How to Write a Prescription for Magic Mouthwash
For cancer patients with oral mucositis, prescribe magic mouthwash containing equal parts diphenhydramine, viscous lidocaine 2%, and aluminum hydroxide-magnesium hydroxide antacid, with instructions to swish 15 mL in the mouth for 1-2 minutes, 4-6 times daily, then spit out—never swallow. 1, 2, 3
Standard Prescription Format
Write the prescription as follows:
Rx: Magic Mouthwash
- Diphenhydramine 12.5 mg/5 mL elixir
- Lidocaine viscous 2%
- Aluminum hydroxide-magnesium hydroxide-simethicone suspension
- Mix equal parts (1:1:1 ratio)
- Dispense: 480 mL
- Sig: Swish 15 mL in mouth for 1-2 minutes, then spit out. Use 4-6 times daily. Do not swallow.
- Refills: 2-3 as needed 1, 2, 4
Critical Administration Instructions
Always instruct patients to spit, not swallow, because lidocaine works as a topical anesthetic requiring only mucosal contact—swallowing provides no additional therapeutic benefit for oral mucositis and increases systemic lidocaine absorption. 2, 3, 5
The swish-and-spit method is appropriate for oral mucositis; only consider swish-and-swallow if pain extends into the pharynx or esophagus from cancer treatment. 1, 5
Patients should avoid eating or drinking for 30 minutes after rinsing to allow the medication to take effect. 2
Stability and Storage Considerations
When compounding in a 1:1:1 ratio and storing at room temperature in amber oral syringes, assign a beyond-use date of 21 days. 6
Consider packaging lidocaine separately from other ingredients with a 90-day beyond-use date, allowing patients to mix immediately before use for optimal stability. 6
Important Limitations and When to Escalate
The European Society for Medical Oncology found no evidence that magic mouthwash effectively treats oral mucositis, and morphine mouthwash is significantly more effective for pain control. 2, 3, 7
Magic mouthwash provides statistically significant but clinically modest pain relief—the effect size (2.9-3.0 points on a 0-10 scale) is less than the minimal clinically important difference of 3.5 points. 8
If pain is not adequately controlled after 24-48 hours of magic mouthwash use, escalate to more effective alternatives:
- For head and neck chemoradiation patients: Switch to 0.2% morphine mouthwash (Level III evidence) 2, 3, 7
- For HSCT patients: Use patient-controlled analgesia with morphine (Level II evidence) 2, 3
- For conventional/high-dose chemotherapy: Consider transdermal fentanyl (Level III evidence) or 0.5% doxepin mouthwash (Level IV evidence) 2, 3
Essential Complementary Oral Care Protocol
Magic mouthwash should never be used as monotherapy—always prescribe alongside comprehensive oral care measures: 2, 3
- Brush teeth twice daily with a soft toothbrush using gentle technique 1, 2, 3
- Rinse with alcohol-free mouthwash at least 4 times daily, separate from magic mouthwash use 2, 3
- Avoid crunchy, spicy, acidic, or hot foods and drinks that further traumatize inflamed mucosa 1, 2
- Maintain adequate hydration throughout the day to keep oral mucosa moist 1, 2, 3
- Consider chlorhexidine or fluoride oral rinse if toothbrushing is too painful 1
Common Pitfalls to Avoid
Do not use magic mouthwash for prevention—it has no role in mucositis prevention, only symptomatic relief. 2
Do not prescribe chlorhexidine or sucralfate for mucositis treatment—these are specifically not recommended. 2
Magic mouthwash compositions vary significantly between institutions with no standardized formulation, making efficacy evaluation difficult. 1, 3, 4
Be aware that doxepin mouthwash causes more drowsiness (1.5 points higher), unpleasant taste (1.5 points higher), and stinging/burning (4.0 points higher) compared to placebo, though diphenhydramine-lidocaine-antacid mouthwash has a better tolerability profile. 8
Alternative Formulations
Some institutions use different ratios (1:2.5:2.5) or add corticosteroids (liquid dexamethasone 0.5 mg/5 mL elixir or fluocinonide 0.05% gel) and nystatin, though evidence for these variations is limited. 1, 4
For topical steroid alternatives in moderate-to-severe cases, consider clobetasol 0.05% gel or compounded budesonide 3 mg/10 mL solution. 1