Effectiveness of Topical Intervention with Modified “Magic Mouth-Wash” in Treating the Pain of Oral Mucositis in Non-malignant Dermatological Conditions: An Observation Report of Three Case Profiles
Renuka Pai1, Jerome Jose Valiyaparambil2, Parashuram Pai3
1Consultant, Rangadore Memorial Hospital, Bangalore.
2Junior Resident, Studying for Post Graduation.
3Medical Intern, SDM Medical College, Dharwad, India.
*Corresponding Author E-mail: pairenuka@yahoo.co.in
ABSTRACT:
The pathophysiology of oral mucositis is complex and its management is a challenge. Reduced immunity as in cancers, exposure to chemotherapy, exposure to radiotherapy in head and neck cancers are common causes. Oral mucositis is also seen as a manifestation of dermatological conditions affecting the muco-cutaneous structures of the body. We describe the effectiveness of “modified magic mouth wash” in a few such cases.
KEYWORDS: Modified “magic mouth-wash”, Painful oral mucositis, Painful oral mucositis in dermatology.
INTRODUCTION:
The pathogenesis of oral mucositis (OM) involves destructive pan-mucosal inflammation with release of cytokinins, cytokines and enzymes. The management of pain of this debilitating condition is challenging. While cancer and its treatments are common causes of OM, dermatological conditions also cause OM.
In muco-cutaneous pemphigus vulgaris (as in Patient 1), the muco-cutaneous lesions occur due to autoantibodies against the keratinocyte antigens (desmogleins) and inter-epithelial cell binding protein that leads to acantholysis, blisters and ulcers1.
In oral psoriasis (as in Patient 2), the initiation phase of OM is possibly triggered by trauma/infection/drugs and the auto-immune inflammation is characterised by uncontrolled proliferation of keratinocytes, dysfunctional differentiation and neovascularisation. The altered innate and adaptive cutaneous immune responses contribute to the pathology2.
In toxic epidermal necrolysis (as in Patient 3), the drug-induced mucocutaneous disease manifests as full thickness epidermal necrosis. It is caused by antigenic moiety (prohapten)/metabolite stimulating peptide-induced T cell activation, exocytosis of substances like granulysin, perforin/granzyme B, FS-7 associated surface antigen (Fas ligand), TNFα and NO that cause keratinocyte apoptosis3.
Topical coating agents cover exposed nerve endings, protect the oral mucosa and facilitate healing.
Benzydamine inhibits production of inflammatory cytokines5.
Topical morphine (0.2 to 2.0%), inhibits neuronal excitability and acts on opioid receptors on the afferent nerve endings6.
The bio-diversity on the exposed mucosa is vast; anaerobic super-infection is common. Metronidazole inactivates reactive-oxygen-species production characteristic of anaerobic infections and thus modulates pathogenesis of OM.
Dexamethasone has anti-inflammatory action.
Glycerine is a demulcent, a lubricant and is palatable. It has also shown anti-infective properties in non-human studies7.
OM due to cancer and its therapeutics is an archetypical example for OM in other muco-cutaneous diseases. Hence, analgesic regimens used in the former should theoretically address pain in the latter conditions too.
We agree that the administration of systemic analgesics could have confounded the response to pain, but, symptoms other than pain- swallowing, inflammation and involvement in activities of daily living improved after the use of the mouth wash (Table). The multiple ingredients used in the Glycerine mix (Table), each with its distinct action, contributes to pain relief in one way or the other (action on nerve endings, anti-infective or anti-inflammatory). We agree that the observation wholly focuses on symptom relief and doesn’t highlight its effect on the status of lesions. Nevertheless, we hope that the regimen gets standardised by virtue of more non-heterogenous studies given the fact that the intervention is highly symptom-palliative, cost-effective, reproducible, user-friendly and devoid of major side-effects.
Table: Demographic, clinical, analgesic regimen (pre and post use of modified “magic mouth wash”) details of three patients, each with a different dermatological condition manifesting with oral muco-cutaneous lesions Protocol For Modified Magic Mouth Wash:
|
No |
Sex/Age/Body weight (Kg) |
Diagnosis (Primary)
|
Gap from onset of lesions to initial visit of pain management team |
Grade of mucositis @ initial visit by pain management team |
NRS of the burning pain
|
Follow- up by pain management team |
Systemic analgesics
|
Neuromods added |
Reduction in NRS of burning pain |
Effect on oral intake |
|
1 |
F/50/60 |
Pemphigus vulgaris |
Day 6
|
IV |
10/10 |
10 days |
Yes, IV Morphine 2.5 mg 6th hourly; IV PCT 1g 6th hourly in the initial few days; Pulse therapy with steroids |
- |
1/10 |
Improved |
|
2 |
M/36/45 |
Chronic plaque Psoriais on MTX |
Day 15 |
III |
10/10 |
1 week
|
IV PCT 1g 6th hourly in the initial few days; Tab Morphine 5 mg 6th hourly for few days |
- |
2/10 |
Improved |
|
3 |
F/35/60
|
Toxic Epidermonecrolysis (Lamotrigine induced) |
Day 8 |
IV |
10/10 |
30 days |
Yes, IV Morphine 2.5 mg 6th hourly; IV PCT 1g 6th hourly in the initial few days. Later, the patient was on tab morphine 10mg 4th hourly as there was pain in lesions all over body |
Yes; Cap Pegaba 75mg HS as there was pain in lesions all over body |
1/10 |
Improved |
|
Adverse Effects: Nil; Side Effects: Nil |
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Benzadyamine mouth wash: 2 tablespoons in half a glass of water; use 30 minutes before EACH meal; To Swish (1 minute) -> To Gargle (1 minute) -> To Spit Out
Glycerine mix: Tab Morphine 10mg (2 tablets) (2%) + Tab Dexamethasone 4mg (1 tablet) + Tab Metrogyl 400mg (1 tablet) to be crushed and added to 100ml glycerine; Shake Bottle Before Each Use; 10 ml fourtimes in a day 15 minutes before EACH meal; To Swish (1minute) -> To GARGLE (1minute) -> To Swallow
Common salt: 2 teaspoons in half a glass water; use after EACH meal; To Swish (1 minute) -> To Gargle (1 minute) -> To Spit Out
ACKNOWLEDGEMENTS:
Our heartfelt thanks to Mrs Arathi Bhargav for the language edits and suggestions for this manuscript.
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Received on 13.12.2023 Revised on 23.08.2024 Accepted on 16.01.2025 Published on 17.05.2025 Available online from May 20, 2025 Int. J. Nursing Education and Research. 2025;13(2):104-106. DOI: 10.52711/2454-2660.2025.00021 ©A and V Publications All right reserved
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