Magic mouthwash recipe: why there is no standard formula, ingredient by ingredient

There is no standard magic mouthwash recipe. The version most people mean is a 1:1:1 mixture of three ingredients in equal parts: diphenhydramine (an antihistamine), an antacid (usually aluminum and magnesium hydroxide), and viscous lidocaine (a numbing medicine). Past that, formulas differ from one hospital, clinic and prescriber to the next, so magic mouthwash is compounded to whatever your prescriber ordered.

There is also no FDA-approved magic mouthwash product. The name is a nickname, not a defined medicine, which is why every version of it is compounded and used off-label. This post goes through the three ingredients in the common formula, the difference between the versions, and what the published trials of this kind of rinse have reported. Bayview Pharmacy compounds it on a prescriber's order. We do not diagnose, and we do not decide whether it is appropriate for you.

What is magic mouthwash?

"Magic mouthwash" is the informal name for a compounded prescription mouth rinse. Prescribers order it for pain from oral mucositis, the raw, inflamed lining of the mouth and throat that often follows chemotherapy or radiation. Mucositis can make swallowing, eating and even talking painful, and it is a major reason people lose weight during cancer treatment.

It is also ordered for painful mouth sores from other causes, including canker sores and sores related to some medications and illnesses, and it is widely used in hospice and palliative care, where keeping the mouth comfortable enough to talk, eat and drink matters a great deal.

Is there a standard magic mouthwash recipe?

No. Formulas vary widely between hospitals, clinics and individual prescribers. Some add a corticosteroid, an antifungal, or an antibiotic. Some leave out the antacid. Some use a different anesthetic instead of lidocaine. The 1:1:1 combination is the one most people are describing when they say "magic mouthwash," but it is a convention, not a defined product.

What is in your bottle is whatever your prescriber ordered, so read your label and ask the pharmacy if anything on it is unclear. Two bottles that both say magic mouthwash can contain different ingredients.

This post is not a set of mixing instructions. Combining prescription ingredients in measured ratios is compounding, which happens in a pharmacy on a valid prescription, not at a kitchen counter.

What are the magic mouthwash ingredients, one at a time?

Each ingredient in the common formula does a different job, and they are mixed so that one rinse carries all three.

Viscous lidocaine

Viscous lidocaine is a local anesthetic. It temporarily blocks nerve signals in the surface of the mouth and throat, so sore areas feel numb for a short time (MedlinePlus, Lidocaine Viscous Oral Rinse). It is the ingredient that accounts for most of the numbing, and it is also the ingredient that carries most of the safety cautions on this page.

The antacid (aluminum and magnesium hydroxide)

The antacid component is thick. It coats the lining of the mouth, which keeps the mixture in contact with sore spots instead of running straight down the throat. Antacids can also interfere with the absorption of some other medicines taken around the same time, so ask your pharmacist about spacing doses.

Diphenhydramine

Diphenhydramine is an antihistamine with mild local numbing and anti-itch properties (MedlinePlus, Diphenhydramine). It can cause drowsiness and a dry mouth, and both of those are more noticeable in a version that is swallowed and in older adults.

None of these ingredients heals mucositis or makes it go away faster. The rinse is a comfort measure. It does not change the course of the mucositis itself.

How do the swish-and-spit and swish-and-swallow versions compare?

The two versions differ in what you do at the end of the rinse. Your prescriber decides which one you get, and the label tells you which it is.

With the expectorate version, less lidocaine is absorbed and the throat is less likely to be numbed. The swallow version is ordered when sores extend into the throat or esophagus, and because more lidocaine reaches the body that way, the dose limits on the label matter more. Custom formulas are written when a prescriber wants something added, such as a corticosteroid, an antibiotic, or an antifungal like compounded nystatin, and there is no standard recipe for any of them.

The versions are described here for education only. Nothing above is a statement that one formula is better for a particular person. Your prescriber selects the formula, the volume and the schedule.

What does the research say about magic mouthwash for mouth sores?

The best trial of this question is Alliance A221304 (Sio TT and colleagues, JAMA, 2019). It randomized 275 people receiving head-and-neck radiation to a doxepin rinse, a diphenhydramine-lidocaine-antacid rinse, or placebo. Both active rinses reduced mouth pain more than placebo over the first four hours, and both differences were statistically significant. Both were also smaller than the difference the researchers had decided in advance would be clinically meaningful.

The National Cancer Institute puts bland rinses first, meaning 0.9% salt water and sodium bicarbonate rinses to keep the mouth clean and moist, and adds topical anesthetics such as lidocaine as a next step. The MASCC/ISOO mucositis guidelines recommend basic oral care, benzydamine mouthwash for head-and-neck radiation, oral cryotherapy for certain chemotherapy regimens, and photobiomodulation. No guideline endorses a specific compounded mixture, largely because the mixtures have never been standardized enough to study as one thing.

