Cross-Sectional Study on Proportions of Type 2 Diabetic Patients Presenting with Oral Candidal Lesions

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript by J Weerasingheet al., entitled “ Cross Sectional Study on Proportions of Type 2 Diabetic 3 Patients Presenting with Oral Candidal Lesions”. The author assesses candida-associated oral mucosal lesions (candidiasis) in Type-2 DM patients, which have an influence on oral health, particularly in females over the age of >60 with inadequate observation. Hence the overall conclusions of the manuscript are likely correct, but there are a couple of major comments that need to be addressed. Some of the individual issues are listed below.

Comments:

Introduction: Author provides relevant background  with appropriate references.

Page 1, line 16, "findings suggest that males" the current article discussed T2-DM female individuals, thus why did the author specify male in the featured application section?

Materials and methods:

• Study design, inclusion and exclusion criteria need more clarity (it should be in separate headings).
• Missing information on swab collection for fungal testing, sample preparation for staining, and reagents.
• Samples were taken from many places in the mouth, requiring clarification on the collection method and procedure.
• Statistical analysis should be in separate headings with appropriate information and p-value with appropriate significance (Fig.2 is not sufficient for the readership).
• 1 overview of Methodology also should be in method section with more details.

Results and discussion:

• To distinguish the oral lessons, see Fig. 3c and Fig. 4b (negative control non-DM persons' staining is missing).
• The scale bar is missing in Fig.3 and Fig.4.
• The author could also show the area of Candida species in their pseudo hyphae or hyphal structure (pathogenic) that you noticed in the images.
• Oral mucosal lesions also apply for denature wearers. So, if possible, the author should provide PAS staining or clarify the consequences of DM patient’s vs denature wearers for Oral Candidal Lesions in the discussion section.
• The author should discuss the severity of the oral lesson in this section.
• Tables 1 and 3 use bar graphs to explain the data, making the results easy to follow.

 

Discussion - The authors emphasize the significance of this work in the discussion section, and they specifically highlight and explain the candida-induced mucosal lesion in T2-DM patients, along with the necessary reference.

References – author cited an adequate reference in this manuscript.

Author Response

Please see the attachment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for your insightful and well-structured article titled “Cross-Sectional Study on Proportions of Type 2 Diabetic Patients Presenting with Oral Candidal Lesions.” The topic is clinically relevant and addresses an important intersection between systemic and oral health. However, I have several suggestions:

1. The flowchart in Figure 2 could be improved for clarity and visual appeal. Currently, there are several formatting issues, including text overflow beyond the boundaries of boxes, inconsistent font sizes, and some typographical errors. Additionally, standardizing terminology (e.g., “candida lesions” vs “candidal lesions”) and ensuring consistent alignment would enhance readability. I recommend redrawing the figure using a professional diagramming tool and thoroughly proofreading the content.

2. Please describe in detail the calculation of the sample size.

3. The layout of the pictures needs to be more standardized. For instance, figure labels (e.g., A, B, C) should be aligned consistently and should not obstruct the images themselves.

4. The study states that all lesions were incidental findings. Was there any assessment of patient-reported symptoms such as oral discomfort or burning? Distinguishing between symptomatic and asymptomatic infections may have clinical value in diabetic populations.

5. Given the immune dysregulation in diabetes, did the study consider correlating oral Candida lesions with immune markers such as HbA1c, leukocyte counts, or salivary IgA? This could help clarify the mechanisms of susceptibility.

6. While denture-related candidiasis is addressed, was overall oral hygiene or periodontal status assessed in the full cohort? Factors such as plaque index or gingival condition could influence colonization and lesion development.

7. The study focuses on clinically diagnosed lesions, but did the team explore whether these correlate with Candida colony-forming units (CFU)? Are high CFU counts always accompanied by visible lesions, and vice versa?

8. As antibiotics and corticosteroids are known risk factors for Candida overgrowth, were patient histories of these medications recorded or controlled for in the analysis?

9. Since this is a cross-sectional study, it cannot establish causality between diabetes progression and Candida infection. Are there plans for longitudinal studies to explore how lesion risk evolves over time in diabetic patients?

10. Given the regional focus in Sri Lanka, how might dietary habits, oral hygiene practices, or cultural behaviors influence the prevalence of Candida lesions? Comparison with other geographic populations could enhance generalizability.

11. While inclusion required at least one year of treatment, was glycemic control status (e.g., HbA1c trends) evaluated over time? This might strengthen conclusions about the role of hyperglycemia in Candida lesion development.

12. The conclusion recommends routine oral examinations. Could the authors further suggest actionable interventions such as oral health education, screening protocols in diabetes clinics, or awareness campaigns targeting high-risk individuals?

 

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

In this version of the manuscript, the author addressed concerns raised by reviewers. From my point of view, the manuscript would now be acceptable for publication.