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Stenberg, E., Milosavljevic, A., Götrick, B. & Lundegren, N. (2024). Continuing professional development in general dentistry-experiences of an online flipped classroom. European journal of dental education
Open this publication in new window or tab >>Continuing professional development in general dentistry-experiences of an online flipped classroom
2024 (English)In: European journal of dental education, ISSN 1396-5883, E-ISSN 1600-0579Article in journal (Refereed) Epub ahead of print
Abstract [en]

Introduction: Continuing professional development is a lifelong learning process. One pedagogical approach that can be used is active learning. Flipped classroom is a method that has been shown to improve deeper conceptual understanding. In an online setting, the method saves travel, time, and costs. To our knowledge, flipped classroom is rarely used in continuing professional education. This study in general dentistry explored experiences of an online flipped classroom course in continuing professional development.

Materials and Methods: Fifteen dental hygienists, clinically active in general dental care, were interviewed. They were recruited from an online course on the latest classification system for periodontal diseases. The course had been conducted using an active learning and flipped classroom model. The interviews were semi-structured. Data were extracted using qualitative content analysis.

Results: The experiences of the dental hygienists could be summarized in three themes: Stimulation of knowledge gain through self-paced studies, The ease of virtual networking among colleagues, and Fostering of direct practical application through collaboration.

Conclusion: New and emerging communication technology seems to open new possibilities for continuing professional development in general dentistry. Study participants felt that, in an online environment, mixing asynchronous and synchronous communication in a flipped classroom model facilitated learning in continuing professional development. Online active learning seems to work well in continuous professional development in general dentistry. After the course, the participating dental hygienists stated that they were able to use their new knowledge clinically and felt confident doing so.

Place, publisher, year, edition, pages
John Wiley & Sons, 2024
Keywords
active learning, continuing education, flipped classroom, general dentistry, online, qualitative content analysis
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-67306 (URN)10.1111/eje.13013 (DOI)001206884300001 ()38654701 (PubMedID)2-s2.0-85191199491 (Scopus ID)
Available from: 2024-05-21 Created: 2024-05-21 Last updated: 2024-05-21Bibliographically approved
Shmarina, E., Ericson, D., Götrick, B. & Franzén, C. (2023). Dental professionals' perception of their role in the practice of oral health promotion: a qualitative interview study. BMC Oral Health, 23(1), Article ID 43.
Open this publication in new window or tab >>Dental professionals' perception of their role in the practice of oral health promotion: a qualitative interview study
2023 (English)In: BMC Oral Health, E-ISSN 1472-6831, Vol. 23, no 1, article id 43Article in journal (Refereed) Published
Abstract [en]

Objective

To explore dental professionals’ perceptions of their role in the practice of oral health promotion.

Material and method

In-depth interviews were conducted with three dentists, one specialist dentist and seven dental hygienists. All were employed in the public dental service in Kalmar County, Sweden and had at least two years’ work experience. The interview questions addressed the experience and views of dental professionals with reference to their role in the practice of health promotion. The interview data were subjected to qualitative content analysis.

Results

Analysis revealed two themes which capture the essence of the dental professionals’ perception of their role in the practice of oral health promotion. One theme, having person-focused approach, comprised four categories: ‘considering the patient’s life situation’, ‘establishing a trusting relationship with patients’, ’strengthening patients’ commitment to oral health’ and ‘health education’. The other theme, perceiving social responsibility for oral health, comprised three categories: ‘dissemination of oral health knowledge’, ‘interprofessional collaboration’ and ‘equality in oral health care’.

Conclusion

Dental professionals perceived promotion of oral health to be an important aspect of their professional role. They aspired to patient participation in the decisionmaking process and educational activities, as well as practising and evaluating skills development. Although the dental professionals perceived that they undertook health promotion activities, they did not clearly distinguish between oral health promotion and disease prevention. There was intra- and interprofessional agreement among the dentists and dental hygienists with respect to expected outcomes for health promotion activities.

