Dental Emergency Management Techniques in Medical Practice

Dental Emergency Management Techniques in Medical Practice during the COVID 19 Pandemic Dr Jacqueline Stuart BDSc, PhD Adjunct Lecturer JCU James Cook University, College of Medicine and Dentistry T: 0419112769 E: [email protected] Presentation Outline

1. Dental Practice limitations imposed during Co-Vid 19 2. Prevalence of Dental Presentations to the Medical Practitioners. 3. The Importance of Improving Interprofessional communications. 4. Dental Anaesthetic Techniques. 5. Antibiotic Use in Dental Emergency Management. 6. Common Emergency Dental Presentations and their Treatment Options. Dental professionals are reported to be at very high risk of COVID-19 infection due to the close face-to-face patient contact required during patient care (Peng et al., 2020).

Studies suggest that COVID-19 may be airborne through aerosols formed during dental and medical procedures or indirectly through saliva (Wax et al., 2020., Tsang et al., 2020) ADA Dental Service Restrictions in COVID 19

Five restriction levels for dental practice during the pandemic exist. These are based on published triaging systems in Australia for Dentistry and take into consideration the following key objectives:

1. A proportionate, pre-planned response to the possible escalation of COVID-19 based on the evolving community context.

2. Staged restrictions of dental services to reduce transmission risks for COVID-19

3. Avoidance of likely burden on medical primary care and emergency services should access to urgent dental care cease.

• Patients confirmed with COVID-19 may either be a hospital in-patient or being managed by ‘hospital in the home’.

• Dental treatment will be provided with transmission based, contact and airborne precautions. Airborne precautions include the need for the patient to be treated in a negative pressure room, with dental staff wearing P2/N95 respirators which have been previously fit-tested, and then fit checked at time of use.

• All confirmed coronavirus cases will only have dental treatment as an in-patient or within a hospital setting by appropriately trained and credentialled dental personnel.

Australian Dental Association, Managing COVID-19 Guidelines 25-03-2020 https://www.ada.org.au/Managing-Covid-19-Guide A patient with a significant dental emergency who is at risk of COVID-19 infection or with a confirmed diagnosis, will most often be able to be managed with analgesics until the patient has reached the end of any mandatory quarantine period, or is no longer at risk of being infectious.

Australian Dental Association, Managing COVID-19 Guidelines 25-03-2020 https://www.ada.org.au/Managing-Covid-19-Guide Services that can be performed Restricted services, defer treatment No All dental services No restrictions apply restrictions

Level 1 All dental treatments using Defer non-urgent treatment for Restrictions standard precautions for people people who DO meet who do not meet epidemiological epidemiological or clinical or clinical risk factors for COVID-19 symptom criteria for COVID-19 infection transmission risk.

Australian Dental Association, Managing COVID-19 Guidelines 25-03-2020 https://www.ada.org.au/Campaign/COVID-19/Managing-COVID-19/Practice- Resources/Dental-restriction-Levels/ADA-dental-restriction-levels-in-COVID-19-Publishe.aspx Services that can be performed Restricted services, defer treatment Level 2 Provision of dental treatments Defer all treatments that are Restrictions that are unlikely to generate likely to generate aerosols aerosols or where aerosols generated have the presence of minimal saliva/blood due to the use of rubber dam.

• Examinations and hand scaling • Restorative procedures using high speed handpieces only provided with the use of rubber dam • Non-surgical extractions • Denture procedures • Orthodontic treatment Services that can be performed Restricted services, defer treatment Level 3 Only urgent dental treatments that do Defer all routine recall Restrictions not generate aerosols, or where examinations and non-urgent treatments generating aerosols is dental treatments. limited to management of;

• Acute dental pain e.g. endodontic treatment under rubber dam • Non-Surgical Extractions • Dental tooth trauma performed under rubber dam Services that can be performed Restricted services, defer treatment Level 4 Very limited urgent dental Defer all dental treatments for Restrictions treatments which include patients not fitting the risk management of the following : categories identified on the left.

