Mouth care

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

Introduction

The mouth is important for eating, drinking, speech, communication, taste, breathing and the immune system.

Oral hygiene is an integral part of health care.  It encompasses health promotion, preventative strategies, assessment and treatment interventions.  Assessment and delivery of appropriate oral care can prevent potential infections as well as reduce distress and discomfort (Whiteing and Hunter, 2008). The principal objective of oral care is to maintain the mouth in a good condition. More specifically it aims to" 

  • Keep the oral mucosa and lips clean, soft, moist and intact.
  • Remove, and prevent the build-up of food debris/dental plaque without damaging the gingiva.
  • Alleviate pain/discomfort.
  • Prevent halitosis and freshen the mouth.
  • Maintain oral function.
  • Decrease the risk of oral and systemic infection.
  • Increase general well-being. 

Oral Physiology

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 membranes consisting of stratified squamous epithelium, which contain 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: 

  • 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 (McErlean, 2016).

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 are involved in conveying the mood of a person via facial expressions e.g. smiling and grimacing.

The tongue 

This is covered with stratified squamous epithelium for protection, 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 (McErlean, 2016). 

The teeth

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

  • The crown – protrudes from the gum.
  • The root – embedded in the bone.

The interior of the tooth consists of a pulp cavity that contains the blood vessels, lymph tissue 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 cementum. This fixes the tooth into its socket. The functions of the teeth include biting off pieces of food, grinding and chewing food, and social functions such as smiling (McErlean, 2016). 

The first tooth normally erupts around six months of age, with the full complement of 20 deciduous (temporary or milk) 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 (McErlean, 2016).  

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 these ill effects. Younger children, due to their age and development, require assistance with carrying out oral hygiene routinely, in addition children and young people with a number of conditions may have compromised oral well-being. 

General conditions that can compromise oral well-being include:

  • Cerebral palsy, craniofacial surgery, stroke, trauma and other illnesses: can lead to neurological impairment, unconsciousness, loss of a limb, maxillofacial injury which may lead to difficulty or inability to perform oral hygiene independently and require assistance from others. 
  • 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 deterioration.
  • 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 molar teeth.
  • Restricted movement of the tongue due to surgery or pain may lead to the body’s usual removal of debris being ineffective.
  • Chronic constipation: may cause a foul mouth and odour. 
  • Down’s syndrome has a spectrum of presentations and severity which can impact on the oral health of children or young people.  They may have underdevelopment of the bones in their face, along with an enlargement of their tongue, and the growth and development of teeth may be affected.  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.  Any number of these may lead to a change in oral health, in particular dry mouth, and cracked lips which may cause discomfort (Shore et al, 2010).
  • Cleft lip and palate: children with cleft lip and palate can have more tooth decay than the general population. This means extra attention should be given to highlighting prevention, especially reducing sugar in the diet and performing effective tooth brushing. Referral to a paediatric dentist is recommended for these patients.
  • Cancer/Bone Marrow Transplant: Mucositis and ulceration causing pain, infection and bleeding can arise in children and young people receiving chemotherapy or radiotherapy (specifically to their head or neck). See under cytotoxic agents for further information and definition of mucositis.
  • Immunodeficiencies: Children and young people with immunodeficiencies such as acquired immune deficiency syndrome (AIDS), severe combined immune deficiency (SCID) 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.
  • Measles: The presence of Koplik spots (small white spots) in the mouth may indicate the early stages of measles.
  • Fever: may lead to a dry mouth and coated tongue. 
  • Grinding of the teeth may result in loss of tooth surface. 
  • Thumb/finger 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 foul odour in the mouth. 

Medications and treatments that can compromise oral well-being include:

Antibiotics: may alter the child or young person's oral and gut flora and increase the risk of opportunistic infections such as candida albicans. Tetracyclines may cause staining of the teeth from yellow to brown.

Chlorhexidine-based mouthwash: may result in temporary brown staining of teeth, a stinging or burning sensation or a bitter taste/altered after taste (British National Formulary for Children (BNFC), 2016).

Corticosteroids: Corticosteroids can lead to delayed healing of tissue, gum hyperplasia, altered taste perception (often metallic) and absent or ropy saliva. Inhaled corticosteroids used for the treatment of asthma can increase the risk of candidiasis occurring (BNFC, 2016).

