Life-threatening bite injury of the lower lip after use of metamizole

Introduction

Bite wounds of the oral mucosa heal after eliminating the causative irritant, but there are serious exceptions from the rule. We present the case of a 37-year-old woman with an ulcer of the mucosa of the lower lip, which had been present for 10 days, and leucopenia.

Discussion

Agranulocytosis after the use of metamizole is part from leukaemia and lues, a rare reason for non-healing ulcers of the mucosa of the oral cavity without fulminant signs for inflammation.

Conclusion

As this is a life-threatening disease, medical therapy must begin immediately.     

Identifikation eines rezidivierenden, oralen Plattenepithelkarzinoms mittels Bürstenzytologie

Background

Large oral lesions comprise the risk that an incisional biopsy does not reveal the most aggressive site in spite of carefully selecting the place of biopsy.

Case report

The first incisional biopsy of a large, clinically suspect, oral lesion could not identify the subepidermal spread of a recurrent oral squamous cell carcinoma. Atypical cells obtained by a simultaneous brush biopsy prompted a renewed, incisional biopsy which finally established the diagnosis of a recurrent, oral squamous cell carcinoma.

Conclusions

The presented case emphasizes the value of brush biopsy in the follow-up of oral squamous cell carcinoma, especially in examination of oral lesions covering a large area.     

Postoperative failure of platelet recovery is an independent risk factor for poor survival in patients with oral and oropharyngeal cancer

Objective

The aim of this study was to evaluate the postoperative platelet count changes in patients with oral and oropharyngeal squamous cell carcinoma undergoing preoperative chemoradiotherapy in order to test the hypothesis that the failure of platelets to recover to normal range within 7 days after surgery represents a significant risk factor for poor survival.

Materials and methods

A cohort of 102 patients with primary locally advanced oral and oropharyngeal squamous cell carcinoma undergoing neoadjuvant chemoradiotherapy and surgery was retrospectively analyzed. For each patient, platelet counts were evaluated prior to neoadjuvant treatment, prior to surgery and throughout postoperative days 1 to 7. The Kaplan–Meier method and Cox regression models were used to assess the impact of platelet count changes on survival.

Results

Overall survival rate at 5 years was 28 % for patients whose platelets did not recover by day 7, with 52 % for patients whose platelets remained within a normal level or recovered to this by day 7 (p?=?0.005). In multivariate analysis, failure of platelet recovery by day 7 was independently associated with shorter overall survival (p?=?0.03).

Conclusions

We demonstrated that the failure of platelets to recover to normal range by the seventh postoperative day is an independent adverse prognostic factor in patients with oral and oropharyngeal cancer undergoing neoadjuvant treatment and surgery.

Clinical relevance

Our results indicate that physicians should pay closer attention to monitoring the postoperative platelet count course, as it may predict the clinical outcome of patients with oral and oropharyngeal cancer.     

Imaging of mandible invasion by oral squamous cell carcinoma using computed tomography,cone-beam computed tomography and bone scintigraphy with SPECT

Objectives

The objective of this paper is to evaluate the predictability of preoperative tumour bone invasion of the mandible by squamous cell carcinoma of the oral cavity using CT, cone-beam CT and bone scintigraphy with SPECT.

Material and methods

Eighty-four patients who had received CT, SPECT or cone-beam computed tomography (CBCT), as well as a further 48 patients who undergone all these investigations for preoperative evaluation of bone invasion were included in the study. A case–control analysis and the receiver operating characteristics were performed. Histological results of bone specimens served as the gold standard for assessment of bone invasion.

Results

CBCT and SPECT showed a comparable sensitivity for bone invasion (93 % [CI 0.816–0.972] and 96 % [CI 0.867–0.990], respectively) which was significantly higher than that of CT (63 % [CI 0.488–0.752]). Further, CBCT obtained higher specificity than SPECT (62 % [CI 0.478–0.743] and 48 % [CI 0.342–0.614], respectively), whereas CT showed the best specificity among the investigation methods (81 % [CI 0.677–0.896]).

Conclusions

CT scan provides by its high specificity and positive predictive value a precise imaging technique for clinical routine. However, CBCT shows a much higher sensitivity for cortical bone invasion and a better negative predictive value. With a significantly lower exposure dose it can rule out this invasion effectively and prevent overtreatment.

