1. Ross, Stephanie Maxine MHD, MS, HT, CNC, PDMT

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Mouth dryness is a common occurrence among patients hospitalized in intensive care units (ICUs).1,2 There are numerous factors that cause mouth dryness, including restricted fluid intake in patients with cardiac, renal, or respiratory conditions, damage to salivary glands resulting from head and neck radiation treatment, diseases such as diabetes, Sjogren's syndrome, and other autoimmune disorders, as well as decreased salivation resulting from diarrhea, fever, or medication.3,4 In addition, endotracheal intubation, which keeps the mouth open, creates mouth dryness and a hospitable environment for gram-negative bacteria (bacterial plaque) to colonize in the mouth and pharynx that in effect predisposes ICU patients to pneumonia.5

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"Aloe vera-peppermint moisturizing gel (Veramin) is effective in relieving mouth dryness, improving oral health, and reducing dental plaque formation in intubated ICU patients."


Common symptoms associated with mouth dryness include mouth pain, inflammation, peeling, or swelling of the tongue. Mouth dryness causes gingivitis, oral mucositis, bacterial plaque, and bacterial colonization in the mouth and throat.6 The colonization of bacteria is associated with several complications such as dental caries, periodontitis, systemic infection, and even endocarditis.7 Furthermore, mouth dryness, decreased salivation, mucositis, and bacterial colonization in the mouth and throat put patients at increased risk for pneumonia.8 Therefore, providing oral moisturizing is a critical component for the prevention of mouth dryness and associated symptoms.


Although there are different oral moisturizers to assist in the prevention and treatment of mouth dryness, studies have shown that preparations in the form of gels are more effective in protecting the oral cavity against dental plaque and bacterial colonization.9,10


Aloe vera-peppermint moisturizing gel (Veramin) is a proprietary plant-based medicine that has demonstrated to be extremely effective in relieving mouth dryness, preventing dental plaque formation, and improving oral health.11



Aloe (Aloe vera L.)

Aloe vera is a succulent perennial with fleshy, grayish-green leaves that are lance shaped, tapering to a point like a spear. They have small, spiny teeth along the leaf margins. Each leaf arises directly from the root and emerges in a concentric cluster. Throughout history, Aloe vera's medicinal value has been focused on its wound healing and moisturizing properties. In ancient Egypt, aloe was recognized for its moisturizing effects on the skin, as well as its ability to heal wounds. Even today, freshly snipped aloe leaves are known as an effective home aid for minor cuts, burns, sunburn, and insect bites.


Phytochemistry and phytopharmacology

The chemical composition of Aloe vera leaf gel is very complex, consisting of more than 75 active ingredients, which include vitamins, minerals, enzymes, sugars, phenolic compounds, lignin, saponins, sterols, amino acids, and salicylic acid.12 Approximately 99% of the inner gel is composed of water that has potent moisturizing effects. The high concentration of water in combination with mucopolysaccharides helps to bind moisture into the skin and mucosa, improving skin and mucosa hydration through a humectant mechanism.12


The pharmacokinetic actions of Aloe vera as studied in vitro and in vivo include anti-inflammatory, antioxidant, antibacterial, immune-boosting, and hypoglycemic properties.13,14


Aloe vera exhibits wound healing effects by stimulating fibroblast activity and proliferation, anti-inflammatory properties, as well as immune-stimulating effects, which combined provides potent phytopharmacological attributes for oral health care.


Peppermint (Mentha x piperita L.)

Peppermint is an aromatic perennial, with highly branched square stems and small lance-shaped, toothed leaves. The aromatic essential oil that is extracted from its leaves is the most extensively used essential oil in the world today. Peppermint is respected for its antibacterial activity, as a soothing aid for stomach and intestinal complaints, for its effectiveness in alleviating pain associated with aphthous stomatitis and in managing dental plaque.15-18



In a triple-blind 2-group randomized placebo-controlled clinical trial, the efficacy and tolerability of a proprietary gel (Veramin) of aloe (Aloe vera) leaf extract and peppermint (Mentha x piperita) essential oil was evaluated in a study population of intubated hospitalized ICU patients. The purpose of this study was to assess the effects of the aloe-peppermint moisturizing gel on mouth dryness and oral health in ICU patients.



This triple-blind 2-group randomized placebo-controlled study was conducted in 2016-2017 in a teaching hospital, located in Isfahan, Iran. The study population included 80 intubated hospitalized ICU patients, aged 18 to 65 years, that were randomly assigned either the aloe-peppermint moisturizing test agent or the placebo gel. The oral care gel for patients in the test group consisted of 100% Aloe vera leaf extract, 3% peppermint essential oil, carboxymethyl cellulose, 10% propylene glycol, and 0.1% potassium sorbate, while the placebo gel contained carboxymethyl cellulose, 10% propylene glycol, 0.1% potassium sorbate, and water up to 100%. The smell of the placebo gel was provided with a food-grade mint flavor. The application of oral care using the test agent or placebo was provided for 5 successive days. Authors, practitioners, and statistical analysts were blind to contents until the final data results.


The primary measurement was mouth dryness, which was evaluated by a dentist on the first day, and served as the baseline, followed by the 3rd-day, and 5th-day evaluation of the study using the Challacombe Scale. The Challacombe Scale is a mouth dryness assessment tool, with a 1- to 10-point scale, with higher scores representing the highest level of dryness.19


The secondary measurement was oral health that was assessed by a dentist on days, 1, 3, and 5, respectively, using the Mucosal-Plaque Index. This index provides a mucosal and a plaque score, which measures levels of inflammation and erythema that ranges from 1 to 4. The higher score represents poorer oral health.



The goal of this study was to evaluate the effects of the Aloe vera-peppermint moisturizing gel (test group) on both mouth dryness and oral health in ICU patients who were intubated. On the 5th day of assessment, the mean score of mouth dryness in the test group was significantly lower than in the placebo group (P = .0001). In addition, on days 3 and 5, the oral health mean score in the test group was considerably lower than in the placebo group (P = .0001). These results indicated that the test gel intervention had notable positive effects on both mouth dryness and oral health parameters in study.


The proprietary formulation of Aloe vera-peppermint moisturizing gel (Veramin) is effective in relieving mouth dryness, improving oral health, and reducing or preventing dental plaque formation. These considerations warrant further research studies for using Veramin as a viable treatment agent to improve oral outcomes with ICU patients.




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