Why does magic mouthwash need a prescription, and why is it compounded?

The mixture only exists because a pharmacy makes it. The individual ingredients are commercially available, but no manufacturer sells them premixed in the ratios and volumes that prescribers want. Because formulas differ from one prescriber to the next, each order is compounded to that specific recipe. A valid prescription is required, and magic mouthwash is not a controlled substance.

If the idea of a prescription being mixed to order is new to you, what a compounding pharmacy is covers the basics, and compounded prescriptions are priced as cash prescriptions, which is the subject of do compounding pharmacies take insurance. Other preparations Bayview makes are listed in the compounded medications catalog.

What are the safety concerns with the lidocaine?

The lidocaine is the part of this rinse that needs the most respect. It is the reason the limits printed on your label are limits and not suggestions.

Numbness affects swallowing. A numb mouth and throat make it easier to choke, and easier to inhale food or liquid into the lungs, which is called aspiration. That risk matters most with the swallow version, in older adults, in anyone who already has trouble swallowing, and in people who are frail or sedated. Numb tissue also makes it easy to bite your tongue or cheek, or to burn yourself on hot food, without feeling it.

Too much lidocaine can be absorbed. The risk rises with repeated doses, when the mouth is very raw and inflamed, and when the rinse is swallowed rather than spit out. Warning signs of too much lidocaine include:

• Numbness or tingling around the mouth
• A metallic taste
• Ringing in the ears
• Blurred vision
• Dizziness or drowsiness
• Confusion or slurred speech
• Muscle twitching or seizures
• Changes in heart rhythm or breathing

Get emergency care right away for any of those after a dose, and for signs of a serious allergic reaction such as rash, swelling, or trouble breathing.

Children and small adults reach a dangerous dose at much smaller volumes. Serious harm and deaths in young children have been reported with viscous lidocaine (MedlinePlus). Keep the bottle tightly closed and out of the reach of children. Call Poison Control at 1-800-222-1222 or seek emergency care if a child swallows it.

The other two ingredients have their own effects. Diphenhydramine can cause drowsiness, dry mouth, blurred vision, constipation, trouble urinating, and confusion, so do not drive until you know how your formula affects you. The antacid can cause constipation or loose stools. Local stinging or an unpleasant taste is common, particularly on very raw tissue.

Do not use magic mouthwash if you are allergic to lidocaine or other local anesthetics, to diphenhydramine or other antihistamines, or to any ingredient in your formula. Talk with your prescriber first if you have significant trouble swallowing or a history of aspiration, serious liver disease or heart rhythm problems, glaucoma, or an enlarged prostate or trouble urinating. Tell your prescriber and pharmacist about your health history, your allergies, every medicine and supplement you take, and whether you are pregnant or breastfeeding.

Contact your prescriber if mouth pain is not controlled, if sores get worse, or if you develop a fever, thick white patches, or new bleeding in the mouth.

How is a magic mouthwash prescription usually written and used?

Follow the directions on your label exactly, both the amount per dose and how many times a day. A common order is about one teaspoon (5 mL) swished around the mouth for one to two minutes and then spit out or swallowed as directed, up to every four to six hours. That is a description of what prescribers commonly write, not a direction for you. The per-dose volume and the number of daily doses printed on your label are limits, not suggestions. Dose and appropriateness are your prescriber's decisions, not ours.

Shake the bottle before each dose, because the antacid settles, and measure with the device the pharmacy provides rather than a kitchen spoon. After a dose, your mouth and throat will be numb for a while. Your prescriber will tell you how long to wait before eating or drinking, often around an hour, and that instruction is worth following rather than guessing.

Store it as the label directs. Most magic mouthwash is kept at room temperature away from heat, light and moisture, though some formulas are refrigerated. Do not freeze it, do not share it, and do not use it past the beyond-use date on the label.

What Bayview compounds for this

On a prescriber's order, Bayview prepares magic mouthwash as a 1:1:1 diphenhydramine, antacid and lidocaine rinse, dispensed as either expectorate or swallow, in volumes including 100 mL, 237 mL, 240 mL and 900 mL for the expectorate version and 280 mL for the swallow version. The standard 1:1:1 is made with diphenhydramine 12.5 mg/5 mL elixir, aluminum hydroxide and magnesium hydroxide suspension, and lidocaine HCl 2% viscous solution. Custom formulas, including those that add nystatin, a corticosteroid, or an antibiotic, are compounded on request. It is prepared as USP 795 non-sterile compounding, in the volume ordered.

How to order

Ask your prescriber whether a rinse like this fits your situation. If they decide it does, they can send the prescription to Bayview, and because there is no standard formula it helps when the order names each ingredient, its concentration and the ratio, states expectorate or swallow, and gives a maximum number of doses per 24 hours. We can fill it and ship it within the states where Bayview is licensed, which is covered on our FAQ page. A Bayview pharmacist is available if you have questions about a prescription you already have.