Manifestations of the oral mucosa and salivary glands in irritable bowel syndrome and microscopic colitis – A systematic review

Authors

  • Hanna Göthlin Department of Oral Medicine & Pathology, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  • Bengt Hasséus Department of Oral Medicine & Pathology, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  • Klas Sjöberg Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden; Department of Gastroenterology and Nutrition, Skåne University Hospital, Malmö, Sweden
  • Maria Bankvall Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden; Department of Odontology and Oral Sciences, School of Health and Welfare, University of Jönköping, Sweden

DOI:

https://doi.org/10.2340/aos.v84.43870

Keywords:

Gastrointestinal disease, irritable bowel syndrome, microscopic colitis, oral cavity, oral mucosal disease

Abstract

Objective: There is a well-established association of oral manifestations in the non-infectious chronic diarrhoeal conditions namely, Morbus Crohn, ulcerative colitis, and coeliac disease. Such a connection may exist also for the remaining non-infectious chronic diarrhoeal conditions, that is irritable bowel syndrome (IBS) and microscopic colitis (MC).

Materials and methods: A systematic search was performed in Scopus and PubMed, rendering a total of 710 articles to be screened. All articles were screened independently and assessed for eligibility reporting comorbidity between either IBS or MC, and oral symptoms/disease. Quality assessment and data extraction were performed.

Results: In all, 17 articles were included. Sjögren’s syndrome (SS) in patients with IBS ranged from 3% to 33% and for IBS in SS between 29% to 62%. Dry mouth, bad breath, and foul taste were overrepresented in these patients. The occurrence of SS in patients with MC ranged from 2% to 9%, and for MC in SS from 1% to 2%.

Conclusions: An association between SS and IBS and MC, respectively, is plausible. Few articles have explored other oral manifestations. Therefore, no specific conclusions can be drawn. It is pivotal to further explore oral manifestations of these conditions bridging the gap between dental care and general medicine to optimise diagnostics, treatment strategies, and ultimately patient care.

Downloads

Download data is not yet available.

References

Jurge S, Hegarty AM, Hodgson T. Orofacial manifestations of gastrointestinal disorders. Br J Hosp Med (Lond). 2014;75:497–501. https://doi.org/10.12968/hmed.2014.75.9.497 DOI: https://doi.org/10.12968/hmed.2014.75.9.497

Tan CX, Brand HS, de Boer NK, Forouzanfar T. Gastrointestinal diseases and their oro-dental manifestations: Part 1: Crohn’s disease. Br Dent J. 2016;221:794–9. https://doi.org/10.1038/sj.bdj.2016.954 DOI: https://doi.org/10.1038/sj.bdj.2016.954

Fatahzadeh M, Schwartz RA, Kapila R, Rochford C. Orofacial Crohn’s disease: an oral enigma. Acta Dermatovenerol Croat. 2009;17:289–300.

Tan CX, Brand HS, de Boer NK, Forouzanfar T. Gastrointestinal diseases and their oro-dental manifestations: Part 2: ulcerative colitis. Br Dent J. 2017;222:53–7. https://doi.org/10.1038/sj.bdj.2017.37 DOI: https://doi.org/10.1038/sj.bdj.2017.37

Kumar KM, Nachiammai N, Madhushankari GS. Association of oral manifestations in ulcerative colitis: a pilot study. J Oral Maxillofac Pathol. 2018;22:199–203. https://doi.org/10.4103/jomfp.JOMFP_223_16 DOI: https://doi.org/10.4103/jomfp.JOMFP_223_16

Sahin Y. Celiac disease in children: a review of the literature. World J Clin Pediatr. 2021;10:53–71. https://doi.org/10.5409/wjcp.v10.i4.53 DOI: https://doi.org/10.5409/wjcp.v10.i4.53

Pastore L, Carroccio A, Compilato D, Panzarella V, Serpico R, Lo Muzio L. Oral manifestations of celiac disease. J Clin Gastroenterol. 2008;42:224–32. https://doi.org/10.1097/MCG.0b013e318074dd98 DOI: https://doi.org/10.1097/MCG.0b013e318074dd98

van Gils T, Brand HS, de Boer NK, Mulder CJ, Bouma G. Gastrointestinal diseases and their oro-dental manifestations: part 3: coeliac disease. Br Dent J. 2017;222:126–9. https://doi.org/10.1038/sj.bdj.2017.80 DOI: https://doi.org/10.1038/sj.bdj.2017.80

