Effects of Oil Pulling On Chemo-radiotherapy Induced Oral Mucositis in Head and Neck Cancer Patients

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Effects of Oil Pulling On Chemo-radiotherapy Induced Oral
Mucositis in Head and Neck Cancer Patients
INTRODUCTION
lobally, the sixth most frequently encountered
cancers are head and neck cancers (HNC),
categorized into cancers of lip and oral cavity,
pharynx, larynx, tongue, salivary glands, nasal cavity and
paranasal sinus.1 It is the ninth most frequent cause of death
worldwide.2 Amongst all HNC, the second most prevalent
and often diagnosed cancer in Pakistan are of lip and oral
cavity.3 Its proportion is much higher in males as compared
to females with ratio of 2:1.4 Almost over 90% of all head
and cancers are squamous cell carcinomas (HNSCC).5
Based on the Grading, the treatment of HNSCC includes
Surgery, Radiotherapy and Chemotherapy. Patients with or
without surgery and having locally advanced head and neck
cancers, the concomitant chemo-radiation is the standard
protocol followed worldwide.6
Oral mucositis is the most frequently occurring
complication of chemo- radiotherapy for cancer treatment.
About 40% of patients who undergo chemo-radiation
encounter this as the earliest symptom.7 According to a
1. Lecturer, Department of Oral Biology, Ziauddin College of Dentistry Karachi.
2. Dean, Ziauddin College of Dentistry, Ziauddin University, Karachi.
3. Consultant Radiation Oncologist, Department of Radiation Oncology, Ziauddin Cancer
Hospital Karachi.
4. Lecturer, Department of Pharmacology, Ziauddin College of Medicine.
5. Resident, Department of Internal Medicine, Aga Khan University Hospital.
6.
Student,
Ziauddin College of Medicine.
Corresponding author: Dr. Fizza Saher < fizza.saher@zu.edu.pk >
03
G
JPDA Vol. 28 No. 01 Jan-Mar 2019
Fizza Saher1BDS
Mervyn Hosein2FDS RCS (Eng), FDS RCSE(Edin), FFDRCSI(Ire)
Abne Hasan3M.D.
ORIGINAL ARTICLE
Jabbar Ahmed Qureshi4BDS
Tazein Amber5MBBS
Nisa Fatima Sunderjee6MBBS
OBJECTIVE: To compare the effects of coconut oil pulling on chemo-radiotherapy induced oral mucositis in head and neck
cancer patients with Magic mouthwash.
METHODOLOGY: This was a double-blind, randomized controlled trial, total of n=80 patients of chemo-radiotherapy induced
oral mucositis of head and neck cancer were randomized into two arms A and B. A= Oil pulling using pure coconut oil and
B= commercially prepared Magic Mouthwash. Each arm consisted of n=40 patients evaluated for a total duration of nine weeks
using the WHO scale of oral mucositis and four different pain scores including Verbal pain intensity scale, Numeric pain intensity
scale, Visual analog scale and FACES scale. Patients were evaluated at baseline 0, week 3, 6 and 9.Data was analyzed by using
SPSS version 20.
RESULTS: Total of n=72 participants completed the study between December 2017 to August 2018; randomly assigned to
Group A (n=36) and group B (n=36).Of these n=48 were male and n=24 female. In both groups there was a reduction in WHO
oral mucositis scores over the time of nine weeks; however, the differences were not statistically significant (p=0.633). The
two treatments did not differ on the main outcome measure i.e. WHO mucositis scale from baseline, or on any other measure
of pain, while followed for the nine weeks of trial period. Adverse effects were similar between the two arms and the most
frequently reported side effects were radiation induced rash, mouth fatigue and dry mouth.
CONCLUSION: Oil pulling and magic mouthwash was similar in reducing both the severity of oral mucositis and relieving
the pain of chemo radiation induced oral mucositis in head and neck cancer patients. Oil pulling with coconut oil can be used
as an alternative therapy to magic mouthwash for treating chemoradiation induced oral mucositis.
KEY WORDS: Oral mucositis, oil pulling, magic mouthwash, coconut oil.