• Swelling of the face, neck or mouth • Dental trauma causing change in the position of teeth, soft tissue damage and/or significant pain • Significant bleeding

Level 5 No routine dental treatment Any dental treatment without Restrictions provided. All patients with acute expressed permission from the dental concerns to be directed to public health authorities. emergency care centres. People who have difficulty in accessing dental services frequently present to:

• Hospital Emergency Departments (Cohen, Bonito, Akin, Manski, & Macek, 2008; Cohen et al., 2011)

• Private Medical Practices (Britt et al., 2000)

• Pharmacists (Cohen, Bonito, et al., 2009)

• Aboriginal Health Centres (Tennant et al.,2014:Walker et al., 2013) When restrictions are placed on accessing routine oral health care, a significant concern exists for overall patient dental/medical care. During this Pandemic, more patients than usual may access Accident and Emergency Hospital Departments. These patients may potentially need hospital admission for the management of acute dental infections that may threaten the airway and require intensive care (Manus et al., 2020). • From 2016-2017 there were 70,200 avoidable hospital admissions for dental conditions (Australian Institute of Health and Welfare, 2019)

• It is estimated that there were 750,000 consultations with medical practitioners in 2011 for dental-related issues in Australia (National Advisory Council on Dental Health, 2012). Medical practitioners generally lack substantive training in dentistry (Cohen, Harris, et al., 2009; Skapetis, Gerzina, & Hu, 2011)

Very few doctors at the Emergency Hospital Departments have been trained in the management of dental problems (Skapetis, Gerzina, & Hu, 2011) Potentially Preventable Hospitalisations in Regional Queensland 2012-2014

UTI

Convulsions

ENT Infections

DentalDental Conditions Conditions Cellulitis

Gangrene

Pelvic Inflammatory Disease

Perforated or Bleeding Ulcer

Pneumonia

Number of Indigenous and Non-Indigenous Hospitalisations

Harriss et al, (2019). Preventable hospitalisations in regional Queensland; potential for primary health? Australian Health Review, 43, 371-381. Dental Conditions Number of Potentially Preventable Hospitalizations due to Dental Conditions 2016-2017

One in 10 potentially preventable hospitalisations in Australia from 2015-2016 were for conditions of dental origin

(Australian Institute of Health and Welfare, 2019) (AIHW,2017) Patients with substantial facial swellings may progress to life-threatening emergencies. For such patients, extractions of the causative pathogenic teeth should be prioritised over restorative rescue, and input from dedicated oral surgery and maxillofacial services and close follow-up is indicated (Manus et al., 2020). Improving interprofessional communications will ensure better patient outcomes • OPG Interpretation • Basic Dental Anatomy • Australian Tooth Numbering System Orthopantomogram...... OPG The image provides an overview of the state of the dentition as well as information regarding the mandible, maxilla, sinuses and the temporomandibular joints. Dental Pathology on OPG

Dental Abscess

Odontogenic Ameloblastoma Dentigenous Cyst OPG of a 7 year old with a mixed dentition Anatomy of the Normal Healthy Tooth

Enamel

Crown Dentine

Pulp

Periodontal Root ligament

Alveolar bone

Tooth apices

(Douglass & Douglass, 2003) Australian tooth numbering system: Permanent Dentition

13 12 25 22 23 11 21 24 46 37 45 36 44 35 43 42 33 34 41 31 32 Australian tooth numbering system: Deciduous Dentition

54 53 62 63 52 51 61

84 74

83 73 82 81 71 72 Eruption Times for Deciduous and Permanent Teeth

16 mo 29 mo 8 mo

7-8 yr 17-21 yr Dental Anaesthesia Although the efficacy of using a mouth rinse before commencing dental procedural treatments cannot be guaranteed to have a significant effect on viral load in a patient with COVID-19, it is recommended by the ADA that all patients should be asked to undertake a 20-30 second pre-procedural mouthrinse with either: 0.2% povidone iodine, 1% hydrogen peroxide or 0.2% chlorhexidine rinse (alcohol free).

Australian Dental Association, Managing COVID-19 Guidelines 25-03-2020 https://www.ada.org.au/Managing-Covid-19-Guide Provide Dental Anaesthetic pain relief and refer. The Trigeminal Nerve Different Dental Anaesthesia Techniques

Submucosal injection of local Infiltration anaesthetic directly into an area of terminal nerve endings. This typically provides pulpal anaesthesia for 1-2 teeth.