Place, publisher, year, edition, pages
BioMed Central (BMC), 2023
Keywords
salutogenesis, Ottawa Charter, helath promotion
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-58093 (URN)10.1186/s12903-023-02756-y (DOI)000918442200004 ()36698102 (PubMedID)2-s2.0-85146747153 (Scopus ID)
Available from: 2023-02-07 Created: 2023-02-07 Last updated: 2024-07-04Bibliographically approved
Johansson, K., Götrick, B., Holst, J., Tranæus, S. & Naimi-Akbar, A. (2023). Impact of direct oral anticoagulants on bleeding tendency and postoperative complications in oral surgery: a systematic review of controlled studies. Oral surgery, oral medicine, oral pathology and oral radiology, 135(3), 333-346, Article ID S2212-4403(22)01047-1.
Open this publication in new window or tab >>Impact of direct oral anticoagulants on bleeding tendency and postoperative complications in oral surgery: a systematic review of controlled studies
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2023 (English)In: Oral surgery, oral medicine, oral pathology and oral radiology, ISSN 2212-4403, E-ISSN 2212-4411, Vol. 135, no 3, p. 333-346, article id S2212-4403(22)01047-1Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: The recommendations for the management of direct oral anticoagulants (DOACs) in oral surgery are inconsistent. The present review evaluated whether DOACs increase the risk of bleeding during oral surgery and postoperative complications.

STUDY DESIGN: The patients undergoing oral surgery and receiving a DOAC were compared with the patients receiving a DOAC different from the exposure, a vitamin K antagonist (VKA), or no anticoagulant. Three electronic databases were searched for eligible clinical trials and systematic reviews. The risk of bias was assessed, data were extracted, a meta-analysis was done, and the Grading of Recommendations, Assessment, Development and Evaluations certainty-of-evidence ratings were determined.

RESULTS: Three clinical trials comparing patients receiving DOAC medication with patients on a VKA were eligible. A meta-analysis of bleeding 7 days postoperatively detected no significant differences between patients continuing DOAC or VKA medication during and after surgery. All of the point estimates favored uninterrupted DOAC over VKA therapy. Tranexamic acid was topically administered to some patients.

CONCLUSIONS: Based on an interpreted trend among 3 studies with mixed patient populations, the risk of bleeding during the first 7 postoperative days may be lower for patients on uninterrupted DOAC than VKA therapy (⨁⨁⭘⭘), but the effect size of the risk is unclear. 80 of 274 included patients experienced postoperative bleeding.

Place, publisher, year, edition, pages
Elsevier, 2023
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-56338 (URN)10.1016/j.oooo.2022.07.003 (DOI)000990228100001 ()36100547 (PubMedID)2-s2.0-85137711821 (Scopus ID)
Available from: 2022-12-01 Created: 2022-12-01 Last updated: 2024-05-21Bibliographically approved
Vähäsarja, N., Lund, B., Ternhag, A., Götrick, B., Olaison, L., Hultin, M., . . . Naimi-Akbar, A. (2023). Oral streptococcal infective endocarditis among individuals at high risk following dental treatment: a nested case-crossover and case-control study. eClinicalMedicine, 63, Article ID 102184.
Open this publication in new window or tab >>Oral streptococcal infective endocarditis among individuals at high risk following dental treatment: a nested case-crossover and case-control study
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2023 (English)In: eClinicalMedicine, E-ISSN 2589-5370, Vol. 63, article id 102184Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: It is not clear whether Viridans Group Streptococcal Infective Endocarditis (VGS-IE) among individuals at high risk is more frequent following bacteraemia caused by invasive dental procedures (IDPs) than after daily bacteraemia caused by chewing and tooth brushing. The aim of this nested study was to assess if VGS-IE was temporally associated with IDPs in a national cohort of individuals at high risk.

METHODS: This nested case-control and case-crossover study was based on a Swedish national cohort study of 76,762 individuals at high risk of IE due to complex congenital heart disease, prosthetic heart valve or previous IE. Participants were living in Sweden between July 1st, 2008 and January 1st, 2018. The frequency of IDPs during the 3 months before VGS-IE was calculated and compared to controls (sampled 1:10). A case-crossover study was conducted to account for residual confounders. Participants were identified using the national patient register, and IDPs were identified using the national dental health register.

