National Guide

Chapter 11 | Oral and dental health







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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    12. Chapter 11 | Oral and dental health

Oral and dental health

Prof Julie Satur

Key messages

  • Oral diseases (tooth decay, gum disease, tooth erosion, oral cancers) have significant impacts on general health, eating, sleeping, self-esteem and social participation.
  • Cleaning the teeth and mouth twice a day using fluoride toothpaste reduces decay and improves gum health.1
  • Sugars are metabolised to produce acid that demineralises teeth. Reducing sugar consumption reduces dental decay.2
  • Water (especially fluoridated) is the best choice of drink. 1–3
  • Regular mouth checks help with prevention and early intervention.4,5
  • The role of primary healthcare providers is critical to promoting oral health, identifying oral diseases and providing preventive advice and appropriate referral.
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Children aged 0–5 years Undertake an oral health review including the assessment of teeth, gums and oral mucosa, as part of a regular health check (Box 1)

Consider risk behaviours (sugar intake, smoking, alcohol), fluoride exposure and disease symptoms (eg pain)

Provide preventive advice or referral to dental practitioner if required/possible		 Opportunistically (with parents) and as part of an annual health check Strong National guidelines5,6 Early childhood caries can occur at any age after teeth erupt, and can lead to hospital admissions; look for white or brown spots that do not brush off
People aged 6–18 years Annually Strong Judgment statement7 Risk-based recall period recommended
Adults with poor oral health and/or risk factors for dental disease Annually Conditional Judgment statement7 Interval dependent on risk
People with diabetes, immunosuppression, haematological conditions, bleeding disorders or anticoagulant therapy Regularly check oral health and plaque control (oral hygiene) with review of condition Strong National guideline4 Consider bidirectional effects of oral health and condition, and impact of medications
All pregnant women At first antenatal visit Strong National guidelines2,5,6 Improving oral health and treating oral disease in the mother improves oral health for the infant
Encourage breastfeeding
Adults with good oral health Every two years Strong Judgment statement7 Support good practices
People with a  past history of rheumatic heart disease or with risk factors for subacute bacterial endocarditis and cardiovascular abnormalities Every six months Strong National guideline4 Gingival bleeding, periodontal disease and dental decay are risk factors for infections

Good oral hygiene is important for the prevention of bacteraemia
 
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people Advise healthy diet and minimising sugar consumption, including sugary drinks

Promote water as the main drink
                                                                    		 Opportunistically and as part of annual health check Strong National guideline2 A healthy diet supports oral and dental health, especially avoiding acidic and high-sugar foods and drinks
 
Type of preventive activity - Medication (fluroide) 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Children aged 0–18 months Teeth should be cleaned without toothpaste by a responsible adult where water is fluoridated

In areas where water is not fluoridated, earlier use of fluoride toothpaste is recommendedA		 Daily Strong National guideline3 Fluoride strengthens and remineralises enamel and protects against dental caries
Children aged 18 months – 5 years Recommend the use of toothpaste containing 500–550 mg/g fluoride at least once daily from the time the teeth start to eruptA Twice daily Strong National guideline3 Fluoride strengthens and remineralises enamel and protects against dental caries
People aged over 6 years Recommend the use of toothpaste containing 1,000–1,500 mg/g fluoride twice daily

Advise to spit out the toothpaste, not to swallow it and not to rinse		 Twice daily Strong National guideline3 Fluoride strengthens and remineralises enamel and protects against dental caries
Children aged 18 months – 5 years where families have evidence of tooth decay and/or poor oral hygiene Application of a fluoride varnish from the age of 2 years by a dental team or trained medical, health or Aboriginal health practitioner where appropriate

If resources do not permit, then recommend the daily use of fluoride toothpaste and provide dietary advice		 At least every six months and for a period of not less than 24 months Strong National guideline3 Fluoride strengthens and remineralises enamel and protects against dental caries
People aged 5 years and over at high risk of tooth decay (Box 2) Two to four times per year for professional application of fluoride varnish Conditional National guideline3 Requires assessment of risk and fluoride intake
 
