Oral Care

CLINICAL GUIDELINES

Oral care of infants and young children may be performed by a registered nurse (RN), licensed practical nurse (LPN), or an appropriately trained caregiver.
Oral hygiene is introduced during infancy, before the eruption of the first tooth, and as the child matures independence should be encouraged to promote good habits.
Monitor oral hygiene practices (brushing and flossing) until the child has manual dexterity and the practice is firmly established, often until the child is 8 or 9 years of age. Ensure that the child does not swallow toothpaste.
The first visit to a pediatric dentist is recommended at the time of eruption of the first tooth and no later than 12 months of age to determine risk factors and evaluate fluoride needs before eruption of the child’s permanent teeth. In addition, the American Academy of Pediatric Dentists recommends that this first visit include counseling with the family about oral hygiene, nonnutritive habits, speech and language development, diet, oral injury prevention, and fluoride supplementation.
Visits to the pediatric dentist should be repeated every 6 months or as indicated by the child’s risk status, susceptibility to disease or evidence of oral discomfort or injury.
Scheduled healthcare visits to primary healthcare providers (e.g., those at 6 months, 9 months) include oral assessment and health teaching to promote optimum oral health.
Strongly encourage caregivers not to put the child to bed with a bottle at any time. Both the incidence of dental caries and otitis media are elevated in children who are allowed to go to bed with a bottle of milk or juice.
For children aged 6 months to 3 years, if community water is not fluoridated or is fluoride deficient (<0.3 parts per million [ppm]), evaluate the need for supplementary fluoride use (see Community Care).
Evaluate the need for application of pit and fissure sealants for caries of susceptible molars, permanent molars, premolars, and anterior teeth. Sealants are used based on the child’s caries risk, not on the child’s age, though sealants are not used before 2 years of age.
For pediatric oncology patients:
- Perform oral hygiene two to three times a day and more often if needed (see Community Care).
- Perform oral assessments on a daily basis for children receiving chemotherapy treatments or radiation of the head or neck regions or if child has undergone a bone marrow transplantation.
- All children with cancer should have an oral examination prior to initiation of oncology treatments to identity existing or potential problems that may exacerbate or induce complications during cancer treatment, to develop and communicate the child’s oral health status and plan for dental intervention if needed, and to educate the family about optimal oral care, acute and long-term oral complications from cancer therapy, and effective interventions to enhance oral hygiene and manage oral complications of therapy.

EQUIPMENT

For oral care of infants:

Soft washcloth or soft bristle toothbrush
Clean warm water
Nonsterile gloves

For oral care in early childhood, middle childhood, and adolescents:

Soft bristle toothbrush—manual or powered (with American Dental Association Seal of Approval)
Toothpaste with fluoride (if recommended by dentist)
Dental floss, once there is more than two teeth together
Clean water
Nonsterile gloves

For oral care of children receiving oncology treatments:

Soft bristle brush, soft toothettes, or gauze (choice dependent on absolute neutrophil count [ANC] and platelet count)
Toothpaste with fluoride
Dental floss
Clean water
Nonalcoholic 0.1% chlorhexidine mouthwash rinse, saline, sterile water, sodium bicarbonate or other prescribed oral care product
Nystatin (if ordered)
Lanolin or petroleum-based creams, ointments, or topical lubricating anesthetic as needed
Pain medication as ordered and if needed for severe mucositis
Nonsterile gloves

For oral care of children in the pediatric intensive care unit:

Soft bristle brush, soft toothettes, or gauze
Clean water or normal saline
Toothpaste with fluoride
0.1% chlorhexidine mouthwash rinse or other prescribed oral care product
Lanolin or petroleum-based ointment or lip balm
Nonsterile gloves
Oral suction apparatus

CHILD AND FAMILY ASSESSMENT AND PREPARATION

Assess current dental care practices. If possible, observe the older child performing dental self-care.
Assess feeding practices (e.g., breast, bottle, cup), sucking practices (pacifier or thumb), dietary intake (what is consumed, amount of fruits, vegetables, foods with high sugar content), and oral hygiene practices.
Assess oral cavity for the following:
- Integrity and color of the lips, tongue, gingivae, and mucous membranes
- Irritations, potential infections, trauma, or other disease processes
- Impending tooth eruptions and placement of present teeth
- Child’s ability to salivate, swallow, and eat

caREminder

Assess for any pain associated with oral cavity.
Assess caregiver knowledge base regarding tooth eruption and physical side effects (sore red gums, profuse salivation, slight temperature elevation, mild diarrhea, skin eruptions, fussiness).
Review child’s medical record for any current healthcare treatments that may impact oral health (e.g., chemotherapy, radiation, bone marrow transplantation).