Hujoel IA. Nutritional status in irritable bowel syndrome: a North American population-based study. JGH Open. 2020;4:656–62. https://doi.org/10.1002/jgh3.12311 DOI: https://doi.org/10.1002/jgh3.12311

Khayyat Y, Attar S. Vitamin D deficiency in patients with irritable bowel syndrome: does it exist? Oman Med J. 2015;30:115–8. https://doi.org/10.5001/omj.2015.25 DOI: https://doi.org/10.5001/omj.2015.25

Wang L, Alammar N, Singh R, Nanavati J, Song Y, Chaudhary R, et al. Gut microbial dysbiosis in the irritable bowel syndrome: a systematic review and meta-analysis of case-control studies. J Acad Nutr Diet. 2020;120:565–86. https://doi.org/10.1016/j.jand.2019.05.015 DOI: https://doi.org/10.1016/j.jand.2019.05.015

Jegadeesan R, Liu X, Pagadala MR, Gutierrez N, Butt M, Navaneethan U. Microscopic colitis: is it a spectrum of inflammatory bowel disease? World J Gastroenterol. 2013;19:4252–6. https://doi.org/10.3748/wjg.v19.i26.4252 DOI: https://doi.org/10.3748/wjg.v19.i26.4252

Aziz I, Simren M. The overlap between irritable bowel syndrome and organic gastrointestinal diseases. Lancet Gastroenterol Hepatol. 2021;6:139–48. https://doi.org/10.1016/S2468-1253(20)30212-0 DOI: https://doi.org/10.1016/S2468-1253(20)30212-0

Fikree A, Byrne P. Management of functional gastrointestinal disorders. Clin Med (Lond). 2021;21:44–52. https://doi.org/10.7861/clinmed.2020-0980 DOI: https://doi.org/10.7861/clinmed.2020-0980

Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV. Gastroenterology. 2016; 150: 1262-1279. https://doi.org/10.1053/j.gastro.2016.02.032 DOI: https://doi.org/10.1053/j.gastro.2016.02.032

Ng QX, Yau CE, Yaow CYL, Chong RIH, Chong NZ, Teoh SE, et al. What has longitudinal ‘Omics’ studies taught us about irritable bowel syndrome? A systematic review. Metabolites. 2023;13(4):484. https://doi.org/10.3390/metabo13040484 DOI: https://doi.org/10.3390/metabo13040484

Enck P, Aziz Q, Barbara G, Farmer AD, Fukudo S, Mayer EA, et al. Irritable bowel syndrome. Nat Rev Dis Primers. 2016;2:16014. https://doi.org/10.1038/nrdp.2016.14 DOI: https://doi.org/10.1038/nrdp.2016.14

Ford AC, Sperber AD, Corsetti M, Camilleri M. Irritable bowel syndrome. Lancet. 2020;396:1675–88. https://doi.org/10.1016/S0140-6736(20)31548-8 DOI: https://doi.org/10.1016/S0140-6736(20)31548-8

Mearin F, Lacy BE, Chang L, Chey WD, Lembo AJ, Simren M, et al. Bowel disorders. Gastroenterology. 2016; 150:1393-1407. DOI: https://doi.org/10.1053/j.gastro.2016.02.031

Chey WD, Kurlander J, Eswaran S. Irritable bowel syndrome: a clinical review. AMA.2015;313:949–58. https://doi.org/10.1001/jama.2015.0954 DOI: https://doi.org/10.1001/jama.2015.0954

Tome J, Kamboj AK, Pardi DS. Microscopic Colitis: a concise review for clinicians. Mayo Clin Proc. 2021;96:1302–8. https://doi.org/10.1016/j.mayocp.2021.03.022 DOI: https://doi.org/10.1016/j.mayocp.2021.03.022