Clinical relevance

Considering the high-resolution images delivered by CBCT along with minimized artefacts in the mandible it provides an alternative imaging technique, which could be combined and accomplished with another soft-tissue imaging modality like MRI to obtain optimal hard and soft-tissue visualisation in patients with squamous cell carcinoma of the oral cavity.     

The role of human papillomavirus in oral squamous cell carcinoma: myth and reality

Introduction

As the traditional risk factors for oral squamous cell carcinoma, especially tobacco, decline, new potential causative agents become the focus of research. Since the discovery of human papillomavirus (HPV) and its importance in carcinogenesis in cervical cancer, a lot of research has been undertaken to define its role in different types of cancer. In the present study, we evaluate the role of high-risk HPV types in initiation and progression of oral squamous cell carcinoma (OSCC) using a systematic review of the current literature.

Material and methods

A literature research with the search term “HPV oral squamous cell carcinoma” was performed via PubMed. Results were screened systematically for relevance and classified into the following categories: molecular biology, genetics, clinical aspects, and prevalence. Articles were then further analyzed to assess quality.

Results

The literature research led to 527 results, with an overall HPV prevalence of 30.1 % in OSCCs. The most frequently identified subtypes were HPV-16 and HPV-18 (25.4 and 18.1 %, respectively). Prognostic relevance of HPV was discussed controversially. HPV detection via polymerase chain reaction is the most established method today. Molecular changes according to carcinogenic pathways described for cervix carcinoma were not routinely found in OSCC. In general, no definite role of high-risk HPV is currently deducible from the literature.

Conclusions

High-risk subtypes 16 and 18 are present in the genome in approximately one third of OSCC. Its role as a causative agent is less clear than the role in oropharyngeal tumors. The infection might not be the cause of carcinogenesis in a significant number of patients but may become proportionally more important with the decrease of the classical risk factors of tobacco and alcohol.     

Endosonographische Darstellung der Tumordicke von oralen Plattenepithelkarzinomen und deren Einfluss auf die Inzidenz von Lymphknotenmetastasen

Background

The correlation between increasing tumor thickness and lymph node metastases as well as reduced survival in oral cancer has been proven by several studies. In most investigations the tumor thickness was assessed in histological sections. The aim of our prospective study was to assess tumor thickness in oral squamous cell carcinoma (OSCC) by intraoral ultrasonography and to evaluate the predictive value of tumor thickness for incidence of cervical lymph node involvement and survival.

Patients and methods

A total of 64 patients with primary carcinomas of the oral cavity (stage I–IV) were included. Endosonographic assessment of patients was carried out using a 7.5-mHz probe (Hitachi EUP F334). The primary tumor could be visualized in all cases as a hypoechoic, sometimes irregular mass.

Results

The average tumor thickness in all tumors was 14±7 mm. The N+ patients showed a greater tumor thickness (15±7 mm) than N0 OSCCs with 12±6 mm (p =0.032, t -test). Less advanced T1/T2 carcinomas revealed a tumor thickness of 10±5 mm in contrast to T3/T4 carcinomas with 16±7 mm (p <0.001, t-test). The overall survival was reduced in patients with tumors thicker than 14 mm (48.9 versus 28.3 months, p =0,0102 log rank test).

Conclusion

Although this technique facilitates the accurate assessment of tumor thickness in OSCC, only in less advanced tumors could endosonography provide additional information, since these tumors were not visible on CT or MRT scans. Nonetheless endosonography is a fast, cost-effective, and reliable technique for assessment of tumor extent in oral cancer.     

CCND1 amplification and cyclin D1 immunohistochemical expression in head and neck squamous cell carcinomas

Objectives

Gene products, which show a significant association to cell proliferation and cell cycle control, are of high scientific interest, because genes as well as gene products could be possible targets for a specific therapeutic approach and eventually be prognostic markers.

Materials and methods

Cyclin D1 expression and amplification as well as the Ki-67 expression status were examined in a two tissue microarray analysis for head and neck squamous cell carcinoma (HNSCC) including 546 patients. A tumour site-specific analysis and a survival analysis of 222 oral squamous cell carcinoma (OSCC) patients were performed. Cyclin D1 amplification status was examined with fluorescence in situ hybridisation analysis, while cyclin D1 expression and Ki-67 expression status were examined with IHC.