Cytotoxic agents: A common side effect of cytotoxic agents is mucositis, a painful inflammation and ulceration of the mucous membrane (Bennett, 2016). Detailed information about mucositis in children and young people receiving cancer therapy can be found in the Mouth Care for Children and Young People with Cancer: evidence-based guidelines (UKCCSG-PONF Mouth Care Group, 2006). 

Mucositis is a toxic inflammatory reaction that can affect the entire gastro intestinal tract from the mouth to the anus, in response to receiving cytotoxic therapy or radiation. Symptoms can include: inflammation; dry mouth; ulceration of mucosa, overproduction of saliva: gingiva and the palate; dry, cracked and bleeding lips (McCulloch et al, 2013).  

The terms mucositis and stomatitis are often used interchangeably. There are, however, some general distinctions, whereas mucositis described above is a reaction to cytotoxic therapy or radiotherapy. Stomatitis refers to any inflammatory reaction affecting the oral mucosa, with or without ulceration (Eilers et al 2014).  

  • Iron supplements: can cause temporary green/black staining of teeth.
  • High sucrose-content medications: can lead to an increased incidence of dental caries.
  • Nifedipine: can lead to gingival enlargement (BNFC, 2016)
  • Phenytoin and ciclosporin: either can cause enlarged gingiva (BNFC, 2016)

Dry mouth: Anticholinergics; Antihistamines; Atropine; Opioid analgesics; Oxygen therapy; Radiotherapy to the head and neck; Tricyclic antidepressants (BNFC, 2016).

Assessment of the oral cavity 

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

Whenever possible the child or young person should be involved in the assessment (Rationale 2). 

When assessing the mouth of a young child, it is advisable to have a second adult present to support the child's head (Rationale 3). 

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

Hand hygiene should be performed and an apron 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 in children and young people of all ages (Rationale 8) (Gibson et al 2006). This may need to be adapted for each clinical area, as this tool has been utilised and validated primarily for use with children and young people with cancer (Rationale 9). There are other assessment tools available such as the Children’s International Mucositis Evaluation Scale (ChIMES) that are currently being researched for their validity in children and young people (Jacobs et al, 2013).

Staff undertaking assessment of the oral cavity should be trained in the use of the OAG (Rationale 10). Nursing staff or healthcare support workers may be best placed to perform regular assessment of a child or young person’s oral status (UKCCSG-PONF Mouth care group 2006). 

An effective oral assessment should involve the following eight aspects of the mouth: swallow; lips and corner of the mouth; tongue; saliva; mucous membranes; gingiva; teeth; voice. The OAG comprises the above eight categories, with each category descriptor assessed using a numerical scale of 1 to 3. The eight subscale scores are added together to obtain an overall assessment score (minimum 8, maximum 24) (Gibson et al 2006). 

Score  
1  Normal
2  Mild alteration without severe compromise of either epithelial integrity or systemic function
 Definite compromise 

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 or young person’s health care record and on the Oral Assessment Score Sheet (see appendix 1). 

An effective oral assessment should involve examination of all eight categories (Rationale 15, 16, and 17). 
The people best placed to assess the oral cavity are dentists. If following assessment there are any concerns, advice may be sought from a dental practitioner or dental Consultant.

Performing oral assessment using the OAG 

See the Oral assessment guide (appendix 2), adapted from Eilers et al. (1988) by the mouth care working party at Great Ormond Street Hospital for Children NHS Trust (2005).

Swallow 

Ask the child or young person to swallow or observe the swallowing process. Ask the parent/carer if there are any notable changes. Observe the swallowing process to check the child or young person'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 or young person 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 observe for any ulceration or 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. Look carefully at the teeth for any discoloured areas, especially brown staining, or holes in the teeth as this is normally a sign of tooth decay and requires treatment.

Voice

Talk to and listen to the child or young person. Ask the parent/carer 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 (Gibson et al 2006; UKCCSG-PONF Mouth care group 2006). 

Delivering oral hygiene care to children and young people

Oral hygiene tools: Equipment

Toothbrushes

A small headed, soft, nylon bristled toothbrush, with round ended filaments should be used to brush/clean teeth (Rationale 18). These should be changed every three months or sooner if the bristles become splayed (Department of Health (DH) 2017).

Children up to the age of 12 years should be supervised when brushing their teeth. They should brush for a minimum of two minutes to ensure optimal oral health.