Miehlke S, Verhaegh B, Tontini GE, Madisch A, Langner C, Munch A. Microscopic colitis: pathophysiology and clinical management. Lancet Gastroenterol Hepatol. 2019;4:305–14. https://doi.org/10.1016/S2468-1253(19)30048-2 DOI: https://doi.org/10.1016/S2468-1253(19)30048-2

Langner C, Aust D, Ensari A, Villanacci V, Becheanu G, Miehlke S, et al. Histology of microscopic colitis-review with a practical approach for pathologists. Histopathology. 2015;66:613–26. https://doi.org/10.1111/his.12592 DOI: https://doi.org/10.1111/his.12592

Tong J, Zheng Q, Zhang C, Lo R, Shen J, Ran Z. Incidence, prevalence, and temporal trends of microscopic colitis: a systematic review and meta-analysis. Am J Gastroenterol. 2015;110:265–76; quiz 77. https://doi.org/10.1038/ajg.2014.431 DOI: https://doi.org/10.1038/ajg.2014.431

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. https://doi.org/10.1136/bmj.n71 DOI: https://doi.org/10.1136/bmj.n71

Booth A, Clarke M, Dooley G, Ghersi D, Moher D, Petticrew M, et al. The nuts and bolts of PROSPERO: an international prospective register of systematic reviews. Syst Rev. 2012;1:2. https://doi.org/10.1186/2046-4053-1-2 DOI: https://doi.org/10.1186/2046-4053-2-4

Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5:210. https://doi.org/10.1186/s13643-016-0384-4 DOI: https://doi.org/10.1186/s13643-016-0384-4

ResearchRabbit. ResearchRabbit (Version 4.0) [Software tool]. Human Interlligence Technologies, Incorporated. Available from: https://researchrabbitapp.com/2021

Moola SMZ, Tufanaru C, Aromataris E, Sears K, Sfetcu R, Currie M, et al. Chapter 7: systematic reviews of etiology and risk. In: Aromataris E, Munn Z, editors. JBI manual for evidence synthesis. JBI; 2020. DOI: https://doi.org/10.46658/JBIRM-17-06

Munn Z, Aromataris E, Tufanaru C, Stern C, Porritt K, Farrow J, et al. The development of software to support multiple systematic review types: the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Int J Evid Based Healthc. 2019;17:36–43. https://doi.org/10.1097/XEB.0000000000000152 DOI: https://doi.org/10.1097/XEB.0000000000000152

Andreasson K, Ohlsson B, Mandl T. Elevated levels of faecal calprotectin in primary Sjogren’s syndrome is common and associated with concomitant organic gastrointestinal disease. Arthritis Res Ther. 2016;18:9. https://doi.org/10.1186/s13075-015-0907-8 DOI: https://doi.org/10.1186/s13075-015-0907-8

Liden M, Kristjansson G, Valtysdottir S, Venge P, Hallgren R. Cow’s milk protein sensitivity assessed by the mucosal patch technique is related to irritable bowel syndrome in patients with primary Sjogren’s syndrome. Clin Exp Allergy. 2008;38:929–35. https://doi.org/10.1111/j.1365-2222.2008.02983.x DOI: https://doi.org/10.1111/j.1365-2222.2008.02983.x

Kim-Lee C, Suresh L, Ambrus JL, Jr. Gastrointestinal disease in Sjogren’s syndrome: related to food hypersensitivities. Springerplus. 2015;4:766. https://doi.org/10.1186/s40064-015-1557-7 DOI: https://doi.org/10.1186/s40064-015-1557-7

Barton A, Pal B, Whorwell PJ, Marshall D. Increased prevalence of sicca complex and fibromyalgia in patients with irritable bowel syndrome. Am J Gastroenterol. 1999;94:1898–901. https://doi.org/10.1111/j.1572-0241.1999.01146.x DOI: https://doi.org/10.1111/j.1572-0241.1999.01146.x

Canataroǧlu A, Gümürdülü Y, Erdem A, Çolakoǧlu S. Prevalence of fibromyalgia in patients with irritable bowel syndrome. Turk J Gastroenterol. 2001;12(2):141–4.

