Tube feeding - The importance of a clean mouth

Disclaimer: This fact sheet is for education purposes only. Please consult with your doctor or other health professional to make sure this information is right for your child.

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A healthy mouth and teeth are crucial for good health and appearance.  Children with good oral health can maintain a better quality of life and avoid unnecessary pain. 

Brushing, flossing and keeping a child’s mouths clean can be a challenge for all children and their carers. For the carers of children with special needs, who are sensitive around the mouth area, this is particularly challenging.  It is for this and other reason these children are at increased risk of developing tooth decay. Paediatric dentists and speech pathologists can help you make oral care manageable and even pleasant. 

Regular / 6 monthly check up by your child’s dentist can help identify and treat oral health problems early.  All children up to the age of 18 years can access free dental care at public dental clinics. This includes specialist care for children with special needs.

What are the signs of oral health problems?

If your child is experiencing any of the below signs they may have oral health issues.

  • mouth sores
  • bleeding or inflamed gums
  • dry mouth
  • food refusal
  • smelly mouth
  • broken or discoloured teeth
  • a preference for softer foods or liquids
  • sensitivity in the mouth
  • chest infections (aspiration pneumonia) can be caused by:

- food, drink and saliva entering the lungs. 

- calculus (hardened plaque on the teeth) which can break off and be inhaled into the lungs and 

- bacteria from the mouth that can also be inhaled into the lungs.

Children who are only tube fed, that is having no oral intake, are at increased risk of developing chest infections.

What increases the risk of oral health problems?

Medical conditions that cause: physical limitations, cognitive impairment, gastroesophageal reflux and neuromuscular problems.  At increased risk are:

  • children with genetic disorders that cause defects in tooth enamel, missing teeth or poorly aligned teeth. 
  • children with down syndrome and immune deficiencies that can suffer from gum disease. 
  • children who have:
    • decreased or increased sensation in the mouth,
    • difficulty chewing hard foods,
    • unable to move the tongue to clear food and drink, or have problems swallowing.

Medications that are sweet or medications for specific disorders (eg, epilepsy) can cause tooth decay and gum disease. Taking multiple medications can reduce saliva, putting the teeth and gums at high risk of disease.

Frequent carbohydrate intake has been shown to be the strongest risk factor for development of tooth decay in children. This includes:

  • simple sugars: lollies, fruit juice, chocolate etc, and
  • refined complex carbohydrates made from wheat, rice or potatoes.

Teeth should have a rest of at least 2 hours between food or drink intake. The exception is water.

High energy diets often contain high levels of carbohydrate.  The bacteria in the mouth feed on the carbohydrate which gives them energy to create decay

Use of a bottle at night time (besides water), on demand breastfeeding or frequent night-time feeds beyond the age of 14 months can also increase the risk of decay.

Lack of saliva can cause a dry mouth and limit a child’s ability to: wash away food and bacteria, and neutralise decay causing acid.

Too much saliva in the mouth, caused by infrequent swallowing, often results in calculus (tartar) formation that can cause significant gum disease.

Build-up of bacteria (dental plaque) can cause tooth decay.

Texture modified diets consisting of only pureed foods.  Pureed food will likely stick to the teeth.

How can I help keep my child’s mouth clean?

If you have concerns about your child’s swallow, you should seek individualised advice on how to best clean your child’s teeth and mouth from his / her dentist and or speech pathologist.

Some general ideas to consider:

When:

  • If your child is having some oral intake food, try to brush his/ her mouth and teeth after each meal. Make brushing part of the daily routine.
  • If your child is being exclusively tube fed, bacteria will still gather on the teeth. Brushing is still recommended at least twice a day, morning and night.
  • Going to bed with a clean mouth and teeth is important.

With:

  • Use a soft toothbrush with a small head. Multiple sided toothbrushes are also available.
  • Use a new toothbrush every 3 months.  The change of season is one good way to remember when to change your child’s toothbrush.
  • Do not share toothbrushes as this spreads bacteria.
  • Store toothbrushes in a dry warm place.
  • If tolerated, use a toothpaste with a higher strength of fluoride for added protection:

- for children under 6 years of age use a smear of adult toothpaste on the brush.

- for children older than 6 years of age use a pea-sized amount of adult strength toothpaste. 

  • If sensitive to taste, try a flavourless toothpaste.
  • If foam is an issue, try a low foaming toothpaste variety.
  • If your child can swallow safely, spilling the toothpaste out after brushing is not necessary.
  • Try using an oral swab or toothbrush dipped in mouthwash to give a quick rinse following meals or tube feeds.

How:

  • When brushing, scrub the biting surfaces of the teeth.  Then brush the sides of the teeth using a circular motion at the gum line.  If the gums bleed it is a sign that they are not healthy so please clean this area regularly rather than avoid it.
  • Brush the top of the tongue gently.  There are special tongue cleaners available.
  • Brush for two minutes.  An egg timer is a good way for you and your child to keep track of time.
  • Tooth brushing is 90% of the battle!  Flossing is the ‘icing on the cake’ but may be too difficult to fit into the daily routine.
  • Have a routine for oral care.

Tips to help with your routine for oral care:

  • Do a pleasant relaxing activity before and after oral care
  • Choose a place where you and your child are comfortable, it does not have to be in the bathroom over a sink
  • Avoid bright lights in your child’s eyes but make sure there is enough light for you to see inside your child’s mouth
  • Use your child’s favourite song or TV show, perhaps a toy to hold, or telling a funny story to help him / her relax.
  • Use the ‘Tell-Show-Do” approach to help your child understand the process.  Tell your child what you are going to do, show how you’re going to do each step and then do each step in the same way you have demonstrated.  You can use words, pictures, signs, gestures, touch or any other clues to help your child understand the routine.
  • Give your child the toothbrush to hold and if possible brush their teeth together.
  • Give your child lots of encouragement for good behaviour before, during and after oral care.

Remember:

Oral health care is equally important for children who are fed by a tube as it is for those who eat and drink by mouth.

  • If you have concerns about your child’s swallow, you should seek individualised advice on how to best clean your child’s teeth and mouth from his / her dentist and or speech pathologist.
  • Clean your child’s mouth at least twice a day for two minutes. Make sure one of those times is just before bed. Clean more often if you have been advised to do so by your child’s dentist.
  • Regular check-ups every 6 months with your child’s dentist will help to identify any early problems and enhance their health.
  • Your child’s speech pathologist can help you make the experience of oral health care more pleasant for you and your child.

This factsheet was developed by Paediatric Dentists and Speech Pathologists at the Children’s Hospital Westmead.

References:

Novita Children’s Services

Scope Dental Health Services Victoria

California Childcare Health Program

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The Children's Hospital at Westmead
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Sydney Children's Hospital, Randwick
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Hunter New England Kids Health
www.hnekidshealth.nsw.gov.au

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