Mouth Care Advice for Inpatients (For Children with an Unsafe Swallow)

Why is mouth care important?

Mouth care (oral hygiene), including brushing your teeth, are important parts of health care.

Good mouth care can:

• Prevent potential infections, including lung infections
• Reduce distress and discomfort
• Prevent pain and soreness in your child’s mouth
• Reduce avoidance/refusal reactions to any foods and drinks that they are able to eat or drink safely
• Increase positive experiences around the face and mouth
• Increase enjoyment and safety of eating and drinking
• Help to maintain oral skills
• Increase appetite
• Improve quality of life

Risks to health from poor mouth care

• Swallowing and saliva are important for keeping the mouth healthy
• Children with swallowing problems are at greater risk of poor oral hygiene and oral infections (thrush/candida)
• Children with poor oral hygiene and an unsafe swallow are at increased risk of bacteria moving into the lungs (aspiration) causing chest infections or pneumonia
• Some children may need mouth care more often if they:
  • have a feeding tube to meet all food/drink needs
  • have a tracheostomy
  • are on long-term ventilation
  • are admitted to critical care
• Some treatments or drugs may also cause a dry mouth (xerostomia) – please speak to your child’s doctor or nurse if you are concerned this is happening to your child’s mouth

Problems for children who are nil by mouth

When your child is nil by mouth (NBM), plaque can build up on their teeth, bacteria can build up in the mouth and throat and the mouth can become dry and unclean.

One problem related to being NBM is reluctance to begin eating and drinking again due to discomfort in the mouth. Helping to keep your child’s mouth and teeth clean and comfortable will promote a more positive oral experience while NBM. Good mouth care will also prepare them for eating and drinking (when safe to do so) in the future.

Please ask your nurse to contact Children’s Speech & Language Therapy if you have further questions about how to carry out mouth care and teeth brushing safely.

Tooth brushing

If tolerated, and if it is safe to do so, you can help/encourage your child to keep brushing their teeth twice a day (see Resources below for different toothbrushes).

Use an age appropriate no foam (SLS free) toothpaste. SLS (Sodium Lauryl Sulfate) is a foaming agent. Avoiding this ingredient helps to reduce the amount of foam build-up in your child’s mouth. Use a dry toothbrush, or shake off the water before brushing,

Apply the thinnest coating of toothpaste to the brush and push it a little into the bristles, then gently clean their teeth. A finger guard can help to gently prop their mouth open and protect your fingers if they often bite down.

You can use suction to remove any excess foam/saliva if you are trained to do this.

There is no need to rinse their mouth as any remaining toothpaste protects your child’s teeth. But do remove and excess foam, debris and saliva using gauze or a soft dry brush

Mouthwash

Mouthwashes are not usually recommended for children under 6 years old and those containing Chlorhexidine are not licensed for children under 12 years old.

DO NOT use mouthwash if NBM or on thickened fluids as it may be swallowed and go down to their lungs (aspiration). Products containing Chlorhexidine can also irritate the tissues/lining of the mouth.

Mouthwash is not recommended as a substitute for good oral hygiene as they can irritate the sensitive linings of your mouth and gums, cause a dry mouth and discolour teeth.

Please speak to your dentist if you are worried about keeping your child’s teeth clean if they are nil by mouth or have an unsafe swallow.

How to carry out mouth care safely

• Mouth care is an additional activity to brushing your child’s teeth. Mouth care can be done every 2-3 hours as needed or tolerated
• To avoid aspiration (fluid going down to the lungs):
  • Help your child in to an upright and midline sitting position in their usual chair, or adjust the bedhead and support with pillows if in bed
  • If they can’t sit up in bed, then support their head, neck and upper body with pillows in a side-lying position, or gently turn their head to the side
• Check in your child’s mouth for any food before you start. A small toothbrush or cleansing stick can be used to clean soft tissues of the mouth, remove food and to apply an age appropriate mouth gel if your child’s mouth is dry. (See Resources page for products)
• A finger guard can help gently prop your child’s mouth open and it protects your fingers. Place the guard on the middle finger of the hand opposite to the toothbrush, stand behind or to the side of your child, support their head and slide the finger guard between your child’s teeth to help access the mouth for tooth-brushing
• Dampen the mouth using a cleansing stick, or small soft toothbrush, or a dampened piece of gauze wrapped around your little finger. Use clean water/saline. You MUST shake off/squeeze excess water from the stick/brush/gauze so it is barely damp (i.e. no free-flowing water) to avoid any fluid being swallowed
• Use a clean finger or soft brush to apply an age-appropriate water-based moisturising gel every 2-3 hours (or as needed) to the lips, gums, tongue, palate and the inside of cheeks, to protect these areas. DO NOT use petroleum-based lip balms or moisturisers if your child is on oxygen. Many common brands produce non-petroleum based moisturisers

Resources / Products

• Wards can order products marked with an asterisk (*), other products are available in most supermarkets/pharmacies
• Check ingredients of toothpastes and gels for allergens, intolerances (e.g. lactose free) and animal products (for those following vegetarian/vegan diets)
• Toothpastes (No foam/SLS-free) – check ingredients before using:
  • Colgate First Smiles toothpaste – SLS free (0-2 yrs)
  • Brush-baby Apple Mint (0-3 yrs), Tutti Frutti (3-6 yrs)
  • OraNurse unflavoured No Foam (0-3 yrs, 4+ yrs, Original)
  • Aquafresh Children’s Little Teeth (3-5 yrs)
  • Sensodyne Pronamel for Children (6-12 yrs)
  • BioXtra Dry Mouth Mild Toothpaste (6+ yrs)
  • Organic SLS-free toothpastes are also available

• Toothbrushes:
  • *Basic small child’s toothbrush – Item No. MRA186
  • Small headed electric or battery operated brush
  • Dent-O-Care Fingertip Brush
  • *OroCare Aspire Suction Toothbrush 3016000
  • *Toothbrush with suction oral care – Item No. FSQ374
  • Aquafresh milk teeth 3 sided brush – 0-2 years
  • *Oralieve 360 child’s toothbrush – Item No. ILA1100

• Mouth cleaning:
  • *MC3 (MouthEze cleanser) – Item No. ILA901
  • *Oralieve 360 child’s toothbrush – Item No. ILA1100

• Finger Guard:
  • Dent-O-Care dental finger shield

• Mouth Gels – Not suitable for children 12 years or under unless directed by a medical professional:
  • *Oralieve Dry Mouth Relief – Item No. ILA747
  • Biotene Dry Mouth Oral Balance
  • BioXtra Gel

Who to contact