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

Electric toothbrushes 

There are many forms of powered toothbrush available (electric, sonic, ultrasound) which have differing modes of action – (side to side, rotation oscillation, circular and more). Brushes that work with a rotation oscillation action remove more plaque and reduce gingivitis more effectively than a manual tooth brush, and may be more effective than other modes of action (Yaacob et al, 2014). However, the most important factor is that whether manual or powered the brushes are used effectively twice a day (DH, 2017). As the bristles are hard, they are not advisable for children with a fragile mucosa (Rationale 19). 

An electric toothbrush may be useful for children or young people with any limitations to their cognitive or motor skills who find it difficult to use a manual toothbrush (DH 2017). 

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 20). Foam cleaning sponges are ineffective at removing plaque (Munro and Grap 2004). 

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 or young person has severe mucositis that prevents them from brushing their teeth – foam sponges can be moistened with water (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.

In neonates these sponges may be too large to be able use for mouth care – these should NEVER be cut and an alternative for this population may need to be found.

Staff should be aware of the Medicines and Healthcare products Regulatory Agency (MHRA) (2012) medical device alert relating to oral swabs with a foam head and should ensure that the instructions for use by the manufacturer are followed. 

Dental floss and interdental brushes

Combined with a toothbrush, interdental brushes are the most effective method of removing plaque. They reach the parts that toothbrush bristles are unable to reach, specifically between the teeth. Interdental brushes should be used first, then the toothbrush. Dental floss must be used with care and is not recommended for children under 10 years of age (Rationale 21). 

For children or young people 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 and young people should have their teeth brushed with fluoride toothpaste containing at least 1,000 parts per million (ppm), (NHS Choices, 2015). 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 or young people 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 or young people likely to develop dental cavities, the use of 1,350-1,500 ppm fluoride toothpaste may be recommended by a dentist (DH 2017). If the risk of fluorosis is a concern, 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 in patients with pre-existing xerostomia. Fluoride supplements should only be prescribed by dental practitioners on an individual basis (BNFC, 2016). 

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 tooth brushing. 

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 tooth brushing for painful periodontal conditions e.g. primary herpetic stomatitis, if the child has a haemorrhagic disorder, or is disabled (BNFC 2016).  

Prolonged use of chlorhexidine causes reversible brown staining of the teeth and tongue. Its action is inhibited by some of the ingredients in toothpaste. Therefore, at least 60 minutes should be allowed between using mouthwash and toothpaste (BNFC 2016).  

Chlorhexidine is not recommended for the prevention or treatment of radiotherapy/chemotherapy induced mucositis (Lalla et al, 2014), nor the prevention of candidiasis in children or young people with cancer. Chlorhexidine is not recommended for this patient group unless the child or young person 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/Lip Balms 

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.  The National Patient Safety Agency (NPSA) has highlighted the fire hazard risks associated with paraffin-based skin products (NPSA 2007

Some patients may wish to continue using their own lip balm, ensure they are aware to maintain hygiene when using these.

Drugs and other agents

Antifungal agents 

Fungal infections of the mouth are generally caused by candida albicans. 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 antibiotics. Thrush may also occur in patients with serious systemic disease or receiving treatment associated with a reduced immunity e.g. cancer, chemotherapy, and HIV infection (DH, 2017).  

Treatment of oral candidiasis in IMMUNE COMPETENT children and young people

For the treatment of oropharyngeal candidiasis in children and young people with a functioning immune system, topical therapy is generally adequate. 

  • Prescribe topical treatment for 7 days (and advise the person to continue treatment for 2 days after symptoms resolve).
    • Offer miconazole oral gel first-line (off-label use in children younger than 4 months of age).
    • Offer nystatin suspension (off-label use in neonates) if miconazole oral gel is unsuitable (for example if the child has liver dysfunction or is taking medication extensively metabolized by the liver).
  • If the infection has not resolved after 7 days, and: 
    • There has been some response, extend the course of miconazole oral gel for a further week.
    • Miconazole has had little or no effect despite adequate adherence, offer a 7-day course of oral nystatin suspension.
  • If the child or young person is using an inhaled corticosteroid, provide advice on the prevention of oral candida infection (see Inhaled corticosteroids).
  • If the child or young person has extensive or severe candidiasis, consider seeking specialist advice.
  • Fluconazole may be used for unresponsive infections, or itraconazole for fluconazole resistant infections (BNFC 2016). Oral antifungals should only be used under specialist advice or supervision.  

