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Keywords:

  • Residential aged care facilities;
  • dental care;
  • dentists;
  • directors of nursing

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Background:  The Australian population is ageing, and a growing proportion of elderly Australians are now living in residential aged care facilities (RACFs). These residents are at high risk of developing dental diseases, have more teeth present now than at any time in the past 50 years and often have difficulty maintaining adequate oral hygiene. Traditionally, dental service provision has been problematic and sporadic for these residents.

Methods:  A postal survey of a random sample of Victorian general dentists and Directors of Nursing (DONs) of Victorian RACFs was undertaken in 2006 to ascertain the participation of dentists in the provision of dental care and to identify factors impacting on the organization and provision of dental care for residents.

Results:  The response rate for dentists was 57.3 per cent, and for DONs 64.4 per cent. Half of the dentists reported that they had provided care to residents of aged care facilities in the past 12 months, and they spent an average of one hour per month providing care. Overall, dentists were concerned with their level of undergraduate education and training in various aspects of dentistry for residents of aged care facilities. DONs reported significant difficulty obtaining adequate dental care for their residents. Common problems identified by both dentists and DONs included a preference for dentists to treat residents in their own practice, dentists not willing to go to RACFs and a lack of portable dental equipment for dentists to use.

Conclusions:  There were low levels of interest and participation from Victorian dentists in providing dental care for residents of aged care facilities. Dentists had a strong preference for treating patients at their own practice, and there were a number of significant barriers that appeared to impact on the provision of dental care in RACFs.


Abbreviations and acronyms:
DONs

Directors of Nursing

DPBV

Dental Practice Board of Victoria

RACFs

residential aged care facilities

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

The institutionalized elderly have long been identified as a significant risk group for dental disease in Australia. They display some of the poorest oral health in Australia, and face significant barriers in their ability to access dental services, including poor working conditions in residential aged care facilities (RACFs) and lack of available dental staff.1 The changing demography and oral health needs of older Australians is a looming crisis in the provision of dental care. Population projections show that while older people aged 65+ years comprised only 13.0 per cent (2.60 million) of the population in 2004, by 2021 this will increase to 18.7 per cent (4.47 million) and by 2051, more than one in four Australians will be aged over 65 years (7.30 million).2

In Victoria, there were approximately 663 000 people aged 65 years or older, and 76 200 people aged 85+ in 2004, with similar increases projected for Victoria as for the rest of Australia.2 In 2005, approximately 6 per cent (41 000) of these older Victorians were living in 824 high or low care residential facilities on a permanent basis, with 30 000 of these in Melbourne, and the remaining 11 000 in regional and rural Victoria.3

Dental care is particularly important for this age group, since oral diseases tend to be cumulative and become more complex with time. Furthermore, there has been an increase in the number of natural teeth retained in this population, with decreasing rates of edentulism over the past 30 years.4 More retained teeth means more teeth at risk of dental caries and periodontal disease. Institutionalized older adults often have cognitive and physical impairments that affect their ability to maintain oral hygiene, and are dependent on others for daily maintenance of their oral hygiene and accessing dental services. They are often medically compromised, and are taking a large number of medications that may affect salivary flow and increase the risk of dental caries.5 Oral problems have a negative affect on quality of life, and problems with the teeth and mouth can affect nutrition, which in turn can affect general health. There is a growing body of evidence that links poor periodontal health with a range of medical problems, including cardiovascular disease, atherosclerosis and stroke.6–8 Aspiration pneumonia and bacteraemia can also be a significant problem for residents with poor oral health.9

Periodontal disease is common in residents of aged care facilities, and most dentate residents have a high level of plaque, calculus and debris accumulation present.10 Access to periodontal and oral health promotion services is essential for these residents. Dental services should focus on prevention and oral hygiene care provision, as well as education for carers.11 These issues have previously been identified as a significant problem in Victoria, with a number of strategies identified and implemented to improve service delivery and health promotion activities.12