PROCEDURE
Providing Oral Care

Steps	Rationale/Points of Emphasis
1 Perform hand hygiene and gather all necessary supplies.	Reduces transmission of microorganisms. Promotes efficient time management and provides an organized approach to the procedure.
2 Professional caregivers should don gloves before performing procedure.	Maintains standard precautions to protect against contact with body fluids.
Oral Care for Infants
3a Position infant on lap or in infant seat. Caregiver should have access to mouth. A second person may be necessary for support or restraint.	Maintains child’s comfort.
3b Reassure infant; make this a gentle, nonaggressive routine.	Reduces infant crying and fear. If teeth are erupting, gums may be sore, and these procedures will soothe the irritated gums.
3c Clean gums and teeth:
• After each feeding, use corner of a soft washcloth dampened with warm water or a soft toothbrush to wipe or massage the gums.	Regular cleansing of the gums soothes the discomfort due to eruptions of new teeth, removes excess plaque and bacteria, and accustoms the infant to the daily ritual of dental hygiene. Accustoms infant to daily ritual of dental hygiene.
The U.S. Food and Drug Administration (FDA) warns against the use benzocaine, the main ingredient in over-the counter gels and liquids (e.g., Anbesol, Orajel, Baby Orajel, Orabase) applied to the gums to reduce teething pain in infants and young children. Methemoglobinemia, a rare and serious condition may develop with gel use. The amount of oxygen carried through the blood stream can be greatly reduced leading to respiratory distress and possible death.
3d As teeth erupt, a dab of fluoride toothpaste (the size of a rice grain) may be added to the cloth and used to wipe teeth.	Eliminates chance of swallowing fluoride-containing toothpaste, resulting in fluorosis (brown discoloration with white specks on teeth). The flavor of adult toothpaste may be too intense, causing an aversion to the procedure, and the toothpaste may contain too much fluoride, leading to chronic excessive fluoride intake.
3e When most of the teeth are in, a soft bristle brush and a smear of fluoride toothpaste may be used to cleanse the teeth twice daily.	At about 6 months of age, promotes the use of toothbrush on the infant’s gums. Select fluoridated toothpaste that is specifically recommended for young children.
3f Clean the gums and the gingival tissue adjacent to any teeth to remove plaque. Floss teeth when adjacent tooth surfaces cannot be cleaned with a toothbrush.	Promotes optimal oral cleansing. Flossing aids to remove plaque between tooth surfaces.
3g Excess toothpaste should be spit out, but rinsing should be discouraged so as to prevent the infant from swallowing the toothpaste.	Residual toothpaste on the teeth increases the caries prevention effects.
Oral Care During Early Childhood
4a Engage the young child in the activity of tooth brushing if developmentally appropriate and if the child is medically stable enough to engage in self-care activities. Allow the child to brush his or her teeth, followed by the caregiver brushing the child’s teeth until the child can achieve the manual dexterity necessary to complete the task successfully.	Promotes the child’s cooperation. The procedure should be routine and not be a reward or punishment. Although family caregivers must still assume complete responsibility for dental hygiene, encouraging the child to participate in this routine develops good habits.
