Mouth care

The purpose of this guideline is to provide guidance about mouth care at Great Ormond Street Hospital (GOSH).

NOTE: We review our guidelines regularly and this guideline is now past its review date. The content of the guideline below may not reflect the most recent evidence based practice. Please use with caution.

Introduction

The mouth is important for eating, drinking, speech, communication, taste, breathing and defence.

Oral hygiene is an integral part of total care. Assessment and planned interventions can help prevent, minimise or reverse changes in the oral cavity (Gibson and Nelson 2000).

The principal objective of oral care is to maintain the mouth in a good condition. 

It specifically aims to (Gibson and Nelson 2000):

  • Keep the oral mucosa clean, soft, moist and intact, thus preventing infection.
  • Keep the lips clean, soft, moist and intact.
  • Remove food debris/dental plaque without damaging the gingiva.
  • Allieviate pain/discomfort, thus enhancing oral intake.
  • Prevent halitosis and freshen the mouth.
  • Decrease the risk of oral and systemic infection.
  • Increase general well-being.

Oral physiology

The anatomy and physiology of the mouth is complex. There are two major functions of the mouth: digestion and non-specific defence. The oral cavity is the first part of the alimentary tract. The structures visible on examination are:

Diagram of mouth
Structures of the mouth visble on examination

The mucosal lining and saliva

The oral cavity is lined throughout with mucous membrane, consisting of stratified squamous epithelium, containing small mucus-secreting glands. Saliva is the combined secretions from the salivary glands and the small mucus-secreting glands of the lining of the oral cavity. Saliva consists of water, mineral salts, enzyme (salivary amylase), mucus, lysozyme, immunoglobulins and blood clotting factors.

The functions of saliva are (Waugh and Grant 2001):

  • Chemical digestion of polysaccharides by the enzyme amylase.
  • Lubrication of food so that it is ready to be swallowed.
  • Cleansing and lubricating the mouth, keeping the tissues soft, moist and pliable. It also helps prevent damage to the mucous membranes from rough and abrasive foods.
  • Lysozymes, immunoglobulins and clotting factors help combat invading microbes.
  • The taste buds are stimulated only by substances in solution. Dry foods once mixed with saliva are then able to stimulate the sense of taste.

The lips

These form a muscular entrance to the mouth. They are covered by squamous, keratinized epithelial tissue, which is vascular and very sensitive. They are necessary for ingestion of food, enunciation of words and to convey the mood of a person, eg smiling and grimacing.

The tongue

This is covered with mucous membrane from which project numerous papillae and taste buds on the upper surface. The tongue plays an important part in mastication (chewing), deglutition (swallowing), speech and taste (Waugh and Grant 2001).

The teeth

Although the shape of teeth vary, the structure is the same and consists of:

  • The crown – protrudes from the gum.
  • The root – embedded in the bone.
  • The neck – slightly narrowed region where the crown merges with the root.

The tooth consists of a pulp cavity that contains the blood vessels, lymph vessels and nerves.

Surrounding the pulp cavity is a hard substance called dentine. Outside the dentine of the crown is a thin layer, the enamel. This is a very hard substance. The root of the tooth is covered with a substance that resembles bone, called cement. This fixes the tooth into its socket. The functions of the teeth include biting off pieces of food, grinding and chewing food (Waugh and Grant 2001).

The first tooth normally erupts around six months of age, with the full complement of 20 deciduous teeth being acquired by the age of 24 months. Permanent dentition begins in the sixth year of age, with 32 teeth usually present by the 24th year (Waugh and Grant 2001). 

Compromised oral well-being

Pain and soreness in the mouth can cause an aversive reaction to food and eating, therefore the aim should be to minimize the ill effects. Children with a number of conditions may have compromised oral well-being.

Causes of compromised oral well-being

General conditions

Cerebral palsy, craniofacial surgery, accidents or other illnesses leading to neurological damage, unconsciousness, loss of a limb or maxillofacial injury, may lead to difficulty or inability to perform oral hygiene. This may result in the build up of dental plaque, dental caries and halitosis.
Physical complications such as orthodontic or maxillofacial surgery and craniofacial surgery can lead to restricted oral access, which may cause difficulty in performing oral hygiene.

Children with respiratory problems and/or an enlarged or protruding tongue, may be mouth breathers and consequently can experience dry mucosa with an increased risk of mucosal detoriation.

Friable mucosa may be experienced by children with epidermolysis bullosa (EB). In addition, dystrophic EB causes severe microstomia which can limit or prevent access to back molars.
Restricted movement of tongue due to surgery or pain may lead to ineffective removal of debris.

Chronic constipation may cause a foul mouth and odour.

Children with a cleft palate who may have a prothesis, are prone to developing pressure sores on their lips, gums and palate from food becoming trapped under the prosthesis. Patients should be advised to flush their mouths after food, medicine and milky drinks with 5-10 mls of water for two weeks post-operatively.
Children with Downs syndrome may habitually lick or bite their lips. They may also have a tendency towards thick, ropy, sticky saliva, which adheres to the surface of the teeth and lacks the natural cleansing properties of normal saliva. They may have deformed teeth that retain plaque. In addition, dry, cracked or inflammed lips may cause discomfort.