A number of significant barriers to the provision of adequate dental care for residents of aged care facilities have been identified by dentists and RACF staff, particularly the lack of portable equipment, difficult working conditions in RACFs, apathy of residents and staff, uncooperative administrators, residents’ behavioural and communication problems and perceived lack of training in geriatric dentistry.11,13–17 Financial considerations are also known to affect the decision to provide treatment for residents. Carers often have limited knowledge and education in oral hygiene care and dental disease, and this impacts on their ability to provide adequate care to residents.18

There is limited research into dental service provision for residents of aged care facilities in Australia. Chalmers et al.10 found that while just under 50 per cent of Adelaide dentists had provided dental care to residents over a 12-month period, they were providing care for an average of 1.8 RACFs, but were spending only one hour per month actually providing care. Only 29.5 per cent had provided care at an RACF, with the majority preferring to treat patients in their own practices. Only 6.1 per cent of dentists reported that their practice had a hygienist who provided dental care for residents in the previous 12 months, and there was little awareness of recent legislative change permitting hygienists to practice unsupervised in RACFs in that state. Few dental practices were assisting RACFs with education of their staff regarding dental issues. Directors of Nursing (DONs) at Adelaide RACFs felt that they were able to obtain the quality of dental services required for their dentate (70.0 per cent) and edentulous (78.4 per cent) residents.

The aims of the study were to quantify the dental care provided to residents of Victorian aged care facilities, and investigate the attitudes of Victorian dentists and DONs toward dental care for residents.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

There were 2328 dentists registered with the Dental Practice Board of Victoria (DPBV) in June 2005. A list of practice addresses was obtained from the Board. A random sample of 220 dentists was selected from the Victorian addresses on the DPBV register, stratified for practice location (metropolitan Melbourne or regional Victoria). A questionnaire, plain language statement and stamped return envelope were mailed to the randomly selected dentists.19 Non-responders were identified after four weeks, and a second questionnaire pack was mailed. There were seven questionnaires returned where the dentist was no longer practising, giving a final sample population of 213.

There were 824 accredited RACFS in Victoria in 2006, and a list of facilities was stratified by nine metropolitan and rural regions (Eastern Metropolitan, Northern Metropolitan, Western Metropolitan, Southern Metropolitan, Barwon-South Western, Gippsland, Grampians, Hume and Loddon-Mallee).20 A random sample of 20 per cent from each region was selected to participate in the study, for a total sample population of 163. In addition, 31 RACFS that had participated in a pilot project using dental hygienists to undertake screening examination of residents were also included (unpublished data). A questionnaire based on one developed by Berkey and used by Chalmers et al., a plain language statement and a stamped return envelope were mailed to the DONs of the randomly selected RACFs.10,16,19 Non-responders were identified after two weeks and sent a reminder letter, and after four weeks a second questionnaire pack was mailed to non-responders in order to maximize the response rate.

Univariate statistics and bivariate analysis (t-tests and Chi-squared tests) were used to describe various aspects of dental service provision in RACFs and attitudes of dentists and DONs to dental care in RACFs. Logistic regression analysis was used to model the characteristics of dentists who reported that they were interested in providing care to residents, and dentists who provided care to residents in the past 12 months. For the bivariate and logistic regression, interest in providing care was dichotomized into those who were extremely interested, very interested or interested (interested) and those who were somewhat or not interested (not interested).

Ethics approval was obtained from The University of Melbourne Human Research Ethics Committee.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

A total of 125 useable questionnaires were returned by the DONs, a response rate of 64.4 per cent. A total of 122 useable questionnaires were returned by dentists, a response rate of 57.3 per cent.

The majority of dentists were older than 45 years of age and had been working as dentists for more than 10 years, predominantly in private practices in metropolitan Melbourne (Table 1). There were twice as many males as females in the sample population. Although nearly two-thirds of dentists felt they had adequate undergraduate education and training in geriatric dentistry, less than half felt they were adequately trained in treating medically compromised patients and only one-third felt they had received adequate training in the clinical care of residents of aged care facilities. There were no differences in attitudes towards the level of education and training by gender, age or number of years practising as a dentist.

