"Magic" Mouthwash (Mixed Medication Mouthwash)

STUDY PURPOSE: To systematically review oral care interventions for the prevention and treatment of oral mucositis (OM) in patients undergoing cancer treatment

TYPE OF STUDY: Systematic review

DATABASES USED: Ovid MEDLINE

KEYWORDS: mucositis, stomatitis, cancer, oral care, oral care protocol, dental care, dental cleaning, oral decontamination, oral hygiene, saline, sodium bicarbonate, baking soda, chlorhexidine, magic/miracle mouthwash, calcium phosphate

INCLUSION CRITERIA: Primary research article, reflects a variety of research designs, rested the effects of intervention on severity of OM or mucositis-related symptoms

EXCLUSION CRITERIA: Review articles, clinical case reports, literature reviews, non-research articles

TOTAL REFERENCES RETRIEVED = 129

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Hadorn et al. criteria was used to assess the flaws in the selected publications, and levels of evidence were rated using the Somerfield schema.

FINAL NUMBER STUDIES INCLUDED = 52

SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW: Not stated

PHASE OF CARE: Active antitumor treatment

The guidelines are as follows.

• Oral care protocols: Oral care was suggested for the prevention of OM in adult and pediatric populations for all types of cancer therapies. No population-specific guidelines were recommended.
• Dental care (by a professional): No guidelines were recommended for dental care in the prevention of OM.
• Normal saline: No guidelines were recommended for normal saline for the prevention or treatment of OM.
• Sodium bicarbonate rinse: No guidelines were recommended for sodium bicarbonate for the prevention or treatment of OM.
• Chlorhexidine: No guidelines were recommended for chlorhexidine for the prevention or treatment of OM in patients receiving standard chemotherapy or hematopoietic stem cell transplantation. Guidelines suggest that chlorhexidine not be used to prevent OM in patients with head and neck cancer treated with radiotherapy.
• Mixed medication mouthwash: No guidelines were recommended for mixed medication mouthwash for the prevention or treatment of OM.
• Calcium phosphate: No guidelines were recommended for calcium phosphate for the prevention or treatment of OM.

Oral care protocols are recommended to patients for the prevention and treatment of OM. Chlorhexidine is not recommended for patients with head and neck cancer who receive radiotherapy treatment.

Evidence for interventions to prevent and treat OM are limited, making guideline recommendations difficult.

Nurses should teach patients appropriate oral care to help prevent OM.

To determine the efficacy of three different mouthwashes in the treatment of chemotherapy-related mucositis

All patients received the PRO-SELF Mouth Aware (PSMA) educational program from a nurse who was blinded to the intervention treatment. The program included didactic information, the development of self-care strategies, and nurse support in the treatment setting. Good oral hygiene was an emphasis of the program, and patients were provided with specific oral hygiene practices to follow during chemotherapy. Nurses contacted the patients via telephone every other day. Patients were randomly assigned to receive one of three possible intervention treatments that were given to the patient in 1-pint opaque plastic bottles. The interventions were either salt and soda, chlorhexidine, or magic mouthwash. Nurses received training in the PSMA program every six months. Patients used the mouthwash four times per day until symptoms resolved or for 12 days. Patients swished 20 mL of their intervention mouthwash for 20 seconds and spit. Mouthwash bottles were collected when symptoms resolved or on day 12, whichever came first, and remaining medication was measured to gauge patient compliance. Oral assessments began upon enrollment, and the first assessment was conducted by a physician or nurse. Patient-directed oral assessments continued thereafter, four times per day, or until mucositis resolved or for 12 days, whichever came first.

• N = 142  
• MEAN AGE = 59.25 years
• MALES: 36%, FEMALES: 64%
• KEY DISEASE CHARACTERISTICS: Multiple types of cancer 

• SITE: Multi-site    
• SETTING TYPE: Outpatient    
• LOCATION: United States

• PHASE OF CARE: Active antitumor treatment

Randomized, double-blinded clinical trial

• Oral Assessment Guide (OAG)

There were no differences between any of the groups in the time to cessation of mucositis symptoms (F2,141 = .52, p = .59). The mean number of days to cessation of symptoms was 6.59 days in the chlorhexidine group, 7 days in the salt and soda group, and 7.17 days in the magic mouthwash group.

Although clinicians regularly use chlorhexidine mouthwash, this study demonstrates that there is no difference between treatments of salt and soda rinses and magic mouthwash as part of a treatment protocol for chemotherapy-induced oral mucositis. Participants in the magic mouthwash group reported the highest mean number of days to cessation of symptoms, indicating this is the least effective treatment of the three.

• Unintended interventions or applicable interventions not described that would influence results 
• Other limitations/explanation: It is unclear what additional interventions for mucositis were used during the intervention period.

Educating patients about proper oral hygiene while receiving chemotherapy is important. Nurses should be aware, however, that there is no difference between chlorhexidine mouthwash, salt and soda rinses, and magic mouthwash, the three mouthwashes traditionally used in the clinical setting. As the least effective of the mouthwashes in terms of mean days to cessation of symptoms, magic mouthwash does not appear to be an effective intervention in the treatment of chemotherapy-induced oral mucositis.