Mucositis and ulceration causing pain, infection and bleeding can arise in children with fragile mucosa, children receiving chemotherapy and children with EB.

Immunodeficiencies

Children with immunodeficiencies such as HIV, combined immunodeficiency or following treatment for cancer, may experience persistent candida infections and be at risk of bacteraemia/septicaemia. They may also have reduced production of protective immunoglobulins in their saliva resulting in an increased risk of infection.

Common childhood illnesses and dental habits

Measles is associated with Koplick spots in the mouth.

Fever may lead to a dry mouth and coated tongue.

Grinding of the teeth may result in mild/severe loss of tooth surface.

Thumb sucking can alter the position of teeth.

Poor nutritional intake

Anorexia, dehydration, metabolic disorders (requiring high intake of oral carbohydrates) and some types of glycoprotein storage disease, can result in vitamin deficiency, tissue vulnerability, an increase in dental caries and oral ulceration.

Foreign body in the nose

Commonly inserted into the nose are peas, peanuts and small toys. This may lead to a sudden foul odour in the mouth.

Drug induced

Antibiotics may alter the child's flora and increase the risk of opportunistic infections.

Antihistamines and atropine cause reduced salivary production.

Anticholinergics and tricyclic antidepressants may cause dry mouth.

Chlorhexidine-based mouthwash may result in temporary brown staining of teeth, a stinging or burning sensation or a bitter taste/altered after taste.

Corticosteroids can lead to delayed healing of tissue, gum hyperplasia, altered taste perception (often metallic) and absent or ropy saliva.

One of the most common side effects of cancer treatment (cytotoxic agents) is mucositis, a painful inflammation and ulceration of the mucous membrane (Kennedy and Diamond 1997). Detailed information about this group of patients can be found in the Mouth Care for Children and Young People with Cancer: evidence-based guidelines, available from the CCLG (Children's Cancer and Leukaemia Group) website.

Iron supplements can cause temporary green/black staining of teeth.

Long-term use of high sucrose content medication eg lactulose can lead to an increased incidence of dental caries.

Morphine can cause dry mucosa.

Nifedipine can lead to gingival enlargement.

Oxygen therapy may result in dry mucosa.

Phenytoin can cause enlarged gingiva.

Inhaled corticosteroids used for the treatment of asthma can increase the risk of candidiasis occcuring.

Methotrexate can cause stomatitis.

Ciclosporin can cause gingivitis and gingival enlargement. 

Definition of mucositis

Mucositis is a painful inflammation and ulceration of the mucous membrane and is one of the most common side effects of cancer treatment (Glenny et al 2004). The terms mucositis and stomatitis are often used interchangeably.

There are, however, some general distinctions. Mucositis describes a toxic inflammatory reaction that affects the gastrointestinal tract from the mouth to the anus, as a result of cytotoxic chemotherapy or ionising radiation. It appears as an erythematous, burn-like lesion or as random, focal-to-diffuse ulcerative lesions.

Whereas, stomatitis refers to any inflammatory reaction affecting the oral mucosa, with or without ulceration (National Cancer Insitute 2000). 

Dental disease in children with chronic illness

Poor oral health (tooth decay, gingivitis and periodontitis) in children with chronic illness, is a major cause of morbidity and can be a risk factor for severe and sometimes life-threatening complications.

Dental caries, left untreated, can result in pain and infection. Children who may be medically compromised, ie immunocompromised from effects of the disease or therapy, are at an increased risk of developing systemic complications from dental infections, which can be fatal. Poor oral health is a risk factor for candidiasis, bacteraemia and septicaemia, especially if the child is receiving immunosuppressant medications (Foster and Fitzgerald 2005).

Many chronic childhood diseases have been associated with poor oral health and increased risk of cavities. Some children with chronic disease have several risk factors for poor oral health. These include: social disadvantage, long-term exposure to sugar-loaded medicines and poor dietary habits.

Other factors compound the risk, such as learning disabilities and/or anxieties about medical/dental interventions. In addition preventative dental care may not be seen as a priority for these children (Foster and Fitzgerald 2005).

Chronic diseases associated with poor oral health and at high risk of caries (Foster and Fitzgerald 2005):

  • structural congenital heart disease

  • bleeding diatheses (eg haemophilia, leukaemia, or complication of immunosuppressive treatments)

  • chronic suppurative lung disease (eg cystic fibrosis)

  • epilepsy

  • diabetes mellitus – dry mouth

  • juvenile idiopathic arthritis 

  • inflammatory bowel disease

  • chronic renal disease

  • immunodeficiency

  • organ transplantation

  • craniofacial abnormalities 

Assessment of the oral cavity

To enable appropriate mouth care to be implemented, a through oral assessment is required. The oral assessment represents the vital first step in planning effective oral care (Gibson et al 2006). The assessement procedure should be explained to the child and family, including why the assessment is necessary and what it entails (Rationale 1).