Erbasan F, Cekin Y, Coban DT, Karasu U, Suren D, Cekin AH. The frequency of primary Sjogren’s syndrome and fibromyalgia in irritable bowel syndrome. Pak J Med Sci. 2017;33:137–41. https://doi.org/10.12669/pjms.331.11168 DOI: https://doi.org/10.12669/pjms.331.11168

Cheung D, Trudgill N. Managing a patient with burning mouth syndrome. Frontline Gastroenterol. 2015;6:218–22. https://doi.org/10.1136/flgastro-2014-100431 DOI: https://doi.org/10.1136/flgastro-2014-100431

Whorwell PJ, McCallum M, Creed FH, Roberts CT. Non-colonic features of irritable bowel syndrome. Gut. 1986;27:37–40. https://doi.org/10.1136/gut.27.1.37 DOI: https://doi.org/10.1136/gut.27.1.37

Zimmerman J. Extraintestinal symptoms in irritable bowel syndrome and inflammatory bowel diseases: nature, severity, and relationship to gastrointestinal symptoms. Dig Dis Sci. 2003;48:743–9. https://doi.org/10.1023/A:1022840910283 DOI: https://doi.org/10.1023/A:1022840910283

Maxton DG, Morris J, Whorwell PJ. More accurate diagnosis of irritable bowel syndrome by the use of ‘non-colonic’ symptomatology. Gut. 1991;32:784–6. https://doi.org/10.1136/gut.32.7.784 DOI: https://doi.org/10.1136/gut.32.7.784

Melchor S, Sanchez-Piedra C, Fernandez Castro M, Andreu JL, Martinez Taboada V, Olive A, et al. Digestive involvement in primary Sjogren’s syndrome: analysis from the Sjogrenser registry. Clin Exp Rheumatol. 2020;38 Suppl 126:110–5.

Widgren S, MacGee W. Collagenous colitis with protracted course and fatal evolution. Report of a case. Pathol Res Pract. 1990;186:303–6; discussion 6–8. https://doi.org/10.1016/S0344-0338(11)80551-0 DOI: https://doi.org/10.1016/S0344-0338(11)80551-0

Mohammed A, Ghoneim S, Paranji N, Waghray N. Quantifying risk factors for microscopic colitis: a nationwide, retrospective cohort study. Indian J Gastroenterol. 2022;41:181–9. https://doi.org/10.1007/s12664-021-01199-z DOI: https://doi.org/10.1007/s12664-021-01199-z

Vigren L, Tysk C, Strom M, Kilander AF, Hjortswang H, Bohr J, et al. Celiac disease and other autoimmune diseases in patients with collagenous colitis. Scand J Gastroenterol. 2013;48:944–50. https://doi.org/10.3109/00365521.2013.805809 DOI: https://doi.org/10.3109/00365521.2013.805809

Barta Z, Mekkel G, Csipo I, Toth L, Szakall S, Szabo GG, et al. Microscopic colitis: a retrospective study of clinical presentation in 53 patients. World J Gastroenterol. 2005;11:1351–5. https://doi.org/10.3748/wjg.v11.i9.1351 DOI: https://doi.org/10.3748/wjg.v11.i9.1351

Soulier C, Saraux A, Baron D, Robert FX, Leroy JP, Le Goff P. Is collagenous colitis a new etiology of sicca syndrome? Rev Rhum Engl Ed. 1996;63:600–5.

Barco D, Barnadas MA, Roe E, Sancho FJ, Ricart E, Alomar A. Neutrophilic dermatoses in a patient with collagenous colitis. Dermatol Reports. 2010;2:e5. https://doi.org/10.4081/dr.2010.e5 DOI: https://doi.org/10.4081/dr.2010.e5

Choung RS, Talley NJ. Food Allergy and Intolerance in IBS. Gastroenterol Hepatol (N Y). 2006;2:756–60.

