Oral health advice for tube-fed children and adults

Brushing is important because:

• It will make a mouth feel more comfortable.
• It can reduce plaque build-up, leading to reduced calculus (tartar) build-up and can reduce plaque bacteria; some plaque bacteria have the potential to cause chest infections. Plaque bacteria can also cause bad breath (halitosis), bleeding gums (gingivitis) and gum disease and dental decay (caries).
• Brushing and massaging around the mouth and cheeks can improve muscle tone, increase saliva flow and help to desensitise the mouth area.

If plaque is not removed it can harden and become calculus. Studies have found that those who are tube-fed are more likely to have calculus build up than other people who are not tube-fed. This is largely because those who are tube-fed do not use their chewing muscles as effectively and so do not clear their mouth in the usual manner.

Abnormal muscle tone and altered tongue and lip movements can often result in the teeth becoming crowded. This can then make them more difficult to clean and so can make them more likely to have calculus build-up.

The presence of calculus around the base of the tooth makes it harder to clean around the gum margin and as a result can lead to inflammation of the gums (gingivitis) and result in bleeding on brushing.

Your dentist will discuss with you the best way to manage calculus build-up.

People who are tube-fed often have Gastro-Oesophageal Reflux (GOR) which can result in acid from the stomach reaching the mouth and teeth. This acid may cause tooth wear called erosion that will result in thinning or shortening of the teeth.

Sometimes medication can help to reduce GOR and so we can work with your doctor to see if there is any way to help reduce this.

Acidic foods and/or drinks (for example citrus fruits, fruit juice, diluting juice, and fizzy drinks) can make tooth erosion worse. If some food is still being taken by mouth, then these types of food/drink should be kept to a minimum.

Your dentist will be able to give you more personal advice about this at your appointment

Those who are tube-fed often have the feeling of a dry mouth, which may be caused by a lack of saliva stimulation. Some medications and certain medical treatment (such as radiotherapy) can also affect saliva flow to make the mouth feel dry.

A dry mouth can cause discomfort and problems with ease of swallowing, oral clearance and removal of secretions. Ensuring that a water based gel is applied to the lips, tongue, cheeks and palate regularly can help the mouth to feel more comfortable and may optimise any swallowing function that is present. See ‘Mouth Hydration’ below for examples of suitable gels.

Ensuring that the person with the feeding-tube is adequately hydrated is also important.

Yes, it is important to look after the gums and keep the mouth clean and free of debris even if there are no teeth present. This applies for very young children and adults.

All parents and guardians are advised to ensure that young children in their care are taken to see a dentist as soon as their first teeth come through, and before their first birthday.

Those who are tube-fed may also have neuromuscular impairment that can cause swallowing problems, called dysphagia.

This can increase the risk of aspiration pneumonia (inflammation of the lungs due to breathing in food/liquid/saliva/calculus). This risk can be reduced by good mouth care. Sometimes this can be more difficult if a person who is tube-fed has a sensitive mouth and is orally defensive.

Your dentist will be able to suggest some ways to manage effective tooth brushing

Toothpastes (examples below in ‘Plaque Removal’) are widely available to buy in supermarkets, pharmacies and from online shops.

Water based mouth gels (examples below in ‘Mouth Hydration’) are available to buy from pharmacies. Occasionally your doctor may be able to prescribe these for you in specific cases.

The specialised toothbrushes (‘Collis Curve’, ‘Dr Barman’s Superbrush’), ‘Mouth-Eze’ (MC3) oral cleanser and ‘OpenWide’ foam mouth rest can be bought from online shops

