetes control group. This result in agree with the results reported by(24, 25, 26). However, Al-Dahan, (1991) (27) reported an equal results of caries free subjects between control and diabetic groups. Nonetheless, there is no consensus concerning the association between metabolic control and dental caries. In the current study positive highly significant correlation between HbA1c and caries experience was found just among uncontrolled diabetes group. The elevation in the severity of dental caries among diabetic patients especially among uncontrolled diabetes group in the current study may be related to changes in the salivary physical properties involving the flow rate and salivary pH. A reduction in the flow rate of saliva and pH were reported among study groups. This may give an indication that the diabetes disease has an influence on salivary flow rate. These results are in agreement with reports of other researchers who found the same reduction in the salivary flow rate of diabetic patients (8, 6, 7, 28). It seems likely that the thirst and dry mouth characteristic among uncontrolled diabetes group are related to the poor metabolic control of disease with increased diuresis and fluid loss, and that salivary flow rate is restored when the disease is well controlled among controlled diabetic J Bagh College Dentistry Vol. 25(1), March 2013 Dental caries, Orthodontics, Pedodontics and Preventive Dentistry156 group. The possible explanation for the low salivation could be the neuoropathy of salivary gland(29). Another explanation for the reduction of flow rate among the study groups especially uncontrolled diabetes group, is that the increase in glucose concentration in the blood may increase the osmolality of the glomerular filtrate and thus prevent the reabsorption of water as the filtrate passes down the renal tubular system. In this way the volume of urine is markedly increased in diabetes and polyuria and nocturia occur (30). The decreased in the salivary flow rate among diabetic patients could give some explanation to the increased severity of dental caries by the significant inverse relation with DS that were reported by the data of present study as well as in previous Iraqi studies among diabetic (31, 32, 28). Among uncontrolled diabetic group the salivary pH associated inversely with highly significant relation with DS and DMFS. This is consistent with other clinical studies that reported an inverse association between salivary pH and dental caries (33, 34). But disagree with other studies that reported no association with caries (35, 36). The Streptococcus mutans the main microorganism responsible for the occurrence of dental caries in humans. Due to its ability to adhere to tooth surface, the Lactobacillus is more related to a later stage of caries development (37). Therefore, one can suggest that diminished salivary flow create an attractive environment for establishment of mutans streptococci and lactobacilli in the oral cavity of diabetic patients especially among uncontrolled diabetes group. High levels of these bacteria in saliva can be considered a reasonable indicator of a cariogenic environment in the mouths of uncontrolled diabetes subjects, this is also shown by the data of present study that showed the severity of caries lesion was highly significant (or significant) correlated in positive direction with salivary mutans streptococci and lactobacilli in all groups. These results are in agreement with reports of other Iraqi researcher who found the same positive correlation between caries lesion severity and both mutans streptococci and lactobacilli (38, 39, 40). In conclusion, dental professionals need to have comprehensive knowledge of their patients’ diabetes: knowledge that the patient has diabetes is not sufficient to assess the effects of diabetes with respect to oral diseases and dental treatment. This need is emphasized by the high and ever increasing number of patients with diabetes in Iraq. On the other hand, the members of the team responsible for diabetes treatment should pay attention to dental care and guidance to dental treatment. Finally, co-operation and consultation between all the members of the team responsible for the treatment of patients with diabetes is highly recommended. REFERENCES 1. American Diabetes Association (ADA). Diagnosis and Classification of Diabetes Mellitus. Diabetes care 2007; 30:S42-S47. 2. Guyton C, Hall JE. Text book of Medical Physiology. 12th ed. Elsevier Saunders. Philadelphia, 2012. 3. Beers MH, Porter RS, Jones TV. The Merck Manual of Diagnosis and Therapies: Endocrine And Metabolic Disorders .Section 2.Chapter13. Merck Research laboratories. Glasgow. Washington. 2006. 