Mouth care

Some children receiving chemotherapy and/or radiotherapy will develop sore mouths. This information explains why this occurs and what you, as a parent, can do to help.

What is mouth care?

Why does the mouth get sore?

Chemotherapy is the name for a group of drugs used to destroy cancer cells. Chemotherapy acts by damaging the rapidly dividing cancer cells so that they can no longer divide and grow.

Unfortunately, chemotherapy cannot tell the difference between healthy cells, which also divide rapidly, and cancer cells. Consequently, some healthy cells are also damaged. One such group of healthy cells are those inside the mouth. Therefore, some children receiving chemotherapy will develop sore mouths as a result of their treatment.

Why is mouth care important?

Your child is receiving treatment for cancer that has the potential to affect the inside of their mouth (causing a condition called mucositis). The lining of the mouth is very sensitive and can be damaged by chemotherapy and/or radiotherapy. Other problems that your child may experience are infection, pain in the mouth, difficulty with swallowing and trouble with eating. Even a small affected area in the mouth can cause pain.

Mucositis usually resolves as the white blood cells and neutrophils recover.

Oral care at time of diagnosis

During treatment

Ideally your child should have a dental assessment every three to four months, either by the community dentist or hospital dentist. Remember to tell the dentist that your child is receiving chemotherapy.

Whilst in hospital, a nurse and/or doctor will check inside your child’s mouth at least once a day using a pen torch. They will be able to see if your child’s mouth is clean and healthy, and will detect any problems.

They will look for any:

• White patches or spots on the tongue or cheek areas,
• Inflammation or sores around the tongue, cheeks and gums,

• your child if it hurts to swallow or if it’s hard to talk,
• if there is any bleeding in the mouth when you are doing mouth care.

The nurses on the ward will help support you to do mouth care whilst in hospital and teach you how to look in your child’s mouth and the things you need to look out for.

How to do mouthcare

• A small headed, soft toothbrush (only to be used by your child) or pink, cleaning sponges
• Fluoride toothpaste (avoid using strong tasting toothpaste which can sting sore mouths and may cause nausea and vomiting).
• Tap water unless indicated otherwise.

1. Your child should clean his or her teeth twice a day using the toothbrush and fluoride toothpaste. If your child is too young to use a toothbrush, use a pink, cleaning sponge and water.
2. Moisten the brush or sponge with water.
3. If using a toothbrush, add a pea-sized amount of fluoride toothpaste.
4. Use careful small circular movements to clean the teeth thoroughly but try to avoid brushing too hard as this may cause bleeding from the gums. Try to make tooth-brushing part of your daily routine morning and evening.
5. Rinse using the water. Make sure your child spits out toothpaste and doesn’t swallow it on a regular basis as this can lead to areas of discolouration appearing on your child’s teeth (fluorosis).
6. If your child’s lips are dry or sore, apply yellow soft paraffin regularly throughout the day.

When you go home

Continue brushing or helping your child to brush their teeth at least twice a day. Use toothbrushing time to have a good look inside your child’s mouth, this should make it easier for you to spot any developing problems.

If you notice any changes in your child’s mouth, you should contact your community team or shared care hospital for further advice. If your child develops mucositis or any other problems in the mouth, he or she may need extra medicines, which stop the soreness and treat the problems. These may include pain relief, antifungal or antiviral medicines.

When you finish treatment

Dental advice

What problems can occur?

• Mucositis – This is another word for when your child’s mouth is inflamed and painful. He or she may also have ulcers. It can cause problems for someone receiving chemotherapy or radiotherapy as the mouth is one route by which infection can travel into the bloodstream.
• Taste alterations – (partial or complete loss of taste) are common for children undergoing chemotherapy/radiotherapy. If your child is already ‘off’ their food, having a sore mouth will not help. Food that they usually like may now taste completely different to them.
• Pain – difficulty in swallowing, voice changes and a sore throat can be early signs of developing mucositis. Younger children may dribble a lot or not enjoy a dummy as much as usual. Although your child’s mouth may appear normal, it is important to tell your nurse or doctor if you notice any of these symptoms.
• Bleeding – This is due to the mouth becoming more sensitive. It is especially common around the gums and in the corners of the mouth. Bleeding can also occur due to a low platelet count.

Sometimes if children develop a very sore mouth and are experiencing lots of pain, they may have to come into hospital for further treatment.

• Infections – There are three sorts of infection:
  • Bacterial: The most common type. It is unlikely that you will notice any visible symptoms
  • Fungal: commonly called thrush. These usually show up as white patches on the tongue or inside the cheeks. They can spread to the throat, which will lead to pain and difficulty in swallowing.
  • Viral: common cause of cold sores (herpes) on the lips. These usually show up as blisters or dark crusts in the corners of the mouth. Herpes simplex virus causes cold sores and some children get recurrent problems. If your child develops a cold sore whilst receiving chemotherapy let your nurse or doctor know.

10 Top Tips/Mouth care Quick reference guide

1. Try to make mouth care part of the daily routine
2. Look at your child’s mouth daily checking for any sores, red inflamed (raw) areas, white spots or patches or any unusual bleeding.
3. To clean your children’s teeth – either sit or stand behind your child, cupping the chin in your hand so you can reach both top and bottom teeth more easily. Use small circular movements.
4. Brush teeth at least twice daily or after each meal
5. Use a small-headed soft toothbrush or use pink sponges if your child's mouth becomes sore.
6. Apply yellow soft paraffin ointment or an alternative to dry/sore lips
7. Change toothbrush every three to six months unless directed otherwise by healthcare professionals
8. Visit the dentist regularly
9. If your child’s mouth is sore contact your community team or shared care hospital who will be able to give you advice.
10. Encourage children and young people to eat a varied diet with fruit & vegetables.

Last reviewed by Great Ormond Street Hospital: September 2009
Ref: 2009F0605 © GOSH Trust September 2009
Compiled by the Haematology/ Oncology department in collaboration with the Child and Family Information Group with thanks to the children who helped with the leaflet.

This information does not constitute health or medical advice and will not necessarily reflect treatment at other hospitals. If you have any questions, please ask your doctor. No liability can be taken as a result of using this information.