Injection of the local anaesthetic Peripheral Nerve solution into the vicinity of a peripheral nerve to anaesthetize that nerve’s Block entire area of innervation. Maxillary Infiltration Injection

This involves the extravascular placement of the local anaesthetic in the region to be anaesthetised. Infiltration injections are most routinely used to anesthetise the maxillary nerve supplying these teeth. Xylocaine (Lignocaine) is the most common anaesthetic choice but Marcaine is often used for longer duration anaesthesia. Topical Anaesthetic and pressure at Injection site directed at the tooth injection site reduce discomfort. root tip at a 45 degree angle. Inferior Alveolar Block aims at the deepest part of ascending ramus parallel to the occlusal plane and lateral to the raphe. The needle tip will hit bone with the bevel aimed away to assist in needle deflection and direction of local anaesthetic solution. Aspirate so as not to inject into the blood vessel. Deposit 1.8-2.2 ml. Mandibular Infiltration Injection

The introduction of Articaine has allowed success rates of mandibular buccal infiltration anaesthesia of 64%- 70% in adult mandibular first molar with almost 100% success rated in anterior permanent and deciduous mandibular anaesthesia.

Jung et al (2008) Corbett et al (2008) Commonly used Dental Local Anaesthetics

• Lidocaine...... ”Xylocaine” • Prilocaine...... ”Citanest” • Bupivacaine....”Marcaine” • Articaine...... ”Septocaine/ Septonest”

Vasoconstrictors should be included in dental local anaesthetic solutions unless specifically contraindicated by the medical status of the patient or by the duration of the planned treatment. (Said Yekta-Michael, Stein, & Marioth-Wirtz, 2015) Contraindications to Vasoconstrictors and/or Local Anaesthetic Agents

• Recent myocardial infarction (<1 month or symptomatic) • High risk Arrhythmia • Uncontrolled or severe Hypertension • Patients taking digoxin • Uncontrolled diabetes mellitus • Uncontrolled hyperthyroidism • Documented allergy • Drug abuse (Cocaine, Methamphetamine- known use within past 6-24 hours)

(Daublander et al., 2012) SEPTANEST 1:100,000 Articaine Hydrochloride 4% with adrenaline (epinephrine) Injection Dental Conditions that may present to the Emergency Department or to the Medical Practitioner Common Emergency Dental Presentations

Oral Pain Dental Other Trauma Emergencies

Hard Tissue Injuries: • Post extraction •Dental Caries •Jaw Fracture haemorrhage •Dental Abscess •Tooth fracture • Denture related •Gingivitis •Avulsed Tooth issues •ANUG •Tooth Intrusion • Lost or broken •Periodontal Disease Soft Tissue Injuries: restorations or •Perichoronitis •Degloving crowns •Dry Socket •Tongue piercing • Broken orthodontic •Lacerations brackets •Aspirin/ Chemical Burn Dental Caries Cause Odontogenic Pain

Pulp becoming Carious lesion severely encroaching inflamed, on pulp causing acute pain because of confined space

(Douglass and Douglass 2003) Silver Diamine Fluoride 37%? (Hendre, Taylor, Chavez, & Hyde, 2017) Aetiology of Dental Caries Aetiology of the Dental Abscess A dental abscess is pus enclosed in the periapical tissue of an infected tooth. Usually the abscess originates from a bacterial infection in the dead pulp of the tooth caused by dental caries, broken teeth or extensive periodontal disease. The Dental Abscess Antibiotics are not an effective treatment for most dental emergencies!

The principles of managing infection, such as, remove the cause, drain the pus and support the host, have been known since the time of Hippocrates. “Antibiotics should not be used for dental pain, pulpitis or infection localised to the teeth, or to delay providing dental treatment”.

Oral and Dental Expert Group. Therapeutic Guidelines - Oral and Dental, version 2. Therapeutic Guidelines Limited; Melbourne 2012. • Antibiotic prophylaxis is no longer required for patients with orthopaedic joint replacements.

• Antibiotic prophylaxis is no longer required for patients with mitral heart valve prolapse or structural or valvular heart disease.

