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Clinical questions.
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Do patients with gastroesophageal reflux disease (GERD) have a higher prevalence of dental erosion (DE)? Do patients with DE have a higher prevalence of GERD?
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Review methods.
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The authors searched two databases for studies of humans published in English from January 1966 through September 2007: MEDLINE and the Cochrane Controlled Trials Register. They identified 19 studies in which investigators compared GERD with DE, 17 of which met their inclusion criteria: seven observational studies, six case-control studies, two cross-sectional studies, one retrospective study and one questionnaire-based study.
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Main results.
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In their systematic review, the authors identified trials that involved patients who had either GERD or DE. The diagnostic criteria, trial designs and reported prevalences of the trials varied considerably. In adult patients, the reported prevalence of DE among patients with GERD ranged from 5 to 48 percent. Conversely, the reported prevalence of GERD among adults with DE ranged from 21 to 83 percent. In children, the reported prevalence of DE among patients with GERD ranged from 17 to 87 percent.
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Conclusions.
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The authors of this systematic review suggested a strong association between GERD and DE. They also suggested that the severity of DE correlates with the presence of GERD. These associations were based on multiple diagnostic measures, trial types, patient identification schemes and outcomes. The rationale provided for these multiple assessments was that GERD has a variety of manifestations and presentations and is subject to some uncertainty in terms of classification. To address this uncertainty, the authors looked for GERD in patients with DE. Again, they identified an association.
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COMMENTARY
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Importance and context.
GERD is a serious form of acid reflux or regurgitation. It occurs when the lower esophageal sphincter opens spontaneously and does not close properly, whereupon stomach contents rise into the esophagus. Acid erosion is commonly accepted by the dental community as a cause of loss of tooth surface.1,2 DE is considered to be a comorbidity with GERD.3
Strengths and weaknesses of the systematic review.
The review’s authors used established methods and standards to conduct a comprehensive and systematic search. However, they did not provide data tables that would have identified the key control and experimental outcome measures from the original trials, although they indicated that those data are available on request. They reported only qualitative findings. Without the validation of the original data regarding the presentations of correlation coefficients, relative risks or etiologic fractions, the data provided do not support the authors’ claim of a "strong" association. The lack of original data weakens the integrity of the reported outcomes. For example, the abstract indicates that the "median prevalence of DE in GERD patients was 24 percent, with a large range (5 percent–48 percent), and the median prevalence of GERD in DE adult patients was 32.5 percent (range, 21 percent–83 percent)." However, these data are incongruent with the information in the results, and the written results are incongruent with the tabular data. The authors made contradictory statements regarding the prevalence of DE in the general population and made unsupported statements regarding the ease of diagnosis of DE by primary care physicians and gastroenterologists. Finally, the authors grouped the outcome data from all trial types. The results would have been more useful had the authors grouped the trial types according to evidence level for analysis.
Strengths and weaknesses of the evidence.
Poor data presentation in the systematic review made it difficult to analyze the original evidence. The lack of an analytical framework and controls prohibits any accurate assessment of the results.
Implication for dental practice.
The authors of this systematic review did not find strong evidence of a link between GERD and DE, a finding that does not support the acceptance of this association in the Montreal global consensus conference definition and classification of GERD.3 This conclusion is in agreement with that of the review by Milosevic,4 which states, "In summary, the review could have been more critical of the studies. The association between GERD and dental erosion is entirely plausible but the strength of association and the epidemiological evidence remains unclear."
More high-quality studies are needed to confirm this possible association. However, dental care and medical care providers should continue to be vigilant in examining the oral cavity in any patient with GERD.
TOP
Clinical questions.
Review methods.