Drug doses for antifungal agents should be prescribed according to the BNFC

Treatment of oral candidiasis in IMMUNE COMPROMISED children and young people

Immunocompromised children and young people are especially at risk of fungal infection and may require prophylactic antifungal drugs (Science et al, 2014). For the prevention of oral candidiasis, a drug that is absorbed from the gastro intestinal tract is recommended e.g. fluconazole, ketoconazole or itraconazole. There is no evidence to support the use of nystatin for the prevention of candidiasis in children treated for cancer (UKCCSG-PONF Mouth care group 2006). 

For the treatment of oral candidiasis in immunocompromised children and young people, an oral ‘triazole’ antifungal such as fluconazole, itraconazole or ketoconazole is recommended (UKCCSG-PONF Mouth care group 2006). Topical antifungal therapy may be ineffective for the treatment of oral candidiasis in the immunocompromised, and is therefore not recommended (Worthington et al, 2010).

Anti-viral agents 

Herpes infection of the mouth and lips is generally associated with the herpes simplex virus serotype 1 (HSV-1) (Aggarwal et al, 2014). Primary infection with herpes simplex virus is usually mild and self-limiting, and most children and young people can be managed symptomatically. Oral antiviral drugs are not usually needed in uncomplicated primary gingiva-stomatitis (Clinical Knowledge Summary, 2013).

Treatment of oral herpes simplex virus in IMMUNE COMPETENT children and young people

If treatment is required for a herpes simplex infection of the lips (herpes labialis, commonly referred to as ‘cold sores’) a topical antiviral drug is suggested, such as:

  • Aciclovir 5% cream can be used in children aged over 3 months
  • Penciclovir 1% cream can be used in young people aged over 12 years 

These topical preparations can be used for treatment of initial and recurrent infections. They are best applied when prodromal changes of sensation are felt in the lip, such as tingling, before the vesicles appear (Clinical knowledge summary 2016). 

For further information on the use of topical antiviral agents, see Clinical Knowledge Summary for Herpes Simplex - oral (2016) or the British National Formulary for Children

Treatment of oral herpes simplex virus in IMMUNE COMPROMISED children and young people; NEONATES, and in cases of SEVERE infection 

Severe infection, neonatal herpes infection or infection in immunocompromised children and young people requires treatment with a systemic antiviral drug (Aggarwal et al, 2014). Specialist advice should be sought in these situations (Clinical Knowledge Summary 2016). 

For children and young people with cancer, the following recommendations apply: 

  • Mild and/or non-progressive lip lesions: topical acyclovir (as per above suggestions). 
  • 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). 

Artificial saliva 

Dry mouth (xerostomia) may be caused by (BNFC, 2016):

  • Drugs with antimuscarinic side effects e.g. antispasmodics, sedating antihistamines. 
  • In palliative care, drugs such as opioids, hyoscine, antidepressants and some antiemetic medicines 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 or young person. Complications such as dental caries, periodontal disease and candida may occur. Dry mouth may be relieved by simple measures, e.g. frequent sips of cool drinks, sucking ice chips, sugar-free gum or sugar free pastilles. 

Artificial saliva can provide relief for a dry mouth, although the most effective treatment is regular sips of water. All sugary drinks should be avoided 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 and young people with cancer, there is insufficient 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. Artificial 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 and young people with cancer. Pain associated with mucositis can be severe and opiates should be used to control such pain (UKCCSG-PONF Mouth care group 2006). In particular, analgesia should be considered prior to performing oral hygiene cares where there is evidence of mucositis (Rationale 22).

Topical or oral means of pain relief may be necessary in the management of cold sores or primary gingiva-stomatitis caused by the herpes simplex virus. Refer to Clinical Knowledge Summary. Herpes Simplex - oral (2016) for details. 

A thorough pain assessment should be conducted if a child or young person is showing any signs of mucositis, or condition which may affect the oral cavity – such as dental caries, surgery. Please refer to the Trust’s pain control service webpage for further information.

Other agents used for oral ulceration and inflammation 

These include: 

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

For details refer to the British National Formulary for Children section 12.3.1  

Gelclair®

Gelclair® (a viscous gel formulated to aid in the management of lesions of the oral mucosa) has been shown to reduce the pain of oral conditions in adults following cancer therapy (Berndtson 2001), including those receiving head and neck radiotherapy (Barber et al, 2007). It has also been shown to reduce pain in patients receiving palliative care (Innocenti et al 2002). However prophylactic use not been studied for its benefit.

It has been used by children and young people with oral pain after chemotherapy and bone marrow transplant within the cancer unit at GOSH for many years. Gelclair® is classed as a medical device class 2a  as it is not pharmacologically active within the EU and by the MHRA, and is listed in the Drug Tarrif Part IXA appliances as an oral film forming agent. 