4. Sultanpur CM, Deepa K, Kumar SV. Comprehensive review on HbA1c in diagnosis of diabetes mellitus. Internat. Pharmace Scien Rev& Res 2010; 3(Issue 2):119-124. 5. Alemzadeh R, Wyatt DT. Diabetes mellitus. In: Kliegman RM, Behrman RE, Jensen HB, Stanton BF (Editors), Nelson textbook of pediatrics. 17th ed. Chapter 583. Philadelphia: W.B. Saunders.2003; pp: 1947-1972. 6. Mata AD, Marques D, Rocha S, Francisco H, Santos C, Mesquita MF. Effects of diabetes mellitus on salivary secretion and its composition in the human. Mol Cell Biochem 2004; 261: 137-142. 7. Siudikiene J, Machiulskiene V, Nyvad B, Tenovuo J, Nedzelskiene I. Dental caries and salivary status in children with type 1 diabetes mellitus, related to the metabolic control of the disease. Eur J Oral Sci 2006; 114: 8-14. 8. Lopez M, Colloca M, Paez R, Schulimach J, Koss M, Chervonagura A. Salivary characteristics of diabetic children. Braz Dent J 2003; 14(1): 26-31. 9. Swanljung O, Meurman JH, Torkko H, Sandholm L, Kaprio E, Maenpaa J. Caries and saliva in 12-18-year- old diabetics and controls. Scand J Dent Res 1992; 100: 310-313. 10. Edblad E, Lundin SA, Sjodin B, Aman J. Caries and salivary status in young adults with type 1 diabetes. Swed Dent J 2001; 25: 53-60. 11. Miura H, Isogai E, Hirose K, Wakizaka H, Ueda I, Ito N. Application of sucrose indicator strip to evaluate salivary sucrose clearance. J Dent 1991; 19: 189-191. 12. Sakeenabi B, Hiremath SS. Dental caries experience and salivary streptococcus mutans, lactobacilli scores, salivary flow rate and salivary buffering capacity among 6 year old Indian school children. J Clin Exp Dent 2011; 3(5):e412-7. 13. Gawri S, Shukla P, Chandrakar A. micro flora present in dental caries and it’s relation to environmental factors. Recent Research in Science and Technology. 2012; 4(3): 09-12. 14. Wallengren MLL, Hamberg K, Ericson D, Nordberg J. Low salivary IgA activity to cell--surface antigens of mutans streptococci related to HLA -DRB1*04. Oral. Microbiol. Immunol. 2005; 20: 73 -81. 15. Zaiter S, Ferencz , Tomazinho PH. Evaluation of salivary microbiota of pediatric patients with and without mellitus type1 diabetes. RSBO. 2006; 3:24 - 27. 16. Manji F, Fejerkov O, Baelum V. Pattern of dental caries in an adult rural population. Caries Res 1989; 23:55-62. J Bagh College Dentistry Vol. 25(1), March 2013 Dental caries, Orthodontics, Pedodontics and Preventive Dentistry157 17. Tenovuo J, Lagerlöf F. Saliva. In: Textbook of clinical cardiology. Thylstrup A and Fejerskov O. 2nd ed. Munksgaard, Copenhagen. 1994, 17-43. 18. Gold O.G; Jordan H V; Van Haute J. A selective medium for Streptococcus mutans. Archs. Oral Biol 1973; 18: 1357-64. 19. Brenner MJ, Krieg NR, StaleyJT. Berge's Manual of Systematic Bacteriology 10th ed,Williams and Wilkins Co., USA.2005. 20. Koneman EW, Schreeckenberge PC, Allens SD, Janda WM. Diagnostic Microbiology,4th ed, JB.Lippincott Co., USA, 1992. 21. Brown AF. Benson's Microbiological applications. Laboratory Manual in general Microbiology 9th ed. McGraw-Hill. New York.USA, 2005. 22. Lamster IB, Lalla E. Periodontal disease and diabetes mellitus: discussion, conclusions, and recommendations. Ann Periodontol 2001; 6:146-9. 23. Bakhshandeh S, Murtomaa H, Vehkalahti MM, Mofid R, Suomalainen K. Dental findings in diabetic adults. Caries Res 2008; 42(1):14-18. 24. El-Samarrai S, Sabri N, Makki Z. Dental caries among young diabetic patients in Baghdad-Iraq. Iraqi Dent J 1997; 20: 14-23. 25. Twetman S, Petersson GH, Bratthall D. Caries risk assessment as a predictor of metabolic control in Young type 1 diabetics. Diabet. Med 2005; 22: 312 -5. 26. Iqbal S, Kazmi F, Asad S. Dental caries and diabetes mellitus. Pak Oral& Dent J 2011; 31(1):60-3. 27. Al-Dahan Z. Oral health status among IDDM on population group of teenagers in Baghdad-Iraq. A master thesis, College of Dentistry, University of Baghdad, 1991. 28. Al-Rawi NF. Salivary Constituents in Relation to Oral Health Status among a Group of (Type 1) Diabetic Children. A Ph.D. Thesis. College of Dentistry, University of Baghdad, 2009. 29. Moore PA, Guggenheimer J, Etzel KR. Type 1 diabetes mellitus, xerostomia, and salivary flow rates. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001; 92:281-291.17: 343-64. 30. Siudikiene J, Machiulskiene V, Nyvad B. Dental caries increments and related factors in children with type 1 diabetes mellitus. Caries Res 2008; 42: 354 -62. 31. Al-Sagri A. Oral health status of Iraqi diabetic patients' salivary and microbial analysis. A Ph.D. Thesis, College of Dentistry, University of Baghdad, 2005. 32. Al-Zaidi WH. Oral immune proteins and salivary constituents in relation to oral health status among pregnant women. A Ph.D. Thesis, College of Dentistry, University of Baghdad, 2007. 