Type of preventive activity - Medication
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People at high risk of endocarditis (rheumatic heart disease, previous infective endocarditis, prosthetic cardiac valves, certain forms of congenital heart disease, cardiac transplantation) Consider antibiotic prophylaxis prior to dental procedures (refer Useful resources Therapeutic guidelines and ARF and RHD guidelines) Opportunistically Strong National guideline4 Refer to Therapeutic Guidelines (see Useful resources)
 
Type of preventive activity - Environmental 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Communities Advocate for fluoridation of community water supply Opportunistically Strong National guidelines3,8 Fluoride strengthens and remineralises enamel and protects against dental caries
 
AUse a smear of paste for children aged <18 months and a pea-size amount for children aged 18 months – 5 years with a child-sized soft toothbrush. Toothpaste with a fluoride concentration of 500–550 ppm (0.5–0.55 mg/g fluoride) for children aged under 18 months and 1,000 ppm for children aged over 18 months is recommended, unless there is a risk of fluorosis. Toothpaste should be used under the supervision of a responsible adult; young children should not be permitted to lick or eat toothpaste.3
BFor teenagers, adults and older adults who do not consume fluoridated water or who are at elevated risk of developing caries, dental professional advice should be sought to determine whether they should brush more frequently, use a fluoride mouth rinse or use a toothpaste containing a higher concentration of fluoride (5 mg/g or 5,000 ppm).3
 
Box 1. Oral health for non-dental health professionals

Although review with dental professionals is recommended to comprehensively assess for caries risk and the presence of disease, the following general principles are recommended for non-dental professionals:

Assessment

  • Visual inspection of the teeth for evidence of caries, periodontal disease and oral mucosal abnormalities, as well as assessment of facial swellings, pain, maternal caries and/or oral hygiene (plaque levels and gingival inflammation)
  • Assessment of oral hygiene practices
  • Assessment of water consumption and access to fluoridated water supply
  • Identification of barriers to oral health

Advice

  • Brush teeth twice daily with a soft toothbrush and fluoride toothpaste and advise to spit out, not rinse, excess paste
  • Advise about the hazards of high-carbohydrate and high-sugar or acidic snacks and drinks, especially between meals
  • Encourage water as the preferred drink. Advise against high and regular consumption of black cola, sweetened fizzy drinks and sports drinks, especially between meals
  • Where risk and/or disease levels are high, provide advice about fluoride use
  • Gingival inflammation (bleeding) can usually be resolved with regular brushing of teeth and interdental cleaning
  • Promote breastfeeding, with weaning to a baby cup, not a bottle. Discourage the consumption of sugars and sweetened drinks by young children, especially in baby bottles, ‘honey on the dummy’ or other sweet substances (eg such as glycerine) on the dummy and the intake of sugared medicines
  • If bottles are used, advise against the use of any fluid apart from water or milk, and do not put the baby to sleep with a bottle
  • Advise about smoking cessation and limiting alcohol consumption
  • Use sugar-free chewing gum for saliva stimulation
  • Use a mouth guard when playing contact sport
  • Recommend regular dental check-ups
  • Support water fluoridation
Box 2. Risk factors for dental disease
  • Low exposure to fluoride
  • Poor diet and nutrition (eg high and regular consumption of sucrose- and carbohydrate-containing foods and drinks, especially black cola and sweetened fizzy drinks)
  • Tobacco smoking and alcohol consumption, which are risk factors for the development of oral cancer, with the risk enhanced when smoking and alcohol consumption occur at the same time
  • Poor oral hygiene practices (eg no/irregular toothbrushing, using a hard toothbrush, no use of fluoride toothpaste, inadequate brushing technique)
  • Poor salivary composition and flow, reducing the protective effect of saliva
  • Unmanaged xerostomia or dry mouth, which can also contribute to development of tooth decay. Risk factors for xerostomia include dehydration and many common medications (eg antidepressants, antihypertensives, anticoagulants, antiretrovirals, hypoglycaemics, non-steroidal anti-inflammatory drugs and steroid inhalers), radio- and chemotherapy for cancers of the head and neck, Sjögren’s syndrome, human immunodeficiency virus (HIV) infection and diabetes, particularly in people with poor glycaemic control
  • High consumption of acidic foods and drinks, such as sports drinks and juices, which can contribute to tooth erosion; bulimia is also an erosion risk factor
  • General risk factors for periodontal disease include smoking, diabetes, advancing age, stress and poor oral hygiene
  • HIV infection can also contribute to a greater risk of periodontal disease, oral ulceration and cancer
 