Gelclair® provides a simple, highly effective way to relieve the pain of oral mucositis and painful mouth ulcers − helping to maintain normal dietary/fluid intake and supporting completion of full-dose therapy. 

  • Gelclair® contains PVP (polyvinylpyrrolidone) and sodium hyaluronate in a liquid gel.
  • When washed around the mouth, these agents combine to form a bio protective coating that adheres to the lining of the mouth.
  • The bio protective coating offers rapid and effective pain management.
  • Pain is significantly reduced following the first administration of Gelclair®.
  • Gelclair® can potentially improve the ability to eat and drink and, unlike preparations with an alcohol or anaesthetic base, does not sting on application.

(Gelclair® 2014). 

For instructions on how to use Gelclair® visit their website

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 or young person and/or the family member/carer. Whenever possible, encourage the child or young person to take control of their mouth care (Rationale 23). 

Play specialists can help prepare children and young people for oral care (Rationale 24). 

The child or young person should be encouraged to handle the mouth care equipment 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 25). 

The child or young person’s need for privacy must be respected when undertaking any aspect of oral care (Rationale 26). 

Older children and/or teenagers have increased concerns regarding body image and. Involve this age group in planning their oral care so that they will understand its importance (Rationale 27). 

Performing oral care in a child or young person where there is no compromise to carrying out regular oral care:  

Dental hygiene should begin as soon as primary teeth erupt, (DH 2017) (Rationale 28). 

The child or young person’s mouth should be assessed and appropriate mouth care given. The assessment should be carried out daily using the Oral Assessment Guide (inpatients) (Rationale 29). 

Children should be helped or supervised by an adult when brushing their teeth, until at least twelve years (Oral Health Foundation, 2017) (Rationale 30).

Normal practice/routine from home may be continued if appropriate. 

A small headed toothbrush with a handle which is comfortable should be used to brush/clean teeth (DH 2017). 

Brushing should occur twice daily for a minimum of two minutes, last thing at night before bed and at least one other time each day (DH 2017). 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. 

Manual or powered toothbrushes can be used. Children and young people may brush their teeth more regularly using an electric/powered toothbrush, because of the novelty of using the device (NHS Choices, 2015). 

Prior to performing oral care, the nurse should 

  • put on an apron 
  • perform a social handwash. Refer to hand hygiene guideline.  
  • put on a pair of non-sterile, powder and latex-free gloves (Rationale 31).

Cleaning a younger child's teeth 

To clean a younger child's teeth, it may be easier to stand or sit behind them, and cradle their chin in your hand. This will allow you to reach the top and bottom teeth more easily (Oral Health Foundation, 2017). 

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 (DH 2017). 

Encourage them to spit out excess toothpaste and not rinse with water. Rinsing with water reduces the caries-preventative effect of the fluoride toothpaste (DH 2017). Do not allow the child to eat the toothpaste (Rationale 32). 

Use small circular movements when cleaning the teeth and try to brush each surface of every tooth, brush behind the teeth, onto the gums and your tongue (Oral Health Foundation 2017). 

For more information on tooth brushing refer to the Oral Health Foundation website.

Soft paraffin ointment if used should be used sparingly and applied using a gloved finger if necessary. Each container of soft paraffin ointment is for single patient use (Rationale 5). Use with caution in children and young people receiving oxygen therapy due to the flammable nature of soft paraffin.

Performing oral care in a child or young person where there is some compromise to the ability to carry out regular oral care.

Swallowing difficulties 

If a child or young person 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 ensure that the pharynx does not become anaesthetised before meals, as this may lead to choking or burning (BNFC 2016). 
Dry, cracked or ulcerated lips 
  • Apply soft paraffin ointment.
Plaque or debris on teeth 
  • refer to a dentist. 
  • consider referral to a dietitian. 
  • commence health education as and when appropriate. 
Immunocompromised child or young person with cancer 
  • Brush their teeth twice daily, using fluoride toothpaste and a soft toothbrush. 
  • If unable to brush teeth, clean the mouth with oral sponges moistened with water, or Gelclair® made up to manufacturers specifications. 
  • Use of additional aids (floss, fluoride tablets, electric/powered toothbrushes) by recommendation of dental team only. 

For more information about mouth care for this patient group, please read the Mouthcare for Children and Young Peole with Cancer: Evidence-based guidelines (UKCCSG-PONF Mouth Care Group 2006).