FINDINGS: 98,247 IDPs were carried out in the cohort during the study period: 624 occasions of oral surgery, 44,190 extractions and 53,433 sessions of subgingival scaling. The study could not confirm that IDPs were more common among cases (4.6%) than controls (4.1%), OR = 1.22 [95% Confidence Interval (CI) 0.64-2.3], or during case- (3.3%) than reference periods (3.8%), OR = 0.89 [95% CI: 0.68-1.17]. Restricting the analysis to the period when cessation of antibiotic prophylaxis for the prevention of IE in Swedish dentistry was recommended, from the 1st of October 2012 to the 1st of January 2018, did not alter the results of the case-control study: OR 0.64, 95% CI: 0.20-2.09, or the case-crossover study: OR 0.58, 95% CI: 0.15-2.19.

INTERPRETATION: The study could not confirm that VGS-IE is associated with IDPs among individuals at high risk. A study with larger sample size could clarify whether there is a lack of association. The finding of a small (<5%) proportion of cases temporally associated with IDPs is similar to that of the previous large-scale study on IDPs and VGS-IE.

FUNDING: Funding was provided by the Board of doctoral education at Karolinska Institutet, the Public Health Agency of Sweden, Folktandvården Stockholm AB, Steering Group for Collaborative Odontological Research at Karolinska Institutet and Stockholm City County, and the Swedish Dental Association.

Place, publisher, year, edition, pages
Elsevier, 2023
Keywords
Dentistry, Infective endocarditis, Prophylactic antibiotics, Viridans group streptococci
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-62704 (URN)10.1016/j.eclinm.2023.102184 (DOI)001072163000001 ()37680946 (PubMedID)2-s2.0-85169046598 (Scopus ID)
Available from: 2023-09-20 Created: 2023-09-20 Last updated: 2024-05-21Bibliographically approved
Momand, P., Becktor, J. P., Naimi-Akbar, A., Tobin, G. & Götrick, B. (2022). Effect of antibiotic prophylaxis in dental implant surgery: A multicenter placebo-controlled double-blinded randomized clinical trial. Clinical Implant Dentistry and Related Research (1), 116-124
Open this publication in new window or tab >>Effect of antibiotic prophylaxis in dental implant surgery: A multicenter placebo-controlled double-blinded randomized clinical trial
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2022 (English)In: Clinical Implant Dentistry and Related Research, ISSN 1523-0899, E-ISSN 1708-8208, no 1, p. 116-124Article in journal (Refereed) Published
Abstract [en]

Background The growing resistance of bacteria to antimicrobial medicines is a global issue and a direct threat to human health. Despite this, antibiotic prophylaxis is often still routinely used in dental implant surgery to prevent bacterial infection and early implant failure, despite unclear benefits. There is a lack of sufficient evidence to formulate clear clinical guidelines and therefore there is a need for well-designed, large-scale randomized controlled trials to determine the effect of antibiotic prophylaxis. Purpose To compare the effect of a presurgical antibiotic regimen with an identical placebo regimen in healthy or relatively healthy patients receiving dental implants. Materials and Methods The 474 patients participating in the study were recruited from seven clinics in southern Sweden. We randomized the patients into a test and a placebo group; the study was conducted double-blinded. Preoperatively, the test group received 2 g of amoxicillin and the control group, identical placebo tablets. The primary outcome was implant failure; secondary outcomes were postoperative infections and adverse events. Patients were evaluated at two follow-ups: at 7-14 days and at 3-6 months. Results Postoperative evaluations of the antibiotic (n = 238) and the placebo (n = 235) groups noted implant failures (antibiotic group: six patients, 2.5% and placebo group: seven patients, 3.0%) and postoperative infections (antibiotic group: two patients, 0.8% and placebo group: five patients, 2.1%). No patient reported any adverse events. Between-group differences in implant failures and postoperative infections were nonsignificant. Conclusion Antibiotic prophylaxis in conjunction with implant placement is likely of small benefit and should thus be avoided in most cases, especially given the unabated growth in antibiotic-resistant bacteria. Clinical trial registration number: NCT03412305.