Oral and Dental Expert Group. Therapeutic Guidelines - Oral and Dental, version 2. Therapeutic Guidelines Limited; Melbourne 2012 Emergency Drainage of the Dental Abscess A piece of sterile rubber glove is inserted into the incision site to keep the wound open to allow drainage until definitive dental treatment can occur. Cut drainage insert shape this way……

Referral to the Dentist is Vital Only Dental Abscess causing Acute Oral, Medical and Surgical Conditions with Facial Swelling requires Antibiotics Ludwig’s Angina

• Ludwig’s Angina is a rare but life threatening infection with mortality close to 100% • Dental infection is the cause in 90% of cases • Bilateral infection of sublingual and submandibular glands and facial tissues Gingivitis Acute Necrotising Ulcerative Gingivitis (ANUG)

Can be easily identified by the involvement of the interproximal papillae and the presence of a pseudomembranous necrotic covering of the marginal tissue Periodontal Disease Pericoronitis Operculum • Pericoronitis associated with wisdom tooth eruption causes the formation of operculum which can be very painful and cause swelling.

• Treatment is irrigation under the operculum flap with saline or chlorhexidine and supportive medication such as anti- inflammatory medications and pain killers.

• Antibiotics are rarely required ...

(Douglass and Douglass 2003) Dry Socket

Dry socket following a tooth extraction is caused when the post operative blood clot is prematurely lost. This may be due to vigorous rinsing, interference with the extraction site, smoking or idiopathic origins.

Treatment • Chlorhexidine rinse • Alvogyl placement in some instances • Analgesics • Antibiotics are not indicated

Alvogyl (eugenol, iodoform and butamen) Dental Trauma Consider other issues related to dental trauma

1. Other injuries - Head injury/ concussion - Jaw/ facial bone fracture 2. Social issues. - Who can give consent for treatment if a child patient? -Third parties involved ? -Records need to be kept for 25 years. 3. Trauma History .... suspected child abuse, insurance claims -When...timing essential for re-implantation success -Where..... -How.... -Who.... Injuries to hard dental tissues -Jaw fracture -Crown fracture with/without pulpal involvement -Root fracture -Avulsions/Intrusions

Injuries involving soft dental tissues -Degloving -Tongue Piercing -Lacerations - Aspirin/Chemical Burns Hard Tissue Injuries: Jaw Fractures Fractured Mandible Signs of a fractured mandible include inability to open the mouth, sideways canting of the jaw upon opening, uneven teeth that appears different from before the accident, and inability to close the teeth together properly.

Reduce the fracture by wiring the jaw with fine gauge wire . Simple Jaw Stabilisation

Locked Jaw

https://youtu.be/s3DrqQrAhi4 Tooth Fracture with no pulpal involvement

TREATMENT The patient should be advised to eat soft food till seen by dentist – 48 hrs. If a tooth fragment is available, it can be bonded to the tooth. Otherwise perform a provisional treatment by covering the exposed dentin with glass-ionomer. Then referral to a dentist. Tooth Fracture with pulpal involvement

Involvement of the nerve causes pain and In the ED department, in the absence of a the possible eventual death of the tooth. dentist, the application of a sedative Pain Relief with dental analgesia or dressing with calcium hydroxide and glass medication must be administered. ionomer to cover exposed dentine will seal the tooth till a dentist can see it. Dental Trauma Kits The Avulsed Tooth

• If the root tip is not fully formed then the prognosis for survival is possible if it is not left out for longer than 15- 60 minutes.

• If the root is fully formed and reimplantation rapid, vitality may be maintained but is not predictable. Treatment for an avulsed permanent tooth Avulsed baby teeth should not be replanted.

Calm the patient down Clean debris from tooth as gently Apply a temporary splint. Have the avulsed tooth with as possible without touching the Refer to the dentist immediately to them in either a glass of room root surface. Use milk or sterile splint the tooth in place ideally temperature milk or in their own saline not tap water. Reimplant the using fishing line and glass ionomer mouth in the buccal sulcus tooth making sure it is not back to cement front!

(Resource Centre for Rare Oral Diseases and Department of Oral and Maxillo-Facial Surgery at the University Hospital of Copenhagen, 2010) Emergency temporary splint options for the GP

A good temporary splint can be Use the patients mouthguard as a splint made using Al Foil and Blu-Tac Use ConvaTec Stomahesive® wafer for provisional splinting

Use patients existing orthodontic Final Splinting by a dentist as splint or night guard soon as possible Post operative instructions after re-implantation of avulsed tooth

1. Tetanus immunisation if necessary 2. Oral Doxycycline ( 100mg for adults) 2x/day for 7 days if >12 years. If < 12 years give penicillin V. 3. Chlorhexidine mouth rinse 2x/day for 7 days 4. Soft diet for 2 weeks 5. Follow up with dentist as soon as possible

(Skapetis, 2012) Tooth Intrusion This tooth is pushed up into the socket.

