Reviewer's report
Title:Self-induced vomiting and dental erosion - a clinical study
Reviewer:Fabiana Vargas-Ferreira
Many thanks for the constructive criticism and the valuable comments on our
manuscript. We emended the text in rexpect of the comments. Below you will find a
detailed listing of our amendments.
Reviewer's report:
The literature has suggested the etiology of dental erosion is associated with
gastroesophageal reflux, however, it is important to mention that articles had
some limitations, such as the number of the participants (generally, low), the
index used to assess tooth erosion (there is not a gold standard), calibration of
examiners and the influence of other types of wearing.
Answer: This is an important topic, which is discussed on page 4, line number 83 –
88.
- Abstract – the authors need to clarify, for example, the types of eating
disorders and their influence on dental erosion;
Answer: We appreciate the suggestion. However, the authors’ instructions
emphasizes that the abstract section should not exceed 350 words. Therefore, we
find it necessary to summarize the article as precisely as possible. In addition, the
rest of the article focuses only on eating disorders with self-induced vomiting and
their possible influence on the etiology of dental erosion.
- Introduction – the authors showed a literature focusing in behavioral
conditions and dental erosion;
Answer: Our interpretation of this comment is that the reviewer requests that the
authors points out that dental erosions not only are caused by behavioral conditions,
such as eating disorders. Therefore, we have added a sentence to clarify this on
page 3, line 49 - 51.
- Methodology – why this index was used? Unfortunately, there is not an index
which is considered the “gold standard” and the literature shows that indexes
are not comparable because they used different criteria to assess tooth wear,
including dental erosion;
Answer: We are aware of this dilemma and appreciate that the reviewer emphasizes
it. We have more thoroughly explained why the VEDE index was used on page 6, line
138 - 141.
In the questionnaire, what questions are used? This
questionnaire was tested previously? Is it exclusively for dental erosion or
included other types of tooth wear, such as attrition?
Answer: To clarify, we have changed the term «questionnaire» to «interview», and
we have explained this on page 5 - 6, line 113 - 128.
How the authors handle with early forms of tooth erosion, because, generally it
is accompanied by few clinical signs and rarely any symptoms?
Answer: All patient who were receiving treatment for their eating disorder at the
eating disorder clinics were offered a referral for a dental examination. Therefore, no
one of the participants searched the dental clinic because of symptoms. The severity
grading of the dental erosions were exclusively based on visual signs. The visual
signs are described under the description of the VEDE index on page 6 - 7, line 141 144.
- Results are well described, maybe, it is interesting to assess separately the
influence of gender. Female, generally, showed more episodes of self-inducing
vomiting? Or this situation can be explored more in discussion section;
Answer: The prevalence and characteristics of dental erosions in male individuals
with self-induced vomiting would be an interesting and desirable topic to discuss.
However, only 3 out of the 66 participants in this study were men, and the material
was therefore considered to be too small. A comment on this can be found in the
discussion section on page 14, line 325 - 328.
- Discussion is adequate, however, there is need to approach the limitations of
the study and mainly, how is this influence on outcome and what the likely
factors affected the teeth in individuals > 10 years of SIV
Answer: We totally agree with the reviewer: A description of the limitation of the study
has been added in the discussion section, on page 14 -15, line 325 -342.
A discussion on why the individuals mentioned (with a long lasting eating disorder
with self-induced vomiting) showed more erosions and more severe lesions has been
added on page 11 - 12, line 265 - 270.
- The authors need to show the p value and this influence on outcome.
Association must be presented better.
Answer: We decided to only show the p values <0.005, only for the associations
which were statistical significant, page 9, line 208 - 210. Under the paragraph
statistical analysis we have defined the p value (page 7, line 156 - 161).