Calcium montmorillonite clay: a clinically oriented narrative review of emerging perioperative and supportive applications

Introduction

Natural clays have played a role in traditional medicine across numerous cultures for centuries (1). Used externally and internally, their appeal lies in both their natural origins and observable therapeutic effects (2). As the modern healthcare system evolves to integrate nutraceuticals, holistic and integrative therapies, materials like calcium montmorillonite (CMM) have re-entered the scientific conversation for their low-cost, safe, and versatile uses (1,3,4).

Among these, CMM stands out due to its unique layered structure, which allows for ionic exchange and toxin adsorption (4,5). Derived from volcanic ash and rich in calcium, CMM has shown promising applications in detoxification, inflammation modulation, and gastrointestinal (GI) health (2,6,7). Its versatility makes it an attractive subject for general medical and surgical research, particularly in an era of growing concern about environmental toxin exposure, chronic low-grade inflammation, and dysbiosis (7).

A 2017 review by Moosavi highlighted the broad therapeutic potential of bentonite, including CMM, on skin health, GI function, kidney protection, bone integrity, and even cancer models (7). The widespread applications suggest that more rigorous studies are needed to determine the clinical efficacy in specific patient populations, particularly those undergoing surgical or oncologic treatments.

Despite extensive historical use and a growing body of experimental literature, CMM remains underrepresented in clinical reviews that integrate mechanistic insights with translational relevance. A growing body of literature has emphasized the industrial, veterinary, or narrowly defined GI applications, but there remains a gap in the medical literature regarding its broader role as a low-risk, non-systemic adjunct in modern clinical practice. Early studies show positive results in several applications, although there is a paucity of level one prospective, randomized and double blinded studies. Furthermore, the increasing accessibility of good manufacturing practice (GMP)-grade formulations raises the feasibility of clinical adoption in perioperative and chronic disease contexts. The goal of this narrative review is to synthesize current scientific and clinical knowledge on CMM clay, describing its background, indications, safety, efficacy, and emerging therapeutic roles relative to other similar products. We present this article in accordance with the Narrative Review reporting checklist (available at https://atm.amegroups.com/article/view/10.21037/atm-25-143/rc).

What is CMM?

CMM is one type of montmorillonite. It is a smectite clay mineral composed primarily of hydrated aluminum silicates with interlayer calcium cations (8). It is characterized by a high surface area and strong cation-exchange capacity (9). These properties make it exceptionally effective in adsorbing positively charged molecules, including heavy metals, bacterial endotoxins, mycotoxins, and metabolic byproducts (7). This physical chemistry underpins many of its medicinal uses.

Unlike sodium-based montmorillonite, CMM has a more stable structure with less expansion upon hydration, reducing the risk of GI side effects (2,4). This makes it better suited for long-term use in therapeutic settings. Its lower swelling index and strong binding efficiency allow it to function as an effective detoxifying agent in both humans and animals, as confirmed by a large body of veterinary and food science literature (8,10-12).

CMM is primarily administered either orally or topically (13). When taken orally, it is commonly available in capsule, tablet, powder, or suspension forms, although powder forms possess greater dispersion characteristics. Oral use (powder, capsule or tablet formulations) is designed to act locally within the GI tract, where the clay binds to toxins, bacterial byproducts, and heavy metals without being absorbed into systemic circulation (13). This local activity makes it particularly suitable for applications related to gut health, detoxification, and inflammatory bowel conditions (14). Dosing typically ranges from one to two teaspoons per day, typically either 4 g once daily or in 2 g twice daily. It is often taken with water and should be separated from medications by at least one to two hours to prevent interference with drug absorption (15). Topical applications of CMM are also widely used, particularly in dermatologic and wound care settings (16,17). It is commonly included in creams, pastes, and wound dressings due to its astringent, antimicrobial, and absorptive properties. Topical use helps draw out moisture, reduce inflammation, and promote healing in skin conditions such as acne, dermatitis, and minor wounds (8).

Bioavailability of CMM is effectively zero in the traditional pharmacokinetic sense, as it is not absorbed systemically (18). Instead, it passes through the GI tract without entering the systemic circulation. Its overall inert behavior underpins its strong safety profile, making it an ideal adjunct for both acute and long-term use in diverse clinical and wellness settings (3). Its effectiveness is mechanical rather than pharmacological, lending it a favorable safety profile. CMM has been also explored its role as a drug delivery vehicle and as a matrix for slow-release medications, due to its ability to adsorb and protect biologically active compounds (1). This adds another dimension to its potential clinical use, particularly in the controlled delivery of antibiotics or anti-inflammatory agents in surgical patients (1,7,19).

