1957; Volume 56; Pages 1037-1039

Fluoride Dentrifice and Stomatitis

Thomas E. Douglas, M.D.
Seattle, Washington

Stomatitis has been seen with increasing frequency the past fifteen months (prior to October 1956). At first I was quite aware that a gastrointestinal disturbance, gall bladder disorder or some physical or pyschologic factor might be producing some of the oral lesions which I was seeing. However, as time passed I became more and more cognizant of one basic underlying factor -- namely, practically all of the patients whom I was seeing were using dental powder or cream which contained one of the fluorides. I have compiled a list of the last 133 patients with this complaint who had the common factor -- namely, the usage of fluoride dentrifice. Other than this one basic factor there seems little, statistically, of significance.

Age (of the 133 patients) ranged from 3 1/2 to 92 years (table 1). A classification agewise follows: There were 11 patients between the ages of 3 and 9, 4 in the second decade, 43 in the twenties, 21 in the thirties, 30 in the fourties, 12 in the fifties, 7 in the sixties and 3 patients in the seventies. One patient was in the eighties and one in the nineties.

I have treated as many as six of a family of seven with stomatitis of fluoride origin. The only member of this family who was not treated was the 11 month baby who did not use the same brand of dental cream which was being supplied to the other six members of the family. I have had another family of four who were affected with similar lesions.

Patient Test-Courses

I have been able to have 32 patients cooperate over a range of two to six courses (table 2).

Each course consisted of use for three weeks of the dentrifice containing fluorides followed by use of non-fluoride dentrifice until normalcy had been maintained three weeks. The age range for these cooperative patients was from 11 to 44. There were two patients who were able to last through six courses before disgust and the inconveniences caused by the stomatitis prompted them to decline further experimental courses. Five saw the effects of five courses, 7 through three courses and 18 through two courses of three weeks of fluoride dentrifices followed by three weeks of dentrifice did not contain fluorides.

These courses all commenced following complete clearing of the patient's symptoms and signs. One common denominator was noted with each of the patients -- namely, each time the patient commenced using the fluoride dentrifice, it took less time to acquire more severe lesions than it had the previous time. Also, each became more difficult to clear of the signs and symptoms produced by the fluorides. In several of the patients, symptomatology was increased as much as four fold after two or three courses -- both in severity and time required for complete clearing of the lesions.

The group of patients listed under this category were derived mainly from the following sources: 1. Those who had been seen by an internist or general practitioner or both for gastrointestinal disturbances and for treatment of oral lesions. These patients were tested for general physical fitness and gastrointestinal disease was ruled out. 2. Several had been seen by dentists and were referred for more specific therapy when a definitive diagnosis was not forthcoming from a dental standpoint. 3. Patients whom I had seen previously or who were referred by their friends or those who dropped in on non-referral bases. On the whole, most of the patients who were referred by the dentist, the general practitioner or the internist had had large and adequate doses of antibiotics either parenterally or in the form of troches. Many had had gastric alkalizers or gall bladder therapy. Most had had the oral lesions treated with silver nitrate ranging in strength from 10 to 25 per cent. Following referral, the patients were taken off antibiotics for a few days as adequate dosage had been carried out in most cases and had proved to be of no avail. Following the withdrawal of antibiotics, and this refers most specifically to the oral troches, 27 of the patients had improvement of the vesicles but the remaining lesions did not clear or show a tendency to improve.

Description of Lesions

There is nothing specific in the appearance of the lesions which would distinguish or differentiate them from any of the other common oral pathologic processes. I believe that if one were to describe the lesions, it would be as shallow, superficially ulcerated areas which tend to have a whitish exudate on the surface and surrounding areas. The worst lesion and, indeed, the earliest lesions, commenced on the buccal mucosa opposite the teeth - that is, in those areas which come in contact with the teeth. The tongue, hard palate, soft palate, floor of the mouth, gingival regions and oral pharynx also produced similar ulcerations. Indeed, the longer the patient had used the fluoride dentrifice, the more chance he had of showing general involvement of the entire oral and pharyngeal regions. This was anticipated and found to be true.

All of the 133 patients showed whitish exudate over the superficially ulcerated lesions with gingivitis and stomatitis (table 3). Seventeen of this group had a foul breath but most of the group described "a bad taste in the mouth." Very few had unpleasant breath odor discernible by a social acquaintance. However, examination of the breath showed most to be fetid. In the series of the courses, frequency of finding foul breath was increased to approximately 90 per cent. In the overall series of 133, 94 produced bleeding rather easily upon manipulation of the gums or mucous membranes of the mouth or cheeks. Twenty-nine described soreness of the teeth. This soreness was more in the form of tightness, a peculiar feeling of the teeth not being "set right in the socket" instead of a definite ache or pain. Eighteen patients described ptyalism.

Bacteriologic Examination

Bacteriologic examinations of these patients was regretably not carried out in all cases, either due to financial status of the patient, lack of cooperativeness or other reasons. However, the bacteriologic examinations which were done showed increase of staphylococcic organisms and, in the more severe cases, an increase in anaerobic organisms. All smears and cultures returned to normalcy at the time of lessening of the severity of the lesions.

Vesicle formation may be a part of this inflammatory reaction or disease process. However, the 27 patients I have seen with vesicles which improved after removal of the antibiotic troches lead me to believe that a dual factor may be at work to produce the vesicles.

Treatment

Treatment of these lesions is rather simple in the early-stages -- namely, changing to a dentrifice which does not contain a fluoride. Clearance of the lesions can be aided by painting with 10 to 20 per cent silver nitrate solution. This is especially favorable in the more advanced ccases. Simple mouth washes to change pH of the oral or pharyngeal cavities or both has also proved of value. Cessation of smoking during the course of therapy has proved of value although it is very difficult to get the patients to cooperate in this respect, especially for a statistical series. Also included with the above there should be attention to general health and systemic care of the patient. Those patients who had repeated courses of fluoride testing proved to be very grave problems indeed. In fact, some of them became so resistant to clearing of the oral lesions that I began to wonder if the lesions had not become irreversible. Duration from the time we actually commenced trying to rid the patients of their lesions until actual improvement was noted, was, indeed, very prolonged in those who had three, four or more courses of fluoride testing. The period from partial clearing to complete clearing of the lesions was even more prolonged and uncertain. Following the three, four, five or six courses of therapy, the patient's oral resistance must have been markedly lowered in that any little bump to the cheek or trauma of any nature would immediately cause the lesions to revert to the more severe ulcerative states.

Summary

Statistical data of 133 patients who have been using fluoride dental cream or powder have been presented. Each has developed intraoral ulcerative lesions. Many have been treated for other complaints without clearance of the lesions. Age is not significant. Repeated insults with the fluoride dentrifices produced increasingly severe excoriations. There seems to be nothing specific about the lesions to differentiate them from other diseases of an oral nature. The main diagnostic requisite seems to be the ability to think of and elicit a history of dental fluoride hygiene.