Oral hygiene for the highly dependent or critically ill infant or child

PROCEDURE

RATIONALE

Provide age appropriate explanation of the procedure.

To ensure that the child understands the procedure and to avoid undue distress.

Ensure head of bed tilted at 30° angle if appropriate (15-30° in neonates)¹³

Head up tilt is recommended to prevent aspiration of oral secretions

Wash hands thoroughly with appropriate antibacterial skin cleanser then don disposable gloves.¹⁶

In order to minimise the risk of cross- infection.

Prepare solutions/mouthwash required

Solutions should be prepared immediately prior to use to maximise their efficacy and minimise risk of microbial contamination.

Inspect child’s mouth with aid of torch.

The mouth should be examined for changes in condition with respect to moisture, cleanliness, infected or bleeding areas, or ulcers.

Oral assessment will help determine the most appropriate oral care tools and frequency of care required. ^14,15

For neonates and infants under 1yr with no teeth:

Wrap non-gauze swabs moistened with sterile water around a gloved finger and gently wipe the gums and mucosa.¹⁷

May be carried out as often as required to moisten and freshen mouth.

Sterile water will help freshen the gums and mucosa.

For infants and children <1yr up to 3yr old with teeth :

12 hourly¹⁸:

If gingiva not damaged or bleeding, or if infant not heparinised, use a small-headed soft toothbrush and no more than a smear of fluoride toothpaste to brush infant’s teeth, gums and tongue.¹⁸

Use suction to remove excess toothpaste but do not rinse.¹⁹

After brushing with toothpaste the infant or child’s mouth may be moistened using a very small amount of sterile water on the toothbrush or a foam stick

Ensure toothbrush used is rinsed after each use, stored upright and kept clean and dry. Replace brush as necessary (i.e. if bristles ‘splayed’ or sooner)²³

2-4 hourly:

Use swabs or foam stick soaked in sterile water and wipe gums and mucosa to moisten and freshen mouth.¹⁷

Brushing correctly will remove adherent materials from the teeth, tongue and gum surface.¹⁸

Brushing gum gently stimulates gingival tissues to maintain tone and prevent circulatory stasis.

N.B rinsing with water can reduce efficacy of fluoride.¹⁹

However, the glycerine content of residual toothpaste can dry the mouth.

Moistening the mouth after brushing removes loosened debris and toothpaste and makes the mouth feel fresher.²⁰

Toothbrushes must be kept clear of infection as they may harbour organisms that may contribute to oropharyngeal infections.^21,22

For children with teeth > 3yr old:

12 hourly:

If gingiva not damaged or bleeding, or if child not heparinised, use small-headed soft toothbrush and:

-  pea-sized amount of fluoride toothpaste (>3 yrs) to brush child’s teeth, gums and tongue.^18,19

If required, use suction to remove excess toothpaste but do not rinse.

After brushing with toothpaste the child’s mouth may be moistened using a small amount of sterile water on the toothbrush or a foam stick

Ensure toothbrush used is rinsed after each use, stored upright and kept clean and dry. Replace brush as necessary (i.e. if bristles ‘splayed’ or sooner)²³

To remove adherent materials from the teeth, tongue and gum surface.

Brushing the gum gently stimulates gingival tissues to maintain tone and prevent circulatory stasis.

N.B rinsing with water can reduce efficacy of fluoride¹⁹.

However, the glycerine content of residual toothpaste can dry the mouth.

Moistening the mouth after brushing removes loosened debris and toothpaste and makes the mouth feel fresher.²⁰

Toothbrushes must be kept clear of infection as they may harbour organisms that may contribute to oropharyngeal infections.^21,22

All intubated infants & children > 1yr

12 hourly:

30 minutes after brushing teeth with fluoride toothpaste¹¹, apply chlorhexidine gluconate 1% to foam stick and apply to teeth and gums.^7,11,24 Use yankeur suction to suction excess solution/gel out of mouth.

Do not rinse or brush teeth with water following this.