​Box 3. Guidelines for the use of fluorides: Summary
  • From the time that teeth first erupt (about six months of age) to the age of 17 months, children’s teeth should be cleaned by a responsible adult, but not with toothpaste.
  • For children aged between 18 months and five years (inclusive), the teeth should be cleaned  twice a day with toothpaste containing 0.5–0.55 mg/g (500–550 ppm) fluoride. Toothpaste should always be used under the supervision of a responsible adult. A small pea-sized amount should be applied to a child-sized soft toothbrush and children should spit out, not swallow, and not rinse. Young children should not be permitted to lick or eat toothpaste. Standard toothpaste is not recommended for children aged under six years unless on the advice of a dental professional or a trained health professional.
  • For people aged six years or more, the teeth should be cleaned twice a day or more frequently with standard fluoride toothpaste containing 1–1.5 mg/g (1,000–1,500 ppm) fluoride. People aged 6 years or more should spit out, not swallow, and not rinse.
  • For people who do not consume fluoridated water or who are at elevated risk of developing caries for any other reason, guidelines about the use of toothpaste should be varied, as needed, based on dental professional or trained health professional advice. Variations could include more frequent use of fluoridated toothpaste, starting toothpaste use at a younger age or earlier commencement of the use of standard toothpaste. This guideline may be applied particularly to preschool children at elevated risk of caries.
  • For teenagers, adults and older adults who are at elevated risk of developing caries, dental professional or trained health professional advice should be sought to determine whether they should use toothpaste containing a higher concentration (5 mg/g or 5,000 ppm) of fluoride.
  • Children below the age of six years should not use fluoride mouth rinse.
  • Fluoride mouth rinse may be used by people aged six years or more who have an elevated risk of developing caries. Fluoride mouth rinse should be used at a time of day when toothpaste is not used, and it should not be a substitute for brushing with fluoridated toothpaste. After rinsing, mouth rinse should be spat out, not swallowed.
  • High-concentration fluoride gels (those containing more than 1.5 mg/g fluoride ion) may be used for people aged 10 years or more who are at an elevated risk of developing caries.
  • Include oral and teeth checks in general health checks
  • Provide toothbrushes and toothpaste when available (from government dental services in some jurisdictions)
  • Work with local dental services to establish clear and accessible referral pathways, including for emergency dental services
Clinical guidelines

Health promotion resources

Background

Oral health is fundamental to overall health, wellbeing and quality of life. A healthy mouth enables people to eat, speak and socialise without pain, discomfort or embarrassment. Dental disease is one of the most prevalent and costly diseases in our community and, in Australia, oral health is a significant marker of social inequality. Poor oral health erodes self-esteem and impacts social participation, school attendance, employment and job seeking. In addition to affecting people's ability to fully participate in society, poor oral health is associated with low socioeconomic status. Further, there is increasing evidence of associations between poor oral health and systemic health, including diabetes, Alzheimer’s disease, cardiovascular diseases and some cancers.9,10 Given that approximately half of the Australian population has poor access to dental care, the role of primary healthcare providers is critical to identifying oral diseases and providing preventive and referral advice, including oral health in general health.

The impacts of colonisation,9 assimilation, exclusion, racism and victim blaming, along with corporatisation of food supplies, food insecurity, maldistribution of fluoridated water supplies and remote living, combine as social determinants of health that create inequitable barriers to achieving oral health for Aboriginal and Torres Strait Islander people.11,12 Shame, lack of trust, cultural insecurity and low income also inhibit access to dental services. Despite recent leadership from the Australian Health Practitioner Regulation Agency around cultural safety and racism in healthcare, the outcomes of these new policies have not yet been widely seen at service level. Access to care is also limited by the maldistribution of the oral and dental health workforce in rural and remote areas, very low participation by Aboriginal and Torres Strait Islander people in the dental workforce, structural impediments to the provision of preventive services by dental assistants13 and the particularly low level of funding of public dental programs, both generally and particularly in Aboriginal Community Controlled Health Organisations. Although higher numbers of Aboriginal and Torres Strait Islander people live in major cities, there is a higher representation of Aboriginal and Torres Strait Islander people in rural and remote locations.

