What is the composition of magic mouthwash?

Magic Mouthwash Composition

Magic mouthwash typically contains equal parts of diphenhydramine, viscous lidocaine, and magnesium hydroxide/aluminum hydroxide (antacid), though compositions can vary based on specific clinical needs. 1

Standard Composition

Magic mouthwash is a compounded oral rinse used to manage oral mucositis and related oral discomfort. The most common formulation includes:

• Diphenhydramine (antihistamine) - for local anesthetic effect
• Viscous lidocaine (topical anesthetic) - for pain relief
• Magnesium hydroxide/aluminum hydroxide (antacid) - to coat and protect mucosa

This three-drug combination is supported by evidence showing effective symptomatic relief for patients with chemotherapy-induced mucositis 2.

Variations and Additional Components

Depending on specific clinical needs, magic mouthwash may also include:

• Nystatin - when fungal infection is present or suspected 3
• Corticosteroids (e.g., betamethasone sodium phosphate) - for anti-inflammatory effect 1, 3
• Antibacterial agents - for prevention or treatment of bacterial infections

Administration Guidelines

• Typical dosing: 10-15 mL every 4-6 hours 3
• Instructions for use:
  • Swish solution in mouth for 1-2 minutes
  • Either spit out or swallow based on specific formulation and clinical needs
  • Avoid eating or drinking for 30 minutes after use

Evidence-Based Alternatives

For specific conditions, alternative formulations may be more appropriate:

• For Stevens-Johnson syndrome/toxic epidermal necrolysis:

  • Benzydamine hydrochloride rinse every 3 hours, particularly before eating 1
  • Topical corticosteroid preparations (e.g., betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse-and-spit preparation) 1

• For immunotherapy-related oral mucositis:

  • Chlorhexidine oral rinse twice daily 1
  • Saline mouth rinses 1

Clinical Considerations

• For severe pain in head and neck cancer patients receiving chemoradiotherapy, morphine mouthwash has shown superior pain relief compared to standard magic mouthwash 4

• For fungal infections, adding nystatin suspension (100,000 units four times daily) is recommended 1

• When using magic mouthwash containing lidocaine, be aware that numbing of the throat may affect swallowing reflexes and increase risk of aspiration

Pitfalls to Avoid

• Avoid alcohol-based mouthwashes as they can further irritate damaged mucosa 1
• Be cautious with prolonged use of chlorhexidine as it may cause tooth staining and taste alterations
• Ensure patients understand not to swallow lidocaine-containing formulations unless specifically instructed, as systemic absorption may cause adverse effects
• Magic mouthwash formulations have limited shelf life - typically 7-30 days depending on components

Despite widespread use, there is a need to standardize magic mouthwash ingredients to better evaluate efficacy in managing chemotherapy-induced oral mucositis 3.