Whenever possible the child should be involved in the assessment. When assessing the mouth of a young child, it is advisable to have a second adult present to support the child's head (Rationale 2 and 3).

A good source of light is required to examine the oral cavity (Rationale 4).

Standard (universal) precautions should be adopted and non-sterile gloves worn (Rationale 5).

The teeth should, if possible, be cleaned prior to the examining the oral cavity (Rationale 6 and 7).

An oral assessment tool such as the Oral Assessment Guide (OAG), is useful if recording the status of the oral cavity (Rationale 8)(Gibson et al 2006). This may need to be adapted for each clinical area, as this tool has been utilised primarily for children with cancer (Rationale 9).

Staff undertaking assessment of the oral cavity should be trained in the use of the OAG. Nursing staff may be best placed to perform regular assessment of a child's oral status (UKCCSG-PONF Mouth care group 2006). An example of a teaching package may be obtained from the authors of this document.

An effective oral assessment should involve the following eight aspects of the mouth

  1. swallow
  2. lips and corner of the mouth
  3. tongue
  4. saliva
  5. mucous membranes
  6. gingiva
  7. teeth
  8. voice

The OAG comprises eight categories that reflect oral health. Each category descriptor is assessed using a numerical scale of 1 to 3. A score of 1 = normal, 2 = mild alterations without severe compromise of either epithelial integrity or systemic functioning, and 3 = definate compromise. The eight subscale scores are added together to obtain an overall assessment score (minimum 8, maximum 24) (Gibson et al 2006).

Conditions that compromise oral well-being should also be considered when undertaking an oral assessment.

It is important to accurately record the assessment in the child's health care record and on the oral assessment score sheet (Rationale 10, 11, 12, and 13).

An effective oral assessment should involve examination of all eight categories (Rationale 14, 15, and 16).

Performing oral assessment using the OAG

(Gibson et al 2006; UKCCSG-PONF Mouth care group 2006)

Swallow

Ask the child to swallow or observe the swallowing process. Ask the parent if there are any notable changes. Observe the swallowing process to check the child's ability to do so, any pain experienced, or pooling/dribbling of secretions.

If there are any doubts about the swallow and gag reflex, the child should be referred to a speech and language therapist for further assessment.

Lips and corner of the mouth

Observe the appearance of tissue. It should be smooth, pink and moist. Check for any dryness, cracks, ulceration and bleeding

Tongue

Observe the appearance of the tongue using a pen torch to illuminate the oral cavity. The tongue should be pink and moist with papillae present. Check tongue for loss of papillae with a shiny appearance, fissures (cracking or splitting), presence of oral candida,redness, ulceration and sloughing (with or without bleeding).

Saliva

Observe the consistency and quality of saliva. Saliva should be thin and watery. Check for excess amount of saliva and drooling (excessive saliva may be present if child is teething). Observe for thick, ropy or absent saliva. 

Mucous membranes

Observe the appearance of the tissue using a pen torch to illuminate the oral cavity. The mucous membranes should be pink and moist. Observe for any redness or coating without ulceration, and/or oral Candida. Also any ulceration and sloughing with or without bleeding.

Gingiva

Observe the appearance of the tissue using a pen torch to illuminate the oral cavity. The gingiva should be pink or coral with a stippled (dotted) surface. The gum margins should be tight and well defined, with no swelling. Observe for the presence of oedema with/without redness, smooth gingivae, or spontaneous bleeding.

Teeth

Observe the appearance of the teeth using a pen torch to illuminate the oral cavity. The teeth should be clean with no debris present. Observe for the presence of plaque or debris in localised areas, or generalised along the gum margin. If the child has no teeth, score 1.

Voice

Talk to and listen to the child. Ask the parent if there are any notable changes. Assess for any deepness and/or raspiness. Check for absence of voice, difficulty or pain experienced when talking or crying.

Oral hygiene tools: implements

Toothbrushes

A small headed, soft, nylon bristled toothbrush, with round ended filaments should be used to brush/clean teeth (British Dental Health Foundation 2005; Department of Health 2009)(Rationale 17).

Toothbrushes should be changed every three months, or sooner if the bristles become splayed (British Dental Health Foundation 2005; UKCCSG-PONF Mouth care group 2006).

The tooth brush should be for the sole use of the child. It should be changed following an oral infection (UKCCSG-PONF Mouth care group 2006).

Toothbrushes should be changed daily if the child is undergoing bone marrow transplantation.

Electric toothbrushes

These have a rotating, oscillating and vibratory action, which are effective against short and long-term decay. Brushes that work with a rotation oscillation action remove more plaque and reduce gingivitis more effectively than a manual tooth brush (Robinson et al 2005).

As the bristles are hard, they are not advisable for children with a fragile mucosa.

An electric toothbrush may be useful for children with conditions that cause upper limb disability, for example juvenile idiopathic arthritis (Foster and Fitzgerald 2005) or children who find it difficult to use a manual toothbrush (Department of Health 2009).

