Clinical Efficacy of a Topical Gel for the Treatment of Minor Oral Ulcers: A Triple-Blind Randomized Controlled Trial

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

After reading the Abstract, I have two observations:

1. Why did you use the phrase „recurrent aphthous disease” when you talk about small ulcers on the oral mucosa, as a quick search on PubMed shows no result for it, only for „recurrent aphthous stomatitis” (RAS). 2.The conclusions of your study show nothing else except for what we already know after using current treatment strategies.

In the Introduction, in lines 42-60 you present the information similar to an undergraduate lecture, not as a scientific article. This paragraph must be reformulated and references provided for studies on the predisposing factors. When presenting the treatment options developed over time, I consider that you should have mentioned the main results of previously published data that unanimously consider that there is no standard or curative therapy and that it is based on identification and control of the possible predisposing factors and exclusion of systemic diseases.

In Material and Methods, explanations given in lines 86-91 are not needed, being enough to declare that your study was carried out according to the principles of Good Clinical Practice. Regarding the Gel device, please clarify what is the basic antiseptic substance used; is this product already on the market or it is a new formulation? Other information about the gel should be placed here, not in lines 143-151, in a separate paragraph (Device characteristics and composition). Did you study a gel or a mouthwash (as it arises from the description of the protocol- lines 113-114)? The inclusion criteria are not well defined, some more aspects must be taken into consideration in order to put the diagnosis of RAS. In Study visits and treatments you present in a few lines very demanding procedures such as ruling out the neoplastic or infectious origin of an ulceration. How were the examinators instructed to perform the differential diagnosis? In line 183 you describe the application of the gel by the patient. In my opinion, patients should have been instructed to apply the product in a specific time interval, according to the variation of salivary secretion rate.

Lines 214-220 are not necessary, as they repeat the information from the flow chart. Please do not use an abbreviation (Tab.) unless you mention the full name first.

In Results, the first lines (288-302) describe the methodology and therefore should be included in Material and Methods. You should reconsider Table 2, as it presents different data in separate locations. It is very unusual the way you decided to present the collected data. Table 8 is not necessary, the explanation based on the statistical analysis is enough.

The Discussion section is very short and in the first lines (372-380), representing almost 50%, you repeat the results. The scientific literature on RAS is extensive and every year many articles are published. The topic offers you the possibility to discuss about treatment options, but you provide no comparison with other similar investigations. Furthermore, you include some considerations about predisposing factors, which are not the object of your research. You did not formulate Conclusions, but if I should consider that the last paragraph is a concluding remark, in my opinion it is irrelevant and not convincing.

My conclusion is that, despite the measurements made during the investigation and statistical analysis of the data, the manuscript still lacks important parts in order to be published.

Author Response

20th June 2025

RE: Clinical Efficacy of a Topical Gel for the Treatment of Minor Oral Ulcers: A Triple-blind Randomized Controlled Trial.

 

Dear Editor,

Please find here attached the revised version of the above-mentioned manuscript.  All the suggested changes have been carried out in the text.

All the changes suggested by the reviewers have been carried out in the manuscript, and have been highlighted in yellow.

 

 

Reviewer 1

Comments and Suggestions for Authors

Dear Authors,

After reading the Abstract, I have two observations:

1. Why did you use the phrase „recurrent aphthous disease” when you talk about small ulcers on the oral mucosa, as a quick search on PubMed shows no result for it, only for „recurrent aphthous stomatitis” (RAS). 2.The conclusions of your study show nothing else except for what we already know after using current treatment strategies.

 

[ANSWER] The current nomenclature has been adopted in the main text recurrent: “recurrent aphthous stomatitis” (RAS)”.

 

In the Introduction, in lines 42-60 you present the information similar to an undergraduate lecture, not as a scientific article. This paragraph must be reformulated and references provided for studies on the predisposing factors. When presenting the treatment options developed over time, I consider that you should have mentioned the main results of previously published data that unanimously consider that there is no standard or curative therapy and that it is based on identification and control of the possible predisposing factors and exclusion of systemic diseases.

[ANSWER] The following period has been revised:

 

A recent study by Altay et al. reported that a higher salivary expression of irisin, interleukin-2 (IL-2) and interferon-ɣ (IF-ɣ) have been detected in RAS group compared to smoker and non-smoker cohort[12]. The authors supposed that higher level of irisin could be involved with the mucosal healing process in the digestive system [12] and this biomarker could be used for this purpose due to its high sensitivity for this disorder group.

 Among the main individual and environmental predisposing factors are recognized:

• Family history and heredity
• Local trauma
• Microbiological factors
• Hypersensitivity
• Immunological disorders
• Hormonal alterations
• Smoking
• States of stress and psychological disorders

A series of systemic disorders and pathologies such as [4–6,8–11]:

• Vitamin deficiencies such as zinc, iron, vitamin B1, B2, B6, B12, folic acid.
• Gastrointestinal diseases, celiac disease and chronic inflammatory bowel diseases
• Syndromic conditions such as Behcet's Syndrome, Reiter's Disease, Sweet's Syndrome, PFAPA Syndrome, MAGIC Syndrome (oral and genital ulcers and inflammation of the cartilage)
• HIV/AIDS infection: recurrent HIV-associated aphthosis
• Neutropenia
• Drug-induced aphthosis for the use of beta-blockers, bisphosphonates, NSAIDs, protease inhibitors, sulfonamides.

 

[ANSWER] The following period has been revised:

 

From the point of view of clinical treatment, several protocols have been proposed in the literature that are mainly symptomatic therapies that do not produce an elimination of the disease or do not influence its possible recrudescence both in adulthood and in pediatric age [5,6,13–16]. Although no curative treatment have been detected, several therapeutic approaches and active ingredients have been described including chlorhexidine 0.2% in mouthwash, topical applications of benzidamine, zinc chloride and polycresulene [6,8–11] devices. Possible therapeutic efficacy has been associated with tetracycline and lidocaine 1%, where many ulcerative lesions may sometimes recur and be refractory to such administrations[16–18].

