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.