Nationally, Aboriginal and Torres Strait Islander adults have greater levels of tooth decay (dental caries) than non-Indigenous Australians, with higher levels of untreated caries and missing teeth and lower numbers of filled teeth. For Aboriginal and Torres Strait Islander children, the rate of current and past decay in deciduous (first) teeth and adult teeth is at least three- and twofold greater, respectively, than for non-Indigenous Australian children, with higher experience of disease in remote communities. The proportion of untreated dental caries and hospitalisations for dental conditions is also higher among Aboriginal and Torres Strait Islander children, which often reflects a lack of access to dental services.12,14,15

Oral diseases

The two main dental diseases are tooth decay (dental caries) and gum (periodontal) disease. Tooth decay is caused by is localised infection and destruction of the hard tissues of the teeth that starts when organic acids, which may come from metabolised sugars, cause demineralisation of tooth enamel. Dental plaque, a complex biofilm that builds up on teeth, contains bacteria that produce acids after fermenting carbohydrates found in food and drinks. The rate of enamel destruction increases with frequent exposure to fermentable carbohydrates and poor oral hygiene. The impact of dental caries is cumulative over a lifetime, so early prevention and intervention can have lifelong effects. 

Tooth decay is considered to be a multifactorial disease, with some of the contributing factors being diet (especially high and regular consumption of sugar- and carbohydrate-containing food and drinks, such as black cola, sweetened fizzy drinks and sports drinks), inadequate exposure to fluoride (in water and toothpastes), lack of toothbrushing and salivary composition and flow. Xerostomia (dry mouth) may also contribute to the development of dental caries. Risk factors for xerostomia include inadequate water consumption (leading to dehydration), many medications (eg including antidepressants, antihypertensives, anticoagulants, antiretrovirals, hypoglycaemics, non-steroidal anti-inflammatory drugs and steroid inhalers), illicit drug use, radio- and chemotherapy for cancers of the head and neck and Sjögren’s syndrome.15,16

Important general risk factors for periodontal disease (ie disease of the gum and supporting tissues characterised by gum [gingival] inflammation, bleeding and loss of attachment, and with acute or advanced disease, pain and tooth mobility and bone inflammation) include poor oral hygiene, smoking, diabetes, poor diet, stress and hormonal imbalances. Hormonal imbalances can exacerbate inflammatory reactions to dental plaque during puberty, pregnancy, in women taking oral contraceptives and at the postmenopausal stage. Although data are limited, the prevalence of periodontal disease appears to be greater in Aboriginal and Torres Strait peoples compared with non-Indigenous Australians.13 The risk of periodontitis is increased two- to threefold in people with diabetes compared with individuals without diabetes, and the effects are bidirectional in that severe periodontitis is also associated with an increased risk of developing diabetes. High blood glucose levels can cause dry mouth, which can lead to plaque build-up on the teeth and tooth decay. Excess glucose in the blood can also feed bacteria in the mouth, leading to tooth decay and oral thrush. Inflammation from periodontitis (gum disease) drives blood glucose levels up and makes managing diabetes difficult. In people with type 2 diabetes, periodontitis is associated with higher HbA1c levels and worse diabetes complications. Treatment of pre-existing periodontitis has demonstrated small but significant improvements in glycaemic control for people with type 2 diabetes, underscoring the importance of regular oral health assessments and treatment in this population.17

There is growing evidence that periodontitis is also associated with other systemic conditions, such as cardiovascular disease, stroke, obesity, cancer and dementia.9,10,18 Holistic approaches to common risk factor reduction that address plaque accumulation on the teeth and gums, smoking cessation, reduced sugar consumption and weight control are likely to confer multiple health benefits related to periodontal disease, dental caries, diabetes, heart disease, some cancers and social and emotional wellbeing. HIV infection can also contribute to a greater risk of periodontal disease, oral ulceration and cancer.4

Other major oral and dental conditions of concern are oral cancer, tooth erosion (hard tissue degradation of the teeth by acids such as those found in acidic foods and drinks, and in patients with bulimia, whose teeth are susceptible to acid attacks from frequent vomiting) and oral trauma (eg through sports injuries, transport accidents and assault). Tobacco smoking, e-cigarettes and alcohol consumption are risk factors for periodontal disease and for the development of oral cancer, and the risks from these exposures are additive.4,18–20

Standard preventive measures against dental caries are twice-daily toothbrushing using fluoride-containing toothpaste, minimising sugar and maximising water consumption and referral for a professional dental check where disease is identified by a primary health practitioner.

