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Gastrostomy

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This is the text from the oral care programme for children and adolescents with a gastrostomy.

The dental care teams at Mun-H-Center have many years’ experience of clinical care of children and adolescents with a gastrostomy. This leaflet summarise the most important aspects of meeting and treating this group of patients.

Background

When a child or adolescent has feeding difficulties, and adapted food or dietary supplements cannot meet their nutritional and energy needs, nutrition can be provided by other means than through the mouth. This can be done intravenously – parenteral nutrition – or through the gastrointestinal tract – enteral nutrition. When enteral nutrition is needed for a longer period of time, a feeding tube can be inserted through the abdomen into the stomach – this is known as a gastrostomy. This oral care programme will use the term gastrostomy, even if children and adolescents with severe feeding difficulties can receive feeding support by various means.

Gastrostomy can be used in a broad range of different morbidities. Having a gastrostomy is common in children and adolescents with neurological disorders, as well as in the event of rare medical conditions. Some patients will have a gastrostomy for a limited period while others need nutrition via gastrostomy throughout their lives.

Carrying out oral hygiene procedures on children and adolescents with a gastrostomy can be a challenge. Reduced oral motor control and difficulties handling fluids in the mouth are common. Involuntary bite and vomiting reflexes can occur, which complicate the procedure. Cognitive functional impairment and neuropsychiatric conditions, often in combination with hypersensitivity in the mouth, are also difficulties which occur and which affect treatment as well as the oral hygiene procedure at home.

Many children with a gastrostomy are in contact with multi-professional dysphagia teams, nutrition teams or habilitation. These can be important collaboration partners in caring for children and adolescents with a gastrostomy.

Dental care for children and young people with a gastrostomy

Need for preventive dental care

It is important for children to come into contact with dental care services, ideally a pediatric dentist, at an early stage. Children and adolescents with a gastrostomy need regular and reinforced dental care in order to maintain good oral health.

Risk factors for oral health

Swallowing problems are a common reason for needing nutrition by other means than through the mouth. Swallowing problems imply an increased risk of choking and aspiration, which is important to bear in mind in connection with dental treatment.

Receiving nutrition by other means than through the mouth affects oral health. A person who only eats small amounts, or nothing at all, through their mouth can easily develop hypersensitivity in the mouth, which can lead to difficulties accepting both self-care and treatment by dental care services. If oral motor function is reduced, this leads to a deterioration of self-cleaning and a risk that food remains in the mouth. This in turn implies an increased risk of developing gingivitis, and in some cases caries. These problems are made worse if xerostomia, or dry mouth, also occurs. Calculus forms easily and abundantly when a person’s mouth is inactive. Gastroesophageal reflux and frequent vomiting have an eroding effect on the teeth. Weak orofacial muscles and imbalances between the intraoral and perioral muscles affect the development of the face, jaws and dental arches, which can lead to malocclusion, and this should be monitored regularly.

Guidance for family members and assistants

Children and adolescents with a gastrostomy may need help from dependents and carers to carry out oral hygiene. In order for them to be able to help in the best possible way, they need practical guidance from the dental care services as well as access to oral hygiene aids.

Contact with other care providers

Contact the child’s/adolescents’s speech therapist or dysphagia team for information about:

  • Oral motor or sensory difficulties
  • If desensitisation is a possibility
  • Information about eating difficulties

Appointments procedure
  • Consider using images in the invitation if the patient has cognitive difficulties.
  • Arrange plenty of time for the appointment.
  • Consider the patient’s routines/daily rhythm when setting the appointment time, including whether the patient has recently eaten, as this can influence the risk of vomiting.

Adapt the dental care environment
  • Create a calm environment
  • Use supportive cushions (e g Tumle dental cushions) to provide stability, security and better comfort in the dental chair.

Adapt the dental treatment

Treat the patient in seated/half-seated position:

  • in the event of discomfort lying down due to e g breathing difficulties.
  • in the event of reduced ability to cough and swallow.

Work in brief sessions:

  • if the child/adolescents needs to change their sitting position
  • if the child/adolescents has problems breathing or with mucus formation.
  • if the child/adolescents has a reduced general condition and is tired.

Equipment that should be available to facilitate treatment: bite support, mouth angle expander, oral wipes.

