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

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Scope

This nursing procedural guideline is intended to be followed by nurses involved in caring for the highly dependent or critically ill infant or child requiring oral hygiene within the Paediatric Critical Care Unit at the Royal Hospital for Children (Glasgow).

Audience

All nursing staff involved in caring for infants or children in the Paediatric Critical care unit should be familiar with this nursing procedural guideline.

Introduction

Oral hygiene is a fundamental aspect of nursing care and significantly affects the health and well being of the individual. In paediatrics, oral hygiene is essential for the development of healthy teeth and to minimize the risk of infection. In children tooth development begins in utero with the first teeth, known as the deciduous or milk teeth, erupting at around 6 months of age. Permanent teeth then begin to erupt between the ages of 6 to 12 years of age with the final permanent teeth erupting at 17 to 25 years of age. Teeth act as hosts for dental plaque, which in turn acts as a host for harmful pathogens.1

Dental plaque is the accumulation of mainly oral micro-organisms and their products on the surface of the tooth and surrounding soft tissues. Normally, oral health is maintained by regular eating and drinking, regular maintenance such as tooth brushing and by saliva production. Saliva plays a vital role in cleansing the mouth. It keeps the mucous membranes moist, it regulates the pH of the mouth and aids in the digestion of food. 2 Furthermore, saliva contains natural antimicrobial proteins that protect the mouth against invading pathogens and contributes to the formation of a biofilm or pellicle, which acts as a protective layer on teeth.3

Poor oral hygiene leads to the accumulation of dental plaque and dental caries, and the development of gingivitis.  In paediatric critical care, poor oral hygiene and the resulting increase in dental plaque, is associated with an increase in bacterial colonisation of the oropharynx and a higher risk of ventilator-associated pneumonia (VAP).4,5,6 VAP has been documented as being the second most common hospital acquired infection in paediatric intensive care patients and is associated with increased length of paediatric critical care stay and increased morbidity.In Paediatric critical care, the risk of VAP is increased due to the placement of an endotracheal tube, especially an uncuffed tube, which provides a pathway for bacteria into intubated child’s lungs.4,5,8 .

In addition, the acutely or critically ill infant or child may not be able to maintain oral hygiene and normal saliva production due to a number of factors, including the use of sedation, fluid restriction, nil fluid or diet orally and the administration of medicines that can exacerbate xerostomia, thus further increasing the risk of VAP.1,9

Research suggests that by improving oral hygiene and introducing a VAP prevention care bundle in vulnerable patients, bacteria in the oropharynx can be reduced, which will further impact upon the incidence of VAP.6,10,11 In addition, good oral hygiene will improve the overall comfort and well-being of the child. The nurse caring for those at risk infants and children should be aware of the need to provide comprehensive oral hygiene for the infant or child using appropriate oral assessment methods (Appendix 1 Paediatric critical care unit oral assessment tool) and evidence-based oral hygiene procedures and care bundles.12,13

Equipment & assessment
  • Small pen torch (for assessment)

  • Spatula (for assessment)

  • Disposable apron

  • Goggles/visor

  • Disposable non-sterile gloves

  • Clean disposable tray

  • Non-gauze swabs (infants)

  • Plastic gallipot

  • Foam sticks

  • Sterile water

  • Small-headed soft clean toothbrush

  • Yankeur suction (attached to suction tubing)

  • Fluoride Toothpaste

  • Yellow soft paraffin – for lips

  • Chlorhexidine Gluconate mouth gel* (E.g. Corsodyl 1%.) (*Must be prescribed)

Oral hygiene should be carried out following appropriate assessment of the mouth and lips.14,15 using an oral assessment guide. (Appendix 1). Any problems should be documented in the nursing notes and oral hygiene adapted accordingly. Assessment should be carried out every 12 hours as a minimum and increased in frequency if there are any identified or potential problems.

Assessment: Oral hygiene assessment tool and care pathway (see Appendix 1)

Procedure

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 maycontribute 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 maycontribute 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 wateris 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.

 

Precautions and further information

Recommendations:

All infants and children should be assessed as to whether they require this ‘standard’ oral hygiene or whether they have additional problems or requirements not on this guideline.14,15 Please refer to the accompanying oral assessment chart and the problem solving guides.

Ideally a complete oral assessment should be done once a shift (12 hourly) with a quick assessment each time oral hygiene is to be given.14,20,28

Frequency of oral hygiene can be more important than either the tools or cleansing solutions used. To moisten and freshen the mouth and prevent oral mucositis, oral hygiene should be carried out 4 hourly.9This should be increased in frequency (2-4 hourly) in those infants/children at higher risk of mucositis (E.g. chemotherapy, neuromuscular blockade).9  Tooth brushing with a fluoride toothpaste (strength indicated by age and dentition) should be carried out 12 hourly.18,19

Precautions:

This nursing procedural guideline is intended for infants and children in Paediatric critical care requiring ‘standard’ oral hygiene. A number of infants and children may have additional oral problems that require adapting this oral hygiene procedural guideline. For instance, if the infant or child is immunosuppressed, or has an oral infection. In these cases medication or medicated mouth washes or gels may be required. These should always be prescribed by a doctor or advanced nurse practitioner.  

Appendix 1: oral hygiene assessment tool and care pathway

(adapted from NHS Greater Glasgow & Clyde Oral Hygiene Care Bundle, Wotherspoon 2012)28

This tool should be used in conjunction with Nursing Procedure: oral hygiene for infants and children in Paediatric Intensive Care. The infant or child should have their mouth and lips assessed before carrying out oral hygiene measures.14,15

 

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

 

 

 

Further care:

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
Appendix 2: flow chart summary of standard oral hygiene

References
  1. Johnstone, L Spence, D Koziol-McClain, J (2010) Oral hygiene in the pediatric intensivecare unit: Practice recommendationsPediatric Nursing, Vol. 36 (2), pp.85-97.