HOW TO CITE: Saher F, Hosein M, Hasan A, Qureshi JA J, Amber T, Sunderjee NF. Effects of oil pulling on chemo-
radiotherapy induced oral mucositis in head and neck cancer patients. J Pak Dent Assoc 2019;28(1):03-12.
DOI: https://doi.org/10.25301/JPDA.281.03
Received: 25 October 2018, Accepted: 17 December 2018

study, the frequency of acute mucositis towards the end of
the first week of chemo-radiation is about 33.3% which
gradually progresses until the end of the fifth week to
93.3%.8 Patients usually report with oral soreness, severe
pain, discomfort, and gastrointestinal distress, independent
of the grade or severity of mucositis. During chemo
radiotherapy, the mucosa becomes highly prone to injury
due to the rapid rate of mitosis in oral tissues and pain is
reported to be the most in tolerable symptom.9 Mucositis
can directly affects the appetite resulting in weight loss, it
can cause difficulty in speech and swallowing, severe
dehydration and systemic infections which indirectly affect
patient's quality of life and financial burdens related to the
treatment. Extreme cases of oral mucositis can hinder the
deliverance of radiotherapy; hence the effectiveness is
compromised with treatment interruptions.10,11 These
interruptions can compromise patients health and also
directly affect the chances of survival.12,13
Most common treatment for such symptoms is Magic
mouthwash, which is prescribed to patients for relieving
the oral symptoms related to cancer therapy. The combination
of a topical analgesic, steroid, antifungal , antibacterial
and (perhaps) a mucosal coating agent is included in the
formulation but there is no standard recipe for this
preparation.14 Some possible side effects may include a
burning or itching in the mouth, nausea, diarrhea and
drowsiness is less likely to occur. It may also alter the taste
sensation, resulting in loss of appetite.15
Oil pulling is a well known ancient herbal procedure
that includes prolonged swishing of oil in the oral cavity
to improve oral environment. "Oil pulling" is not a new
concept and around 3000BC oil pulling had been discussed
in Ayurvedic texts. During 1990's in Russia the concept of
oil pulling was reinvented by Dr. F. Karach.16 It is currently
a well renowned Complementary and Alternative Medicine
remedy for different illnesses.17 Oil pulling is claimed to
reduce the chances of dental caries, bleeding gums, halitosis,
xerostomia, cracked lips and for improving overall health
related to teeth, gums, and jaws.18 Oil pulling can be an
alternative cleaning method in those patients where brushing
is difficult as in mouth ulceration, or in those who have a
tendency to gag as in asthmatics and severe cough.19 In oil
pulling, a teaspoonful of any kind of oil is swished around
the mouth early in the morning preferably before having
breakfast, for about 15-20 minutes. The oil is 'pulled' and
forced around the oral cavity and at the end the viscous oil
should become milky white and thinner, if the guidelines
to oil pulling have been followed appropriately. It is then
expectorated; the mouth is thoroughly washed with warm
saline or normal tap water followed by routine tooth
brushing. The therapy can be limited to five to ten minutes,
if jaw aches.20 The procedure is useful in number of
systemic diseases like diabetes, bronchitis, thrombosis,
asthma and eczema.21
The oils which are commonly used are coconut oil,
sesame oil, palm oil and sunflower oil.18 Coconut oil is
commonly and culturally used throughout the sub continent
especially in India and Pakistan. Coconut oil has an
exceptional role in the diet with added health and nutritional
benefits as it acts as an anti-inflammatory, immune
modulator22, moisturizer and wounds healer.23,24 Oil pulling
(coconut oil) was used in this study as it is assumed to
reduce inflammatory effects and provide additional health
benefits to the oral mucosa. The objective of the study was
to compare the effects of coconut oil pulling versus "Magic"
mouthwash on chemo-radiotherapy induced oral mucositis
in head and neck cancer patients.