Hedstrom A, Kvarnstrom M, Lindberg G, Alsabeah S, Alsabeah H, Ndegwa N, et al. High prevalence of gastrointestinal symptoms in patients with primary Sjogren’s syndrome cannot be attributed to pancreatic exocrine insufficiency. Scand J Gastroenterol. 2022;57:1250–6. https://doi.org/10.1080/00365521.2022.2065888 DOI: https://doi.org/10.1080/00365521.2022.2065888

Katsanos KH, Saougos V, Kosmidou M, Doukas M, Kamina S, Asproudis I, et al. Sjogren’s syndrome in a patient with ulcerative colitis and primary sclerosing cholangitis: case report and review of the literature. J Crohns Colitis. 2009;3:200–3. https://doi.org/10.1016/j.crohns.2009.03.005 DOI: https://doi.org/10.1016/j.crohns.2009.03.005

Palm O, Moum B, Gran JT. Estimation of Sjogren’s syndrome among IBD patients. A six year post-diagnostic prevalence study. Scand J Rheumatol. 2002;31:140–5. https://doi.org/10.1080/rhe.31.3.140.145 DOI: https://doi.org/10.1080/rhe.31.3.140.145

He L, Xie M, Zhang H, Meng L, Zhang X. Autonomic dysfunction in patients with irritable bowel syndrome evidenced by alterations of salivary alpha-amylase secretion. Neuro Endocrinol Lett. 2018;39:125–9.

Gholami N, Hosseini Sabzvari B, Razzaghi A, Salah S. Effect of stress, anxiety and depression on unstimulated salivary flow rate and xerostomia. J Dent Res Dent Clin Dent Prospects. 2017;11:247–52.

Banerjee A, Sarkhel S, Sarkar R, Dhali GK. Anxiety and depression in irritable bowel syndrome. Indian J Psychol Med. 2017;39:741–5. https://doi.org/10.4103/IJPSYM.IJPSYM_46_17 DOI: https://doi.org/10.4103/IJPSYM.IJPSYM_46_17

Kinberg S, Stein M, Zion N, Shaoul R. The gastrointestinal aspects of halitosis. Can J Gastroenterol. 2010;24:552–6. https://doi.org/10.1155/2010/639704 DOI: https://doi.org/10.1155/2010/639704

Yarandi SS, Nasseri-Moghaddam S, Mostajabi P, Malekzadeh R. Overlapping gastroesophageal reflux disease and irritable bowel syndrome: increased dysfunctional symptoms. World J Gastroenterol. 2010;16:1232–8. DOI: https://doi.org/10.3748/wjg.v16.i9.1232

Struch F, Schwahn C, Wallaschofski H, Grabe HJ, Volzke H, Lerch MM, et al. Self-reported halitosis and gastro-esophageal reflux disease in the general population. J Gen Intern Med. 2008;23:260–6. https://doi.org/10.1007/s11606-007-0486-8 DOI: https://doi.org/10.1007/s11606-007-0486-8

Minhas S, Sajjad A, Kashif M, Taj F, Waddani HA, Khurshid Z. Oral ulcers presentation in systemic diseases: an update. Open Access Maced J Med Sci. 2019;7:3341–7. DOI: https://doi.org/10.3889/oamjms.2019.689

Kiliç S, Cevizci S, Sen H, Isik S, Gunes F, Binnetoglu E, et al. Dyspepsia, irritable bowel syndrome, and hematological parameters in recurrent aphthous stomatitis. J Clin Anal Med. 2017;8(1):40–3.

Lindstrom CG. ‘Collagenous colitis’ with watery diarrhoea – a new entity? Pathol Eur. 1976;11:87–9.

Manning AP, Thompson WG, Heaton KW, Morris AF. Towards positive diagnosis of the irritable bowel. Br Med J. 1978;2:653–4. https://doi.org/10.1136/bmj.2.6138.653 DOI: https://doi.org/10.1136/bmj.2.6138.653

Goldinova A, Tan CX, Bouma G, Duijvestein M, Brand HS, de Boer NK. Oral health and salivary function in ulcerative colitis patients. United European Gastroenterol J. 2020;8:1067–75. https://doi.org/10.1177/2050640620957138 DOI: https://doi.org/10.1177/2050640620957138

Katz J, Shenkman A, Stavropoulos F, Melzer E. Oral signs and symptoms in relation to disease activity and site of involvement in patients with inflammatory bowel disease. Oral Dis. 2003;9:34–40. https://doi.org/10.1034/j.1601-0825.2003.00879.x DOI: https://doi.org/10.1034/j.1601-0825.2003.00879.x

Sherman A, 3rd, Zamulko A. Burning tongue as initial presentation of celiac disease in an elderly woman: a case report. S D Med. 2016;69:253–5.