Children and young people with EB 

Liaise with the EB clinical nurse specialists, as oral care may depend on the type and severity of EB that the patient has.

Patients should be encouraged to brush their teeth using a small headed toothbrush, however in the event they are temporarily unable to do so due to pain they can use cotton buds, foam cleaning sponges, cotton cloth or gauze.

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

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

EB patients should be seen by a local dentist for their first consultation at around 3-6 months of age.

In 2012 DEBRA published a set of best clinical practice guidelines for oral health care in patients with EB.

Children or young people who are intubated 

Patients who are intubated should not have their oral care forgotten, and their needs should be assessed on an individual basis. They should receive regular oral care as part of the care offered to prevent Ventilator Assisted Pneumonia as part of the Department of Health’s High Impact Interventions (DH, 2007). Local policies and documentation should be followed.

Care must be taken if the patient is intubated orally that the endotracheal tube is not misplaced whilst carrying out oral cares.

Health promotion

Dietary advice

The frequency and amount of sugary food and drink should be reduced and when consumed, limited to mealtimes Drinks that contain free sugars, including natural fruit juices, should be avoided in between meals and should never be put in a feeding bottle. Water should be given instead (DH 2017). 

Children and young people should be encouraged to snack on non-sugary nutritious foods such as - cheese, vegetables, fruit, yoghurt, rice cakes – not dried fruit (Infant and Toddler Forum, 2010). 

Check processed baby foods for sugars. Check the ingredients list – the higher up the list sugar is, the more there is in the product (NHS Choices, 2015; NHS Change4Life). 

Avoid adding sugar to weaning foods (DH 2017). Encourage the use of a cup and straw rather than a bottle. 

Encourage the use of sugar-free medicines (DH 2017). 

Many healthy eating tips can be found on the change4health website

Lifestyle

Young people should be advised against smoking or using smokeless tobacco as this can increase the risk of periodontal disease, and also oral cancers (DH, 2017).

Young people should also be advised about alcohol intake and its effect on oral health (DH, 2017).

Encourage regular dental check-ups – every six months (Oral Health Foundation, 2017). 

For children and young people 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 and young people with chronic diseases. Early involvement of paediatric dental services is vital for these children (Foster and Fitzgerald 2005). 

Rationale

Rationale 1: To obtain informed consent, and assent from child where possible.

Rationale 2: To teach the child or young person about good mouth care.

Rationale 3: To help ensure success.

Rationale 4: To enable good visualisation of the mouth.

Rationale 5: To comply with standard precautions

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 enhance competency of staff; to promote reliability of assessment between staff.

Rationale 11: To monitor any changes.

Rationale 12: To implement appropriate treatment.

Rationale 13: To ensure continuity.

Rationale 14: To evaluate care.

Rationale 15: To provide baseline data.

Rationale 16: To predict, prevent or minimise oral complications.

Rationale 17: To evaluate nursing interventions.

Rationale 18: They provide the most effective method for removing plaque.

Rationale 19: Hard bristles can cause trauma to the oral cavity and bleeding.

Rationale 20: 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 21: 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 22: To prevent causing further pain

Rationale 23: To reduce anxiety, allow time for questions and increase adherence.

Rationale 24: To ensure age appropriate preparation.

Rationale 25: To reduce anxiety.

Rationale 26: To maintain dignity.

Rationale 27: To decrease anxiety or embarrassment from changes in their oral cavity, e.g. gingival enlargement, increased salivation, inability to swallow or speak effectively, halitosis.

Rationale 28: To increase receptiveness to health teaching.

Rationale 29: To accurately and regularly monitor the condition of child's mouth and identify any signs of oral compromise and/or infections.

Rationale 30: To help support the child learn effective brushing and prevent tooth decay

Rationale 31: To comply with standard precautions and handwashing guidelines, and minimise the risk of cross infection.

Rationale 32: Swallowing large amounts of toothpaste increases the risk of fluorosis (white spots or patches on the tooth enamel). 

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Document control information

Lead Author(s)

Emily Baker, Lead Practice Educator, West Division

Additional Author(s)

Lisa Shipway, Nurse Practitioner, Haematology

Document owner(s)

Emily Baker, Lead Practice Educator, West Division

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
17 November 2004
Date approved: 
21 August 2017
Review schedule: 
Three years
Next review: 
21 August 2020
Document version: 
4.0
Previous version: 
3.0