TREATMENT

The treatment of choice for permanent teeth with incomplete root formation with minor or moderate intrusion is to allow spontaneous eruption. If no movement within a few weeks, the dentist will initiate orthodontic or surgical repositioning before ankyloses can develop.

(Resource Centre for Rare Oral Diseases and Department of Oral and Maxillo-Facial Surgery at the University Hospital of Copenhagen, 2010). It is different for Deciduous Teeth

Don’t re-implant avulsed deciduous teeth or extract intruded deciduous teeth as this may inadvertently damage the developing permanent tooth germ apically. Store tooth in UHT milk and refer to dentist

Avulsed Rinse crown with milk or sterile saline and re-implant

Permanent Intrusion < 3mm do nothing Teeth Intruded Intrusion >3mm reposition under LA SPLINT and Crown with exposed Dry and cover pulp with REFER to Fractured DENTIST ASAP Tooth pulp CALCIUM HYDROXIDE PASTE

DENTAL TRAUMA Crown with no Dry and cover exposed pulp fracture with GLASS IONOMER CEMENT

Root fracture Deciduous Teeth Extract if tooth is an inhalation risk, otherwise DO NOTHING!

Adapted from Skapetis et al 2012 Soft Tissue Injuries De-gloving Injuries

TREATMENT: Requires anaesthetic and suturing of soft tissue back into position.

(The Royal Dental Hospital of Melbourne, 2014) Complications of Tongue Piercing Infections

• Bleeding and swelling • Fractured teeth • Abscesses of brain, liver, inner lining of heart due to normal mouth flora (Streptococcus intermedius) • Ludwig’s Angina Soft Tissue Lacerations

Lip Laceration Cheek biting Tongue biting

This may occur as a post operative sequaele to an anaesthetised lip. Suture where necessary or offer palliative support such as saline mouth rinses and topical anaesthesia. Aspirin/ Chemical Burn • Mucosa in direct contact with aspirin becomes necrotic and painful. • Contact stomatitis may occur with some other allergens causing intra-oral erythema, ulceration or a lichenoid mucositis

Aspirin Burn Turpentine Burn Other Emergency Dental Presentations

• Post extraction Haemorrhage • Denture related issues • Lost or broken restorations or crowns • Broken orthodontic brackets Post operative Haemorrhage after dental extractions

• Normal oozing of nutrient canal : apply pressure, suture and do not rinse.

• Severed inferior dental vessel: administer a local haemostatic such as thrombin and insert fibrin foam, gelatin foam or oxidized cellulose into the socket.

• Systemic disease: treatment is directed towards managing that underlying condition by doing the required investigations and local haemostatic, primary closure, sutures and tranexamic acid (Svensson, Hallmer, Englesson, Svensson, & Becktor, 2013) Denture Related Issues Denture Related Issues

• Pain on eating from ill fitting or chipped dentures. • Underlying pathology beneath the fitting surfaces. • Dry mouth due to medications. • Excessive dental plaque accumulation due to poor oral hygiene. The lost crown, bridge or restoration Broken arch wires or brackets on orthodontic brackets