Foam cleaning sponges

These can be used as a temporary measure, or combined with a toothbrush to remove debris and cleanse the mouth when a child is unable to brush their teeth effectively (Rationale 18). Foam cleaning sponges are ineffective at removing plaque (Pearson 1996).

Foam cleaning sponges are useful in the following situations:

  • When a child has no teeth – moisten sponges with water (UKCCSG-PONF Mouth care group 2006).
  • When a child has a platelet count below 20,000 with associated bleeding (Kennedy and Diamond 1997).
  • When a child has severe mucositis that prevents them from brushing their teeth – foam sponges can be moistened with water or diluted chlorhexidine (UKCCSG-PONF Mouth care group 2006).
  • For palliative care situations when comfort is the only intended outcome.

Mouth care packs should be disposed of once opened.

Dental floss

Combined with a toothbrush, dental floss is the most effective method of removing plaque. It reaches parts that toothbrush bristles are unable to reach. Dental floss must be used with care and is not recommended for children under 10 years of age (Rationale 19).

For children with cancer, flossing should only be used following a risk assessment by a dental practitioner (UKCCSG-PONF Mouth care group 2006).

Oral hygiene tools: cleansing agents, soft paraffin ointment, drugs and other agents

Cleansing agents

Fluoride toothpaste

Children should have their teeth brushed with fluoride toothpaste containing at least 1,000 parts per million (ppm)(Scottish Intercollegiate Guidelines Network 2005). It strengthens tooth enamel and decreases the risk of dental cavities (Marinho et al 2003; Walsh et al 2010).

A possible adverse effect of using fluoride toothpaste is the mottling of permanent teeth, or dental fluorosis from the swallowing of excessive fluoride by young children with developing teeth. There is some evidence that using toothpaste with higher levels of fluoride (> than 1,000 ppm) in children less than five to six years of age, is associated with an increased risk of fluorosis.

For some children considered to be at high risk of tooth decay by their dentist, the benefit of preventing dental decay may outweigh the risk of fluorosis. For children likely to develop dental cavities, the use of 1,350-1,500 ppm fluoride toothpaste may be recommended by a dentist (Department of Health 2009). If the risk of fluorosis is a concern, a toothpaste containing less than 1,000 ppm may be recommended (Wong et al 2010).

Fluoride toothpaste can have a drying effect if left in contact with the oral mucosa. Fluoride supplements should only be prescribed by dental practitioners on an individual basis (Scottish Intercollegiate Guidelines Network 2005).

Chlorhexidine-based mouthwash (0.2% solution)

Chlorhexidine is an antiseptic that inhibits plaque formation on the teeth. It is not however, a substitute for effective toothbrushing.

Chlorhexidine can be used as a mouthwash, spray or gel for secondary infection in mucosal ulceration and for control of gingivitis, as an adjunct to other oral hygiene measures. These preparations may be used in place of toothbrushing for painful periodontal conditions eg primary herpetic stomatitis, if the child has a haemorrhagic disorder, or is disabled (Paediatric Formulary Committee 2009). 

Prolonged use of chlorhexidine causes reversible brown staining of the teeth and tongue. It can be incompatible with some ingredients in toothpaste. At least 30 minutes should be allowed between using mouthwash and toothpaste (Paediatric Formulary Committee 2009). 

Chlorhexidine is not recommended for the prevention or treatment of radiotherapy/chemotherapy induced mucositis, nor the prevention of candidiasis in children with cancer. Chlorhexidine is not recommended for this patient group unless the child is unable to brush their teeth, when foam sponges moistened with water or diluted chlorhexidine may be used (UKCCSG-PONF Mouth care group 2006).

Soft paraffin ointment

Soft paraffin ointment can be applied to the lips to soothe dryness. It provides an occlusive barrier which retains moisture. It is easy to apply and will remain in place for many hours (if not licked off).

It should be used with caution, especially with oxygen therapy, smoking and babies under phototherapy as It is highly flammable (Kennedy and Diamond 1997). The National Patient Safety Agency (NPSA) has highlighted the fire hazard risks associated with paraffin-based skin products (NPSA 2007). Soft paraffin ointment can trap bacteria.

Drugs and other agents

Antifungal agents

Fungal infections of the nouth are generally caused by candidia. Acute pseudomembranous candidiasis (thrush) is usually an acute infection. It may however persist for months in patients receiving inhaled corticosteroids, cytotoxic drugs or broad-spectrum antibacterials. Thrush may also occur in patients with serious systemic disease associated with a reduced immunity ie leukaemia, other cancers and HIV infection (Paediatric Formulary Committee 2009). 

Treatment of oral candidiasis (immunocompromised children)

Immunocompromised children are especially at risk of fungal infection and may require prophylactic antifungal drugs (Paediatric Formulary Committee 2009). For the prevention of oral candidiasis, a drug that is absorbed from the GI tract is recommended eg fluconazole, ketoconazole or itraconazole.

There is no evidence to support the use of either nystatin or chlorhexidine for the prevention of candidiasis in children treated for cancer (UKCCSG-PONF Mouth care group 2006).