In Material and Methods, explanations given in lines 86-91 are not needed, being enough to declare that your study was carried out according to the principles of Good Clinical Practice.

[ANSWER] The following sentence has been revised:

The treatments envisaged by this clinical protocol have been carried out according to the principles of Good Clinical Practice (:Update ICH GCP E6 R2) by qualified and experienced personnel regarding the state of the art of the discipline, in producing and providing a dental service with constant attention to the effectiveness and appropriateness of the services and their correct interpretation, providing services in line with the most recent scientific and technological acquisitions and with the utmost efficiency both in the containment of response times and in the use of resources, adopting quality standards from a clinical and organizational point of view.

Regarding the Gel device, please clarify what is the basic antiseptic substance used; is this product already on the market or it is a new formulation? Other information about the gel should be placed here, not in lines 143-151, in a separate paragraph (Device characteristics and composition). Did you study a gel or a mouthwash (as it arises from the description of the protocol- lines 113-114)?

[ANSWER] The following paragraph has been revised:

Masking of assignment

Physicians involved in the patient's treatment are unaware of the treatment. The masking of the bottles and made indistinguishable with mouthwash were prepared by a person designated by the sponsor. The gel mouthwash has been poured into identical vials labeled with a letter (A, B) and only the person designated by the sponsor will be aware of the match of the product or placebo. Random assignment is made by opening the sequentially numbered sealed envelope just before treatment.

 

[ANSWER] The following paragraph has been revised indicating the commercial name of the product:

 

Device characteristics and composition

The hydrogel compound used for the present investigation was composed by purified water, propylene glycol, vp/va copolymer, carbomer, cellulose gum, pvm/ma copolymer, hydrolyzed, rna/dna, leuconostoc/ radish root ferment filtrate, sodium hyaluronate, allantoin, glycyrrhetinic acid, beta-glucan, glycerin, ruscogenin, bisabolol, leptospermum scoparium branch/leaf oil, melaleuca alternifolia leaf oil, o-cymen-5-ol, phenoxyethanol, sodium benzoate, ammonium glycyrrhizate, sodium saccharin, peg40 hydrogenated castor oil, caprylyl glycol, 1,2-hexanediol, aroma (Afterapid Curasept, Saronno CO, Italy). The placebo was deprived by all active components.

 

 

The inclusion criteria are not well defined, some more aspects must be taken into consideration in order to put the diagnosis of RAS. In Study visits and treatments you present in a few lines very demanding procedures such as ruling out the neoplastic or infectious origin of an ulceration. How were the examinators instructed to perform the differential diagnosis?

[ANSWER] The following statement has been added:

According with the Scully et al. consensus report, the diagnosis of RAS and the patients admission in the protocol was made on the basis of history and clinical criteria, since there are no specific laboratory tests available. The diagnosis has been performed by a single specialist operator (AS) [19].

In line 183 you describe the application of the gel by the patient. In my opinion, patients should have been instructed to apply the product in a specific time interval, according to the variation of salivary secretion rate.

[ANSWER] The following sentence has been added:

The patient’s instruction and gel posology has been performed following the protocol of the present gel device. As a topical product, calibration based on salivary flow is not foreseen

Lines 214-220 are not necessary, as they repeat the information from the flow chart. Please do not use an abbreviation (Tab.) unless you mention the full name first.

[ANSWER] The following sentence has been removed:

Indicators:

1. Pain intensity using the VAS scale. The following outcome measures will be recorded by the blinded outcome assessor:
2. Size of each ulcer using a clear plastic sheet

Thermography/ Ulcer severity score (USS)

In Results, the first lines (288-302) describe the methodology and therefore should be included in Material and Methods. You should reconsider Table 2, as it presents different data in separate locations. It is very unusual the way you decided to present the collected data. Table 8 is not necessary, the explanation based on the statistical analysis is enough.

[ANSWER] The following sentence has been moved in materials and methods section:

The screening procedure included a phase of enrolment of the subjects which was carried out at the Department of Innovative Technologies in Medicine and Dentistry of the University "G. D'Annunzio" of Chieti-Pescara which, as observed by the clinical plan, provided for voluntary adherence to the study protocol and the collection of written informed consent.  On 28/11/2023, the recruitment phase was launched and included in phase V1 of the clinical investigation.

[ANSWER] The tab.8 has been removed:

Dunn's multiple comparisons test	Mean rank diff,	Significant?	Summary	Adjusted P Value
I-V1 vs. I-V2	0	No	ns	>0,9999
I-V1 vs. I-V3	58.72	Yes	****	<0,0001
I-V1 vs. II-V1	-12.4	No	ns	>0,9999
I-V1 vs. II-V2	43.23	Yes	*	0.013
I-V1 vs. II-V3	85.55	Yes	****	<0,0001
I-V2 vs. I-V3	58.72	Yes	****	<0,0001
I-V2 vs. II-V1	-12.4	No	ns	>0,9999
I-V2 vs. II-V2	43.23	Yes	*	0.013
I-V2 vs. II-V3	85.55	Yes	****	<0,0001
I-V3 vs. II-V1	-71.12	Yes	****	<0,0001
I-V3 vs. II-V2	-15.48	No	ns	>0,9999
I-V3 vs. II-V3	26.83	No	ns	0.5816
II-V1 vs. II-V2	55.63	Yes	***	0.0003
II-V1 vs. II-V3	97.95	Yes	****	<0,0001
II-V2 vs. II-V3	42.32	Yes	*	0.0168
Pain VAS SCORE
I-V1 vs. I-V2	12.3	No	ns	>0,9999
I-V1 vs. I-V3	72.63	Yes	****	<0,0001
I-V1 vs. II-V1	-9.1	No	ns	>0,9999
I-V1 vs. II-V2	57.72	Yes	***	0.0002
I-V1 vs. II-V3	95.95	Yes	****	<0,0001
I-V2 vs. I-V3	60.33	Yes	****	<0,0001
I-V2 vs. II-V1	-21.4	No	ns	>0,9999
I-V2 vs. II-V2	45.42	Yes	**	0.0094
I-V2 vs. II-V3	83.65	Yes	****	<0,0001
I-V3 vs. II-V1	-81.73	Yes	****	<0,0001
I-V3 vs. II-V2	-14.92	No	ns	>0,9999
I-V3 vs. II-V3	23.32	No	ns	>0,9999
II-V1 vs. II-V2	66.82	Yes	****	<0,0001
II-V1 vs. II-V3	105.1	Yes	****	<0,0001
II-V2 vs. II-V3	38.23	No	ns	0.0597
Lesion Size
I-V1 vs. I-V2	11.2	No	ns	>0,9999
I-V1 vs. I-V3	75.38	Yes	****	<0,0001
I-V1 vs. II-V1	-8.1	No	ns	>0,9999
I-V1 vs. II-V2	50.27	Yes	**	0.0024
I-V1 vs. II-V3	97.35	Yes	****	<0,0001
I-V2 vs. I-V3	64.18	Yes	****	<0,0001
I-V2 vs. II-V1	-19.3	No	ns	>0,9999
I-V2 vs. II-V2	39.07	Yes	ns	0.0407
I-V2 vs. II-V3	86.15	Yes	****	<0,0001
I-V3 vs. II-V1	-83.48	Yes	****	<0,0001
I-V3 vs. II-V2	-25.12	No	ns	0.8926
I-V3 vs. II-V3	21.97	No	ns	>0,9999
II-V1 vs. II-V2	58.37	Yes	***	0.0002
II-V1 vs. II-V3	105.5	Yes	****	<0,0001
II-V2 vs. II-V3	47.08	Yes	**	0.0062
Temperature
Dunn's multiple comparisons test	Mean rank diff,	Significant?	Summary	Adjusted P Value
I-V1 vs. I-V2	7.9	No	ns	>0,9999
I-V1 vs. I-V3	24	No	ns	>0,9999
I-V1 vs. II-V1	3.417	No	ns	>0,9999
I-V1 vs. II-V2	14.58	No	ns	>0,9999
I-V1 vs. II-V3	38	No	ns	0.0705
I-V2 vs. I-V3	16.1	No	ns	>0,9999
I-V2 vs. II-V1	-4.483	No	ns	>0,9999
I-V2 vs. II-V2	6.683	No	ns	>0,9999
I-V2 vs. II-V3	30.1	No	ns	0.3772
I-V3 vs. II-V1	-20.58	No	ns	>0,9999
I-V3 vs. II-V2	-9.417	No	ns	>0,9999
I-V3 vs. II-V3	14	No	ns	>0,9999
II-V1 vs. II-V2	11.17	No	ns	>0,9999
II-V1 vs. II-V3	34.58	No	ns	0.1514
II-V2 vs. II-V3	23.42	No	ns	>0,9999

Tab. 8 Summary chart of the pairwise comparison between Group I and Group II at the different timepoints.

 

The Discussion section is very short and in the first lines (372-380), representing almost 50%, you repeat the results. The scientific literature on RAS is extensive and every year many articles are published. The topic offers you the possibility to discuss about treatment options, but you provide no comparison with other similar investigations. Furthermore, you include some considerations about predisposing factors, which are not the object of your research. You did not formulate Conclusions, but if I should consider that the last paragraph is a concluding remark, in my opinion it is irrelevant and not convincing.

[ANSWER] The following period has been added in discussion section:

A definitive approach for RAS disease was not currently clarified in literature and could difference considering the severity and grading of the path. The approach purposed by a consensus report[19] reported different support protocol including a soft diet, chlorhexidine rinses with no alcohol base and topical corticosteroids[20,21]. An alternative approach for type C RAS provide a topical associated to systemic corticosteroids, azathioprine and immunosuppressants [19]. The systemic approach could enhance the local response to the major lesions, but some side effects should be consider in case of prolonged drugs administration[19]. The minor effects could include gastrointestinal symptoms, diarrhea, male infertility and nausea. Thalidomide have been reported to an increased teratogenicity, polyneuropathy and mood change [19]. To reduce the clinical course and the local pain, the local infiltration of corticosteroid drugs could produce an effective outcome. In this way the support therapy of this disorder could produce a more sustainable course of RAS disorders reducing the related symptoms, especially in case of multiple and more durability lesions.

 

[ANSWER] The following period has been added in discussion section:

The study findings seem to suggest that hydrolyzed, rna/dna could produce an effective action with the clinical course of the lesions, reducing the symptoms and the healing period. As reported by previous in vitro study, this effect could be supported by an effective action against the oxidative stress accompanied by a n -cytotoxic activity[27,28].  

 

My conclusion is that, despite the measurements made during the investigation and statistical analysis of the data, the manuscript still lacks important parts in order to be published.

 

Reviewer 2

Comments and Suggestions for Authors

Thank you for the opportunity to serve as a reviewer for this groundbreaking research. The paper presents a sound approach to the treatment of recurrent ulcers. The introduction is clear, and the methodological design is consistent with the objective. The following recommendations are intended to provide a better understanding of the study and increase its quality.

 

1.- I recommend to the author that the introduction section must include the presentation of the different clinical characteristics of the AOR. Here I provide a reference that could help. 