Place, publisher, year, edition, pages
John Wiley & Sons, 2022
Keywords
antibiotic prophylaxis, dental implants, multicenter placebo-controlled randomized clinical trial
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-49963 (URN)10.1111/cid.13068 (DOI)000746204100001 ()35075765 (PubMedID)2-s2.0-85123502475 (Scopus ID)
Available from: 2022-02-07 Created: 2022-02-07 Last updated: 2024-05-21Bibliographically approved
Vähäsarja, N., Lund, B., Ternhag, A., Götrick, B., Olaison, L., Hultin, M., . . . Naimi-Akbar, A. (2022). Infective Endocarditis Among High-risk Individuals Before and After the Cessation of Antibiotic Prophylaxis in Dentistry: A National Cohort Study. Clinical Infectious Diseases, 75(7), 1171-1178
Open this publication in new window or tab >>Infective Endocarditis Among High-risk Individuals Before and After the Cessation of Antibiotic Prophylaxis in Dentistry: A National Cohort Study
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2022 (English)In: Clinical Infectious Diseases, ISSN 1058-4838, E-ISSN 1537-6591, Vol. 75, no 7, p. 1171-1178Article in journal (Refereed) Published
Abstract [en]

The findings of this cohort study suggest no increased incidence of oral streptococcal infective endocarditis among high-risk individuals in Sweden since the recommended cessation of antibiotic prophylaxis in dentistry for the prevention of endocarditis in October 2012. Background A few years after the publication of the British guidelines, national recommendations were published by the Swedish Medical Products Agency in October 2012, promoting the cessation of antibiotic prophylaxis in dentistry for the prevention of infective endocarditis (IE). The aim of this study was to evaluate whether the incidence of oral streptococcal IE increased among high-risk individuals after October 2012. Methods This nationwide cohort study included all adult individuals (>17 years) living in Sweden from January 2008 to January 2018, with a diagnose code or surgical procedure code indicating high risk of IE. Cox proportional hazard models were performed to calculate adjusted ratios of oral streptococcal IE before and after October 2012 between high-risk individuals and references. Results This study found no increased incidence of oral streptococcal IE among high-risk individuals during the 5 years after the cessation, compared with before. Hazard rate ratios were 15.4 (95% confidence interval [CI]: 8.3-28.5) before and 20.7 (95% CI: 10.0-42.7) after October 2012 for prevalent high-risk individuals. Corresponding ratios for incident high-risk individuals were 66.8 (95% CI: 28.7-155.6) and 44.6 (95% CI: 22.9-86.9). Point estimates for interaction with time period were 1.4 (95% CI: .6-3.5) and 0.8 (95% CI: .5-1.3) for prevalent and incident high-risk individuals, respectively. Conclusion The results suggest that the current Swedish recommendation not to administer antibiotic prophylaxis for the prevention of IE in dentistry has not led to an increased incidence of oral streptococcal IE among high-risk individuals.

Place, publisher, year, edition, pages
Oxford University Press, 2022
Keywords
prophylactic antibiotics, dentistry, infective endocarditis, viridans group streptococci
National Category
Infectious Medicine
Identifiers
urn:nbn:se:mau:diva-51263 (URN)10.1093/cid/ciac095 (DOI)000772984400001 ()35134867 (PubMedID)2-s2.0-85136233086 (Scopus ID)
Available from: 2022-05-03 Created: 2022-05-03 Last updated: 2024-06-18Bibliographically approved
Critén, S., Andersson, P., Renvert, S., Götrick, B., Berglund, J. S. & Bengtsson, V. W. (2022). Oral health status among 60-year-old individuals born in 1941-1943 and 1954-1955 and 81-year-old individuals born in 1922-1924 and 1933-1934, respectively: a cross-sectional study. Clinical Oral Investigations, 26, 6733-6742
Open this publication in new window or tab >>Oral health status among 60-year-old individuals born in 1941-1943 and 1954-1955 and 81-year-old individuals born in 1922-1924 and 1933-1934, respectively: a cross-sectional study
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2022 (English)In: Clinical Oral Investigations, ISSN 1432-6981, E-ISSN 1436-3771, Vol. 26, p. 6733-6742Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: This study aimed to analyze the oral health status of four different birth cohorts: two cohorts of 60-year-olds born in 1941-1943 and 1954-1955 and 2 cohorts of 81-year-olds born in 1920-1922 and 1933-1934.