  2. Dodds, M  Roland, S Edgar, M  Thornhill, M (2015) Saliva. A review of its role in maintaining oral health and preventing dental disease. BDJ Team, online 

  3. Fábián, TK  Hermann, P  Beck, A  Fejérdy, P  Fábián, G (2012) Salivary Defense Proteins: Their Network and Role in Innate and Acquired Oral Immunity. International Journal of Molecular Sciences, Vol. 13, pp. 4295-4320.

  4. Franklin, D Senior, N James, I Roberts, G (1999) Oral health status of children in a paediatric intensive care unit. Intensive Care Medicine, 26, pp. 319-324.

  5. Munro, CL Grap, MJ Kleinpell, R (2004) Oral health and care in the intensive care unit: state of the scienceAmerican Journal of Critical Care, Vol. 13 (1), pp 25-34.

  6. Ullman, A Long, D Lewis, P (2011) The oral health of critically ill children: an observational cohort studyJournal of Clinical Nursing, Vol. 20, pp. 3070-3080.

  7. Foglia, E Meier, MD Elward, A (2007) Ventilator-associated pneumonia in neonatal and pediatric intensive care unit patients. Clinical Microbiology Reviews, Vol. 20 (3), pp. 409-425.

  8. Aelami, MH  Lotfi, M  Zingg, W (2014) Ventilator-associated pneumonia in neonates, infants and children. Antimicrobial Resistance and Infection Control, Vol 3(30) pp 1-10

  9. Düzkaya, DS  Uysal, G  Bozkurt, G  Yakut, T (2017) The effect of oral care using an oral health care guide on preventing mucositis in pediatric intensive care. Journal of Pediatric Nursing, Vol. 36, pp. 98-102.

  10. Hill, C (2016) Nurse-led implementation of a ventilator-associated pneumonia care bundle in a children’s critical care unit. Nursing Children and Young People, Vo. 28 (4), pp. 23-27.

  11. Zand, F  Zahed, L  Mansouri, P  et al (2017) The effects of oral rinse with 0.2% and 2% chlorhexidine on oropharyngeal colonization and ventilator-associtaed pneumonia in adults’ intensive care units. Journal of Critical Care, Vol. 40, pp. 318-322.

  12. Bigham, MT Amato, R Bondurrant, P et al (2009) Ventilator-Associated Pneumonia in the Pediatric Intensive Care Unit: Characterizing the Problem and Implementing a Sustainable Solution. The Journal of Pediatrics, Vol. 154 (4), pp. 582-587

  13. Scottish Patient Safety Paediatric Programme (2015) Driver diagram and change package: VAP prevention bundle. 

  14. Blevins, JY (2011) Oral health care for hospitalized children. Pediatric Nursing, Vol. 37 (5), pp. 229-235.

  15. Gibson, F  Cargill,J  Allison,J  Begent,J  Cole,S  Stone,J  Lucas,V (2006) Establishing content validity of the oral assessment guide in children and young people. European Journal of Cancer, Vol. 42 (12), pp.1817-1825.

  16. NHS GG&C (2017) NHS Greater Glasgow Prevention and Control of Infection Manual NHS Greater Glasgow Control of Infection Committee Policy. NHS Scotland

  17. RCN. (2006) Mouth Care for Children and Young People with Cancer: Evidence-based Guidelines. Published by: UKCCSG-PONF Mouth Care Group 

  18. Scottish Intercollegiate Guidelines Network (2014) Dental interventions to prevent caries in children. SIGN Publication 138, Edinburgh

  19. SDCEP (2010) Prevention and management of dental caries in children. National Dental Advisory Committee, NHS Scotland

  20. Baker, E  Shipway, L  (2017) Clinical Guidelines: Mouth care. Great Ormond Street Hospital, London UK. 

  21. Frazelle, MR  Munro, CL (2011) Toothbrush Contamination: A Review of the Literature. Nursing Research and Practice, Vol. 2012, pp.1-6.

  22. Grap, MJ Munro, CL Elswick Jr., RK Sessler, CN Ward, KR (2004) Duration of a single, early oral application of chlorhexidene on oral microbial flora in mechanically ventilated patients: A pilot study. Issues in Pulmonary Nursing, Vol. 33 (2), pp. 83-91.

  23. ChildSmile (2017) Prevention and control of infection. Standard 3(a). NES: NHS Scotland. 

  24. Hua, F  Xie, H  Worthington, HV  Furness, S  Zhang, Q  Li, C (2016) Oral hygiene for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database of Systematic Reviews 2016, Issue 10.

  25. Kolahi, J  Soolari, A (2006)  Rinsing with chlorhexidine gluconate solution after brushing and flossing teeth: A systematic review of effectiveness. Quintessence International, Vol. 37, pp. 605-612.

  26. C.H.O.P. (2017) Brushing and toothpaste for children. The Children’s Hospital of Philadephia, Pennsylvania USA.   

  27. Pearson, LS Hutton, JL (2002) A controlled trial to compare the ability of foam swabs and toothbrushes to remove dental plaque. Journal of Advanced Nursing, Vol. 39 (5), pp480-489.

  28. Wotherspoon, I (2012) Oral care policy. NHS Greater Glasgow and Clyde, NHS Scotland. [Staffnet link] 
Editorial Information

Last reviewed: 01 November 2017

Next review: 01 November 2020

Author(s): Jeanette Grady, PICU Clinical Nurse Educator

Approved By: PICU Guideline Group

Reviewer Name(s): Dr Neil Spenceley