Minimum Dose of Fluoride Producing Acute Toxicity

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Key Findings - Minimum Dose of Fluoride Producing Acute Toxicity:

1) Each year there are thousands of reports to Poison Control centers in the United States related to excessive ingestion of fluoride dental products (toothpaste, mouthrinses, and supplements).

2) Early symptoms of acute fluoride toxicity (e.g. gastrointestinal pain, nausea, vomiting, headaches) can be produced at doses as low as 0.1 to 0.3 mg/kg. This is about 15 to 50 times lower than the dose (5 mg/kg) that can kill.

3) Ingestion of as little as 1 percent of a tube of flavored children's toothpaste can produce acute fluoride toxicity in a young child.

Excerpts from the Scientific Literature - Early Symptoms of Acute Fluoride Toxicity:

NOTE: For information on the advanced symptoms of acute fluoride poisoning, click here

"Fluoride has several mechanisms of toxicity. Ingested fluoride initially acts locally on the intestinal mucosa. It can form hydrofluoric acid in the stomach, which leads to GI irritation or corrosive effects. Following ingestion, the GI tract is the earliest and most commonly affected organ system."
SOURCE: eMedicine.com

"Ingested fluoride is transformed in the stomach to hydrofluoric acid, which has a corrosive effect on the epithelial lining of the gastrointestinal tract. Thirst, abdominal pain, vomiting, and diarrhea are usual symptoms. Hemorrhage in the gastric mucosa, ulceration, erosions, and edema are common signs."
SOURCE: Environmental Protection Agency. (1999). Recognition and Management of Pesticide Poisonings. 5th Edition. (Available online)

"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.

"The most common symptoms were nausea (97%), vomiting (68%), diarrhea (65%), and abdominal cramps (53%); 14 people (41%) reported headaches, four (12%) reported burning sensations in the throat or chest, and one person reported excessive salivation."
SOURCE: Penman AD, Brackin BT, Embrey R. (1997). Outbreak of acute fluoride poisoning caused by a fluoride overfeed, Mississippi, 1993. Public Health Reports 112:403-9.

"Nausea (90%), vomiting (80%), abdominal pain (52%), diarrhea (23%), loss of appetite (13%), headache (11%), weakness (10%), itching (9%), numbness or tingling of an extremity (4%), shortness of breath (4%), fatigue (4%)."
SOURCE: Gessner BD, et al. (1994). Acute fluoride poisoning from a public water system. New England Journal of Medicine 330:95-9.

"symptoms included: abdominal cramping (66 per cent), nausea (62 per cent), headache (49 per cent), diarrhea (42 per cent), vomiting (13 per cent), diaphoresis (profuse sweating) (12 per cent), and fever (4 per cent)."
SOURCE: Petersen LR, et al. (1988). Community health effects of a municipal water supply hyperfluoridation accident. American Journal of Public Health 78: 711-3.

Excerpts from the Scientific Literature - Minimum Single Dose of Fluoride Producing Acute Toxicity:

"The lowest estimated dose of fluoride that caused symptoms was 0.3 mg per kilogram; 16 percent of the case patients received an estimated dose of less than 1.0 mg per kilogram. The lowest level at which an effect was observed -- a level of less than 1 mg of fluoride per kilogram -- is similar to that reported in some studies..."
SOURCE: Gessner BD, et al. (1994). Acute fluoride poisoning from a public water system. New England Journal of Medicine 330:95-9.

"[A]cute fluoride poisonings have occurred at doses of 0.1 to 0.8 mgF/kg of body weight in the USA... At least seven events of acute fluoride poisoning that are related to the fluoridation of drinking water have formally been reported in the USA... Among these occurrences, the estimated toxic dose was lowest in the 1978 event in New Mexico, which involved children in kindergarten and nursery school with the total amount of fluoride per child of 1.4 to 90 mg, which is calculated to be approximately 0.1 mgF/kg in subjects with a body weight of 15 kg. The estimated minimum toxic doses of fluoride involved 0.21, 0.3, 0.34, 0.5, and 0.8 mg/kg in the other events of acute fluoride poisoning in the list, which are much lower than those reported before... Thienes et al in 1972 reported that the dose of fluoride which induces nausea is 0.12 mg/kg (7.2 mg of fluorine/60 kg of body weight), which is close to the toxic doses estimated in the events of fluoride poisoning in the USA... Kasahara et al estimated the minimum toxic dose of fluoride at about 0.2 mgF/kg. They reported that 60 persons took 10 mg amounts of fluoride and more than 90% of them had symptoms. Asou selected 0.1 mgF/kg as the minimum toxic dose."
SOURCE: Akiniwa, K. (1997). Re-examination of acute toxicity of fluoride. Fluoride 30: 89-104.

Minimum Single Dose Producing Acute Toxicity in Dental Products - Fluoridated Toothpaste: (back to top)

Quantity of Ingested Toothpaste Capable of Producing Symptoms of Acute Toxicity "Colgate for Kids" Toothpaste
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.

U.S. Poison Control Center Reports - Fluoridated Dental Products: (back to top)

Reports to the American Association of Poison Control Centers Related to Fluoride-containing Dental Products and the Outcomes, 1989-1994 (Data from: Shulman 1997)
			# Treated in Health Care Facilities	Medical Outcome*
Year	Product	# Reports		None	Minor	Moderate	Major	Death
1989	Toothpaste	1,392	101	464	371	15	0	0
	Mouthrinse	1,185	56	503	115	3	0	0
	Supplements	4,028	375	1,807	663	14	1	1
	Vitamins**	3,153	184	1,214	135	0	0	0
1990	Toothpaste	1,379	107	468	329	7	0	0
	Mouthrinse	1,299	64	511	109	2	0	0
	Supplements	4,437	338	1,950	653	10	0	0
	Vitamins**	2,938	135	949	0	0	0	0
1991	Toothpaste	1,623	120	497	403	15	0	0
	Mouthrinse	1,418	72	556	112	0	0	0
	Supplements	4,350	368	1,593	667	12	0	0
	Vitamins**	2,741	102	595	93	3	0	0
1992	Toothpaste	2,331	141	700	497	17	1	0
	Mouthrinse	1,338	52	545	92	1	0	0
	Supplements	4,171	340	1,579	624	12	0	0
	Vitamins**	2,949	122	883	111	1	0	0
1993	Toothpaste	2,507	143	725	571	21	0	0
	Mouthrinse	1,144	52	409	75	4	0	0
	Supplements	3,483	249	1,143	503	16	0	1
	Vitamins**	2,650	105	706	100	0	0	0
1994	Toothpaste	3,369	166	852	800	19	1	0
	Mouthrinse	1,220	40	409	79	3	0	0
	Supplements	3,544	240	1,224	489	22	1	0
	Vitamins**	2,493	86	663	111	0	0	0
* No effect: No signs or symptoms as the result of exposure. 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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