Fluorides and oral hygiene

Toothbrushing with a fluoridated toothpaste cleans the teeth and removes food particles, while the fluoride works to strengthen the enamel against demineralisation by bacteria-related acids. Drinking fluoridated water is also effective in preventing enamel demineralisation.1,3 There is only very weak evidence to suggest that mouth rinses containing chlorhexidine and essential oils (less effective) as adjuncts to toothbrushing help to control gingivitis (gum inflammation) and periodontal disease.1

Fluoride varnish is a resin paste with a high fluoride concentration (5% sodium fluoride, 22,600 ppm [22.6 mg/mL] fluoride), which, when applied every six months over at least two years, is effective in preventing caries (tooth decay) in young children, adolescents and adults.1 Fluoride varnish is applied as a thin coating to the tooth surface and provides a highly concentrated, temporary dose of fluoride to the tooth. After specific training, GPs, community nurses, other health workers and Aboriginal health practitioners in most jurisdictions are able to apply fluoride varnish in coordination with the dental team.1,13
 
Because dental caries is considered to be a bacterial infection, improving oral health in pregnant women can lower the risk of transmitting harmful oral bacteria to a newborn. Restoring active dental decay and oral hygiene to promote gingival health in the pregnant woman may reduce risk.5 During pregnancy there may also be a greater risk of tooth erosion from nausea and vomiting, and progression of periodontal disease.1,2,5,6 Rinsing the mouth with water after vomiting and delaying tooth brushing for 30 minutes is recommended to avoid damaging the softened enamel surface (erosion) due to high acid levels.5 The use of fluoride supplements is not recommended in pregnancy because there is no evidence of their effectiveness.3

For people at risk of periodontal disease, twice daily toothbrushing with a fluoridated toothpaste and attention to diet and water consumption, along with other interventions as recommended by dental practitioners for interdental cleaning, such as dental flossing, are also recommended.1

Diet

Sugars are metabolised to produce acid that demineralises teeth. Reducing sugar consumption overall benefits oral health as well as general health. Limiting the frequency of sweet foods and drinks in the diet, particularly between meals, reduces the frequency of acid attack and demineralisation (softening) of enamel. Soft drinks, especially cola and sports drinks, contain high concentrations of sugar, food acids and caffeine, which dehydrates. Lollies and other hard or chewy sweets release sugar into the saliva, which is metabolised to acid, over long periods of time. Fresh fruit and vegetables are better choices than juice or dried fruit; fruit juices often contain high levels of sugar and food acids to add flavour, and dried fruits have concentrated sugar that sticks to the teeth. Unsweetened dairy products, such as natural yoghurt and milk, make good snacks, and eating a piece of cheese or nuts after consuming sugary foods will help protect teeth against decay. Encouraging water as the main drink will also reduce sugar consumption, dilute mouth acids, increase hydration and reduce the risk of dry mouth.2

Oral cancer screening

Oral mucosal diseases are common and can be due to physiological changes, local disease, oral manifestation of a skin condition, an adverse drug reaction or systemic disease, or they may be early indicators of oral cancer. So, primary health practitioners should examine the teeth, gums and oral mucosa for any changes from normal, particularly in older people and those who use tobacco and alcohol.5

Oral health and comorbidities

Antibiotic prophylaxis is important in preventing infective endocarditis (IE) prior to specific dental procedures in people who are at high risk of IE, including people with prosthetic valves, previous infective endocarditis, certain congenital heart conditions and cardiac transplantation. This is particularly important for Aboriginal and Torres Strait Islander people given their much higher rates of rheumatic heart disease. The maintenance of good oral health, combined with six-monthly checks and oral hygiene guidance to prevent gingival bleeding, are advised to reduce the need for invasive procedures and the risk of infective endocarditis.4