Sodium  monoflurophosphate, present in the majority of toothpastes, interacts and inactivates the action of chlorhexidine gluconate mouth rinses and gels. Therefore, at least 30 minutes or more should be allowed to pass between tooth brushing and application of a chlorhexidine gluconate mouth gel*.²⁵

Rinsing or brushing teeth water following this will remove the chlorhexidine gluconate applied, therefore is not recommended.²⁵

* 0.2% chlorhexidine mouth rinse is also available if required

Infants and children with teeth (all ages):

When using a toothbrush, place brush against teeth at 45° angle. Move bristles back and forth (circular or eliptical motiton) gently over a small group of teeth at a time, until all accessible surfaces of the teeth are cleaned.^11,26

Brushing correctly loosens and removes debris from the teeth and gums thus reducing growth medium for pathogenic organisms. It also minimizes risk of plaque formation and dental caries.

If gingival bleeding or damage is evident or likely, or if child unable to tolerate a toothbrush with toothpaste, then a foam stick, with sterile water may be used.

Foam sticks should be used in a rotating action.²⁷

If the child has a sore or infected mouth, damaged gingiva, or is at risk of bleeding profusely then a foam stick with either sterile water is less traumatic and may help freshen the gums and mucosa.

The brush or rotating action of the foam stick may help rinse the mouth and remove loosened debris.

N.B. A foam stick with sterile water can help make the mouth taste fresher but is ineffective at loosening or removing the debris on and between teeth and gums.^20,27

Apply lubricant (E.g. yellow soft paraffin) to lips and corners of mouth.

To increase child’s feeling of comfort as well as to prevent drying and risk of tissue damage.²⁰

Heavily sedated infants/children with endotracheal tubes can have open mouths which are exposed to the environment.

Mouth assessment: document all findings in patient notes in Clinical Information System

Potential problems:

Use:

Small pen torch                              

Disposable gloves & apron

Tongue depressor (with care if indicated)

Mask & visor (if indicated)                       

Assess the following:

If any of the following are identified then ‘standard mouth’ care as per guideline should be done plus further care as suggested.

Tongue

Palate – hard & soft palate

Coated or discoloured mucus membranes

Infected mouth and lips –E.g. candida or herpes simplex

Saliva

Mucus membranes/Lips

Dry cracked lips and dry mucous membranes

Bleeding mucous membranes

Gums

Teeth

Problem

Possible causes

Suggested action

Dry cracked lips & dry mucous membranes

• Insufficient fluid intake
• Insufficient or reduced saliva production
• Excessive mouth breathing
• Nil orally
• Face mask oxygen
• Intermittent oral suction

Standard oral hygiene plus:

• Increase frequency of inspection & assessment

• Review fluid balance & intake – check sufficient fluid intake with medical staff
• If not intubated offer water/ice to moisten mouth 2 hourly*
• If intubated moisten mouth with sterile water/saline & foam sticks (2 hourly*)
• Apply yellow soft paraffin to lips
• Document & report outcome

Coated/discoloured mucous membranes

• Build up of plaque/debris
• Infection such as candida

Standard oral hygiene plus:

• Increase frequency of inspection & assessment
• Moisten & clean mouth more frequently *see above
• If no improvement consider infection – take oral swab
• Seek medical review & report to nurse-in-charge
• Administer any medicines/rinses if prescribed
• Document & report outcome

Infected or blistered mouth and lips

• May be Herpes simplex
• May be candida
• Ulceration

Standard oral hygiene plus:

• Increase frequency of inspection & assessment
• Moisten & clean mouth more frequently *see above
• Apply topical or administer prescribed medicines (E.g. Anti-fungal/anti viral)
• Document & report outcome

Bleeding, red or swollen mouth and gums

• Gingivitus
• Recent oral surgery
• Low platelet count
• On high dose anticoagulant or platelet inhibitor (Heparin or Prostacyclin)

Adapt Standard oral hygiene  (i.e. may not be suitable to use toothbrush) plus:

• Increase frequency of inspection & assessment
• Discuss with medical staff – ascertain if appropriate to perform oral hygiene using toothbrush
• If tooth brushing not suitable - moisten & clean mouth very gently using foam sticks or with swabs & gloved finger (if edentulous) with sterile water
• Administer any prescribed medicines or rinses
• Reassess mouth gums & palate post procedure
• Document & report any concerns to nurse-in-charge & medical staff