METHODOLOGY
This was a multi institutional, double-blinded,
randomized controlled trial conducted at the Department
of Radiation Oncology at Ziauddin Hospital North
Nazimabad and Atomic Energy Medical Center at JPMC
between December 2017 and August 2018. This study
received approval from the ethical review committee of
Ziauddin University (Ref no. 0411117FSOB). Eligible
participants were histopathologically proven consecutive
head and neck cancer patients aged between 25 to 65 years,
who underwent chemo-radiotherapy, with or without primary
surgery. Exclusion criteria included patients whose oral
examination was not possible due to limited mouth opening,
inability to perform the treatment regimen and patients not
willing to stop deleterious habits like consumption of Pan
and betel nut, smoking or alcohol. All patients were treated
with conventional fractionation (5 fractions every week)
with a dose between 60-70 Gy. Sample size was calculated
by sealed envelope software. Total sample came out to 62
which were increased to 90 patients to reduce the dropout
error and patient's lost to follow-up. The significance level
was taken at 5% and power or confidence interval at 90 %,
standard deviation of 2.65 and non inferiority limit or bound
of error was taken at 2.
PREPARATION AND DISPENSING OF
OIL AND MAGIC MOUTHWASH
Magic mouthwash was prepared by Ziauddin Hospital
pharmacy Clifton campus. The constituents of mouthwash
include Mucaine (aluminum hydroxide), Vicous Xylocaine
and Hydryllin (diphenhydramine). Commercially available
pure coconut oil (C.B.C imported from Malaysia) shown in
JPDA Vol. 28 No. 01 Jan-Mar 2019 04
Saher F/ Hosein M/ Hasan A/ Qureshi JA/
Amber T/ Sunderjee NF
Effects of oil pulling on oral mucositis
in head and neck cancer patients

Fig 1a was purchased from the local market, the composition
of which is shown in Fig1b. The trial was kept double blinded
to eradicate the observer bias. A third person (lab assistant)
who was not part of the study was given the task to dispense
both the specimens. The oil and mouthwash was dispensed
in the dark amber colored bottles of same size and shape
having the same amount Fig 1c and d, packed individually
in separate brown colored opaque envelopes. The envelopes
were coded according to the group distribution and at the
time of dispensing the investigator were kept uninformed
from the group labeling i.e. A and B.
RANDOMISATION AND TRIAL INTERVENTIONS
Patients who fulfilled the inclusion criteria and had given
the consent for the trial for nine weeks were registered for
the study. Before starting the chemo-radiation, enrolled
patients were randomized (1:1) to the group A (coconut oil
pulling) or standard oral care regimen Group B (magic
mouthwash). Randomization was performed by using the
sealed envelope randomized sampling technique.25 Patients
were instructed to swish and then spit out 5ml (a teaspoon)
of either the oil or Magic mouthwash 3 times daily on an
empty stomach i.e. morning, afternoon and night for about
minimum of 10 minutes for 9 weeks. Patients were advised
not to eat and drink anything for about half an hour after
swishing and were asked to start the use of oil or magic
mouthwash from the day of their first radiation till the end.
EVALUATION AND DATA COLLECTION
The scoring of chemo-radiation induced oral mucositis
was performed by WHO scale of oral mucositis and mucositis
induced pain was evaluated using four different pain scores
including Verbal pain intensity scale (VPS), Numeric pain
intensity scale (NPS), Visual analog scale (VAS) and FACES
scale (fig 2), at the following time points: baseline, week 3
during radiotherapy, week 6 and 9 post completion of
radiotherapy.
STATISTICAL ANALYSIS
Statistical analysis was completed using SPSS
version 20. Baseline characteristics were calculated through
descriptive statistics. Continuous variables were expressed
as means and Standard deviations and categorical variables
were expressed as proportions. Association between WHO
oral mucositis grades, Verbal Pain intensity scale and FACES
scale was performed using Pearson Chi square, while
Repeated Measure ANOVA was used to compare the Visual
Analogue Scale and Numeric Pain Scale.
RESULTS
Total n=90 patients were interviewed and screened for
the trial out of which n=6 patients did not fulfill the inclusion
criteria and n=4 patients did not give consent. N=80 patients
were then allocated to group A (oil pulling) and B (magic
mouthwash) containing n=40 in each arm. During follow-
up n=3 patients were lost in group A due to change in
JPDA Vol. 28 No. 01 Jan-Mar 201905
Figure 1: (a) locally available imported pure coconut oil (b) composition
of coconut oil (c) (d) Batches of group A and group B bottles.