Scully C, Gorsky M, Lozada-Nur F. The diagnosis and management of recurrent aphthous stomatitis: a consensus approach. J Am Dent Assoc. 2003 Feb;134(2):200-7. doi: 10.14219/jada.archive.2003.0134. PMID: 12636124.

not convincing.

[ANSWER] The following period has been added in discussion section:

A definitive approach for RAS disease was not currently clarified in literature and could difference considering the severity and grading of the path. The approach purposed by a consensus report[19] reported different support protocol including a soft diet, chlorhexidine rinses with no alcohol base and topical corticosteroids[20,21]. An alternative approach for type C RAS provide a topical associated to systemic corticosteroids, azathioprine and immunosuppressants [19]. The systemic approach could enhance the local response to the major lesions, but some side effects should be consider in case of prolonged drugs administration[19]. The minor effects could include gastrointestinal symptoms, diarrhea, male infertility and nausea. Thalidomide have been reported to an increased teratogenicity, polyneuropathy and mood change [19]. To reduce the clinical course and the local pain, the local infiltration of corticosteroid drugs could produce an effective outcome. In this way the support therapy of this disorder could produce a more sustainable course of RAS disorders reducing the related symptoms, especially in case of multiple and more durability lesions.

 

2.- Methodologically, how do they register the recurrence of the aphthous before treatment and posteriorly? or this clinical characteristic was not considered?

[ANSWER] This aspect has been included indirectly in USS score as a query during the medical anamnesis. The recurrency after the treatment was not an object of the present study. Please consider this aspect as a limit of the present investigation and a future research perspective:

Given the limited duration of the present study design, it was not possible to evaluate the effects of treatment on relapse rates. According to the evidence that emerged from the present research, the treatment in question showed a statistically significant reduction in clinical symptoms with an improvement in the clinical course of the disease examined in the absence of adverse or undesirable effects.

3.- Before developing the formulation of the gel, could authors mention the general characteristics of this as organogel or hydrogel, xerogel or aqueous, etc…

[ANSWER] The following paragraph has been added:

Device characteristics and composition

The hydrogel compound used for the present investigation was composed by purified water, propylene glycol, vp/va copolymer, carbomer, cellulose gum, pvm/ma copolymer, hydrolyzed, rna/dna, leuconostoc/ radish root ferment filtrate, sodium hyaluronate, allantoin, glycyrrhetinic acid, beta-glucan, glycerin, ruscogenin, bisabolol, leptospermum scoparium branch/leaf oil, melaleuca alternifolia leaf oil, o-cymen-5-ol, phenoxyethanol, sodium benzoate, ammonium glycyrrhizate, sodium saccharin, peg40 hydrogenated castor oil, caprylyl glycol, 1,2-hexanediol, aroma (Afterapid Curasept, Saronno CO, Italy). The placebo was deprived by all active components.

 

4.- Please briefly describe thermography methodology, including the unit of measurement.

[ANSWER] The following paragraph has been added:

Infrared Thermography

The infrared thermal measurements has been performed adopting a controlled environment (temperature: 20–24 C, relative humidity percentage: 52%, with no direct ventilation). The humidity has been constantly monitored using an integrated sensor (Atmo-Tube, San Francisco, CA, USA). This device sensor measure relative humidity (RH) at regular intervals. The intraoral thermography measurements has been assessed using a 14-bit digital infrared camera (FLIR SC660 QWIP, Flir Systems, Danderyd, Sweden) [18]. The device specifications were 320 240 pixels focal plane array; 8–9 m spectral range; 0.02 K noise equivalent.

 

5.- It seems that the evaluation of the primary and secondary objectives is repeated.

[ANSWER] The following sentence has been removed:

Indicators:

3. Pain intensity using the VAS scale. The following outcome measures will be recorded by the blinded outcome assessor:
4. Size of each ulcer using a clear plastic sheet

Thermography/ Ulcer severity score (USS)

 

6.- Is missing the meaning of “ITT”:

[ANSWER] The following sentence has been added:

This primary efficacy analysis will be performed on intention-to-treat population ITT, using the null hypothesis of no between-group difference in overall VAS change from baseline between both groups:

7.- Homology the presentation of the results. In the text, decimals are separated by a period and in tables by a comma.

[ANSWER] In all tables, the decimals separation has been separated by dot.

8.- It is necessary to add the meaning of the asterisk or double asterisk to the table legend.

[ANSWER] Corrected:

[*last reported presentation; ** from the protocol inclusion].

9.- Tables are outside the margins

[ANSWER] Corrected

10.- In the results the authors must describe the characteristics that distinguish group I from group II

[ANSWER] The following sentence has been moved in materials and methods section:

The screening procedure included a phase of enrolment of the subjects which was carried out at the Department of Innovative Technologies in Medicine and Dentistry of the University "G. D'Annunzio" of Chieti-Pescara which, as observed by the clinical plan, provided for voluntary adherence to the study protocol and the collection of written informed consent.  On 28/11/2023, the recruitment phase was launched and included in phase V1 of the clinical investigation.