Table 1.   Dentists’ practice characteristics by gender (%)
 Male (n = 81)Female (n = 41)Total (n = 122)
Age group (years)
 ≤30 years11.525.616.2
 31–40 years24.423.123.9
 41–50 years25.630.827.4
 51+ years38.520.532.5
Years in practice
 ≤5 years13.925.617.8
 6–10 years15.223.117.8
 11–20 years17.720.518.6
 21+ years53.230.845.8
Type of practice
 Private practice96.397.495.8
 Public practice3.82.63.4
Location of practice
 Melbourne73.482.176.3
 Regional Victoria11.47.710.2
 Rural Victoria15.210.313.6
Received adequate undergraduate education and training in:
 Geriatric dentistry64.659.062.7
 Management of medically  compromised patients44.342.143.6
 Clinical care in RACFs38.528.935.3

DONs perceived little interest from dentists in providing dental care to residents of aged care facilities, although this was higher than the interest actually reported by the dentists (Table 2). Very few dentists reported being interested in providing dental care to residents of aged care facilities, with dentists who provided care to residents more likely to be interested in providing care (χ2 = 11.13, p = 0.025).

Table 2.   Perceived interest of dental care providers in providing dental care to residents of aged care facilities (%)
 Extremely interestedVery interestedInterestedSomewhat interestedNot interested
  1. 2 = 11.13, p = 0.025.

Opinions of DONs (n = 125) regarding the perceived interest of:
 Prosthetists23.024.124.118.410.3
 Hygienists16.711.127.813.930.6
 Private dentists 7.49.536.826.320.0
 Domiciliary dentists 13.818.526.220.021.5
 Public dentists 6.710.030.020.033.3
Interest of dentists who:*
 Provide care (n = 55)3.69.125.532.729.1
 Do not provide care (n = 57)0.01.715.527.655.2

Half of the dentists had provided dental care to residents of an aged care facility in the previous 12 months (Table 3). Dentists in rural and regional Victoria were more likely to have provided care to residents than dentists in Melbourne, and rural dentists appeared to be more interested in providing dental care. Dentists who felt they had received adequate training in geriatric dentistry were more likely to have provided care in the past 12 months.

Table 3.   Characteristics of dentists who were interested in providing care and who actually provided care (%)
 Provided careInterested in providing care
  1. (a)χ2 = 5.75, p = 0.056. (b)χ2 = 4.23, p = 0.040.

Gender
 Male (n = 81)54.525.0
 Female (n = 41)40.532.4
Age
 ≤30 years (n = 19)57.936.8
 31–40 years (n = 27)33.325.9
 41–50 years (n = 30)56.736.7
 51+ years (n = 36)52.814.3
Practice type
 Private practice (n = 110)50.027.5
 Public practice (n = 4)50.025.0
Location of practice(a)
 Melbourne (n = 85)43.522.4
 Regional Victoria (n = 12)58.333.3
 Rural Victoria (n = 16)75.046.7
Received adequate training in geriatric dentistry(b)
 Yes (n = 70)57.130.0
 No (n = 43)37.223.3
Received adequate training in managing medically compromised patients
 Yes (n = 51)52.035.3
 No (n = 61)48.419.7
Received adequate training in clinical care in RACFs
 Yes (n = 40)60.035.0
 No (n = 71)43.722.5

For those dentists who had provided care in RACFs in the previous 12 months, 79.7 per cent had provided care to residents of only one or two facilities, 18.6 per cent to 3–4 homes and only 1.9 per cent to five or more facilities. These dentists spent an average of 1.04 hours per month providing dental care in RACFs, with male dentists spending significantly more time (1.31 hours per month) than females (0.25 hours per month) providing dental care (t-test, p = 0.010). Dentists who provided care to residents of aged care facilities reported that they most frequently provided this care at their own practice (86.2 per cent), with 53.4 per cent providing care at the RACF and 3.4 per cent providing care at a public hospital. Dentists who reported that they were interested in providing care were more likely (67.7 per cent) to have provided care in the last 12 months than dentists who were not interested (42.0 per cent) (χ2 = 5.96, p = 0.015).