Results

Amplification of the CCND1 gene and immunohistochemical expression of cyclin D1 and Ki-67 were examined in 546 tumours of the head and neck region in two tissue microarrays. CCND1 amplification was significantly more frequent in pharyngeal carcinomas (63 %) than in laryngeal (37 %) and oral (25 %) carcinomas. Among the 222 cases of OSCCs, both CCND1 amplification and cyclin D1 expression were significantly associated with overall survival of the patients (p?=?0.0127 and p?=?0.0004, respectively). Ki-67 expression was significantly associated with cyclin D1 expression and with amplification of the CCND1 gene (p?=?0.0002 and p?=?0.0015, respectively) but not with patient overall survival.

Conclusion

Our results suggest the prognostic value of CCND1 amplification and cyclin D1 expression for patients with OSCC and highlight the genetic differences in HNSCC of different subanatomic localisation.

Clinical relevance

Cyclin D1 expression and CCND1 amplification seem to have a prognostic value for OSCC. Further studies of HNSCC should always consider subanatomic genetic differences.     

P53 immunohistochemical expression does not correlate with clinical features in 207 carcinomas of the oral cavity and in the head and neck region

Objectives

The present study aims to investigate the relevance of immunohistochemical p53 expression in carcinomas of the oral cavity and of the head and neck region. Long-term clinical and histopathological follow-up findings as well as HPV status are correlated with the results of this examination.

Materials and methods

Sections made from two tissue arrays composed of 222 oral squamous cell carcinomas and 427 squamous cell carcinomas of the head and neck region, respectively, were examined for p53 expression and Ki-67 index by means of immunohistochemistry. Correlation of long-term clinical findings of the patients and pathological features of tumours with laboratory results were examined statistically.

Results

No significant correlation was found between the p53 immunohistochemical expression in the 207 oral carcinomas and features of the tumours and patient outcomes. There was no significant association between the Ki-67 labelling index and the p53 expression.

Discussion

Our failure in detecting any association of the p53 immunohistochemical expression regardless of HPV status with clinical features of these tumours suggests it lacks a prognostic value for squamous cell carcinomas of the oral cavity.

Clinical relevance

The prognostic value of p53 immunostaining in oral squamous carcinoma is not clarified yet. In the present study, there is no impact on any prognostical item nor even a correlation with cell proliferation (Ki-67) regardless of HPV status.     

Verrucous carcinoma of the oral cavity: a clinico-pathologic appraisal of 133 cases in Indians

Introduction

Verrucous carcinoma (VC), a rare variant of squamous cell carcinoma is an established entity with distinctive morphology and specific clinical behavior. To date, only a small series of head and neck verrucous carcinomas have been reported in the literature.

Materials and methods

The present study evaluated 133 cases of verrucous carcinoma for the age, sex, site of involvement, duration of disease at the time of diagnosis, associated habits and common presenting symptoms, presence of other mucosal lesions, recurrence, and the histopathology.

Results and discussion

Verrucous carcinoma accounted for 16.08% among oral squamous cell carcinoma compared to 2–12% reported in the literature. VC was more common in males with greater predilection to buccal mucosa due to widespread use of tobacco chewing in Indian scenario. Age distribution was lower as compared to other studies with prominence in the fifth decade. Mandibular involvement was more frequent as compared to those in literature.

Conclusion

Development of recurrence following radiotherapy in few cases supports anaplastic changes by radiotherapy.     

Herpes simplex virus reactivation and dental procedures

Objectives

Dental extraction is reported to trigger recurrent herpes labialis (RHL).

Aim

This aims to prospectively study the clinical occurrence of RHL and the oral herpes simplex virus type 1 (HSV-1) viral shedding before and 3 days after different dental procedures.

Materials and methods

Oral HSV-1 DNA was measured by real-time PCR before and 3 days after dental procedures of the inferior dentition in 57 immunocompetent patients (mean age 32.4 years) who were selected and divided into four distinct subgroups (dental inspection without anesthesia, n?=?19; dental filling under local anesthesia, n?=?14; molar extraction under local anesthesia, n?=?15; and molar extraction under general anesthesia, n?=?9) and compared to 32 healthy controls (mean age 33 years).