[ANSWER] The tab.8 has been removed:

Dunn's multiple comparisons test	Mean rank diff,	Significant?	Summary	Adjusted P Value
I-V1 vs. I-V2	0	No	ns	>0,9999
I-V1 vs. I-V3	58.72	Yes	****	<0,0001
I-V1 vs. II-V1	-12.4	No	ns	>0,9999
I-V1 vs. II-V2	43.23	Yes	*	0.013
I-V1 vs. II-V3	85.55	Yes	****	<0,0001
I-V2 vs. I-V3	58.72	Yes	****	<0,0001
I-V2 vs. II-V1	-12.4	No	ns	>0,9999
I-V2 vs. II-V2	43.23	Yes	*	0.013
I-V2 vs. II-V3	85.55	Yes	****	<0,0001
I-V3 vs. II-V1	-71.12	Yes	****	<0,0001
I-V3 vs. II-V2	-15.48	No	ns	>0,9999
I-V3 vs. II-V3	26.83	No	ns	0.5816
II-V1 vs. II-V2	55.63	Yes	***	0.0003
II-V1 vs. II-V3	97.95	Yes	****	<0,0001
II-V2 vs. II-V3	42.32	Yes	*	0.0168
Pain VAS SCORE
I-V1 vs. I-V2	12.3	No	ns	>0,9999
I-V1 vs. I-V3	72.63	Yes	****	<0,0001
I-V1 vs. II-V1	-9.1	No	ns	>0,9999
I-V1 vs. II-V2	57.72	Yes	***	0.0002
I-V1 vs. II-V3	95.95	Yes	****	<0,0001
I-V2 vs. I-V3	60.33	Yes	****	<0,0001
I-V2 vs. II-V1	-21.4	No	ns	>0,9999
I-V2 vs. II-V2	45.42	Yes	**	0.0094
I-V2 vs. II-V3	83.65	Yes	****	<0,0001
I-V3 vs. II-V1	-81.73	Yes	****	<0,0001
I-V3 vs. II-V2	-14.92	No	ns	>0,9999
I-V3 vs. II-V3	23.32	No	ns	>0,9999
II-V1 vs. II-V2	66.82	Yes	****	<0,0001
II-V1 vs. II-V3	105.1	Yes	****	<0,0001
II-V2 vs. II-V3	38.23	No	ns	0.0597
Lesion Size
I-V1 vs. I-V2	11.2	No	ns	>0,9999
I-V1 vs. I-V3	75.38	Yes	****	<0,0001
I-V1 vs. II-V1	-8.1	No	ns	>0,9999
I-V1 vs. II-V2	50.27	Yes	**	0.0024
I-V1 vs. II-V3	97.35	Yes	****	<0,0001
I-V2 vs. I-V3	64.18	Yes	****	<0,0001
I-V2 vs. II-V1	-19.3	No	ns	>0,9999
I-V2 vs. II-V2	39.07	Yes	ns	0.0407
I-V2 vs. II-V3	86.15	Yes	****	<0,0001
I-V3 vs. II-V1	-83.48	Yes	****	<0,0001
I-V3 vs. II-V2	-25.12	No	ns	0.8926
I-V3 vs. II-V3	21.97	No	ns	>0,9999
II-V1 vs. II-V2	58.37	Yes	***	0.0002
II-V1 vs. II-V3	105.5	Yes	****	<0,0001
II-V2 vs. II-V3	47.08	Yes	**	0.0062
Temperature
Dunn's multiple comparisons test	Mean rank diff,	Significant?	Summary	Adjusted P Value
I-V1 vs. I-V2	7.9	No	ns	>0,9999
I-V1 vs. I-V3	24	No	ns	>0,9999
I-V1 vs. II-V1	3.417	No	ns	>0,9999
I-V1 vs. II-V2	14.58	No	ns	>0,9999
I-V1 vs. II-V3	38	No	ns	0.0705
I-V2 vs. I-V3	16.1	No	ns	>0,9999
I-V2 vs. II-V1	-4.483	No	ns	>0,9999
I-V2 vs. II-V2	6.683	No	ns	>0,9999
I-V2 vs. II-V3	30.1	No	ns	0.3772
I-V3 vs. II-V1	-20.58	No	ns	>0,9999
I-V3 vs. II-V2	-9.417	No	ns	>0,9999
I-V3 vs. II-V3	14	No	ns	>0,9999
II-V1 vs. II-V2	11.17	No	ns	>0,9999
II-V1 vs. II-V3	34.58	No	ns	0.1514
II-V2 vs. II-V3	23.42	No	ns	>0,9999

Tab. 8 Summary chart of the pairwise comparison between Group I and Group II at the different timepoints.

 

11.- The discussion needs to be expanded.

[ANSWER] The following period has been added in discussion section:

A definitive approach for RAS disease was not currently clarified in literature and could difference considering the severity and grading of the path. The approach purposed by a consensus report[19] reported different support protocol including a soft diet, chlorhexidine rinses with no alcohol base and topical corticosteroids[20,21]. An alternative approach for type C RAS provide a topical associated to systemic corticosteroids, azathioprine and immunosuppressants [19]. The systemic approach could enhance the local response to the major lesions, but some side effects should be consider in case of prolonged drugs administration[19]. The minor effects could include gastrointestinal symptoms, diarrhea, male infertility and nausea. Thalidomide have been reported to an increased teratogenicity, polyneuropathy and mood change [19]. To reduce the clinical course and the local pain, the local infiltration of corticosteroid drugs could produce an effective outcome. In this way the support therapy of this disorder could produce a more sustainable course of RAS disorders reducing the related symptoms, especially in case of multiple and more durability lesions.

 

[ANSWER] The following period has been added in discussion section:

The study findings seem to suggest that hydrolyzed, rna/dna could produce an effective action with the clinical course of the lesions, reducing the symptoms and the healing period. As reported by previous in vitro study, this effect could be supported by an effective action against the oxidative stress accompanied by a n -cytotoxic activity[27,28].  

 

 

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to serve as a reviewer for this groundbreaking research. The paper presents a sound approach to the treatment of recurrent ulcers. The introduction is clear, and the methodological design is consistent with the objective. The following recommendations are intended to provide a better understanding of the study and increase its quality.

 

1.- I recommend to the author that the introduction section must include the presentation of the different clinical characteristics of the AOR. Here I provide a reference that could help. 

Scully C, Gorsky M, Lozada-Nur F. The diagnosis and management of recurrent aphthous stomatitis: a consensus approach. J Am Dent Assoc. 2003 Feb;134(2):200-7. doi: 10.14219/jada.archive.2003.0134. PMID: 12636124.