Dental Wax is used to cover sharp edges on braces

Death by Power Point Presentation References • Resource Centre for Rare Oral Diseases and Department of Oral and Maxillo-Facial Surgery at the University Hospital of Copenhagen. (2010). Dental Trauma Guide 2010 • Houston, J., McCollum, J., Pietz, D., & Schneck, D. (2002). Alveolar osteitis: a review of its etiology, prevention, and treatment modalities. Gen Dent, 50(5), 457-463; quiz 464-455. • Kaya, G., Yapici, G., Savas, Z., & Gungormus, M. (2011). Comparison of alvogyl, SaliCept patch, and low-level laser therapy in the management of alveolar osteitis. J Oral Maxillofac Surg, 69(6), 1571-1577. doi: 10.1016/j.joms.2010.11.005 • Skapetis, T., Gerzina, T., Hu, W., & Cameron, W. (2013). Effectiveness of a brief educational workshop intervention among primary care providers at 6 months: uptake of dental emergency supporting resources. Rural Remote Health, 13(2), 2286. • Drug Utilisation Subcommittee (DUSC) Antibiotics: PBS/RPBS utilisation, Oct 2014 and Feb 2015. http://www.pbs.gov.au/info/industry/listing/participants/public-release-docs/antibiotics-oct-14-feb-15 • Oral and Dental Expert Group. Therapeutic Guidelines - Oral and Dental, version 2. Therapeutic Guidelines Limited; Melbourne 2012 • Herbart S, Samore MH. Antimicrobial Resistance Determinants and Future Control. Emerg Infect Dis. 2005 Jun; 11(6): 794–801 • World Health Organization. Combat antimicrobial resistance: fact sheet. World Health Organization, 2011. http://www.who.int/world-health-day/2011/WHD201_FS_EN.pdf • NPS Medicine wise: Duration of antibiotic therapy and resistance. http://www.nps.org.au/publications/health- professional/health-news-evidence/2013/duration-of-antibiotic-therapy • Manus, D., Noha, S., & Coulthard, P. (2020). Urgent dental care for patients during the CoVid-19 pandemic. Lancet, 395(10232), 1257. • National Advisory Committee on Oral Health, Australian Health Ministers’ Conference. Healthy mouths healthy lives. Australia’s National Oral Health Plan 2004–2013. Adelaide: Government of South Australia on . behalf of the Australian Health Ministers’ Conference, 2004. • Oral and dental group. Therapeutic guidelines :oral and dental. Version 2.Melbourne:Therapeutic Guidelines Limited, 2012 • Budtz-Jorgensen E. Oral mucosal lesions associated with the wearing of removable dentures. Journal of oral pathology. 1981;10(2):65-80. • Svensson, R., Hallmer, F., Englesson, C. S., Svensson, P. J., & Becktor, J. P. (2013). Treatment with local hemostatic agents and primary closure after tooth extraction in warfarin treated patients. Swed Dent J, 37(2), 71-77. • Hendre AD, Taylor GW, Chavez EM, Hyde S. A systematic review of silver diamine fluoride: Effectiveness and application in older adults. Gerodontology. 2017;34(4):411-9. • Australian Institute of Health and Welfare. Admitted patient care 2015-16. Canberra: AIHW, 2015. • Australia Institute of Health and Welfare. Web update: Potentially preventable hospitalisations in 2015-16 2017. Available from: https://www.myhealthycommunities.gov.au/our-reports/potentially- preventablehospitalisations-update/july-2017. • Australian Dental Association. Managing COVID-19 Guidelines. Web update: 25-03-2020 https://www.ada.org.au/Managing-Covid-19-Guide • Australian Dental Association, Managing COVID-19 Guidelines 25-03-2020 https://www.ada.org.au/Campaign/COVID-19/Managing-COVID-19/Practice-Resources/Dental-restriction- Levels/ADA-dental-restriction-levels-in-COVID-19-Publishe.aspx • Coulthard, P. (2020). Dentistry and coronavirus (COVID-19) - moral decision-making. British Dental Journal, 228(7), 503-505. doi:10.1038/s41415-020-1482-1 • Rothe C, Schunk M, Sothmann P et al. Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. N Engl J Med 2020; 382: 970-971. • Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 2020; 12: 9 • Wax R S, Christian M D. Practical recommendations for critical care and anaesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth 2020; DOI: 10.1007/s12630-020-01591-x. • To K K, Tsang O T, Chik-Yan Yip C et al. Consistent detection of 2019 novel coronavirus in saliva. Clin Infect Dis 2020; DOI: 10.1093/cid/ciaa149 • Australian Institute of Health and Welfare 2019. Oral health and dental care in Australia. Cat. no. DEN 231. Canberra: AIHW. Viewed 17 May 2020, https://www.aihw.gov.au/reports/dental-oral-health/oral-health-and- dental-care-in-australia • Harriss et al, (2019). Preventable hospitalisations in regional Queensland; potential for primary health? Australian Health Review, 43, 371-381.