Results

None of the patients suffered from RHL at day 3. Oral HSV-1 DNA was detected before and after procedure in 1.7 % (1/57) and 5.3 % (3/57), respectively [dental inspection without anesthesia, 5.3 % (1/19); molar extraction under local anesthesia, 6.7 % (1/15); and molar extraction under general anesthesia, 11 % (1/9)]. None of the controls presented RHL or detectable oral HSV-1 DNA. There was no statistically significant difference between the study groups and controls.

Conclusion

Molar extraction increases the risk of oral HSV-1 shedding but not of RHL. Procedure-related nerve damage probably accounts for HSV reactivation.

Clinical relevance

Antiviral prophylaxis for RHL is not routinely recommended for dental procedures, regardless of a prior history of RHL.     

Diffusion-weighted magnetic resonance imaging in oral and maxillofacial lesions: preliminary study on diagnostic ability of apparent diffusion coefficient maps

Objectives

The aim of this study was to investigate the usefulness of diffusion-weighted magnetic resonance imaging (DWI) in oral and maxillofacial lesions, especially the utility of apparent diffusion coefficient (ADC) maps for differential diagnosis of these lesions.

Methods

Fifty-seven patients who underwent magnetic resonance imaging for diagnosis of oral and maxillofacial lesions were included in this prospective study. DWI was performed on a 1.5 T unit with b-factors of 0 and 800 s/mm², and ADC maps were generated. ADC values were measured for all 57 oral and maxillofacial lesions (19 squamous cell carcinoma, 10 medication-related osteonecrosis of the jaw, 6 odontogenic abscess, 4 ranula, 4 osteoradionecrosis, 4 hemangioma, 3 pleomorphic adenoma, 3 odontogenic keratocyst, 2 nasopalatine duct cyst, 1 malignant melanoma, and 1 basal cell carcinoma).

Results

The mean ADC values for ranula (2.69 ± 0.59 × 10^?3 mm²/s) and nasopalatine duct cyst (2.34 ± 0.12 × 10^?3 mm²/s) were significantly higher than those for the other oral and maxillofacial lesions (p = 0.000). In contrast, the mean ADC value for odontogenic abscess (0.67 ± 0.36 × 10^?3 mm²/s) was significantly lower than those for the other oral and maxillofacial lesions (p = 0.000).

Conclusions

The present study suggests the usefulness of DWI in oral and maxillofacial lesions, especially the utility of ADC maps for differential diagnosis of these lesions.

     

Demographic Study of Prevalence of Systemic Diseases in Oral Maxillofacial Surgery Patients of Central India

Summary

An evaluation and consideration of health status of patient prior to any surgical treatment forms an essential part of comprehensive health care. Apparently well but in fact medically compromised patients usually present with unacceptable possibility of complications; whereas adequate pretreatment utilization of many techniques available to diagnose and treat underlying systemic disease significantly decreases morbidity and mortality associated with it.

Aims and Objectives

Purpose of this study was to evaluate, prospectively, prevalence of various systemic diseases in oral surgery patients.

Materials and Methods

For analyzing prevalence of systemic diseases in oral surgery patients, the patients reporting to oral surgery department for various treatments were prospectively evaluated for a period of 6 months and were grouped according to a system involved and findings analyzed to get prevalence in central India.

Result

Of the 12,487 patients who reported to the department 506 (4.055 %) were medically compromised with a highest prevalence of cardiovascular diseases (35.57 %), and least prevalence of infectious diseases (3.55 %). These results are statistically significant (by Chi-square test) at p < 0.01 (χ² = 342.752).

Conclusion

The aim of study was to evaluate prevalence of systemic disease in oral surgery patients of central India which is 4.055 % with highest population showing involvement of cardiovascular disease and minimum population undergoing oral surgical procedures are compromised by various infectious diseases.     

Concentrations of amoxicillin and clindamycin in teeth following a single dose of oral medication

Objectives

The main purpose of this study is the detection of amoxicillin and clindamycin concentrations in teeth.

Materials and methods

Eleven patients received 2 g of amoxicillin, and 11 patients received 600 mg of clindamycin in a single dose of oral medication at least 60 min prior to tooth extraction due to systemic diseases. The concentrations were determined in crowns and roots separately using liquid chromatography–tandem mass spectrometry (LC-MS-MS).

Results

Amoxicillin (13 samples) and clindamycin (12 samples) were detected in the samples of the root and crown preparations of the extracted teeth. The mean concentration of amoxicillin was 0.502 μg/g in the roots and 0.171 μg/g in the crowns. The mean concentration of clindamycin was 0.270 μg/g in the roots and 0.064 μg/g in the crowns.