There are various conditions, and their treatments, that require the achievement and maintenance of good oral health, or treatment considerations to prevent systemic complications or infection. The conditions that require special consideration for dental care and treatment include cancers, bleeding disorders, bone and metabolic disorders, cardiovascular and respiratory conditions, the use of immunocompromising medications, musculoskeletal disorders, neurological and psychological disorders, hepatitis, kidney diseases and organ transplant. Management advice is provided in the oral health section of the Therapeutic Guidelines to support the care of these patients.4

  1. Welti R, Chinotti M, Walsh O, et al. Oral health messages for Australia: A national consensus statement. Aust Dent J 2023;68(4):247–54. doi: 10.1111/adj.12973.
  2. Dental Health Services Victoria (DHSV). Oral health advice. DHSV, 2023 [Accessed 11 April 2024].
  3. Do LG. Guidelines for use of fluorides in Australia: Update 2019. Aust Dent J 2020;65(1):30–38. doi: 10.1111/adj.12742.
  4. Oral and Dental Expert Group, Therapeutic Guidelines Limited. Oral and dental. In: Therapeutic guidelines. Therapeutic Guidelines Limited, 2021.
  5. Committee opinion no. 569: Oral health care during pregnancy and through the lifespan. Obstet Gynecol 2013;122(2 Pt 1):417–22. doi: 10.1097/01.aog.0000433007.16843.10.
  6. NSW Health. Early childhood oral health guidelines for child health professionals. 3rd edn. NSW Government, 2012 [Accessed 11 April 2024].
  7. National Health and Medical Research Council (NHMRC). Information paper – water fluoridation: Dental and other human health outcomes. NHMRC, 2017 [Accessed 11 April 2024].
  8. Bhuyan R, Bhuyan SK, Mohanty JN, Das S, Juliana N, Juliana IF. Periodontitis and its inflammatory changes linked to various systemic diseases: A review of its underlying mechanisms. Biomedicines 2022;10(10):2659. doi: 10.3390/biomedicines10102659.
  9. Sanz M, Marco Del Castillo A, Jepsen S, et al. Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol 2020;47(3):268–88. doi: 10.1111/jcpe.13189.
  10. McAuliffe A, Bourke C, Jamieson LM. Addressing the oral health needs of Indigenous Australians through water fluoridation. Med J Aust 2020;213(6):286-. e1. doi: 10.5694/mja2.50744.
  11. Jamieson L, Do L, Kapellas K, et al. Oral health changes among Indigenous and non-Indigenous Australians: Findings from two national oral health surveys. Aust Dent J 2021;66(Suppl 1):S48–55. doi: 10.1111/adj.12849.
  12. Australian Health Practitioner Regulation Agency (Ahpra). Aboriginal and Torres Strait Islander health strategy. Ahpra, 2020 [Accessed 2 May 2024].
  13. Dimitropoulos Y, Gwynne K, Blinkhorn A, Holden A. A school fluoride varnish program for Aboriginal children in rural New South Wales, Australia. Health Promot J Austr 2020;31(2):172–76. doi: 10.1002/hpja.266.
  14. Australian Institute of Health and Welfare (AIHW). 1.11 Oral health. In: Aboriginal and Torres Strait Islander health performance framework. AIHW, 2023 [Accessed 11 April 2024].
  15. Australian Institute of Health and Welfare (AIHW). Oral health and dental care in Australia. AIHW, 2023 [Accessed 11 April 2024].
  16. Villa A, Connell CL, Abati S. Diagnosis and management of xerostomia and hyposalivation. Ther Clin Risk Manag 2014;11:45–51. doi: 10.2147/TCRM.S76282.
  17. Preshaw PM, Bissett SM. Periodontitis and diabetes. Br Dent J 2019;227(7):577–84. doi: 10.1038/s41415-019-0794-5.
  18. Nazir MA. Prevalence of periodontal disease, its association with systemic diseases and prevention. Int J Health Sci (Qassim) 2017;11(2):72–80.
  19. RHD Australia (ARF/RHD writing group). The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3.2 edition, March 2022). RHD Australia, 2022 [Accessed 2 May 2024].




 

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