Acute Fluoride Toxicity from Toothpaste Ingestion F.A.N. | March 2012 | By Michael Connett

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Acute Fluoride Toxicity from Toothpaste Ingestion

F.A.N. | March 2012 | By Michael Connett

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The Food & Drug Administration now requires that all fluoride toothpastes sold in the United States bear the following poison warning:

“WARNING: Keep out of reach of children under 6 years of age. If you accidentally swallow more than used for brushing, seek professional help or contact a poison control center immediately.”

The FDA warning is necessary because relatively small doses of fluoride can induce symptoms of acute fluoride toxicity (i.e., poisoning). Early symptoms of fluoride poisoning include gastrointestinal pain, nausea, vomiting, and headaches. The minimum dose that can produce these symptoms is estimated to be 0.1 to 0.3 mg/kg of fluoride (i.e., 0.1 to 0.3 milligrams of fluoride for every kilogram of bodyweight). A child weighing 10 kilograms, therefore, can suffer symptoms of acute toxicity by ingesting just 1 to 3 milligrams of fluoride in a single sitting.
As demonstrated in the table, 1 to 3 mgs of fluoride is found in just 1 to 3 grams of toothpaste (less than 3% of the tube) — including toothpaste that is marketed specifically to children with bubble-gum and fruit flavors.

Amount of Bubblegum-flavored “Colgate for Kids” Toothpaste Capable of Causing Acute Toxicity
Age of Child	Average Weight*	Milligrams of Fluoride Capable of Producing Symptoms	Grams of Ingested Toothpaste	Percent of Toothpaste Volume
2 years	~12 kg	1.2 – 3.6 mg	1.1 – 3.3 g	0.8 – 2.5%
3 years	~15 kg	1.5 – 4.5 mg	1.4 – 4.1 g	1.0 – 3.1%
4 years	~16 kg	1.6 – 4.8 mg	1.5 – 4.4 g	1.1 – 3.4%
5 years	~ 18 kg	1.8 – 5.4 mg	1.6 – 4.9 g	1.3 – 3.8%
6 years	~20 kg	2.0 – 6.0 mg	1.8 – 5.5 g	1.4 – 4.2%
7 years	~22 kg	2.2 – 6.6 mg	2.0 – 6.0 g	1.5 – 4.6%
8 years	~25 kg	2.5 – 7.5 mg	2.3 – 6.8 g	1.7 – 5.2%
9 years	~28 kg	2.8 – 8.4 mg	2.5 – 7.6 g	2.0 – 5.9%
*Average weight data obtained here ** The fluoride concentration in Colgate for Kids toothpaste is 1,100 ppm. At 130 grams of paste in the average tube, this equals 143 milligrams of fluoride.

Because the symptoms of acute fluoride toxicity mimic other, common ailments (e.g., upset stomach, nausea, flu), there are undoubtedly countless incidents of fluoride poisoning that routinely go undiagnosed. As noted in the Journal of Public Health Dentistry:

“Estimating the incidence of toxic fluoride exposures nationwide also is complicated by the existence of biases. Parents or caregivers may not notice the symptoms associated with mild fluoride toxicity or may attribute them to colic or gastroenteritis, particularly if they did not see the child ingest fluoride. Similarly, because of the nonspecific nature of mild to moderate symptoms, a physician’s differential diagnosis is unlikely to include fluoride toxicity without a history of fluoride ingestion.”
SOURCE: Shulman JD, Wells LM. (1997). Acute fluoride toxicity from ingesting home-use dental products in children, birth to 6 years of age. Journal of Public Health Dentistry 57: 150-8.

Although many poisoning incidents go undiagnosed, the number of reports to Poison Control Centers in the U.S. has skyrocketed since the FDA issued its poison warning. Indeed, in the early 1990s (prior to the FDA warning), there were about 1,000 poisoning reports each year from fluoride toothpaste. Today, there are over 20,000 reports a year -- a 20-fold increase since the FDA added the warning.

Reports to Poison Control Centers in U.S. Due to Excessive Ingestion of Fluoride Toothpastes Data from: Bronstein (2009, 2010) & Watson (2003)
			# Treated in Emergency Room	Medical Outcome*
Year	Product	# Reports		None	Minor	Moderate	Major	Death
2009	F Toothpaste	24,547	378	4,781	1,146	42	2	0
2008	F Toothpaste	23,468	383	4,395	1,119	43	1	0
2002	F Toothpaste	24,087	411	4,852	1,218	40	1	1
* Minor effect: Minimally bothersome signs or symptoms that generally resolved without residual disability or disfigurement (e.g. self-limiting gastrointestinal symptoms). Moderate effect: More pronounced or prolonged signs or symptoms, or more of a systemic nature than minor systems. While the symptoms are not life-threatening (e.g., disorientation or high fever that responds readily to treatment), some form of treatment is indicated. Major effect: Signs and symptoms that are life-threatening or result in significant residual disability or disfigurement. (Shulman and Wells 1997)
SOURCES: Bronstein AC, et al. (2010). 2009 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 27th Annual Report. Clinical Toxicology 48:979-1178. Bronstein AC, et al. (2009). 2008 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 26th Annual Report. Clinical Toxicology 47:911-1084. Watson WA, et al. (2003). 2002 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. American Journal of Emergency Medicine 21:353-421.

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Reports to Poison Control Centers in U.S. Due to Excessive Ingestion of Fluoride Toothpaste (Pre-FDA Warning) Data from: Shulman and Wells (1997)
			# Treated in Emergency Room	Medical Outcome*
Year	Product	# Reports		None	Minor	Moderate	Major	Death
1989	Toothpaste	1,392	101	464	371	15	0	0
1990	Toothpaste	1,379	107	468	329	7	0	0
1991	Toothpaste	1,623	120	497	403	15	0	0
1992	Toothpaste	2,331	141	700	497	17	1	0
1993	Toothpaste	2,507	143	725	571	21	0	0
1994	Toothpaste	3,369	166	852	800	19	1	0
* Minor effect: Minimally bothersome signs or symptoms that generally resolved without residual disability or disfigurement (e.g. self-limiting gastrointestinal symptoms). Moderate effect: More pronounced or prolonged signs or symptoms, or more of a systemic nature than minor systems. While the symptoms are not life-threatening (e.g., disorientation or high fever that responds readily to treatment), some form of treatment is indicated. Major effect: Signs and symptoms that are life-threatening or result in significant residual disability or disfigurement. ** With fluoride but without iron.
SOURCE: Shulman JD, Wells LM. (1997). Acute fluoride toxicity from ingesting home-use dental products in children, birth to 6 years of age. Journal of Public Health Dentistry 57: 150-8.

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