PEP Topic 

Payayor is an herb that has been used in Thailand for burns, insect bites, rashes, herpes simplex and herpes zoster wounds, and varicella zoster infection. The scientific name is Clinacanthus nutans (Burm. f.). Payayor was evaluated for use in managing mucositis in patients with cancer.

Effectiveness Not Established

Systematic Review/Meta-Analysis

Jensen, S.B., Jarvis, V., Zadik, Y., Barasch, A., Ariyawardana, A., Hovan, A., . . . Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). (2013). Systematic review of miscellaneous agents for the management of oral mucositis in cancer patients. Supportive Care in Cancer, 21(11), 3223–3232.

doi: 10.1007/s00520-013-1884-6


To analyze the available literature and define clinical practice guidelines for the use of the following agents for the prevention and treatment of oral mucositis (OM): allopurinol, midline mucosa-sparing radiation blocks, payayor, pentoxifylline, timing of radiation therapy (morning versus afternoon), pilocarpine, bethanechol, chewing gum, propantheline, and tetrachlorodecaoxide

Search Strategy:

  • KEYWORDS: Oral mucositis, cancer therapy, supportive, palliative, prevention, treatment, and saliva
  • Inclusion and exclusion criteria were not listed in this report, but, rather, were referenced from the criteria listed in another referenced study.

Literature Evaluated:

A total of 99 references were retrieved. Of these, 18 were excluded based on the inclusion/exclusion criteria (which was not stated in the article). Of the remaining 81 papers, 49 pertained to agents of natural origin and the results on those agents were reported separately. This manuscript reported the results of the review of the remaining 32 papers that tested interventions that did not fit in any of the other categories and were classified as miscellaneous agents.

Studies were evaluated based on the list of major and minor flaws published by Hadorn. Level of evidence was assigned for each intervention based on the Somerfield criteria. A well-designed study was defined as a study with no major flaws per the Hadorn criteria. Findings from the reviewed studies were integrated into guidelines based on the overall level of evidence for each intervention.

Sample Characteristics:

  • A final sample of 32 papers addressing 10 interventions were included in the report.
  • The numbers of patients and sample ranges across all studies were not reported.
  • Patient populations included patients receiving high-dose chemotherapy before stem cell transplantation, patients receiving radiation therapy (RT) for head and neck cancer, and patients receiving bone marrow transplantation.

Phase of Care and Clinical Applications:

PHASE OF CARE: Active treatment


Suggestions were made against the use of systemic pilocarpine administered orally for prevention of OM during RT in patients with head and neck cancer and in patients receiving high-dose chemotherapy with or without total body irradiation, prior to hematopoietic stem cell transplantation as well as against the use of systemic pentoxifylline administered orally for the prevention of OM in patients undergoing bone marrow transplantation. No guideline was possible for any other agent reviewed because of inadequate or conflicting evidence.


None of the agents reviewed was determined to be effective for the prevention or treatment of OM. This review was inadequate and difficult for the reader to understand. The methods section was missing needed information to assess the interventions and the associated recommendations.


  • The scope of the analysis was too large, as 32 studies were included from which the review panel attempted to make recommendations about 10 different interventions.
  • The level of evidence was not explained to the reader, making it difficult to assess the results obtained and impossible to know if the study selection was biased.
  • The authors stated that the criteria for a well-designed study was no major flaws per the Hadorn criteria but did not tell the reader what the criteria were.
  • The authors were not clear if only well-designed studies were used exclusively.

Nursing Implications:

Many products on the market claim to prevent or treat OM. Nurses need to be well informed before recommending any products or interventions to patients. Further research is needed. 

Research Evidence Summaries

Putwatana, P., Sanmanowong, P., Oonprasertpong, L., Junda, T., Pitiporn, S., & Narkwong, L. (2009). Relief of radiation-induced oral mucositis in head and neck cancer. Cancer Nursing, 32(1), 82-87.


Study Purpose:

Explore the effectiveness of payayor compared with benzydamine for the prevention and relief of radiation induced mucositis.

Intervention Characteristics/Basic Study Process:

Patients were randomized to receive either benzydamine (BZD) hydrochloride (Difflam, 3M, Australia) 15 ml, rinse 3 times daily or glycerin payayor 3 drops, 3-5 times daily. Payayor is an herb that was prepared in a standardized preparation that contains flavinoids and glycosides with sulfur compounds. A single research assistant instructed participants in oral hygiene care, how to use the product, and avoidance of tobacco, alcohol, or other oral products. All patients received normal saline as a mouth cleaning solution. Oral examinations were done weekly until two weeks after treatment.

Sample Characteristics:

The sample was comprised of 30 patients. The mean age was 55.66, with a range of 32-62 years. Females 25%, Males 75%.

Diagnosis Information: Cancer of the nasopharnyx, larynx, oral cavity and tonsils. All were scheduled to receive radiation therapy daily 5 times per week, up to 6,000cGy.

Other Key Characteristics: Over 50% had concomitant chemotherapy.


Single site

Outpatient setting: Bangkok, Thailand

Study Design:

Prospective, single, blind, randomized controlled trial

Measurement Instruments/Methods:

Oral examination 0-4 scale for symptom grading by the patient World Health Organization grading system for oral mucositis. Patient satisfaction 5 point scale.


All patients developed oral mucositis. Time to onset was 1.24 weeks with payayor versus 0.44 weeks with BZD (p < 0.001). Total radiation dose to onset was higher in the payayor group, but was not significantly different from BZD. Mean mucositis severity scores were lower in the payayor group (p < 0.001). There were more treatment delays in the BZD group, with 30% of these due to oral pain. No treatment delays due to oral symptoms were reported for the payayor group. The mean satisfaction score in the payayor group was significantly higher (p < 0.01). Patients in the payayor group described a feeling of increased saliva in the mouth with alleviation of xerostomia symptoms. All symptoms were mild to moderate.


Results support the protective and relief effects of BZD and payayor in patients receiving radiation therapy for head and neck cancer. Payayor was well tolerated and potentially can be more effective for mucositis prophylaxis.


Small sample <100

No discussion of other medications provided for oral pain relief. The sample size was too small to provide appropriate subgroup analysis by radiation dosage or between those who had concomitant chemotherapy or not.

Nursing Implications:

Payayor and BZD are shown to be at least somewhat effective for the prevention of mucositis in patients receiving radiation therapy, prone to oral complications. Findings here warrant further investigation of efficacy in other patient groups and in comparison to other standard treatments in this area. BZD is not yet approved for this use in the United States.