2.- Methodologically, how do they register the recurrence of the aphthous before treatment and posteriorly? or this clinical characteristic was not considered?

3.- Before developing the formulation of the gel, could authors mention the general characteristics of this as organogel or hydrogel, xerogel or aqueous, etc…

4.- Please briefly describe thermography methodology, including the unit of measurement.

5.- It seems that the evaluation of the primary and secondary objectives is repeated.

6.- Is missing the meaning of “ITT”

7.- Homology the presentation of the results. In the text, decimals are separated by a period and in tables by a comma.

8.- It is necessary to add the meaning of the asterisk or double asterisk to the table legend.

9.- Tables are outside the margins

10.- In the results the authors must describe the characteristics that distinguish group I from group II

11.- The discussion needs to be expanded.

Comments on the Quality of English Language

 

I do not have the faculty to evaluate English.

Author Response

20th June 2025

RE: Clinical Efficacy of a Topical Gel for the Treatment of Minor Oral Ulcers: A Triple-blind Randomized Controlled Trial.

 

Dear Editor,

Please find here attached the revised version of the above-mentioned manuscript.  All the suggested changes have been carried out in the text.

All the changes suggested by the reviewers have been carried out in the manuscript, and have been highlighted in yellow.

 

 

Reviewer 2

Comments and Suggestions for Authors

Thank you for the opportunity to serve as a reviewer for this groundbreaking research. The paper presents a sound approach to the treatment of recurrent ulcers. The introduction is clear, and the methodological design is consistent with the objective. The following recommendations are intended to provide a better understanding of the study and increase its quality.

 

1.- I recommend to the author that the introduction section must include the presentation of the different clinical characteristics of the AOR. Here I provide a reference that could help. 

Scully C, Gorsky M, Lozada-Nur F. The diagnosis and management of recurrent aphthous stomatitis: a consensus approach. J Am Dent Assoc. 2003 Feb;134(2):200-7. doi: 10.14219/jada.archive.2003.0134. PMID: 12636124.

not convincing.

[ANSWER] The following period has been added in discussion section:

A definitive approach for RAS disease was not currently clarified in literature and could difference considering the severity and grading of the path. The approach purposed by a consensus report[19] reported different support protocol including a soft diet, chlorhexidine rinses with no alcohol base and topical corticosteroids[20,21]. An alternative approach for type C RAS provide a topical associated to systemic corticosteroids, azathioprine and immunosuppressants [19]. The systemic approach could enhance the local response to the major lesions, but some side effects should be consider in case of prolonged drugs administration[19]. The minor effects could include gastrointestinal symptoms, diarrhea, male infertility and nausea. Thalidomide have been reported to an increased teratogenicity, polyneuropathy and mood change [19]. To reduce the clinical course and the local pain, the local infiltration of corticosteroid drugs could produce an effective outcome. In this way the support therapy of this disorder could produce a more sustainable course of RAS disorders reducing the related symptoms, especially in case of multiple and more durability lesions.

 

2.- Methodologically, how do they register the recurrence of the aphthous before treatment and posteriorly? or this clinical characteristic was not considered?

[ANSWER] This aspect has been included indirectly in USS score as a query during the medical anamnesis. The recurrency after the treatment was not an object of the present study. Please consider this aspect as a limit of the present investigation and a future research perspective:

Given the limited duration of the present study design, it was not possible to evaluate the effects of treatment on relapse rates. According to the evidence that emerged from the present research, the treatment in question showed a statistically significant reduction in clinical symptoms with an improvement in the clinical course of the disease examined in the absence of adverse or undesirable effects.

3.- Before developing the formulation of the gel, could authors mention the general characteristics of this as organogel or hydrogel, xerogel or aqueous, etc…

[ANSWER] The following paragraph has been added:

Device characteristics and composition

The hydrogel compound used for the present investigation was composed by purified water, propylene glycol, vp/va copolymer, carbomer, cellulose gum, pvm/ma copolymer, hydrolyzed, rna/dna, leuconostoc/ radish root ferment filtrate, sodium hyaluronate, allantoin, glycyrrhetinic acid, beta-glucan, glycerin, ruscogenin, bisabolol, leptospermum scoparium branch/leaf oil, melaleuca alternifolia leaf oil, o-cymen-5-ol, phenoxyethanol, sodium benzoate, ammonium glycyrrhizate, sodium saccharin, peg40 hydrogenated castor oil, caprylyl glycol, 1,2-hexanediol, aroma (Afterapid Curasept, Saronno CO, Italy). The placebo was deprived by all active components.

 

4.- Please briefly describe thermography methodology, including the unit of measurement.

[ANSWER] The following paragraph has been added:

Infrared Thermography

The infrared thermal measurements has been performed adopting a controlled environment (temperature: 20–24 C, relative humidity percentage: 52%, with no direct ventilation). The humidity has been constantly monitored using an integrated sensor (Atmo-Tube, San Francisco, CA, USA). This device sensor measure relative humidity (RH) at regular intervals. The intraoral thermography measurements has been assessed using a 14-bit digital infrared camera (FLIR SC660 QWIP, Flir Systems, Danderyd, Sweden) [18]. The device specifications were 320 240 pixels focal plane array; 8–9 m spectral range; 0.02 K noise equivalent.

 

5.- It seems that the evaluation of the primary and secondary objectives is repeated.

[ANSWER] The following sentence has been removed:

Indicators:

1. Pain intensity using the VAS scale. The following outcome measures will be recorded by the blinded outcome assessor:
2. Size of each ulcer using a clear plastic sheet

Thermography/ Ulcer severity score (USS)

 

6.- Is missing the meaning of “ITT”:

[ANSWER] The following sentence has been added:

This primary efficacy analysis will be performed on intention-to-treat population ITT, using the null hypothesis of no between-group difference in overall VAS change from baseline between both groups:

7.- Homology the presentation of the results. In the text, decimals are separated by a period and in tables by a comma.