Figure 2: (a) WHO Oral mucositis scale and (b) Pain scales
0
NO HURT
2
HURTS
LITTLE BIT
4
HURTS
LITTLE MORE
6
HURTS
EVENMORE
8
HURTS
WHILE LOT
10
HURTS
WORST
Worst
possible
pain
Moderate
pain
No
pain
NO
PAIN
MILD
PAIN
MODERATE
PAIN
SEVERE
PAIN
VERY
SEVERE
PAIN
WORST
POSSIBLE
PAIN
No
pain
Worst
pain
imaginable
0-10 Numeric Pain Rating Scale
VERBAL PAIN INTENSITY SCALE
Visual analogue scale
01 234 6789105
Effects of oil pulling on oral mucositis
in head and neck cancer patients
Saher F/ Hosein M/ Hasan A/ Qureshi JA/
Amber T/ Sunderjee NF

radiation center and one due to death. In group B, n=2 were
lost to follow up due to change in radiation center and n=2
due to discomfort and lack of compliance. In the end total
n=36 patients in group A and n=36 in group B were evaluated
and analyzed for the trial.
STUDY POPULATION AND DEMOGRAPHICS
The study population consisted of n=24(33.3%) women
and n=48(66.7%) men, ranging from 25 to 65 years (mean
48.15 ± 10.79). Good patient compliance was observed in
both arms.
Baseline characteristics were comparable between the two
groups (Table 1). Majority of patients had their tumour in
the buccal mucosa (40.3%) and most were Stage I tumors
(31.9%). The reported deleterious habits showed Pan and
Chalia (62.5%) as the most common habit. Almost all the
patients had SCC (98.6) and only one had mucoepidermoid
carcinoma (1.4%).Chemo-radiation were given to all of the
study patients (100%).
WHO ORAL MUCOSITIS SCALE
Of the 72 patients all reported grade 0(100%) at baseline
in both the treatment groups (Figure. 4). At week 3 around
18 patients (50%) progressed to clinically significant grade
3 mucositis in each arm but association between grades of
oral mucositis and intervention was statistically insignificant
(p value 0.834). Overall reduction was seen at week 6 and
the mucositis grade was found to be clinically significant as
it reduces to grade 2 (34.6%) in group A and to grade 1
(43.9%) in group B, whereas association between grades of
oral mucositis and intervention was statistically insignificant
at week 6(p value 0.144). At the final follow-up week i.e.
week 9, the mucositis had almost dropped to grade 0 in
52.4% of patients in group A and to 47.6% in group B.
Association between grades of oral mucositis and intervention
was statistically insignificant at week 9(p value 0.633)
( Figure 5)
JPDA Vol. 28 No. 01 Jan-Mar 2019 06
Figure 3: Consort Flow Chart
Table 1: Baseline characteristics
Effects of oil pulling on oral mucositis
in head and neck cancer patients
Saher F/ Hosein M/ Hasan A/ Qureshi JA/
Amber T/ Sunderjee NF

VISUAL ANALOG SCALE
At week 0 there was no sign of pain in both the groups
whereas the scores increased at week 3(Figure 6a). Out of
36 patients, 11 recorded a score of 20mm (30.6%) in group
B and highest score recorded was 60mm in 8 (22.2%) patients.
In group A the highest score recorded was also 60mm but
in 10 patients (27.8%) and the least score was 10mm recorded
in only 1 (2.8%) patient. A repeated measures ANOVA with
a Sphericity correction determined that mean VAS differed
statistically significant between time points (F = 286,
P< 0.0001). Post hoc tests using the LSD correction revealed
that time elicited an increase in VAS from Week 0 to
3-weeks after induction in both groups (.00+/-.00 versus
38.2+/-16, P< 0.0001). However, there was a reduction in
VAS from Week 3 to week 6(38.2+/-16 versus 20.1+/-12,
P< 0.0001). Further reduction was observed in VAS
from Week 6 to week 9(20.1+/-12versus5.5+/-8.5,
P< 0.0001).There was no statistically significant difference
in time* induction group interaction (F = .155, P<.926).