Sun A, Wu KM, Wang YP, Lin HP, Chen HM, Chiang CP. Burning mouth syndrome: a review and update. J Oral Pathol Med. 2013;42:649–55. https://doi.org/10.1111/jop.12101 DOI: https://doi.org/10.1111/jop.12101

Chiang CP, Yu-Fong Chang J, Wang YP, Wu YH, Wu YC, Sun A. Recurrent aphthous stomatitis – etiology, serum autoantibodies, anemia, hematinic deficiencies, and management. J Formos Med Assoc. 2019;118:1279–89. https://doi.org/10.1016/j.jfma.2018.10.023 DOI: https://doi.org/10.1016/j.jfma.2018.10.023

Ozler GS. Zinc deficiency in patients with recurrent aphthous stomatitis: a pilot study. J Laryngol Otol. 2014;128:531–3. https://doi.org/10.1017/S0022215114001078 DOI: https://doi.org/10.1017/S0022215114001078

Palsson OS, Whitehead WE. IBS – beyond the bowel: the meaning of co-existing medical problems. 2017. https://drossmancare.com/download/physician-articles/IBS-Beyond-the-Bowel.pdf

Wildt S, Munck LK, Winther-Jensen M, Jess T, Nyboe Andersen N. Autoimmune diseases in microscopic colitis: a Danish nationwide case-control study. Aliment Pharmacol Ther. 2021;54:1454–62. https://doi.org/10.1111/apt.16614 DOI: https://doi.org/10.1111/apt.16614

Eaton WW, Rose NR, Kalaydjian A, Pedersen MG, Mortensen PB. Epidemiology of autoimmune diseases in Denmark. J Autoimmun. 2007;29:1–9. https://doi.org/10.1016/j.jaut.2007.05.002 DOI: https://doi.org/10.1016/j.jaut.2007.05.002

Balaban DV, Mihai A, Dima A, Popp A, Jinga M, Jurcut C. Celiac disease and Sjogren’s syndrome: a case report and review of literature. World J Clin Cases. 2020;8:4151–61. https://doi.org/10.12998/wjcc.v8.i18.4151 DOI: https://doi.org/10.12998/wjcc.v8.i18.4151

Barlow JT, Leite G, Romano AE, Sedighi R, Chang C, Celly S, et al. Quantitative sequencing clarifies the role of disruptor taxa, oral microbiota, and strict anaerobes in the human small-intestine microbiome. Microbiome. 2021;9:214. https://doi.org/10.1186/s40168-021-01162-2 DOI: https://doi.org/10.1186/s40168-021-01162-2

Fourie NH, Wang D, Abey SK, Sherwin LB, Joseph PV, Rahim-Williams B, et al. The microbiome of the oral mucosa in irritable bowel syndrome. Gut microbes. 2016;7:286–301. https://doi.org/10.1080/19490976.2016.1162363 DOI: https://doi.org/10.1080/19490976.2016.1162363

Yde Aagaard ME, Frahm Kirk K, Linde Nielsen H, Harder Tarpgaard I, Bach Hansen J, Nielsen H. Campylobacter concisus is prevalent in the gastrointestinal tract of patients with microscopic colitis. Scand J Gastroenterol. 2020;55:924–30. https://doi.org/10.1080/00365521.2020.1792976 DOI: https://doi.org/10.1080/00365521.2020.1792976

Lauritano D, Boccalari E, Di Stasio D, Della Vella F, Carinci F, Lucchese A, et al. Prevalence of oral lesions and correlation with intestinal symptoms of inflammatory bowel disease: a systematic review. Diagnostics (Basel). 2019;9. https://doi.org/10.3390/diagnostics9030077 DOI: https://doi.org/10.3390/diagnostics9030077

Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to meta-analysis. Chichester: Wiley; 2009. DOI: https://doi.org/10.1002/9780470743386

Savitz DA, Forastiere F. Do pooled estimates from meta-analyses of observational epidemiology studies contribute to causal inference? Occup Environ Med. 2021;78:621–2. https://doi.org/10.1136/oemed-2021-107702 DOI: https://doi.org/10.1136/oemed-2021-107702

Additional Files

Published

2025-06-11