History of montmorillonite clays

The name montmorillonite clay comes from the fact that it is a naturally occurring smectite clay mineral that was discovered in the middle of the 19th century close to Montmorillon in western France (20). Its tiny particle size, layered structure, and high cation exchange capacity define it as a member of the phyllosilicate group (7). Because of these characteristics and its substantial binding/adsorption capacity, CMM can absorb water and swell considerably, which makes it extremely adaptable to a variety of uses (7,21). Usually found in bentonite clay deposits, where it frequently serves as the main mineral component, montmorillonite is largely formed by the weathering of volcanic ash in coastal environments (2,9).

Because of its medicinal and absorptive properties including substantial binding/adsorption capacity, montmorillonite clay has been utilized for centuries by a variety of cultures (20,22-24). Indigenous peoples in Asia, Africa, and the Americas used clay to preserve food, apply it to wounds, and consume it for gut cleansing. The Greeks and Romans utilized clay to treat skin conditions and digestive problems, while the ancient Egyptians are believed to have employed it for mummification and interior treatment (13,21,25,26). Long before the scientific mechanisms of CMM were understood, it was widely known that it could bind heavy metals, microorganisms, and poisons.

As more research was done on CMM’s distinct chemical and structural characteristics in the 20th century, scientific interest in the material increased. Its use in pharmaceuticals, animal feed additives, and industrial applications like oil well drilling muds has increased due to its capacity to swell with water and retain positively charged ions such as heavy metals and toxins (23,27). CMM also has been utilized in agriculture to increase nutrient exchange and soil moisture retention, and in environmental science it is essential for water purification and waste containment (5,20,22,28).

Because of its antibacterial properties, CMM clay has also gained popularity in the cosmetics and health sectors. It is frequently sold under the more general term “bentonite clay” and is utilized in topical ointments, oral detoxification programs, and face masks (21,29). Its antibacterial and absorptive qualities provide scientific evidence for its use in treating diarrhea, absorbing toxins, and stimulating skin healing, even though certain health claims are still anecdotal (21,30). For limited applications, the Food and Drug Administration (FDA) considers montmorillonite to be generally safe; nevertheless, uncontrolled intake should be avoided.

With uses in environmental engineering, medicine, cosmetics, and agriculture, Montmorillonite is one of nature’s most versatile materials. The historical medicinal use of montmorillonite and related smectite clays has been documented in early pharmacologic literature, particularly in the contexts of GI symptom management, wound care, and toxin exposure mitigation (5,12,23). Modern pharmaceutical analyses have since elucidated the structural properties, including high surface area, layered silicate structure, and cation-exchange capacity, which when considered as a whole help provide a rationale for its biologically inert behavior (12,23,31).

Montmorillonite vs. bentonite comparison

While CMM and sodium montmorillonite (SMM) are both categorized under the broad term “bentonite”, their characteristics and safety profiles differ in important ways. From a geological standpoint, “bentonite” is a general classification referring to clay deposits composed predominantly of smectite minerals, most commonly montmorillonite. The specific properties of a bentonite are determined by its dominant interlayer cation (e.g., calcium or sodium) which has implications on inflammation, swelling, and overall biocompatibility.

CMM contains calcium ions that limit its swelling capacity to roughly twice its own weight in water, allowing it to function as a stable and effective binder of toxins in the GI tract and on the skin (7). By contrast, the sodium ions in SMM confer a much stronger hydrophilic effect, enabling it to expand up to eighteen times its weight (21). This marked difference in swelling behavior underlies the divergent applications of these materials. Specifically, sodium bentonite is widely used in industrial settings such as drilling fluids, sealants, and clarification processes (18,32). In contrast, CMM is better suited for biological and clinical contexts due to its structural stability and lower risk of mucosal irritation (20,23).

Mislabeling sometimes occurs when industrial SMM is marketed as “food grade” because it is used in winemaking or other processing applications where only traces remain. On rare occasions, SMM has also been sold for cosmetic purposes, though its strong astringency limits broader use (21). In medical and wellness contexts, it is therefore essential to distinguish between the two: CMM is the only form appropriate for oral administration (2).

Of note, CMM has greater structural stability and swells less upon hydration, reducing GI side effects and improving tolerability for long-term use (13). Functionally, it binds toxins such as mycotoxins, heavy metals, and bacterial endotoxins with greater specificity, while avoiding interference with nutrient or drug absorption, a common concern with sodium bentonite (33). CMM also benefits from greater availability in pharmaceutical-grade, GMP-certified formulations, whereas sodium bentonite is more often used in industrial settings with less stringent quality control (30). These advantages position CMM as a safer, more effective alternative to traditional bentonite for both oral and topical clinical applications.