Neither there was no difference between the two induction
groups on VAS after chemo radiation (F = .012, P<.911).
NUMERIC PAIN INTENSITY SCALE
At week 0 both the groups were free of pain (100%). At
week 3 the highest reading in group A was recorded as 6 in
9 (25%) patients while group B showed 8 as the highest
recorded numeric point in 2 (5.6%) patients(Fig 6b). A
repeated measures ANOVA with a Sphericity correction
determined that mean Numeric pain intensity scale differed
statistically significant between time points (F=318,
P< 0.0001). Post hoc tests using the LSD correction revealed
that time elicited an increase in Numeric pain intensity scale
from Week0 to 3-weeks after induction in both groups
(00+/-00 versus 4+/-1.58, P< 0.0001). At week 6 around 21
patients (58.3%) reported at scale 2 in group A with 20
(55.6%) patients in group B. However, there was a reduction
in mean numeric pain intensity from Week 3 to week 6(4+/-
1.58 versus 2.24+/-1.1, P< 0.0001). Further reduction was
observed from Week 6 to week 9(2.24+/-1.1 versus .58+/-
.9,
P< 0.0001) as 27 patients (75%) were free of pain in group
A and 21(58.3%) patients in group B. However there was
no statistically significant difference in time* induction
group interaction (F = .320, P<.811). Neither was there a
difference between the two induction groups on Numeric
pain intensity scale after chemo-radiation (F = .669, P<.416).
VERBAL PAIN INTENSITY SCALE
Out of 36 patients in group A only one patient suffered
from mild pain (2.8%) at week (Fig 6c).Using Verbal pain
intensity scale association between pain and intervention
was statistically insignificant at 0 weeks (P value .314). At
week 3, 18 (50%) patients suffered from moderate pain in
JPDA Vol. 28 No. 01 Jan-Mar 201907
Figure 6: (a). Visual Analogue Scale (b). Numeric Pain
Intensity scale (c). Verbal Pain intensity scale
(d). FACES scale (A= oil pulling, B= Magic mouthwash)
ca
bd
Figure 4: Frequency of grades of WHO mucositis scale
on 3 weekly follow up
Figure 5: Comparison of Mean WHO mucositis scale
Effects of oil pulling on oral mucositis
in head and neck cancer patients
Saher F/ Hosein M/ Hasan A/ Qureshi JA/
Amber T/ Sunderjee NF

group A whereas only 14 patients (38%) had reported
moderate pain in group B.
Using Verbal pain intensity scale association between
pain and intervention was statistically insignificant at 3 weeks
(P value .775). On the follow-up at week 6 both the groups
showed similar data and almost 26 (72.2%) patients reported
of mild pain. Using Verbal pain intensity scale association
between pain and intervention was statistically
insignificant at 6 weeks (P value 0.171). Week 9 showed that
21(58.3%) patients were free of pain while 15 had mild
pain(41.7%) in group B. Group A showed 26(72.2%) patients
had no pain out of 36 patients. Using Verbal pain intensity
scale association between pain and intervention was
statistically insignificant at 9 weeks (P value 0.216).
FACES SCALE
All patients in both the groups reported no pain at
week 0 (Fig 6d). Around 16(44.4%) patients in group A and
18(50%) patients in group B reported at." hurts little more".
Using Faces scale association between pain and intervention
at week 3was insignificant (p value 0.374). At week 6,
24(66.7%) patients in group A while 26(72.2%) patients in
group B reported at scale "hurts little bit". Using Faces scale
association between pain and intervention at week 6was
insignificant (p value 0.379). At week 9, 23(63.9%) patients
in group B while 27(75%) patients were free of pain. Using
Faces scale association between pain and intervention at
week 9 was insignificant (p value 0.306).
ADVERSE EFFECTS
At the end of the study the most frequently encountered
adverse effect were radiation rash, mouth fatigue and dry
mouth (Table 2). However in Group A, n=34(94.4%) patients
and in group B, n=36(100%) patients suffered from radiation
induced rash. Nausea and vomiting was the least occurring
adverse effects in both the arms (Group A= 1, Group B=2).