• Brush teeth at least twice a day for two minutes, with one of these times being before bed-time.
• Brush using a small circular motion, remembering to brush at the gum margin as well as the teeth themselves. It is also good to brush the tongue as well.
• Use a low-foaming toothpaste (a toothpaste without Sodium Lauryl Sulfate or SLS) which also contains fluoride.
• Under 3 years old: a smear of toothpaste, no less than 1000ppm Fluoride.
• Over 3 years old: a pea-sized amount of toothpaste, 1350-1500ppm Fluoride.
• Examples of low foaming toothpastes currently include:
• Sensodyne Pronamel (mild mint)
• BioXtra Dry Mouth Toothpaste (mild mint)
• Biotene Dry Mouth Toothpaste (mild mint)
• Oralieve Toothpaste (mild mint)
• Oranurse Toothpaste (flavour-free)
• Use a dry toothbrush to minimise the amount of foam produced with the toothpaste rubbed into the bristles.
• Do not rinse away the foam with water. Try and spit it out. If this is not possible, a suction toothbrush or a ‘Mouth-Eze’ (MC3) oral cleanser may be useful to remove foam deposits.
• Additional tooth brushing may be needed after meals to remove food debris. This can be done with a toothbrush, suction or suction toothbrush or a ‘Mouth-Eze’ (MC3) oral cleanser.
• A toothbrush with a small head may be easier to use. Specialised, adapted toothbrushes (e.g. suction toothbrush, ‘Collis Curve’ toothbrush, ‘Dr Barman’s Superbrush’) may also be useful.
• If the person who is tube-fed requires assistance with brushing, this may be easier being done from the side or behind.
• Positioning should ensure the risk of aspiration or choking during brushing is minimised. This includes brushing being done is a sitting position, with head tilted forwards. If the person is unable to sit up, brushing can be performed with them lying down, their head to one side on a towel covered-pillow.
• Tooth brushing may be difficult if there is oral defensiveness. Distraction aids (such as use of a tablet, listening to music or TV) may be useful. To reduce excessive distress, mouth care may have to be staged at different times of day to keep episodes of care short. Regular, routine brushing aims to reduce mouth sensitivity overall. Build up to this slowly, it may take some time for it to be tolerated.
• f the toothbrush is chewed on/clamped on, there are various ways to manage this. Sometimes brushing with 2 people makes it easier; 1 to provide brushing and the other to support and distract. A spare toothbrush can be used as a prop or two small toothbrushes taped together; whilst this one is being chewed or bitten, a second toothbrush can be used to access and clean the teeth on the opposite side. Alternatively, an ‘OpenWide’ foam mouth rest can be used.

• If food/medication is being taken by mouth, as directed by the Speech and Language Therapy Team (SALT), try to ensure this is sugar-free to reduce the risk of developing dental decay (caries).
• Tasters should not be acidic, sugary or too frequent in order to reduce the risk of tooth erosion and decay.
• Additional mouth cleaning may be needed to ensure no debris remains.
• Medications, if taken by mouth, can sometimes be changed to sugar-free formulations following discussion with your doctor.

• Keeping the lips and mouth moist can improve comfort.
• Use of a water-based gel or dry mouth gels on the lips can prevent drying and cracking of the lips. It can also be used inside the mouth to keep the cheeks, tongue and palate moist and to remove dry secretions.
• They can be applied using a patient’s own finger or, if a carer is required to apply it, use of a toothbrush or Mouth-Eze oral cleanser.
• Foam lollipops are no longer recommended due to the risk of detachment and choking.
• Examples of suitable gels include:
• KY jelly
• BioXtra oral gel
• Biotene dry mouth gel
• Oralieve mouth moisturising gel
• This should be applied every 2-3 hours to maintain mouth hydration and improve comfort.
• Ensure that the person with the feeding-tube is hydrated sufficiently, as dehydration can impact on the feeling of a dry mouth.

• Dentures should be removed every night for cleaning and soaking. Ideally, they should be kept in a named container. After soaking, they can be left out to dry in their container.
• A soft brush and soap should be used to clean the denture on every surface at least twice a day. Additional cleaning may be required after meals if there is food debris present.
• If denture fixative is used, this must be removed thoroughly from the denture and the mouth at the end of each day.
• Broken or sharp dentures should not be worn. Contact your dentist for advice.
• The gums should be moisturised using a water-based gel (see ‘Mouth Hydration’) every 2-3 hours to keep them comfortable. This also can help with the retention/fit of the denture, as a denture in a moist mouth stays in place much easier than in a dry mouth.

Barnsley (New Street)
Telephone: 01226 645150

Doncaster (The Flying Scotsman Centre)
Telephone: 01302 563163

Rotherham (Rotherham Community Health Centre)
Telephone: 01709 423110