Conclusions

A single dose of oral amoxicillin and clindamycin leads to concentrations of both antibiotics in teeth which exceed the minimal inhibition concentration of some oral bacteria.

Clinical relevance

The proof of antibacterial activity in dental hard tissue after oral single-dose application is new. The antimicrobial effect of amoxicillin and clindamycin concentrations in roots of teeth may be of clinical relevance to bacterial reinfection from dentinal tubules.     

Platysma Flap: An Alternative to Free Flaps

Objective

The objective of this paper is to show that platysma flaps have good results and should be an alternative in reconstructive surgery for oral tumors when microsurgery is not possible. It is a versatile, portable, and thin flap, is easy to perform, and can be obtained during neck dissection, with a primary closure of the donor site.

Methods

Five cases are presented, three men and two women, 51 and 71 years old, with medium size (2–4 cm) defects of oral cavity after the excision of squamous cell carcinomas. All of them were reconstructed with a platysma flap after neck dissection. This reconstruction technique was chosen because of the poor conditions of these patients to allow a microsurgical reconstruction.

Results

Non-local complications occurred with this technique. Overall aesthetic results were acceptable in all the patients. There were no cases of total necrosis flap, dehiscence, fistula or fibrosis. Only one case of partial necrosis occurred in one end of the flap, which was resolved with excision of necrotic tissue and closure by secondary intention.

Conclusion

The platysma flap is a good method to reconstruct small and medium sized defects of oral cavity, especially in patients where a microsurgery reconstruction is not possible.     

Phase III,randomized, double-blind,placebo-controlled trial of topical 2 % lidocaine for the prevention and treatment of oral mucosal pain in children

Objectives

The aim of this study was to assess the efficacy in pain reduction of topical 2 % lidocaine compared to a placebo cream in children with oral mucosal lesions due to trauma or aphthous ulcers or in the prevention of clamp placement pain.

Materials and methods

The design was a double-blind, randomized, placebo-controlled, four-center trial on 64 patients. Pain intensity and relief were measured using a 100-mm visual analog scale (VAS). One-tailed Student’s t test and ANOVA were used for statistical analyses.

Results

Independent of the pain origin, application of 2 % lidocaine cream led to a mean reduction in VAS pain intensity of 19.7 mm?±?18.3, which was significantly greater than that obtained with the placebo cream (p?=?.025). Analyses showed a statistically significant efficacy of the 2 % lidocaine cream (p?<?.0001). Its efficacy was not associated to any local or systemic adverse drug reaction, as reported by the patients. As the most important population represented in our patients was children whom a rubber dam clamp was placed, we also specifically analysed this population, and we were able to demonstrate a significantly greater efficacy of the 2 % lidocaine cream on the pain caused by the rubber dam clamp placement in comparison to the placebo cream (p?<?.005).

Conclusions

A significant reduction in pain intensity occurred after application of 2 % lidocaine cream, and the effect was significantly greater than that obtained with the placebo cream. Considering the study’s limitations, this product appears safe for use in children.

Clinical relevance

For painful benign lesions of the oral mucosa (trauma or aphthous ulcers) or for preventing painful iatrogenic procedures such as rubber dam clamp placement, it is essential to treat or prevent pain onset, especially in the pediatric population for whom a painful experience could end in refusal of dental care. Application of a topical anesthetic in this specific situation is of particular interest, as is defining its efficacy and safety.     

Bacterial colonization of microbial biofilms in oral squamous cell carcinoma

Objectives

The purpose of this prospective clinical study was to identify the bacterial spectra on the surface of oral squamous cell carcinomas (OSCC) in comparison to oral mucosa of patients with a higher risk to emerge an OSCC and a control group to determine their susceptibility to various common antibiotics.

Material and methods

Swabs from 90 patients, 30 patients of each group, were cultured on media for aerobes and anaerobes and tested with agar diffusion and Etest.