Dentists and DONs strongly supported regular dental examinations for residents, with more than 40 per cent stating that examinations should be conducted on admission to the RACF and at regular intervals for dentate residents, and nearly 50 per cent stating that examinations should be conducted every 6–12 months for dentate residents. For edentulous residents, 38.0 per cent of DONs and 27.5 per cent of dentists thought examination on admission and at regular intervals was required, and one-third advocating 6–12 monthly examinations. Nearly 20 per cent of dentists and DONs thought that edentulous residents needed an examination only as problems arose.

Only 40.0 per cent of DONs reported that they were able to readily obtain dental care for their dentate and edentulous residents, with no differences between regional and metropolitan areas. Private practice dentists were the dental care providers most likely to have provided dental care to residents, with 61.8 per cent of RACFs having care provided by a private dentist, 54.0 per cent by dental prosthetists, 38.7 per cent from a publicly funded domiciliary service, 21.0 per cent from a public dental service and only 10.5 per cent from a dental hygienist. Regional and rural RACFs were less likely to have had dental care provided by a public domiciliary dental service (χ2 = 29.76, p < 0.001) or a hygienist (χ2 = 5.74, p = 0.017). Only 54.8 per cent of DONs reported that dental care was provided at their facility, while 70.2 per cent reported that care was provided for their residents at a private dental practice. Regional and rural RACFs were less likely to have dental services provided on the premises (χ2 = 6.05, p = 0.014), and were more likely to have had care provided at a private practice (χ2 = 10.01, p = 0.002) or community health centre (χ2 = 6.15, p = 0.013).

Dental care providers were not commonly a source of education for RACF staff regarding dental care, with most information coming from journals and books, in-house training sessions run by nurses, or audio-visual media on dental hygiene care. Nearly one-third of DONs reported that their staff did not receive any education on dental care for their residents, while one facility reported receiving their only education from a speech pathologist, and another reported that their only source of education on dental care came from the basic training offered to nurses and personal care assistants.

Dentists and DONs were asked to rate the frequency of various factors impacting on the organization and provision of dental care for residents of aged care facilities (Table 4). The most frequently reported problems encountered by dentists were: a preference to treat residents at their own practice; no portable equipment available to provide care in; dentists not willing to go to RACFs; and no suitable area for dental treatment at RACFs. The most frequently reported problems encountered by DONs were: dentists preferring to treat residents at their practice; dentists not willing to come to RACFs to provide dental treatment; no portable equipment available for dentists to use; and difficulty transporting residents to dental practices.

Table 4.   Problems encountered with the provision and organization of dental care for residents – always/frequently (%)
 DONs (n = 125)Dentists (n = 122)
  1. 2– p < 0.05.

Disinterest of dentists*57.162.9
Dentists prefer to treat residents at their own practice 83.592.5
No portable equipment available to use in RACFs 76.584.0
Poor training of dentists in geriatric dentistry*46.837.1
Low financial reimbursement for dental treatment50.058.4
No suitable area for treatment in facility*39.770.6
Dentists not willing to go to RACFs80.076.0
RACF staff time constraints*37.945.7
Knowledge of RACF staff*36.159.8
Transport of residents to a dental clinic*68.949.5
Low priority given to dental care by RACF staff*30.666.0
Dislike of providing regular oral hygiene by RACF staff*13.147.1
Financial constraints of residents*61.242.3
Obtaining patient consent20.521.0
Behavioural problems of residents46.733.0
Cognitive status of residents57.050.0
Families’ lack of interest28.736.9
Medical problems of residents26.449.5
Disinterest of residents about their dental health47.952.9

A number of variables were modelled using logistic regression to identify dentists’ characteristics that influenced whether they were interested in providing dental care to residents of aged care facilities (Table 5). Older dentists and those who preferred to provide dental care at their dental practice were less likely to be interested in providing dental care to residents of aged care facilities. Rural dentists and dentists who thought they received adequate undergraduate education and training in the clinical care of medically compromised older adults were more likely to be interested in providing dental care for residents.

Table 5.   Logistic regression – dentists who were interested in providing dental care to residents of aged care facilities
 p-valueOdds ratio95% CI
lowerupper
  1. *p < 0.05 (ref) – reference group.