Topical antifungal therapy may be ineffective for the treatment of oral candidiasis in immunocompromised children, and an oral triazole antifungal used such as fluconazole, itraconazole or ketoconazole (UKCCSG-PONF Mouth care group 2006; Paediatric Formulary Committee 2009). 

Treatment of oral candidiasis (immunocompetent children)

Topical therapy is generally adequate for treatment of oropharyngeal candidiasis for a child with a normal immune system. Fluconazole may be used for unresponsive infections, or itraconazole for fluconazole resistant infections (Paediatric Formulary Committee 2009). 

Oral antifungals eg itraconazole and fluconazole should only be used under the specialist advice or supervision (Clinical Knowledge Summary 2009a). 

Treat with a topical antifungal for seven days. First line treatment is miconazole oral gel. Use nystatin suspension if miconazole gel is unsuitable (liver dysfunction, or child taking medication extensively metabolized by the liver.

If the infection has not resolved after seven days and there has been some response, use the miconazole oral gel for another seven days. If miconazole has had little or no effect, try a seven day course of nystatin suspension (Clinical Knowledge Summary 2009a).

There is insufficient evidence to support the use of prophylactic oral antifungal agents to prevent systemic candidia infection in pre term infants (Austin and Darlow 2003).

Nystatin should be given an hour after the use of chlorhexidine (Gibson and Nelson 2000)

Drug doses for antifungal agents should be prescribed according to the British National Formularly for Children.

Anti-viral agents

Herpes infection of the mouth and lips is generally associated with the herpes simplex virus serotype 1 (HSV-1). Primary infection with herpes simplex virus is usually mild and self limiting, and most people can be managed symptomatically. Oral antiviral drugs are not usually needed in uncomplicated primary gingivostomatitis (Clinical knowledge summary 2009b).

If treatment is required, for patients with a normal immune function who have an infection of the lips (herpes labialis or cold sores) a topical antiviral drug such as aciclovir five per cent cream (for child >3 months) or penciclovir one per cent cream (only for use in children >12 years of age) is suggested. 

This can be used for treatment of initial and recurrent infections. It is best applied when prodromal changes of sensation are felt in the lip, before the vesicles appear (Paediatric Formulary Committee 2009; Clinical knowledge summary 2009b).

For further information on the use of topical antiviral agents, see Clinical Knowledge Summary for Herpes Simplex - oral or the British National Formulary for Children.

Severe infection, neonatal herpes infection or infection in immunocompromised patients, requires treatment with a systemic antiviral drug (Paediatric Formulary Committee 2009). Specialist advice should be sought in these situations (Clinical Knowledge Summary 2009b).

For children with cancer, the following recommendations apply:

  • Mild and/or non progressive lip lesions: topical aciclovir.
  • Moderate/severe and/or progressive lip lesions and for mild/moderate oral lesions: oral aciclovir.
  • Severe oral lesions or if oral aciclovir cannot be tolerated: intravenous aciclovir.

For doses see the British National Formulary for Children website.

Aciclovir is only recommended as a preventative strategy for herpes simplex, in patients undergoing high dose chemotherapy with stem cell transplant/bone marrow transplant (UKCCSG-PONF Mouth care group 2006).

Artifical saliva

Dry mouth (xerostomia) may be caused by (Paediatric Formulary Committee 2009):

  • Drugs with antimuscarinic side effects eg antispasmodics, sedating antihistamines.
  • In palliative care, drugs such as opioids, hyoscine, antidepressants and some antiemetics may cause dry mouth.
  • Irradiation of the head and neck.
  • Damage to salivary glands.
  • Disease of the salivary glands.

A persistent dry mouth may lead to a burning or scalded sensation for the child. Complications such as dental caries, periodontal disease and candidia may occur. Dry mouth may be relieved by simple measures, eg frequent sips of cool drinks, sucking ice chips, or sugar free pastilles. If the child has residual salivary function, sugar free chewing gum may stimulate salivation (Paediatric Formulary Committee 2009).

Artifical saliva can provide relief for a dry mouth. It should be a neutral pH and contain electrolytes (including fluoride) that corresponds approximately to the composition of saliva. For examples and doses see the British National Formulary for Children.

For children with cancer, there is insufficent evidence to support the use of amifostine (to prevent salivary gland damage), or pilocarpine (not available in a form suitable for children), or biperiden for the prevention of xerostomia. Artifical saliva and saliva stimulants are recommended for the relief of dry mouth (UKCCSG-PONF Mouth care group 2006).

Analgesia

Pain relief may be necessary to relieve the pain of mucositis for children with cancer. Pain associated with mucositis can be severe and opiates should be used to control such pain (UKCCSG-PONF Mouth care group 2006). 

Topical or oral means of pain relief may be necessary in the management of cold sores or primary gingivostomatitis caused by the herpes simplex virus. Refer to Clinical Knowledge Summary. Herpes Simplex - oral for details.