Results

The predominant pathogens of the normal healthy oral mucosa were aerobes. The ratio between aerobes and anaerobes was 2:1, balanced in risk patients and inverted in the OSCC group. Altogether, 1,006 isolates were cultured. The most frequent strains were 47 viridans streptococci, 30 Staphylococcus species, 14 Enterococcus faecalis, 36 Neisseria species, 14 Escherichia coli, and 23 other aerobes, 66 Peptostreptococcus species, 39 Fusobacterium species, and 34 Prevotella species. The resistance rates in the OSCC group were penicillin 40 %, ampicillin 57 %, doxycycline 23 %, clindamycin 47 %, and amoxicillin/clavulanic acid 20 %, but up to 100 % of pathogens were susceptible to azithromycin, telithromycin, levofloxacin, and moxifloxacin.

Conclusion

Gram-negative anaerobes play a decisive role in the development of postoperative infections in patients with OSCC. This tumor special type of colonization does not agree with the normal flora of the oral cavity. Clinical relevance: Biofilms on OSCC surfaces provide an important reservoir for anaerobic bacteria. As a consequence, a proposal for an antibiotic prophylactic regime should be given.     

Increased frequency of CD4+ CD25+ FOXP3+ cells correlates with the progression of 4-nitroquinoline1-oxide-induced rat tongue carcinogenesis

Objectives

CD4+ CD25+ FoxP3+ T cells (Tregs) play an essential role in sustaining self-tolerance by negatively regulating immune responses. Increased frequencies of Tregs have been reported in a variety of human cancers. The aim of this study was to evaluate the prevalence of Tregs infiltration in the peripheral blood and regional lymph nodes during rat tongue carcinogenesis induced by 4-nitroquinoline-1-oxide (4NQO).

Materials and methods

Forty-eight Sprague–Dawley rats were divided into the control (n?=?16) and experimental groups (n?=?32) to which 4NQO in drinking water was administered. Flow cytometry was used to analyze the prevalence of Tregs in lymphocytes of peripheral blood and regional lymph nodes during 4NQO-induced rat tongue carcinogenesis. CD4+ CD25+ FoxP3+ cells were expressed as a percentage of the total CD4+ cells.

Results

The frequency of Tregs in peripheral blood from squamous cell carcinoma rats was significantly higher than controls (3.82?±?0.62 versus 1.40?±?0.31 %, P?P?Conclusion and clinical relevance Tregs in peripheral blood and lymph nodes were associated with disease progression during 4NQO-induced rat tongue carcinogenesis. This study indicated that the upregulation of Tregs might play important role during oral mucosa malignant transformation.     

Carcinoma ex pleomorphic adenoma in a minor salivary gland: report of a case

Background

Carcinoma ex pleomorphic adenoma is exceedingly rare in minor salivary glands of the oral cavity. We present a case of carcinoma ex pleomorphic adenoma (CEPA) of the buccal mucosa in a 47-year-old Turkish patient. The buccal mass was of a size of 1.5 cm located in the left cheek. Pleomorphic adenoma was the tentative diagnosis.

Methods

The tumor was removed under local anesthesia. Histopathologic evaluation revealed a preexisting pleomorphic adenoma associated with adenoid tumor component with tubulo-cystic and papillary or pseudopapillary structures; CEPA was diagnosed. Capsular integrity was incomplete with infiltration by islands of metaplastic/dysplastic epithelium.

Results

Secondary surgery of the site was performed. No tumor tissue could be detected in the resection specimen. The patient is free of recurrence since 9 months.     

Effectiveness of supervised implementation of an oral health care guideline in care homes; a single-blinded cluster randomized controlled trial

Objectives

The objective of this study was to assess the effectiveness of a supervised implementation of the “Oral health care Guideline for Older people in Long-term care Institutions” (OGOLI) in The Netherlands.

Materials and methods

A sample of 12 care homes in the Netherlands was allocated randomly to an intervention or control group. While the residents in the control group received oral health care as before, the intervention consisted of a supervised implementation of the OGOLI.

Results

At baseline, the overall random sample comprised 342 residents, 52 % in the intervention group and 48 % in the control group. At 6 months, significant differences were observed between the intervention and the control group for mean dental as well as denture plaque, with a beneficial effect for the intervention group. The multilevel mixed-model analyses conducted with the plaque scores at 6 months as outcome variables showed that the reduction by the intervention was only significant for denture plaque.

Conclusions

Supervised implementation of the OGOLI was more effective than non-supervised implementation in terms of reducing mean plaque scores at 6 months. However, the multilevel mixed-model analysis could not exclusively explain the reduction of mean dental plaque scores by the intervention.

Clinical relevance

A supervised implementation of an oral health care guideline improves oral health of care home residents.