Indications/potential uses

One of the best-studied indications for CMM is GI detoxification (6,8,30). Aflatoxins, carcinogenic mycotoxins found in contaminated food, are effectively bound by montmorillonite clays (14,30). Research in livestock and poultry has shown that dietary inclusion of montmorillonite substantially reduces aflatoxin absorption and improves growth outcomes (34,35). The U.S. Food and Drug Administration has acknowledged its use in feed additives as a GRAS (Generally Recognized As Safe) substance for toxin control.

Clinical evidence in humans is growing. A randomized controlled trial (RCT) involving 156 children with diarrhea found that montmorillonite combined with vitamin A and zinc shortened symptom duration and improved inflammatory profiles compared to montmorillonite alone (94.8 vs. 56.4%, P<0.05) (4). Markers such as C-reactive protein (CRP), tumor necrosis factor alpha (TNF-α), and nitric oxide were significantly reduced, while antioxidant activity [superoxide dismutase (SOD) levels] was increased. Importantly, this intervention showed no increase in adverse reactions (4). This has implications not only for pediatric care, but also for managing GI distress in immunocompromised or postoperative patients (18).

In addition, a clinical trial involving 86 patients with radiation enteritis, montmorillonite used in combination with dexamethasone improved mucosal healing and reduced cytokine levels, including interleukin-2 (IL-2) and interferon gamma (IFN-γ) (P<0.001) (5). These results point to its potential in mitigating mucosal injury in the postoperative or post-radiation setting. Topical uses in managing dermatitis, acne, and minor wounds are also supported by published literature and real-world applications, including use in United States over-the-counter (OTC) products containing Quaternium-18 bentonite (21). Moreover, its hygroscopic and astringent properties may promote wound healing in moist environments and support recovery in superficial surgical incisions (21).

Additional research is exploring its use in chronic metabolic conditions (Table 1), including nonalcoholic fatty liver disease (NAFLD), type 2 diabetes, and obesity (1,2,7). Early preclinical studies show that CMM can reduce gut-derived endotoxins and support metabolic homeostasis (3). These properties may offer indirect benefits in surgical patients who have comorbid metabolic conditions, especially where inflammation and delayed wound healing are concerns.

Efficacy

The binding efficacy of CMM has been validated through numerous in vitro and in vivo studies. It effectively adsorbs aflatoxins, zearalenone, ochratoxins, heavy metals such as lead and cadmium, and pesticide residues (30,34,35). These effects have been replicated in food safety and environmental toxicology literature, and now increasingly throughout human health applications (14,17). It demonstrates a strong affinity for polar and nonpolar toxins, an application that traditional agents like activated charcoal do not have.

A murine study by Xu et al. evaluated dietary lipid adsorbent montmorillonite (DLA-M) in mice with obesity, supplementation with lipid montmorillonite (DLA-M) was associated with reductions in free fatty acids (FFAs) and lipopolysaccharides (LPS) in the gut, improved glucose tolerance, reduced liver fat accumulation, and favorable shifts in gut microbial populations (P<0.01) (3). Moreover, mice treated with DLA-M displayed better hepatic histology and reduced serum alanine aminotransferase (ALT) levels, suggesting liver-protective effects (P<0.01) (3). Such findings raise the possibility of using CMM not only for toxin clearance, but also as a prebiotic or adjunct to treat metabolic disease. By lowering gut-derived inflammatory mediators, it may help reduce chronic inflammation and insulin resistance, key considerations in surgical patients and those with multimorbidity (6,13). While human studies are limited, ongoing pilot protocols are exploring its use in metabolic syndrome and nonalcoholic fatty liver disease. Additionally, its efficacy in promoting mucosal healing post-GI surgery may serve as a valuable adjunct to enhanced recovery after surgery (ERAS) protocols (7).

Safety

The safety of CMM is a major strength compared to other detoxification agents (4,18). Studies indicate that it does not alter the absorption of essential vitamins or minerals when taken orally at recommended doses (13). It is excreted unchanged in the feces, and no systemic accumulation occurs. Animal studies involving chronic use have shown no hepatotoxicity, nephrotoxicity, or interference with reproductive function (8,9). This being said, safety depends heavily on the source and processing of the clay. Pharmaceutical- and food-grade clays are subject to GMPs and screening for heavy metals, microbial contamination, and particle size (16). A report on Korean bentonite production emphasized that GMP-compliant facilities in Korea now produce montmorillonite suitable for medicinal use, regulated under both Korean Pharmacopoeia and international ICH guidelines (15,16).