4b Clean teeth and gums.
4c Choose a toothbrush labeled “very soft” or “soft” and with thin bristles with a short trim height and a small enough head to allow maneuverability within the child-sized oral cavity.	Promotes child’s comfort. Prevents plaque buildup and deters dental caries formation. Young children do not possess the manual dexterity needed to effectively brush their own teeth.
4d Brush the child’s teeth gently, using a pea-sized amount of fluoride toothpaste only if the child is capable of spitting out the toothpaste. If the child is unable to spit out the toothpaste, use warm water for cleansing the teeth.	When toothpaste is used to prevent dental fluorosis, it is imperative that the child does not swallow large amounts of the dentifrice. Too much fluoride taken internally between ages 2 and 4 years can lead to enamel fluorosis, or discoloration of the teeth.
4e Gently brush the gums.	Removes bacteria from gums.
4f Floss the teeth once it is noted that two of the child’s teeth have begun to touch.
4g Brush teeth at least twice per day; if the child eats highly sweetened foods, then an extra brushing after the snack should occur.	Promotes routine, decreasing child’s resistance.
Oral Care During Middle Childhood and for Adolescents
5a Explain the procedure to the child; engage the child in the activity.	Encourages good dental hygiene as a lifelong habit. KidKare Use of a timer may be introduced to encourage adequate brushing time.
5b Clean teeth:
5c Have the child/adolescent gently brush all the teeth using a soft bristle brush and a dab of toothpaste.	Prevents plaque buildup.
5d Brush all sides and edges of the gums and teeth.
5e Supervision is necessary until the child is at least 8 years old. Toothbrushes with an interdental brush with a small cone shape are helpful in brushing between braces and fixtures.	By 8 years of age, the child should possess the manual dexterity necessary to perform the procedure.
5f Ensure that flossing is completed. Floss at least once per day; a floss holder may facilitate the process.	Prevents plaque from forming. Children have much more space between their teeth initially, and flossing should be easy. Waxed floss may be easier for the child or caregiver to manipulate. Floss holders are plastic fork-like devices that hold the floss for you, making it easier to floss in hard-to-reach places.
Oral Care for Children Receiving Oncology Treatments
6a Review health records or discuss with family to determine types of medical interventions that may be affecting oral mucosa (e.g., chemotherapy, radiation).	Rapidly dividing mucosal epithelial cells lining the oral cavity and the gastrointestinal tract are easily damaged by chemotherapeutic agents, with mucosal changes appearing within 2-3 days after chemotherapy administration. Changes in the oral mucosa can also be a result of anorexia, radiation to the oral cavity, and poor oral care. Oral complications of cancer treatment include mucositis, stomatitis, salivary gland dysfunction and xerostomia, infection, tooth demineralization, altered taste perception, nutritional compromise, abnormal tooth and craniofacial development, neurotoxicity, bleeding, radiation caries, trismus and tissue fibrosis, and osteoradionecrosis (Figure 78-1).

