What is the treatment for oral ulcers due to paraquat exposure?

Treatment of Oral Ulcers Due to Paraquat Exposure

For oral ulcers caused by paraquat exposure, the recommended treatment includes immediate application of white soft paraffin ointment to the lips every 2 hours, mucoprotectant mouthwashes three times daily, and topical corticosteroids such as betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse-and-spit preparation four times daily. 1, 2

Initial Management

• Apply white soft paraffin ointment to the lips immediately and continue every 2 hours throughout the acute illness 1
• Use mucoprotectant mouthwashes (e.g., Gelclair) three times daily to protect ulcerated mucosal surfaces 1, 2
• Clean the mouth daily with warm saline mouthwashes or an oral sponge, gently sweeping in the labial and buccal sulci to reduce the risk of fibrotic scars 1

Pain Management

• Use an anti-inflammatory oral rinse or spray containing benzydamine hydrochloride every 3 hours, particularly before eating 1, 2
• For inadequate pain control, use topical anesthetic preparations such as viscous lidocaine 2%, 15 mL per application 1
• For severe oral discomfort, cocaine mouthwashes 2%-5% can be used three times daily 1

Infection Prevention

• Use antiseptic oral rinses twice daily to reduce bacterial colonization of the mucosa 1, 2
• Options include:
  • 1.5% hydrogen peroxide mouthwash (e.g., Peroxyl mouthwash, 10 mL twice daily) 1
  • 0.2% chlorhexidine digluconate mouthwash (e.g., Corsodyl mouthwash, 10 mL twice daily) - consider diluting by up to 50% to reduce soreness 1
• Take regular oral and lip swabs if bacterial or candidal secondary infection is suspected 1

Corticosteroid Treatment

• Apply topical corticosteroids four times daily (e.g., betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse-and-spit preparation) 1, 2
• For more potent treatment, clobetasol propionate 0.05% mixed in equal amounts with Orabase can be applied directly to the sulci, labial or buccal mucosae daily during the acute phase 1, 2

Systemic Treatment for Moderate to Severe Paraquat Poisoning

• For moderate to severe paraquat poisoning with systemic effects, consider pulse therapy with cyclophosphamide and methylprednisolone 3, 4
• This regimen may include:
  • Intravenous cyclophosphamide 15 mg/kg daily for two days 4
  • Methylprednisolone one gram daily for three days 4
  • Mesna 15 mg/kg for four days (to prevent hemorrhagic cystitis from cyclophosphamide) 4
• This combination therapy has shown to reduce mortality from 81.8% to 33.3% in moderate to severe paraquat poisoning 4

Monitoring and Follow-up

• Daily oral examination is necessary during the acute illness 1
• For persistent ulcers (lasting >2 weeks) or those not responding to treatment, specialist referral to oral medicine specialists is indicated 5
• Slow healing of the oral mucosa may reflect secondary infection by, or reactivation of, herpes simplex virus 1

Treatment of Secondary Infections

• For candidal infection, treat with nystatin oral suspension 100,000 units four times daily for 1 week, or miconazole oral gel 5-10 mL held in the mouth after food four times daily for 1 week 1

Common Pitfalls to Avoid

• Relying solely on topical treatments without addressing potential systemic paraquat toxicity 5, 6
• Premature discontinuation of treatment before complete resolution of ulcers 2
• Inadequate pain control leading to poor oral intake and nutritional deficiencies 1
• Overlooking the need for protein or amino acid supplementation to promote wound healing 1