Inhalation of dry clay particles should be avoided, as airborne particulate matter may irritate the respiratory mucosa (9). Caution is also advised in pregnant women or individuals who have iron-deficiency anemia, as clay consumption could theoretically interfere with iron absorption, although no clinical data confirms this risk at therapeutic doses (33). Nevertheless, no adverse events have been reported in clinical studies using montmorillonite for GI or skin disorders (8,30). Furthermore, its lack of systemic absorption and inert pharmacokinetics make it suitable for use even in immunocompromised populations, provided high-quality material is used.

Competing products

In the realm of detoxification, activated charcoal is a well-known alternative (36). However, it lacks specificity in binding and often adsorbs essential nutrients and medications. Moreover, it is typically reserved for acute poisoning cases and is not recommended for regular preventive use (37). CMM, by contrast, offers a more targeted, safer approach for longer-term application (38). Furthermore, it does not interfere with drug metabolism, making it a better fit for patients on multiple medications.

Another comparator is diosmectite, used in Europe for managing diarrhea (39). While effective in symptom control, it lacks the broader toxin-binding range and potential metabolic effects of montmorillonite. Diosmectite also tends to be more expensive and less readily available in North American markets (40).

Synthetic bile acid sequestrants such as cholestyramine can bind endotoxins and fatty acids, but require prescriptions and have a higher incidence of GI side effects like bloating and constipation (41). These agents also demand strict timing with respect to other medications, limiting their practical utility.

Probiotic formulations are often considered for microbiome support (29,42,43). Though not competitors, they may in fact be used synergistically with CMM for the treatment of colitis (44). Early data suggest that montmorillonite may enhance the survival and colonization of beneficial microbes by adsorbing harmful metabolites (44). This potential synergy is currently being explored in formulation science and clinical protocols (43). Future dual-delivery systems incorporating prebiotics and montmorillonite may offer a promising new direction in therapeutic gut modulation. A comparative summary of calcium montmorillonite and other commonly used gastrointestinal or detoxification agents is presented in Table 2.

Future directions

While existing evidence supports the safety and biological plausibility of CMM, there remain several gaps in the literature that warrant further investigation. First and foremost, there remains a need for published prospective randomized trials able to evaluate and compare perioperative outcomes, inflammatory modulation, and microbiome interactions (12,45). Additionally, there is a need for research aimed towards more precisely characterizing and helping propose a standardization (e.g., dosing, formulation consistency, and synergy with other probiotics) of CMM use to further increase potential translational and clinical relevance (4,18,31).

Conclusions

Modern CMM clay use incorporates ancient healing wisdom with modern scientific evidence. For general practitioners, it represents a well-tolerated, low-cost option to support patients managing chronic inflammation, metabolic disorders, GI issues, or even postoperative recovery. For the public, it remains a safe product that can be incorporated into daily wellness routines with minimal risk. Its mechanism of action, physically binding harmful substances and promoting their elimination, makes it especially appealing in today’s environment of rising toxin exposure and digestive imbalances. Whether taken orally for digestive health, used topically for skin irritation, or included as part of a broader detox program, CMM remains versatile and adaptable for a host of clinical needs. As more high-quality, pharmaceutical-grade preparations become available, including those from a company like MM Labs LLC, both patients and providers can feel confident in their overall safety and efficacy profiles.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://atm.amegroups.com/article/view/10.21037/atm-25-143/rc

Peer Review File: Available at https://atm.amegroups.com/article/view/10.21037/atm-25-143/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-25-143/coif). M.K.N. has received consulting fees from Stryker, Johnson & Johnson MedTech, Pacira BioSciences Inc., Sage Products Inc., Bonutti Technologies Inc., Hippocrates Opportunities Fund LLC, and Ferghana Partners, Inc. D.J. received royalties from Stryker, and research support from Stryker, Smith-Nephew, and Depuy and owns stock in MM Labs. W.B. received IP roylaties from Zimmer; owns stock in MM Labs, owns stock options in Healthcare Outcomes Performance Company; owns stock in Peerwell, Custom Orthopaedic Solutions, Beyond Limits, Motion MSK, PT Genie, and Capsico Health; and serves as a board member of Healthcare Outcomes Performance Company. M.A.M. received consulting fees from 3M, Johnson & Johnson, Smith & Nephew, Next Science, Pacira BioSciences, Inc., and Stryker; received research funding from the National Institutes of Health, and Stryker; is a shareholder for CERAS Health, Peerwell, and MirrorAR; serves as a board member for the Knee Society, and is the Editor-in-Chief for The Journal of Arthroplasty and an editor for the Journal of Knee Surgery, and Surgical Technology International. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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