If the OAG score is >8, a pain assessment instrument should be introduced. This will allow for more detailed self-reporting of pain, which when added to observation of parents and clinicians, will provide a more complete picture of the symptom (Gibson et al 2006).

Other agents used for oral ulceration and inflammation

These include:

  • simple mouthwashes
  • antiseptic mouthwashes
  • mechanical protection
  • corticosteriods
  • local analgesics

For details refer to the British National Formulary for Children section 12.3.1 (Paediatric Formulary Committee 2009). 

GelclairTM

GelclairTM has been shown to reduce the pain of oral conditions in adults following cancer therapy (Berndtson 2001) and in palliative care (Innocenti et al 2002). It was the focus of a preliminary clinical study that GOSH was involved in: Efficacy of GelclairTM in reducing the pain of oral mucositis in children and young people with cancer (study results awaiting publication).

It has also been used by children with oral pain after chemotherapy and bone marrow transplant within the children's cancer unit at GOSH. GelclairTM is accepted as a Class 1 device as it is not pharmacologically active within the EU and by the MHRA, and is listed in the Drug Tarif Part IXA appliances as an oral film forming agent. For more information about how to use GelclairTM contact Karen Bravery or Tina Say at GOSH.

Performing oral care: preparation

The nurse's role is to facilitate family-centred care, therefore, whenever possible oral care should be performed by the child and/or the family member/carer. Whenever possible, encourage the child to take control of their mouth care (Rationale 21).

Play specialists can help prepare children for mouth care (Rationale 22).

The child should be encouraged to handle the mouth care tools and products in a non-threatening environment, and perform mouth care on a favourite toy, a parent or nurse. Ensure explanations are age appropriate and reinforced with written information (Rationale 23).

The child's need for privacy must be respected when undertaking any aspect of oral care (Rationale 24).

Older children and/or teenagers have increased concerns regarding body image and sexuality. Involve this age group in planning their oral care so that they will understand its importance (Rationale 25).

Performing oral care: normal child

Dental hygiene should begin as soon as primary teeth erupt (Scottish Intercollegiate Guidelines Network 2005; Department of Health 2009)(Rationale 26).

The child's mouth should be assessed and appropriate mouth care given.

Normal practice from home may be continued if appropriate.

A small headed toothbrush with soft, round-ended filaments, a compact, angled arrangement of long and short filaments, and a handle which is comfortable, should be used to brush/clean teeth (Department of Health 2009).

Brushing should occur twice daily, last thing at night before bed and at least one other time each day (Department of Health 2009). Brushing more frequently than twice a day can lead to increased ingestion of toothpaste and risk of fluorosis. Brushing last thing at night allows the fluoride levels to remain high, as salivary flow rates are reduced during sleep (Scottish Intercollegiate Guidelines Network 2005).

Manual or powered toothbrushes can be used (Scottish Intercollegiate Guidelines Network 2005). Children may brush their teeth more regularly using an electric/powered toothbrush, because of the novelty of using the device (British Dental Health Foundation 2005).

Children should be helped or supervised by an adult when brushing their teeth, until at least seven years (Scottish Intercollegiate Guidelines Network 2005; Department of Health 2009).

The child's mouth should be assessed daily using the Oral Assessment Guide (inpatients) (Rationale 27).

Prior to performing oral care, the nurse should (Rationale 28):

  • put on an apron
  • perform social handwash. Refer to hand hygiene guideline.  
  • put on a pair of non-sterile, powder and latex-free gloves

Cleaning a child's teeth

To clean a child's teeth, stand or sit behind the child, and cradle their chin in your hand so you will be able to reach the top and bottom teeth more easily (British Dental Health Foundation 2005).

Use a smear of toothpaste (no less than 1,000 ppm fluoride) for a child less than three years. Use a pea-sized amount of toothpaste for a child greater than three years of age (Scottish Intercollegiate Guidelines Network 2005; Department of Health 2009).

Encourage the child to spit out excess toothpaste and not rinse with water (Scottish Intercollegiate Guidelines Network 2005; Department of Health 2009). Rinsing with water reduces the caries-preventative effect of the fluoride toothpaste (Scottish Intercollegiate Guidelines Network 2005). Do not allow the child to eat the toothpaste (Rationale 29).

Use small circular movements when cleaning the teeth and try to concentrate on one section at a time, Brush behind the teeth and onto the gums (British Dental Health Foundation 2005).

For more information on toohbrushing refer to the British Dental Association's 3D mouth website.

Soft paraffin ointment if used should be used sparingly and applied using a gloved finger. Each container of soft paraffin ointment is for single patient use.

Performing oral care: compromised child

Swallowing difficulties

If a child has been assessed as having swallowing difficulties:

  • Commence a fluid balance chart.
  • Consider monitoring their weight.
  • Refer to a dietitian.
  • Discuss pain management with appropriate personnel. Ensure adequate pain relief.
  • Consider the use of a local anaesthetic spray if swallowing difficulties are caused by pain. When local anaesthetics are used, care must be taken to enusre that the pharynx does not become anaesthetised before meals, as this may lead to choking (Paediatric Formulary Committee 2009).

