Discussion
The primary objective of treatment for mucosal injury after the
ingestion of paraquat focuses on pain management, decreasing
inflammation, antibiotic prophylaxis, antioxidant therapy and removal of
accumulated necrotic tissue. 17 1949 Currently, there is no consensus on a treatment
protocol for corrosive oral mucosal after the ingestion of paraquat.
Different protocols exist, but the basis of all the different protocols
carries the same backbone which aims at maximum pain control for the
patient, prevention of further damage, and prevention of complications
that may arise.50
Despite oral care and medical intervention being important treatment
modalities for oral mucositis, other factors like nutritional and
psychological support also play an important role. Feeding difficulties
due to dysphasia and odynophagia is one of the major complications that
come about from the ingestion of paraquat. 51Patients
who are able to feed normally should avoid any irritants like spicy
foods, acidic or tarty food, dry or rough food, tobacco, alcohol and
alcohol based mouthwash. Patients should also be encouraged to have
adequate fluid intake, which will be essential in maintaining the
patients hydration status and also ensure that the oral mucosa is
adequately hydrated. Patients should be initially be started on smaller,
frequent, energy and protein dense meals or snacks in order to attain
their caloric needs. 52 The consistency and
temperature of food should also be altered to be in tune with the
patients tolerances (for example cool or lukewarm temperature, soft
solids, mashed solids, pureed solids foods). 17 For
those with extensive oral mucosal injury and are unable to feed
normally, nutrition can be achieved by either enteral or parenteral
nutrition. Enteral nutrition involves the delivery of liquid formula
beyond the esophagus, in an area where the gut is functioning normally
and is without injury. This is achieved through the use of either a
feeding tube or a stoma. Parenteral nutrition (TPN) refers to the
delivery of calories and nutrients intravenously through peripheral or
central veins. 16 1718 19
Paraquat poisoning is usually seen in suicidal attempts, where the
patients intentionally expose themselves to the compound. These
patients’ psychiatric state is fragile and unstable. After admission,
caregivers should ensure that the patients are in a safe environment.
Safety can be ensured by the removal of anything that can be fashioned
into a weapon, and also any medication that could be used for deliberate
self-harm. All patients should be monitored frequently. Treatment of
underlying psychiatric or psychological issues should be initiated as
early as possible. The provision of good psychological support has been
shown to be beneficial for patients by reducing both psychological
distress and physical symptoms through increasing quality of life and
enhancing coping mechanisms in relation to stress and
pain.53 54
The primary findings through our systematic review clearly indicated
that most of the studies used a multi-drug combination for the
interventions. These studies incooperated the use analgesics mainly
lidocaine, Chinese traditional herbal remedies, growth factors,
corticosteroids and antioxidants. Seven studies in total used compounded
formulations in their management with the two main components of the
compounded formulation being a bland rinse like normal saline and
lidocaine.16 19 2125 24 2355 The main advantage with compounded formulations is
that they integrate the use of different drugs and also they
formulations are able to cover a wider surface of within the oral
cavity. Because of the integration of the different drugs, compounded
formulations not only actually did improve the healing time as well as
pain control as compared to the control and the placebo groups. Despite
the popularity of compounded formulations other studies still showed
promising results with the use of individual multi-drug management.
Chinese herbal remedies and other natural remedies play an important
role too in the management of paraquat induced oral mucositis. Many
studies have assessed the use of herbal and natural remedies in the
management of oral mucositis. Our highlighted studies have shown that
herbal and natural remedies, like kangfuxin, MEBO, ying er tong and tea
oil and their associated anti-inflammatory, anti-oxidant and
antimicrobial properties make them ideal interventions that can be used
in conditions that cause oral mucosal ulcerations. 18
16 25 28
Although there is no consensus on the management of paraquat induced
oral mucositis, we believe that this systematic review will provide
guidance on the possible effective interventions, and also be a stepping
stone to further studies in order to determine the roles of possible new
therapies.