What are magic mouthwash alternatives that you would recommend?

Many of our patients will make their own DIY MMW per Phil's My Pharmacist (YouTube) instructions -- uses benzocaine/Cepacol lozenges -- they say it's much more effective than the compounded one from the pharmacy. It is also more economical.

If the majority of bothersome mucositis is in the oral cavity, consider dexamethasone oral rinse (swish and spit); look up the SWISH trial.

Also, interesting data from several studies that showed administering radiation treatments in the morning as opposed to later in the day can significantly reduce the severity of mucositis.

For patients with mild to moderate sore throat or esophagitis who are still able to maintain po intake, I recommend Throat Coat tea (licorice, marshmallow, and slippery elm) with honey TID. This is a safe level of licorice which should not impact BP.

I use Oramagic Plus which has benzocaine as a topical anesthetic. It is a liquid that does not coat the entire mouth and is preferred by patients. I also recommend ice chips.

Alliance A221304 is a phase III randomized trial supporting the use of doxepin for this indication (Sio et al., PMID 30990550). This trial compared placebo with magic mouthwash to doxepin oral rinse, with both doxepin and magic mouthwash showing very similar effect sizes compared to placebo. There was originally planned to be a follow-up trial looking at doxepin vs MM vs D+MM, but unfortunately, that never materialized.

I think doxepin hasn’t caught on as much as the effect size was pretty much the same as MM, but the mechanism of action is very different. (Doxepin is a tricyclic used for peripheral nerve effects.) I use both doxepin and MM for this reason, although admittedly, the supporting data isn’t available for joint use for the aforem...

There have been a few studies that suggest generic honey may be useful in reducing the severity of oral mucositis. Hunter et al., Exploratory Research and Hypothesis in Medicine 2020, (University of Canberra) did a retrospective review of 10 small studies concluding that there was potential to reduce mucositis and infection based on this review. An older study by Co et al., PMID 27028991 (University of Santo Tomas Hospital, Manila) reviewed earlier trials and came to a similar conclusion.

It might be worth using generic medicinal honey to reduce the severity of mucositis. There have been mixed reports on whether or not honey reduces the risk of infection in oral mucositis. The only adverse study reported used a specific honey (Manuka). It m...

Wonderful answers. Love this question.

I would add to this:

• Consider aloe vera rinses at intervals
• Absolutely avoid any mouth products with alcohol
• Consider ginger tea (hot or iced) or homemade ginger tea ice pops
• Ice if patients can tolerate it e.g. chemo effect and CTDs like systemic sclerosis related cold intolerance

Another avenue that is being explored in systemic sclerosis related oral manifestations is singing, humming, and chanting (which can be done informally while walking through the house, doing the dishes, etc.)

As well as facial exercises to increase circulation and the myokine benefits of local muscle activation - exercise in other wound situations seems to accelerate healing.

In conjunction with our dietary department, we had made capsaicin pops compounding the powder with honey and freezing it. Patients started them one week before treatment and then throughout and we found a reduction in pain associated with mucositis (unpublished).

Had to give it up when the nutritionist moved on and no one wanted to continue the project.

Doxepin mouthwash

Sio et al., PMID 30990550

Anecdotally from my patients, cultured buttermilk sipped throughout the day helps. However, this is a hard sell to nonSoutherners.