  2. Nagelkerke R2 = 0.253.

  3. Hosmer & Lemeshow Test –χ2 = 6.56, p = 0.585.

Age
 <30 years (ref)0.0591  
 31–40 years0.7300.770.183.32
 41–50 years0.5851.480.366.00
 51+ years*0.0360.160.030.88
Female0.3370.590.201.74
Location of practice
 Melbourne (ref)0.1421  
 Regional Victoria0.8421.180.235.96
 Rural Victoria*0.0484.551.0120.41
Adequate training in geriatric dentistry0.3800.540.132.15
Adequate training in medically compromised patients*0.0205.071.3019.79
Dentists who prefer providing care at dental practice*0.0250.130.020.77

Dentists’ characteristics were modelled using logistic regression to identify those who had actually provided dental care to residents in the past 12 months (Table 6). Dentists who practised in rural Victoria, thought they had received adequate training in the management of medically compromised patients and who were interested in providing care were more likely to have provided dental care. Dentists who thought that there were no suitable areas for dental treatment at an RACF were less likely to have provided care.

Table 6.   Logistic regression – dentists who provided dental care to residents of aged care facilities in the previous 12 months
 p-valueOdds ratio95% CI
lowerupper
  1. *p < 0.05 (ref) – reference group.

  2. Nagelkerke R2 = 0.333.

  3. Hosmer & Lemeshow Test –χ2 = 5.61, p = 0.690.

Gender (Male)0.0702.880.929.05
Age (<30 years)0.1470.370.101.42
Location of practice
 Melbourne (ref)0.1071  
 Regional Victoria0.8380.840.174.31
 Rural Victoria*0.0387.031.1244.23
Adequate training in geriatric dentistry0.5181.520.435.37
Adequate training in medically compromised patients*0.0434.601.0520.08
Adequate training in clinical care in RACFs0.3362.030.488.55
Interested in providing care*0.0134.511.3714.86
Barriers to the provision of dental care
 Lack of portable equipment0.2610.390.072.03
 Prefer to treat at practice0.1305.870.6057.93
 No suitable area for dental  treatment at RACF*0.0280.220.060.85

There was almost unanimous agreement from both dentists and DONs in support of the role of dental hygienists in the provision of dental care for residents of aged care facilities. More than 90 per cent of DONs and nearly 85 per cent of dentists were in favour of changes to the Code of Practice for dental hygienists that would allow them to provide periodontal and oral hygiene care to residents prior to residents being examined by a dentist. Many of the DONs thought that changes to the Code of Practice would improve access to services for their residents, and that changes that would allow direct access to a hygienist would improve the oral hygiene of the residents. Many dentists also agreed that changes would improve access to dental care.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

The overall response rate from DONs was considered high, with a greater response rate from regional DONs (73.4 per cent) than those from metropolitan Melbourne (58.8 per cent). It may be that regional and rural RACFs experience greater difficulty in accessing dental care, with no public domiciliary service available, and this prompted more responses. There was a lower response rate from dentists, although the age and gender profile of the respondents was similar to that of the register from which the sample was selected, so it is likely that they are broadly representative of Victorian dentists.

Despite recent health policy activity in Victoria, the provision of dental care for residents of aged care facilities in Victoria was low, as reported by both dentists and DONs. Only half of the dentists reported providing care to residents, for an average of one hour per month to only one or two facilities. This is similar to the amount of care reported by Adelaide dentists.13 It is unlikely that much preventive care is being provided given the small amount of time spent in homes, with only emergency and symptomatic treatment likely to be provided. This is despite the majority of dentists indicating that residents required regular 6–12 monthly examinations. Therefore, it is more likely that residents will continue to develop dental problems because regular care is not provided. Although Victorian dentists were providing a similar amount of care as Adelaide dentists, only 40 per cent of Victorian DONs felt they were able to obtain adequate care for their residents compared with more than 70 per cent of Adelaide DONs.