MATERIAL AND METHODS: test.

RESULTS: More individuals were dentate in 2014-2015 compared to 2001-2003 in the two age groups: 60 and 81 years (p < 0.001 for both). The mean number of teeth increased in the 60-year-olds from 24.2 to 27.0 and in the 81-year-olds from 14.3 to 20.2. The numbers of at least one intact tooth increased for both age groups (p < 0.001 and p < 0.004, respectively). In the age groups 81 years, there was an increase in having at least one PPD ≥ 6 mm (p < 0.016) and bone loss ≥ 5 mm (p < 0.029) between the two examinations. No such differences were found in the age groups of 60 years.

CONCLUSION: Over 13 years, oral health improved for both 60- and 81-year-old age groups. The most significant changes were in the 81-year-olds where oral health had improved except for periodontal status.

CLINICAL RELEVANCE: More natural teeth and impaired periodontal status potentially impact oral health and should increase focus on preventive and supportive dental care in older individuals.

Place, publisher, year, edition, pages
Springer, 2022
Keywords
Aging, Epidemiology, Older, Oral health status
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-54109 (URN)10.1007/s00784-022-04632-5 (DOI)000832824500001 ()35906339 (PubMedID)2-s2.0-85141111860 (Scopus ID)
Available from: 2022-08-02 Created: 2022-08-02 Last updated: 2024-05-21Bibliographically approved
Shmarina, E., Ericson, D., Franzén, C. & Götrick, B. (2022). Self-perceived oral health-related salutogenic factors in orally healthy older Swedes. A qualitative interview study.. Acta Odontologica Scandinavica, 80(5), 354-362
Open this publication in new window or tab >>Self-perceived oral health-related salutogenic factors in orally healthy older Swedes. A qualitative interview study.
2022 (English)In: Acta Odontologica Scandinavica, ISSN 0001-6357, E-ISSN 1502-3850, Vol. 80, no 5, p. 354-362Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: This study aimed to explore oral health-related salutogenic factors in orally healthy older Swedish people, applying the three components of Antonovsky's Sense of Coherence (SOC) concept: comprehensibility, manageability and meaningfulness.

MATERIAL AND METHOD: Interviews were conducted with 12 orally healthy patients, aged 75 years and older, enrolled at public dental clinics. The interviews were subjected to qualitative content analysis, applying the SOC concept as the theoretical framework.

RESULTS: Three themes were formulated under the predefined SOC components, describing the central meaning of the informants' perception of factors favourable to their good oral health. The theme 'comprehension of cause and effect' consisted of three categories, for example importance of oral hygiene, and reflected the component comprehensibility. The theme 'living in confidence and trust in supporting society' consisted of five categories, for example self-esteem, and reflected the component manageability. The theme 'good oral health as a basis for satisfaction and social confidence' consisted of two categories, for example social norms, and reflected the component meaningfulness.

CONCLUSION: This study discloses how orally healthy elderly Swedish people perceive the lifelong impact of salutogenic factors in response to lifelong stressors on their oral health and highlights the important roles of their internal resources, dental professionals, family and society in supporting and reinforcing lifelong oral health.

Place, publisher, year, edition, pages
Taylor & Francis, 2022
Keywords
oral health, qualitative research, salutogenesis, sense of coherence, social determinants of health
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:mau:diva-49061 (URN)10.1080/00016357.2021.2014068 (DOI)000729051600001 ()34893001 (PubMedID)2-s2.0-85121376562 (Scopus ID)
Available from: 2021-12-29 Created: 2021-12-29 Last updated: 2024-05-21Bibliographically approved
Milosavljevic, A., Wolf, E., Englander, M., Stavropoulos, A. & Götrick, B. (2021). The lived experience of performing a periodontal treatment in the context of general dentistry. BDJ Open, 7, Article ID 7.
Open this publication in new window or tab >>The lived experience of performing a periodontal treatment in the context of general dentistry
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2021 (English)In: BDJ Open, E-ISSN 2056-807X, Vol. 7, article id 7Article in journal (Other academic) Published
Abstract [en]

Aim: To describe what characterises the lived experience of performing a periodontal treatment in the context of general dentistry.