For desensitisation procedures a vibrating appliance, such as a basic electric toothbrush or a Z-vibe oral motor tool, can be useful.

Z-Vibe on the lips.

Z-Vibe at the inside of the cheeks

Z-Vibe on the tongue.

Reinforced prophylaxis
  • Annual examination by a dentist (more frequently as needed).
  • Regular support treatment by a dental hygienist (individual).

Orthodontics
  • Indications for orthodontic procedures include increasing the number of occlusal contacts in order to improve conditions for chewing training and/or safe eating. Another indication is to reduce dental crowding in order to allow for good oral hygiene.
  • Work in brief sessions.
  • In the event of swallowing problems and risk of aspiration, loose items should be handled with caution and be secured (e g with dental floss) to the extent this is possible. See the section ”In cases of dysphagia”.
  • Reinforced prophylaxis during the treatment period is important, as the braces may lead to a greater accumulation of plaque and calculus than normal and make tooth brushing more difficult. Lifelong retention is often required.

In cases of dysphagia
  • Treat the patient in a half-seated position with their head leaning to one side.
  • Make sure to remove all water (possibly use two saliva ejectors); assistance is important here.
  • Consider using a dental dam if there is a risk of aspiration.
  • Consider wiping the inside of the mouth with an oral wipe if the patient is unable to spit or rinse their mouth.
  • It is important to remove calculus which otherwise risks coming loose and entering the airways.
  • Good oral hygiene (a healthy mouth) is extra important if there is a risk that the patient aspirates their own saliva.

Accompanying guardians and assistants
  • Inform them about how feeding difficulties and gastrostomy can affect oral health.
  • Give instructions on adapted working positions and usefull aids when carrying out oral hygiene at home.

References
  • Backman, E., Karlsson, AK. & Sjögreen, L. (2018). Gastrostomy Tube Feeding in Children With Developmental or Acquired Disorders: A Longitudinal Comparsion On Health Care Provision and Eating Outcomes 4 Years After Gastrostomy. Nutrition in Clinical Practice, 33(4):576-583.
  • Bosaeus, I., (2015). Enteral och parenteral nutrition. Läkemedelsboken https://lakemedelsboken.se/kapitel/nutrition/enteral_och_parenteral_nutrition.html#c4_1 [2019-03-11].
  • Cardona-Soria, S., Cahuana-Cárdenas, A., Rivera-Baró, A., Miranda-Rius, J., Martín de Carpi, J. & Brunet-Llobet, L. (2019). Oral health status in pediatric patients with cerebral palsy fed by oral versus enteral route. Special Care in Dentistry, 40(1):35-40.
  • Kreymann, K.G., Berger, M.M., Deutz, N.E.P., Hiesmayr, M., Jolliet, P., Kazandjief, G., Nitenberg, G., van den Berghe, G., Wernerman, J., Ebner, C., Hartl, C. & Spies, C. (2006). ESPEN Guidelines on Enteral Nutrition:Intensive care. Clinical Nutrition, 25:210-223.
  • Nielsen, Magnéli, A., (2019). Oral hälsa hos barn och ungdomar (3-16 år) med Sällsynta diagnposer som har gastrostomi. Magisteruppsats. Göteborg: Göteborgs universitet, Institutionen för odontologi.
  • Owens, B.M., Sharp, H.K., Fourmy, E. E. & Phebus, J.G. (2016). Effect of occlusal calculus utilized as a potential “biological sealant” in special needs patients with gastric tubes: a qualitative in vitro contrast to pit and fissure sealant restorations. General Dentistry, 64(4):24-29.
  • Singer, P., Berger, M.M., van den Berghe, G., Biolo, G., Calder, P., Forbes, A., Griffiths, R., Kreyman, G., Leverve, X. & Pichard, C. (2009). ESPEN Guidelines on Parenteral Nutrition: Intensive care. Clinical Nutrition, 28: 387-400.

Printed version

If you would like further guidance about dental treatment and oral care for children with a gastrostomy, or if you have any feedback about the oral care programme, please contact us.

About the programme

  • Authors: Anna Nielsen Magnéli, Dental Hygienist and Lisa Bengtsson, Speech-Language Pathologist, Mun-H-Center
  • Layout and photographs: Inga Svensson, Communicator, Mun-H-Center. 
  • Printed: 2021

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