Dental care was provided from both the private and public sector, although this varied depending on the location of the RACF. Facilities in regional and rural areas were more likely to rely on private dental care providers to provide care for their residents, while facilities in metropolitan Melbourne had the benefit of the public domiciliary service and dental hospital to provide care. The reluctance of many dentists to provide care in RACFs combined with the difficulties DONs identified in organizing transport for residents to dental practices means that many residents are reliant on a specialized domiciliary service, which are not currently available in regional and rural areas.

There is an obvious reluctance for dentists to become involved in the provision of dental care outside of the comfort of the dental surgery environment. Programmes that provide portable equipment and support for dentists to provide dental care in RACFs are required, as well as financial reimbursement for eligible public patients who could not otherwise afford to be treated by a private dentist but are unable to be seen by a public dentist.21

Dental prosthetists were an important provider of dental services for residents, however dental hygienists were not often utilized, particularly in regional and rural areas. This lack of involvement of hygienists in RACFs highlights concerns raised previously, where there was a low utilization of dental hygienists to provide care in Adelaide RACFs.13 Dental hygienists are ideally suited to provide preventive and periodontal care to residents and assist in health promotion and education activities for the staff of RACFs, areas which are critically lacking at present. There was strong support from Victorian dentists and DONs for the increased utilization of dental hygienists in RACFs. This may be due to recognition of the health promotion and education role that hygienists can offer, in conjunction with an understanding of the importance of maintaining adequate oral hygiene for residents. There was almost unanimous agreement from dentists and DONs to change the regulations governing the scope of practice for dental hygienists in Victoria, to allow them to provide preventive and periodontal dental care directly to residents of aged care facilities without the prior examination of a dentist.

Chalmers et al.13 noted the urgent requirement to increase the education in geriatric dentistry for current and future dental professionals through undergraduate, postgraduate and continuing professional development courses, and the results of this study support this. Although many dentists felt capable of managing older adults in general, the majority felt they had received inadequate education in the provision of clinical care to residents of aged care facilities and management of medically compromised patients. Dentists who believed that they were better trained in dealing with patients with complex medical problems were more likely to be interested in providing care and to have actually provided dental care to residents. Dentists appeared to lack confidence in providing clinical care outside of their own clinical environment, and this may be a result of inadequate undergraduate experience in providing dental care in the RACF environment. Undergraduate education and continuing professional development should focus on clinical care on-site in RACFs. The other significant barrier to the provision of dental care on-site was the lack of portable dental equipment and a suitable area to provide dental treatment. There needs to be readily available portable dental equipment for private dentists interested in provided care in RACFs, as is currently occurring as part of a South Australian Dental Service pilot project.21 Other mechanisms may involve the Victorian Branch of the Australian Dental Association and their regional subgroups to link local practitioners with RACFs and provide continuing education and support.

Although the questionnaire asked for the opinions of DONs regarding the involvement of dental prosthetists and dental hygienists in dental care for residents of aged care facilities, neither of these professional groups was included in the study. Further research on their level of interest and involvement in the provision of dental care to residents is required, particularly with regard to screening and identification of dental problems.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

The majority of Victorian dentists surveyed were not interested in providing dental care for residents of aged care facilities, and had low participation in the provision of care. Not only were dentists not caring for residents, they were also not involved in providing oral health education and support for the staff of RACFs. Dentists had a strong preference for treating patients at their own practice, and were reluctant to travel to RACFs to provide care. Lack of portable equipment and space to provide treatment in facilities were identified as significant barriers to the provision of care to residents. Lack of adequate undergraduate education in the care of residents was identified as a significant issue.

Despite acknowledging the important role that hygienists could play in the provision of dental care for residents, and support from dentists and DONs for increasing the scope of practice, very few hygienists were involved in the provision of care in Victorian RACFs.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

The research described in this paper was supported by the Victorian Department of Human Services and the Cooperative Research Centre for Oral Health Sciences (CRC-OHS). The CRC-OHS’s activities are funded by the Australian Government’s Cooperative Research Centres program. The authors would like to thank Geoff Adams for providing statistical advice and Clare McNally for her assistance in data collection and entry.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References
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