Materials and methods: Three dental hygienists from general dentistry in Sweden, were purposively selected as participants and interviewed. The participants described a situation in which they had performed a periodontal treatment. The descriptions were analysed using the descriptive phenomenological psychological method.

Results: The general meaning structure of the lived experience of performing a periodontal treatment comprised five constituents, (a) an established treatment routine, (b) importance of oral hygiene, (c) self-awareness and motivation of the patient, (d) support and doubt, and (e) mechanical infection control. The periodontal treatment is perceived as being set prior to its commencement and as following established routines, in which the patients’ oral hygiene is experienced as a crucial part. The patients’ self-awareness and a supportive clinician are seen as important factors in motivating the patient towards positive behavioural change, although there is a presence of doubt in patients’ ability to maintain this positive change. Mechanical infection control is perceived as successful but sometimes difficult to perform.

Conclusions: Important, patient-related, factors are constituting the phenomenon of performing a periodontal treatment but an experience that the pre-existing standardised workflow influences patient management was also present.

Place, publisher, year, edition, pages
Nature Publishing Group, 2021
National Category
Dentistry
Research subject
Health and society; Health and society
Identifiers
urn:nbn:se:mau:diva-17784 (URN)10.1038/s41405-021-00059-4 (DOI)000616408800003 ()33510136 (PubMedID)2-s2.0-85100008225 (Scopus ID)
Available from: 2020-07-14 Created: 2020-07-14 Last updated: 2024-05-21Bibliographically approved
Hallmer, F., Bjarnadottir, O., Götrick, B., Malmström, P. & Andersson, G. (2020). Incidence of and risk factors for medication-related osteonecrosis of the jaw in women with breast cancer with bone metastasis: a population-based study. Oral surgery, oral medicine, oral pathology and oral radiology, 130(3), 252-257, Article ID S2212-4403(20)30962-7.
Open this publication in new window or tab >>Incidence of and risk factors for medication-related osteonecrosis of the jaw in women with breast cancer with bone metastasis: a population-based study
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2020 (English)In: Oral surgery, oral medicine, oral pathology and oral radiology, ISSN 2212-4403, E-ISSN 2212-4411, Vol. 130, no 3, p. 252-257, article id S2212-4403(20)30962-7Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: The aim of this study was to prospectively determine the incidence of medication-related osteonecrosis of the jaw (MRONJ) and define risk factors in patients with metastatic breast cancer treated with zoledronic acid and/or denosumab.

STUDY DESIGN: In a prospective cohort study performed in Region Skåne, Sweden, from January 1, 2012, until December 31, 2015, all patients with breast cancer who had radiographic evidence of bone metastases and were treated with zoledronic acid or denosumab were included and followed up until May 31, 2018.

RESULTS: Of the 242 patients, MRONJ developed in 16 (6.6%) during the 77 months of study. The incidence of MRONJ in patients treated with zoledronic acid was 4.1%, and in patients treated with denosumab, it was 13.6%. The risk of MRONJ was higher in patients on denosumab than in those treated with zoledronic acid (P = .011). Corticosteroid use was associated with a decreased risk of MRONJ (P = .008), and diabetes was associated with an increased risk of MRONJ (P = .02).

CONCLUSIONS: The incidence of MRONJ is 6.6% (>3 times higher) in denosumab-treated patients with breast cancer compared with that in patients treated with zoledronic acid. Corticosteroid use decreased the risk of MRONJ.

Place, publisher, year, edition, pages
Elsevier, 2020
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-17598 (URN)10.1016/j.oooo.2020.04.808 (DOI)000573547900011 ()32536575 (PubMedID)2-s2.0-85086574678 (Scopus ID)
Available from: 2020-06-29 Created: 2020-06-29 Last updated: 2024-06-17Bibliographically approved
Projects
Effekten av antibiotikaprofylax i samband med tandimplantatkirurgi; Malmö University
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-6337-4988

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