[ANSWER] In all tables, the decimals separation has been separated by dot.

8.- It is necessary to add the meaning of the asterisk or double asterisk to the table legend.

[ANSWER] Corrected:

[*last reported presentation; ** from the protocol inclusion].

9.- Tables are outside the margins

[ANSWER] Corrected

10.- In the results the authors must describe the characteristics that distinguish group I from group II

[ANSWER] The following sentence has been moved in materials and methods section:

The screening procedure included a phase of enrolment of the subjects which was carried out at the Department of Innovative Technologies in Medicine and Dentistry of the University "G. D'Annunzio" of Chieti-Pescara which, as observed by the clinical plan, provided for voluntary adherence to the study protocol and the collection of written informed consent.  On 28/11/2023, the recruitment phase was launched and included in phase V1 of the clinical investigation.

[ANSWER] The tab.8 has been removed:

Dunn's multiple comparisons test	Mean rank diff,	Significant?	Summary	Adjusted P Value
I-V1 vs. I-V2	0	No	ns	>0,9999
I-V1 vs. I-V3	58.72	Yes	****	<0,0001
I-V1 vs. II-V1	-12.4	No	ns	>0,9999
I-V1 vs. II-V2	43.23	Yes	*	0.013
I-V1 vs. II-V3	85.55	Yes	****	<0,0001
I-V2 vs. I-V3	58.72	Yes	****	<0,0001
I-V2 vs. II-V1	-12.4	No	ns	>0,9999
I-V2 vs. II-V2	43.23	Yes	*	0.013
I-V2 vs. II-V3	85.55	Yes	****	<0,0001
I-V3 vs. II-V1	-71.12	Yes	****	<0,0001
I-V3 vs. II-V2	-15.48	No	ns	>0,9999
I-V3 vs. II-V3	26.83	No	ns	0.5816
II-V1 vs. II-V2	55.63	Yes	***	0.0003
II-V1 vs. II-V3	97.95	Yes	****	<0,0001
II-V2 vs. II-V3	42.32	Yes	*	0.0168
Pain VAS SCORE
I-V1 vs. I-V2	12.3	No	ns	>0,9999
I-V1 vs. I-V3	72.63	Yes	****	<0,0001
I-V1 vs. II-V1	-9.1	No	ns	>0,9999
I-V1 vs. II-V2	57.72	Yes	***	0.0002
I-V1 vs. II-V3	95.95	Yes	****	<0,0001
I-V2 vs. I-V3	60.33	Yes	****	<0,0001
I-V2 vs. II-V1	-21.4	No	ns	>0,9999
I-V2 vs. II-V2	45.42	Yes	**	0.0094
I-V2 vs. II-V3	83.65	Yes	****	<0,0001
I-V3 vs. II-V1	-81.73	Yes	****	<0,0001
I-V3 vs. II-V2	-14.92	No	ns	>0,9999
I-V3 vs. II-V3	23.32	No	ns	>0,9999
II-V1 vs. II-V2	66.82	Yes	****	<0,0001
II-V1 vs. II-V3	105.1	Yes	****	<0,0001
II-V2 vs. II-V3	38.23	No	ns	0.0597
Lesion Size
I-V1 vs. I-V2	11.2	No	ns	>0,9999
I-V1 vs. I-V3	75.38	Yes	****	<0,0001
I-V1 vs. II-V1	-8.1	No	ns	>0,9999
I-V1 vs. II-V2	50.27	Yes	**	0.0024
I-V1 vs. II-V3	97.35	Yes	****	<0,0001
I-V2 vs. I-V3	64.18	Yes	****	<0,0001
I-V2 vs. II-V1	-19.3	No	ns	>0,9999
I-V2 vs. II-V2	39.07	Yes	ns	0.0407
I-V2 vs. II-V3	86.15	Yes	****	<0,0001
I-V3 vs. II-V1	-83.48	Yes	****	<0,0001
I-V3 vs. II-V2	-25.12	No	ns	0.8926
I-V3 vs. II-V3	21.97	No	ns	>0,9999
II-V1 vs. II-V2	58.37	Yes	***	0.0002
II-V1 vs. II-V3	105.5	Yes	****	<0,0001
II-V2 vs. II-V3	47.08	Yes	**	0.0062
Temperature
Dunn's multiple comparisons test	Mean rank diff,	Significant?	Summary	Adjusted P Value
I-V1 vs. I-V2	7.9	No	ns	>0,9999
I-V1 vs. I-V3	24	No	ns	>0,9999
I-V1 vs. II-V1	3.417	No	ns	>0,9999
I-V1 vs. II-V2	14.58	No	ns	>0,9999
I-V1 vs. II-V3	38	No	ns	0.0705
I-V2 vs. I-V3	16.1	No	ns	>0,9999
I-V2 vs. II-V1	-4.483	No	ns	>0,9999
I-V2 vs. II-V2	6.683	No	ns	>0,9999
I-V2 vs. II-V3	30.1	No	ns	0.3772
I-V3 vs. II-V1	-20.58	No	ns	>0,9999
I-V3 vs. II-V2	-9.417	No	ns	>0,9999
I-V3 vs. II-V3	14	No	ns	>0,9999
II-V1 vs. II-V2	11.17	No	ns	>0,9999
II-V1 vs. II-V3	34.58	No	ns	0.1514
II-V2 vs. II-V3	23.42	No	ns	>0,9999

Tab. 8 Summary chart of the pairwise comparison between Group I and Group II at the different timepoints.

 

11.- The discussion needs to be expanded.