	Figure 78-1 The child with stomatitis or mucositis may require specific measures to reduce pain during oral hygiene procedures.
6b In consultation with the oncologist, initiate referral to pediatric dentistry services to complete an oral assessment prior to initiation of cancer treatment interventions.	The eradication of active and potential sites for infection before the initiation of chemotherapy, bone marrow transplantation, or radiation is optimal. This may not be possible because of the medical status of the child.
6c Assess child’s oral cavity.	The child who is immunosuppressed is at risk for septicemia due to oral infections.
6d Perform oral hygiene, assist the child as needed.	Ongoing oral hygiene can decrease the incidence of oral complications.
• Brush with soft toothettes or a soft nylon brush.	Using toothettes prevents bleeding of the gums that might be caused by harder bristle toothbrushes. The toothettes act to loosen the debris on the oral mucosa and teeth.
• Use floss when there are no mouth sores or bleeding.	Prevents food particles from remaining between teeth and making the teeth at risk for cavities.
• Rinse (swish) and spit with nonalcoholic 0.1% chlorhexidine mouthwash, saline, water, sodium bicarbonate, oral care products or nystatin, as ordered.	These solutions assist to keep the oral mucosa clean and free of debris. Recent practice guidelines support the use of oral care products for the prevention of oral mucositis across all cancer treatment modalities. The use of chlorhexidine mouthwash for prevention or oral mucositis in patients receiving head and neck radiation therapy is not recommended. If a chlorhexidine rinse is used, it should be alcohol free to prevent oral discomfort and dehydration of oral tissues.
• Oral intake should be restricted for 30 minutes afterward. KidKare For children who are younger than 6 years and may not be able to swish and spit, cleansing can be done by dipping the toothette in the solution and using this to clean the mucosa and teeth.	Waiting to eat or drink promotes absorption of the medication into the mucosa. These solutions should not be swallowed to prevent them from killing the normal flora of the gastrointestinal tract.
6e Apply lanolin-based or petroleum-based creams, ointments, or lip balm to the lips.	Prevents cracking of the lips. Sore lips can make it difficult for the child to drink or chew.
Oral Care for children with stomatitis or mucositis:
7a Assess for oral pain.	Pain is highly associated with stomatitis.
7b Continue meticulous oral hygiene. Oral rinses can be used to clean the teeth, with a toothette used to remove debris loosened by the rinse.	Foam and super soft brushes do not allow for effective teeth cleaning. Resume use of a soft bristle toothbrush for oral care as soon as the mucositis improves. If fluoridated toothpaste causes oral burning or stinging, use a mild-flavored nonfluoridated toothpaste.
7c Manage pain; healthcare prescribers’ orders should be obtained for use of these agents: • Use topical agents such as diphenhydramine (Benadryl), viscous lidocaine, and sucralfate (Carafate) for mild discomfort. • Moderate to severe mucositis pain may be controlled with IV opioids (e.g., morphine or fentanyl). • When severe mucositis is present, premedication (i.e., using viscous lidocaine) to manage pain control may be necessary before oral care can be completed.	Promotes comfort in the presence of stomatitis or mucositis. The side effects of viscous lidocaine include a decreased gag reflex, tingling, and seizures. If the child is unable to eat or swallow, supplemental intravenous fluids and nutrition must be administered.
Oral Care for Children in the Pediatric Intensive Care Unit
8a For neonates and infants with no teeth, every 2 hours, moisten the mouth with soft toothettes or gauze wrapped around a gloved finger soaked in clean water or normal saline and apply lanolin or petroleum-based ointment or lip balm.	Helps to clean and moisten gums.
8b For infants and children with teeth <6 years of age, every 12 hours brush the child’s teeth with soft toothbrush and a smear of toothpaste. Suction from the mouth the excess toothpaste, but do not rinse.	Intubated and ventilated children are dependent upon others to perform their daily oral care. Poor oral hygiene is associated with increased incidence of ventilator-associated pneumonia (VAP), increased dental plaque accumulation, bacterial colonization of the oropharynx and increased nosocomial infection rates. Fluoridated toothpaste used to brush the teeth helps to reduce dental plaque and prevent caries.
Every 2 hours, moisten the child’s mouth with soft toothette soaked in clean water or normal saline and apply lanolin or petroleum-based ointment or lip balm.	Lanolin or petroleum-based ointment or lip balm should also be applied PRN when lips appear dry or cracked.
8c For children with teeth >6 years of age, every 12 hours brush the child’s teeth with soft toothbrush and a smear of toothpaste. Suction from the mouth the excess toothpaste, but do not rinse.	Rinsing after brushing eliminates many of the beneficial effects of the fluoride.
Wipe the oral mucosa with a soft soaked toothette or irrigate the oral mucosa with a syringe containing 0.1% chlorhexidine mouthwash rinse or other prescribed oral care product. Suction excess solution out of mouth.	Wait at least 30 minutes after teeth brushing to cleanse with the oral care product. This allows fluoride in the toothpaste to have some benefit to the teeth.
Every 2 hours, moisten the child’s mouth with soft toothette soaked in clean water or normal saline and apply lanolin or petroleum-based ointment or lip balm.	Do not rinse the mouth with water as this will negate the beneficial effects of the oral care product.
9 When oral care is completed, dispose of equipment and waste in appropriate receptacle. Store reusable supplies (e.g., toothbrush) in secure location away from easy reach of young children. Allow toothbrush to air-dry between uses.	Standard precautions. Reduces transmission of microorganisms.
10 Remove gloves and perform hand hygiene.	Standard precautions. Reduces transmission of microorganisms.