Dry, cracked or ulcerated lips

Apply soft paraffin ointment.

Plaque or debris on teeth

  • consider referral to dentist
  • consider referral to a dietitian
  • commence health education as and when appropriate

Immunocompromised child with cancer

  • Brush child's teeth twice daily, using fluoride toothpaste and a soft toothbrush.
  • If unable to brush teeth, clean mouth with oral sponges moistened with water or diluted chlorhexidine.
  • Use of additional aids (floss, flouride tablets, electric/powered toothbrushes) by recommendation of dental team only.

For more information about mouth care for this patient group, refer to the following documents (UKCCSG-PONF Mouth Care Group 2006):

Oral phobia

Children who have been, or who are intubated, are known to experience problems having oral hygiene carried out.

Oral care should be assessed on an individual basis, but intubated children should have their teeth cleaned as normal and soft parrafin ointment applied to their lips.

The endotracheal tube will need to be repositioned to the opposite side of the child's mouth if they are intubated orally.

Children with EB

Only the use of mouthwash may be possible.

Mouthwash that contains alcohol may cause 'stinging' and strong flavours should be avoided.

A small toothbrush or foam cleaning sponges may be used.

An electric/powered toothbrush (small, round, oscillating head) may be used for front teeth and whenever access permits.

Liaise with the EB clinical nurse specialists.

Health promotion

Dietary advice

The frequency and amount of sugary food and drink should be reduced and when consumed, limited to mealtimes (Department of Health 2009). Drinks that contain free sugars, including natural fruit juices, should be avoided in between meals. These drinks should not be put in a feeding bottle. Water or milk may be given instead (Scottish Intercollegiate Guidelines Network 2005).

For snacks offer the child cheese, vegetables and fruit – not dried fruit (British Dental Health Foundation 2005).

Food and drink that contains sugar substitutes are preferable to those containing sugars (Scottish Intercollegiate Guidelines Network 2005).

Check processed baby foods for sugars. Check the ingredients list – the higher up the list sugar is, the more there is in the product (British Dental Health Foundation 2005).

Avoid adding sugar to weaning foods (Department of Health 2009). Encourage the use of a cup and straw rather than a bottle.

Encourage the use of sugar-free medicines (Department of Health 2009).

Encourage regular dental check-ups – every six months (British Dental Health Foundation 2007).

For children with cancer a dental assessment is recommended every three to four months (UKCCSG-PONF Mouth care group 2006).

The provision of preventative dental care is an important aspect of the management of children with chronic diseases. Early involvement of paediatric dental services is vital for these children (Foster and Fitzgerald 2005).

To avoid trauma to the teeth, do not leave children unattended whilst they are brushing their teeth. Use non slip mats in the bath.

Rationale

Rationale 1: To obtain informed consent.
Rationale 2: To teach the child about good mouth care.
Rationale 3: To help ensure success.
Rationale 4: To enable good visualisation of the mouth.
Rationale 5: To minimise the risk of cross infection.
Rationale 6: To remove plaque and debris.
Rationale 7: To aid observation and assessment.
Rationale 8: To identify specific problems.
Rationale 9: To enable appropriate advice to be given.
Rationale 10: To monitor any changes.
Rationale 11: To implement appropriate treatment.
Rationale 12: To ensure continuity.
Rationale 13: To evaluate care.
Rationale 14: To provide baseline data.
Rationale 15: To predict, prevent or minimise oral complications.
Rationale 16: To evaluate nursing interventions.
Rationale 17: They provide the most effective method for removing plaque.
Rationale 18: Foam sponges are soft, unthreatening, easy to use, able to be squeezed into hard to reach places, and able to deliver fluids to specific places in the mouth.
Rationale 19: Dexterity is needed to manipulate floss. It is difficult to floss someone else's teeth. In addition there are some conditions that may cause bleeding and increased risk of infection.
Rationale 20: Little or no absorption occurs, thus reducing the risk of systemic adverse effects and drug interactions.
Rationale 21: To reduce anxiety, allow time for questions and increase adherence.
Rationale 22: To ensure age appropriate preparation.
Rationale 23: To reduce anxiety.
Rationale 24: To decrease anxiety or embarassment from changes in their oral cavity, eg gingival enlargement, increased salivation, inability to swallow or speak effectively, halitosis.
Rationale 25: To increase receptiveness to health teaching.
Rationale 26: To prevent tooth decay.
Rationale 27: To accurately and regularly monitor the condition of child's mouth and identify any signs of oral compromise and/or infections.
Rationale 28: To comply with universal precautions and handwashing guidelines, and minimise the risk of cross infection.
Rationale 29: Swallowing large amounts of toothpaste increases the risk of fluorosis (white spots or patches on the tooth enamel).

References

Reference 1:
Austin NC, Darlow B (2003) Prophylactic oral antifungal agents to prevent systemic candida infection in preterm infants. Cochrane Database of Systematic Reviews 4 (CD003478): 1-12.