33. Al-Mashhadani A. Oral health status and salivary Streptococcus mutans in relation to primary and permanent dentition. A M.Sc. Thesis, College of Dentistry, University of Baghdad, 1996. 34. El-Samarrai SK. Major and trace elements of permanent teeth and saliva among a group of adolescent in relation o dental caries, gingivitis and Mutans Streptococci. A Ph.D. Thesis. College of Dentistry, University of Baghdad, 2001. 35. Kirstila V, Tenovuo J, Ruuskanen O, Nikoskelainen J, Irjala K, Vilja P. Salivary defense factors and oral health in patients with common variable immunodeficiency. J Clin Immun. 1994; 14: 229-36. 36. Närhi TO, Kurki N, Ainamo A. Saliva, salivary microorganisms and oral health in the home-dwelling old elderly–a five year longitudinal study. J Dent Res 1999; 78(10):1640-6. 37. Thanyasrisung P, Komatsuzawa H, Yoshimura G. Automutanolysin disrupts clinical isolates of cariogenic streptococci in biofi lms and planktonic cells. Oral Microbiol. Immunol 2009; 24: 451 -455. 38. Al-Mizraqchi A. The occurrence of Lactobacillus in the mouth of children and it's response to chlorhexidine. M.Sc. Thesis, College of Science, University of Al-Mustansiriya, Iraq, 1992. 39. Al-Mizraqchi A. Microbiological and Biochemical studies on; adherence of mutans streptococci on the tooth surfaces. Ph.D.Thesis, University of Al- Mustansiriya, Iraq, 1998. 40. Al-Hayali, AM. Isolation and purification of glucosyltransferase from mutans streptococci and its relation to dental caries, dental plaque and parameters of saliva Ph.D. Thesis, College of Dentistry, University of Baghdad 2002. Table 1: Caries experience DMFS and its component (DS, MS, FS) (mean and standard deviation) among study and control groups. caries exper-ience Uncontrolled diabetic Controlled diabetic Control Statistical analysis Mean ±SD Mean ±SD Mean ±SD F-value p-value DS 31.44 16.95 14.08 7.59 6.36 6.73 31.69* 0.00 MS 2.00 4.33 1.20 2.61 0.60 2.19 1.21 0.30 FS 4.32 5.76 3.28 3.51 5.00 6.48 0.64 0.52 DMFS 37.76 16.83 18.16 9.57 11.96 8.61 30.27* 0.00 *(p<0.01) Highly Significant df=2 Table 2: Salivary flow rate (ml/min) and pH (mean and standard deviation) among study and control groups Salivary Variables Uncontrolled diabetic Controlled diabetic Control Statistical analysis Mean ±SD Mean ±SD Mean ±SD F-value p-value Flow rate 0.84 0.19 1.20 0.31 2.61 0.52 160.03* 0.00 pH 6.08 0.34 7.31 0.36 8.22 0.46 183.94* 0.00 * (p<0.01) Highly Significant df=2 J Bagh College Dentistry Vol. 25(1), March 2013 Dental caries, Orthodontics, Pedodontics and Preventive Dentistry158 Table 3: Colony Forming Units (CFU/ml) of salivary Mutans Streptococci and Lactobacilli (mean and standard deviation ×105) among study and control groups Salivary Flora Uncontrolled diabetic Controlled diabetic Control Statistical analysis Mean ±SD Mean ±SD Mean ±SD F-value p-value Mutans Streptococci 397.04 133.66 232.64 101.87 185.00 96.23 24.74* 0.00 Lactobacilli 22.51 7.96 2.23 1.86 2.06 4.00 124.94* 0.00 * (p<0.01) Highly Significant df=2 Table 4: Correlation coefficients between salivary flow rate and caries experience among study and control groups Caries experience Uncontrolled diabetic Controlled diabetic Control group Flow rate Flow rate Flow rate R P R P R P DS -0.423* 0.03 -0.251 0.22 -0.087 0.68 DMFS -0.360 0.07 -0.216 0.30 -0.225 0.28 *(P<0.05) Significant Table 5: Correlations coefficients between salivary pH and caries experience among study and control groups Caries experience Uncontrolled diabetic Controlled diabetic Control group pH pH pH R P R P R P DS -0.663* 0.00 -0.092 0.66 -0.283 0.17 DMFS -0.655* 0.00 -0.081 0.69 -0.820* 0.00 * (p<0.01) Highly Significant Table 6: Correlations coefficients between salivary Mutans Streptococci and caries experience among study and control groups Caries experience Uncontrolled diabetic Controlled diabetic Control group Mutans Streptococci Mutans Streptococci Mutans Streptococci R P R P R P DS 0.838** 0.000 0.429* 0.03 0.566** 0.003 DMFS 0.741** 0.000 0.432* 0.03 0.652** 0.000 *(P<0.05) Significant ** (p<0.01) Highly Significant Table 7: Correlations coefficients between salivary Lactobacilli and caries experience among study and control groups. Caries experience Uncontrolled diabetic Controlled diabetic Control group Lactobacilli Lactobacilli Lactobacilli R P R P R P DS 0.777** 0.000 0.534** 0.006 0.472* 0.017 DMFS 0.718** 0.000 0.524** 0.007 0.318 0.12 *(P<0.05) Significant ** (p<0.01) Highly Significant Table 8: Correlation coefficients between HbA1c and caries experience among uncontrolled and controlled diabetic groups Caries experience Uncontrolled diabetic Controlled diabetic HbA1c HbA1c R P R P DS 0.574** 0.003 0.214 0.30 DMFS 0.586** 0.002 0.195 0.34 *(P<0.05) Significant ** (p<0.01) Highly Significant