Mouth fatigue was the second most common adverse effect
reported in both the groups. Group A had n=27(75%) patients
whereas group B had n=23(63.9%) no. of patients who
experienced mouth fatigue followed by dry mouth that
occurred in n=11(30.6%) in group B and n=5(13.9%) patients
in group A.
DISCUSSION
To the best of our knowledge, till today no trial has been
done on the efficacy of oil pulling on chemo-radiation induced
oral mucositis. This trial compared the effects of coconut oil
pulling with the conventional treatment (magic mouthwash)
given to the chemo-radiation induced oral mucositis patients.
We found that there is no statistically significant difference
between the two treatment modalities in reducing the severity
of the oral mucositis with its associated pain. The two
interventions did not differ on the primary outcome measure
i.e. WHO mucositis scale from day 0, or on any other scales
of pain, when followed across the nine weeks of trial period.
As there is no available data of using oil pulling in chemo
radiation induced oral mucositis, we are unable to compare
the effects of oil pulling with other studies. Up to now, only
palifermin, (a recombinant keratinocyte growth factor), has
shown significant decrease in the severity and duration of
radiation-induced mucositis in HNC.
6,26
Other treatments,
including artificial saliva, antimicrobial agent and analgesics,
do not sufficiently control the condition.
27
No researcher has
ever used coconut oil for the reduction of oral mucositis but
our results are in agreement with the study done by Suresh
Rao et al in 2014 in which they found that gargling with
turmeric by head and neck cancer patients undergoing
radiation therapy provided significant benefit by delaying
and reducing the severity of mucositis.
28
Triclosan mouthwash
was also effective than sodium bi carbonate mouthwash in
minimizing chemo-radiation induced oral mucositis with
early reversal of symptoms towards the end of chemo-
radiation.
29
Currently, there are only a couple of effective medicines
present available for the treatment of chemo-radiation induced
oral mucositis but the most broadly endorsed topical treatment
is a pharmacist prepared liquid mouthrinse commonly known
as "magic mouthwash".
30,31
McGuire et al, proved that the
pain relief from these mouthwashes is temporary and they
could not be used for the prevention or treatment of
mucositis.
32
According to Kuk et al, mouthwash containing
diphenhydramine plus sucralfate, nystatin and dexamethasone
was when compared with benzydamine, showed no significant
decrease in oral mucositis.
33,34
Sarvizadeh et al, showed that
morphine was more effective in limiting the progression of
JPDA Vol. 28 No. 01 Jan-Mar 2019 08
Table 2: Frequency of Adverse effects encountered in group
A and group B
Effects of oil pulling on oral mucositis
in head and neck cancer patients
Saher F/ Hosein M/ Hasan A/ Qureshi JA/
Amber T/ Sunderjee NF

oral mucositis in chemo-radiation patients when compared
with the magic mouthwash containing magnesium aluminum
hydroxide, viscous lidocaine, and diphenhydramine (also
used in our trial).35
In our study we used pure coconut oil for alleviating
oral mucositis and its related pain, because of its anti
inflammatory effects. According to an animal study done by
S. Intahphuak et al. virgin coconut oil was useful in the
reduction of ear and paw edema. The results showed
significant anti inflammatory and anti-nociceptive effects,
when virgin coconut oil (VCO) was given in high doses.
VCO also inhibits inflammatory markers like prostaglandins,
bradykinin, and histamine responsible for pain and edema
formation.36 In a clinical trial, Daddy et al found that virgin
coconut oil was equally effective as triamcinolone for the
management of minor recurrent aphthous ulcers (stomatitis).37
This study supports our results because both the stomatitis
and mucositis have a similar mechanism and expression in
terms of inflammation. So using coconut oil in mucositis
patients also has the same effects. There are some clinical
studies which have proven the anti-gingivitis effects of
coconut oil pulling. Recently in 2018, Kaliamoorthy et al.
proved that coconut oil pulling is effective than sesame oil
pulling for the reduction in severity of gingivitis.38 Chalke
et al in 2017 reported the use of coconut oil pulling as an
adjunctive therapy for plaque-induced gingivitis.39 Another
study by Peedikayil was done in 2015 reported that coconut
oil pulling could be used as an efficient supportive therapy
in plaque induced gingivitis.40 As we understand, these
clinical trials have proven that coconut oil pulling is efficient
in an inflammatory disease like gingivitis due to its anti
inflammatory effects and possibly supporting its use as a
treatment for the reduction of oral mucositis, being the fact
that this is also an inflammatory process.