Reference 2:
Berndtson M (2001) A preliminary study of Orassist / Gelclair in the management of oral mucositis. Swedish Hospital Dentistry 3 (26): 17-21.

Reference 3:
British Dental Health Foundation (2007) How can I prevent tooth decay in my child?. www.dentalhealth.org.uk/faqs/leafletdetail.php?LeafletID=3#faq606. Viewed on: 11/11/2007

Reference 4:
British Dental Health Foundation (2005) Frequently asked questions. Children's teeth. www.dentalhealth.org.uk/faqs/leafletdetail.php?LeafletID=3. Viewed on: 09/12/2007

Reference 5:
Clinical Knowledege Summary (2009b) Clinical Knowledege Summary. Herpes Simplex - oral. www.cks.nhs.uk/herpes_simplex_oral. Viewed on: 23/06/2010

Reference 6:
Clinical Knowledge Summary (2009a) Clinical Knowledge summary Candidia - oral. www.cks.nhs.uk/candida_oral#-392676. Viewed on: 23/06/10

Reference 7:
Department of Health (2009) Delivering better oral health. An evidence-based toolkit for prevention. Second Edition. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPoli.... Viewed on: 23/06/2010

Reference 8:
Foster H, Fitzgerald J (2005) Dental disease in children with chronic illness. Arch Dis Child 90 (7): 703-8.

Reference 9:
Gibson F, Cargill J, Allison J, Begent J, Cole S, Stone J, Lucas V (2006) Establishing content validity of the oral assessment guide in children and young people. Eur J Cancer 42 (12): 1817-25.

Reference 10:
Gibson F, Nelson W (2000) Mouth care for children with cancer. Paediatr Nurs 12 (1): 18-22.

Reference 11:
Glenny AM, Gibson F, Auld E, Coulson S, Clarkson JE, Craig JV, Eden OB, Worthington HV, Pizer B (2004) A survey of current practice with regard to oral care for children being treated for cancer. European Journal of Cancer 40: 1217-1224.

Reference 12:
Innocenti M, Moscatelli G, Lopez S (2002) Efficacy of gelclair in reducing pain in palliative care patients with oral lesions: preliminary findings from an open pilot study. J Pain Symptom Manage 24 (5): 456-7.

Reference 13:
Kennedy L, Diamond J (1997) Assessment and management of chemotherapy-induced mucositis in children. J Pediatr Oncol Nurs 14 (3): 164-74; quiz 175-7.

Reference 14:
Marinho VCCC, Higgins JPT, Logan S, Sheiham A (2003) Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 1 (CD002278): 1-83.

Reference 15:
Miller M, Kearney N (2001) Oral care for patients with cancer: a review of the literature. Cancer Nurs 24 (4): 241-54.

Reference 16:
National Cancer Institute (2000) Oral complications of cancer and cancer therapy. www.cancerweb.ncl.ac.uk/cancernet/302904.html. Viewed on: 03/04/2008

Reference 17:
NPSA (2007) Fire hazard with paraffin-based skin products. www.nrls.npsa.nhs.uk/resources/?EntryId45=59876. Viewed on: 23/06/2010

Reference 18:
Paediatric Formulary Committee (2009) British National Formulary for children. bnfc.org/bnfc/ . Viewed on: 23/06/2010

Reference 19:
Pearson LS (1996) A comparision of the ability of foam swabs and toothbrushes to remove dental plaque:implications for nursing practice. Journal of Advanced Nursing 23 (1): 62-69.

Reference 20:
Robinson PG, Deacon SA, Deery C, Heanue M, Walmsley AD, Worthington HV, Glenny, Shaw WC (2005) Manual versus powered toothbrushing for oral health. Cochrane Database of Systematic Reviews 2 (CD002281): 1-68.

Reference 21:
Scottish Intercollegiate Guidelines Network (2005) Prevention and management of dental decay in the pre-school child. Quick reference guide. www.sign.ac.uk/pdf/sign83.pdf. Viewed on: 09/12/2007

Reference 22:
UKCCSG-PONF Mouth care group (Children's Cancer and Leukaemia Group) (2006) Mouth care for children and young people with cancer: evidence-based guidelines. www.ukccsg.org/public/followup/PracticeStatement/index.html. Viewed on: 09/12/2007

Reference 23:
Walsh T, Worthington HV, Glenny AM, Appelbe P, Marinho VCC and Shi X (20/01/2010) Fluoride toothpaste of different concentrations for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews (e-pub) www2.cochrane.org/reviews/en/ab007868.html.

Document control information

Lead Author(s)

Karen Bravery, Nurse Practitioner, Infection Cancer and Immunity

Additional Author(s)

Amber Conley, Nurse Practice Educator, Infection Cancer and Immunity

Document owner(s)

Karen Bravery, Nurse Practitioner, Infection Cancer and Immunity

Approved by

Clinical Practice Committee

Reviewing and Versioning

First introduced: 
17 November 2004
Date approved: 
25 February 2014
Review schedule: 
Three years
Next review: 
25 February 2017
Document version: 
3.0
Previous version: 
2.0