[ANSWER] The following period has been added in discussion section:

A definitive approach for RAS disease was not currently clarified in literature and could difference considering the severity and grading of the path. The approach purposed by a consensus report[19] reported different support protocol including a soft diet, chlorhexidine rinses with no alcohol base and topical corticosteroids[20,21]. An alternative approach for type C RAS provide a topical associated to systemic corticosteroids, azathioprine and immunosuppressants [19]. The systemic approach could enhance the local response to the major lesions, but some side effects should be consider in case of prolonged drugs administration[19]. The minor effects could include gastrointestinal symptoms, diarrhea, male infertility and nausea. Thalidomide have been reported to an increased teratogenicity, polyneuropathy and mood change [19]. To reduce the clinical course and the local pain, the local infiltration of corticosteroid drugs could produce an effective outcome. In this way the support therapy of this disorder could produce a more sustainable course of RAS disorders reducing the related symptoms, especially in case of multiple and more durability lesions.

 

[ANSWER] The following period has been added in discussion section:

The study findings seem to suggest that hydrolyzed, rna/dna could produce an effective action with the clinical course of the lesions, reducing the symptoms and the healing period. As reported by previous in vitro study, this effect could be supported by an effective action against the oxidative stress accompanied by a n -cytotoxic activity[27,28].  

 

 

 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors, 

I appreciate your efforts in trying to thoroughly address the proposed comments. 

Author Response

25th June 2025

RE: Clinical Efficacy of a Topical Gel for the Treatment of Minor Oral Ulcers: A Triple-blind

Randomized Controlled Trial.

 

Dear Editor,

Please find here attached the revised version of the above-mentioned manuscript. All the

suggested changes have been carried out in the text.

All the changes suggested by the reviewers have been carried out in the manuscript, and have

been highlighted in yellow.

 

Reviewer 1

Dear Authors, 

I appreciate your efforts in trying to thoroughly address the proposed comments. 

[ANSWER] Thank you for your indication, the section “Thermography” has been moved in the secondary indexes subparagraph.

-Secondary indexes:

• Thermography
• Ulcer Severity Score (USS)

Treatment was started on the same day with strict infection control measures.

The assessor proceeded with the allocation phase as required by the assignment protocol, indicating in the CRF the progressive number of the patient contained in the envelope and to which group (A or B) the patient was assigned.

Patients received an anonymous tube vial, coded with A, B containing the gel and the appropriate applicator. Patients therefore applied the gel. This procedure was performed under supervision providing further explanations to patients if necessary.

Participants were asked to apply the gel twice a day directly to the injured part, inside the mouth, with the help of the applicator provided. Patients were prevented from eating, drinking, or rinsing their mouths for at least one hour after each application.

 

Thermography

The infrared thermal measurements has been performed adopting a controlled environment (temperature: 20–24 C, relative humidity percentage: 52%, with no direct ventilation). The humidity has been constantly monitored using an integrated sensor (Atmo-Tube, San Francisco, CA, USA). This device sensor measure relative humidity (RH) at regular intervals. The intraoral thermography measurements has been assessed using a 14-bit digital infrared camera (FLIR SC660 QWIP, Flir Systems, Danderyd, Sweden) [18]. The device specifications were 320 240 pixels focal plane array; 8–9 m spectral range; 0.02 K noise equivalent.

 

[ANSWER] A revision of the English form has been performed and some typos have been corrected.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

We appreciate the authors’ efforts in addressing the reviewers’ comments and incorporating the suggested revisions. However, the information regarding the thermography methodology should be placed in the appropriate section: Methodology / Secondary Indexes / Thermography

Comments on the Quality of English Language

I am not qualified to assess the quality of English.

Author Response

25th June 2025

RE: Clinical Efficacy of a Topical Gel for the Treatment of Minor Oral Ulcers: A Triple-blind

Randomized Controlled Trial.

 

Dear Editor,

Please find here attached the revised version of the above-mentioned manuscript. All the

suggested changes have been carried out in the text.

All the changes suggested by the reviewers have been carried out in the manuscript, and have

been highlighted in yellow.

 

Reviewer 2

We appreciate the authors’ efforts in addressing the reviewers’ comments and incorporating the suggested revisions. However, the information regarding the thermography methodology should be placed in the appropriate section: Methodology / Secondary Indexes / Thermography

[ANSWER] Thank you for the indication, the section “Thermography” has been moved in the secondary indexes subparagraph.

-Secondary indexes:

• Thermography
• Ulcer Severity Score (USS)

Treatment was started on the same day with strict infection control measures.

The assessor proceeded with the allocation phase as required by the assignment protocol, indicating in the CRF the progressive number of the patient contained in the envelope and to which group (A or B) the patient was assigned.

Patients received an anonymous tube vial, coded with A, B containing the gel and the appropriate applicator. Patients therefore applied the gel. This procedure was performed under supervision providing further explanations to patients if necessary.

Participants were asked to apply the gel twice a day directly to the injured part, inside the mouth, with the help of the applicator provided. Patients were prevented from eating, drinking, or rinsing their mouths for at least one hour after each application.

 

Thermography

The infrared thermal measurements has been performed adopting a controlled environment (temperature: 20–24 C, relative humidity percentage: 52%, with no direct ventilation). The humidity has been constantly monitored using an integrated sensor (Atmo-Tube, San Francisco, CA, USA). This device sensor measure relative humidity (RH) at regular intervals. The intraoral thermography measurements has been assessed using a 14-bit digital infrared camera (FLIR SC660 QWIP, Flir Systems, Danderyd, Sweden) [18]. The device specifications were 320 240 pixels focal plane array; 8–9 m spectral range; 0.02 K noise equivalent.

 

[ANSWER] A revision of the English form has been performed and some typos have been corrected.

 

Author Response File: Author Response.pdf