The main reason for the reduction in pain scores in our
study could be due to the oil used for oil pulling that is
coconut oil. Pain scores were reduced from baseline to the
end of week 9 and suggest that there is no statistically
significant difference in both the arms. This makes coconut
oil equally as effective as magic mouthwash in chemo-
radiation induced oral mucositis. This phenomenon could
be supported by an animal model which showed that VCO
decreased the release of inflammatory mediators like COX-
2, TNF-a and IL-6 and the concentration of thiobarbituric
acid reactive substance with an increase in antioxidant
enzymes.41 The second reason could be due to the presence
of polyphenols in coconut oil42 which possess various
biological properties, including anti-nociceptive activities.
The proliferative phase of chronic inflammation is suppressed
by the anti-nociceptive effect of virgin coconut oil and
throughout the process of inflammation; phagocytic cells
release lysosomal enzymes which damage the surrounding
cells. Gene expression, activation of pro-inflammatory
transcription factors and signal transduction is also affected.43
Presently, no such treatment exists that can completely
resolve or prophylactically treat oral mucositis and is also
devoid of any side effects. The major advantage behind the
use of coconut oil for oil pulling therapy is due to its safety
profile. In an animal toxicity study, an oral dose of 5000mg/kg
coconut oil was found to be safe and well tolerated.44 So, if
the patient accidentally swallows the oil, which is an
exception, it would not adversely affect the health
In the healing phase the use of coconut oil can be helpful
in terms of increased wound healing properties. According
to Ibrahim et al, an animal study confirmed a high angiogenic
and wound healing property of fermented VCO in both in
vitro and in vivo assays that might be mediated by the
regulation of Vascular Endothelial Growth Factor signaling
pathway.45 Horas et al in 2017 showed that topical application
of VCO accelerated palatoplasty wound healing showing an
increased number of fibroblast cells appearing in the wound,
in addition to fewer pain complaints.46 This could be a factor
which has also worked in our study population increasing
the healing capacity in the coconut oil pulling group.
Furthermore, in our study, except for mouth fatigue, all cases
in the oil pulling group had fewer adverse effects when
compared with the magic mouthwash. Fewer patients suffered
from dehydration in the oil pulling group when compared
with the magic mouthwash. This can be supported through
a study done by Agero and Verallo-Rowell, in which they
reported that coconut oil, is as effective and safe as mineral
oil and can be used as a moisturizer for the treatment of
xerosis. VCO showed effectivity through an increase in skin
surface lipid levels and significantly enhanced skin
hydration.47 Due to this phenomenon, usage of coconut oil
could be beneficial on a long term basis, even after the
completion of chemo-radiation, where patients suffer from
complete or partial xerostomia.
CONCLUSION
Oil pulling and magic mouthwash were similar in
reducing both the severity of oral mucositis and relieving
the pain of chemo radiation induced oral mucositis in head
and neck cancer patients. Oil pulling with coconut oil can
be used as an alternative therapy to magic mouthwash for
treating chemo-radiation induced oral mucositis.
ACKNOWLEDGEMENTS
We acknowledge the support of the Ziauddin University.
We would like to express our gratitude to Radiation Oncology
JPDA Vol. 28 No. 01 Jan-Mar 201909
Effects of oil pulling on oral mucositis
in head and neck cancer patients
Saher F/ Hosein M/ Hasan A/ Qureshi JA/
Amber T/ Sunderjee NF

department of Ziauddin hospital and Atomic Energy Medical
Center at JPMC for the recruitment of patients. We also
thank the clinical staff and health care assistants who have
given their support and assistance for this trial. We would
also like to thank the patients, who had voluntarily enrolled
for the study and given their true support for the betterment
of future patients.
CONFLICT OF INTEREST
None
FUNDING STATEMENT
This study was fully sponsored by the Ziauddin
University.
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