Fluoride Action Network

January 2005

Don't Swallow Your Toothpaste

As of April 7th, 1997, the United States FDA (Food & Drug Administration) has required that all fluoride toothpastes sold in the U.S. carry a poison warning on the label. The warning cautions toothpaste users to:

"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."

Why the Need for a Warning?

One of the little-known facts about fluoride toothpaste, is that each tube of toothpaste - even those specifically marketed for children - contains enough fluoride to kill a child.

As detailed below, most "Colgate for Kids" toothpastes - with flavors ranging from bubble gum to watermelon - contain 143 milligrams (mg) of fluoride in each tube. This dose of fluoride is more than double the dose (60 mg) that could kill the average-weighing 2 year old child. It is also greater than the dose capable of killing all average weighing children under the age of 9.

Fortunately, however, toothpaste-induced fatalities have been rarely reported in the US. In a review of Poison Center Control reports between 1989 and 1994, 12,571 reports were found from people who had ingested excess toothpaste. Of these calls, 2 people - probably both children - experienced "major medical outcomes", defined as "signs or symptoms that are life-threatening or result in significant residual disability or disfigurement" (SOURCE: Shulman 1997).

TABLE: "Colgate for Kids" Toothpaste could Kill your Child
Age of Child	Average Weight*	Dose of Fluoride which could kill**	Percent of "Colgate for Kids" toothpaste which, if swallowed, could Kill***
2 years	~12 kg	60 mg	~42% of tube
3 years	~15 kg	75 mg	~53% of tube
4 years	~16 kg	80 mg	~56% of tube
5 years	~ 18 kg	90 mg	~63% of tube
6 years	~20 kg	100 mg	~70% of tube
7 years	~22 kg	110 mg	~77% of tube
8 years	~25 kg	125 mg	~87% of tube
9 years	~28 kg	140 mg	~98% of tube
*Average weight data obtained here ** Potentially fatal dose = 5 mg of fluoride per kg of bodyweight. This is "the minimum dose that could cause toxic signs and symptoms, including death, and that should trigger immediate therapeutic intervention and hospitalization... This does not mean that doses lower than 5.0 mg F/kg should be regarded as innocuous." (SOURCE: Journal of Dental Research 1987; 66:1056-1060.) *** 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.

Other problems with fluoride toothpaste

As common sense might indicate, death is not the only concern with fluoride toothpaste. Other potential problems with fluoride toothpaste include:

Gastric Problems

Ingestion of fluoride has been documented to produce symptoms of gastrointestinal discomfort at doses at least 15 to 20 times lower (0.2-0.3 mg/kg) than the doses which can kill (SOURCE: Gessner 1994; Akiniwa 1997). Thus, a 2 year old child may experience gastrointestinal ailments if they ingest a mere 2 to 3 percent of the bubble-gum flavored paste.

Between 1989 and 1994, over 628 people - mostly children - were treated at health care facilities after ingesting too much fluoride from their toothpaste. Gastrointestinal symptoms appear to be the most common problem reported (SOURCE: Shulman 1997).

Moreover, ingestion of fluoride toothpaste may damage the lining of the gastrointestinal tract - even in the absence of symptoms (e.g. nausea). This was revealed by a carefully conducted study on healthy adult volunteers which found that damage to the gastrointestinal wall occurred - in the absence of symptoms - after a single ingestion of just 3 mg of fluoride (SOURCE: Spak 1990). Undoubtedly, some children will periodically ingest 3 mg of fluoride, or more, from toothpaste in single sittings, especially if they have access to the bubble-gum flavored varieties (which are still being heavily marketed for children).

Dental Fluorosis

One of the most visible and well-recognized side-effects of ingesting fluoride toothpaste is a discoloration of teeth called dental fluorosis. Fluoride produces dental fluorosis by damaging the cells (ameloblasts) which produce the tooth's enamel. The resulting discoloration of teeth can range from white spots in the mild forms of the disorder to brownish and black stains in the the moderate and severe forms. (See pictures here)

Children with dental fluorosis - particularly those with the moderate or severe kinds - can experience significant esteem problems from the perceived unattractiveness of their teeth. As one young girl with dental fluorosis told British television:

"When I first saw that my teeth were discolored, I was teased quite a lot, especially in the middle school by people. They used to say, 'oh you don't clean your teeth or anything' and they used to call me 'shit teeth' which did upset me, even though I knew it was fluorosis."

Being that dental fluorosis is such a visible and tangible effect of over-exposure to fluoride, toothpaste companies are becoming increasingly vulnerable to litigation as public awareness of dental fluorosis increases. As a possible harbinger of what lies ahead for the industry, a family in England won a settlement from Colgate to pay for the costs of treating the dental fluorosis which their toothpaste caused.

Increasing Children's Daily Intake of Fluoride beyond Recommended Levels

Since young children do not have well-developed swallowing reflexes, they tend to swallow a large percentage of the toothpaste placed on their brush. In fact, one of the more consistent findings in the recent dental literature, is that some children - even children living in unfluoridated communities - ingest more fluoride from toothbrushing alone than is recommended as the total daily exposure. As noted by Dr. Steven Levy, of the University of Iowa:

"Virtually all authors have noted that some children could ingest more fluoride from dentrifice alone than is recommended as a total daily fluoride ingestion" (SOURCE: Levy 1999).

It is clear therefore that fluoride toothpaste represents a very important source of ingested fluoride for children. The use of fluoride toothpaste may thereby contribute to the various health risks (e.g. dental fluorosis, bone fractures, bone cancer, neurotoxicity) associated with systemic fluoride exposure.

Allergic Reactions

Among some 'hypersensitive' individuals, the use of fluoride toothpaste may produce canker sores and skin rashes in and around the mouth. The evidence pointing to this possibility is compelling, but has received scant attention from the dental community.

Periodontal Disease?

Another potential side effect of fluoride toothpaste has only recently come to light. Research conducted in the 1990s from the US pharmaceutical company Sepracor indicated that the levels of fluoride in toothpaste may be sufficient to cause or contribute to periodontal bone loss. Sepracor's finding is serious because periodontal bone loss is the #1 cause of tooth loss among adults. According to the scientists at Sepracor who conducted the study:

"We have found that fluoride, in the concentration range in which it is employed for the prevention of dental caries, stimulates the production of prostaglandins and thereby exacerbates the inflammatory response in gingivitis and periodontitis.... Thus, the inclusion of fluoride in toothpastes and mouthwashes for the purpose of inhibiting the development of caries [cavities] may, at the same time, accelerate the process of chronic, destructive periodontitis."

Europe: Taking a More Cautious Approach than U.S.

As with water fluoridation, continental western Europe has taken a more precautionary approach with fluoride toothpaste than has so far been the case in the United States.

Due to concerns about children ingesting too much fluoride from toothpaste, many European countries are now utilizing children's toothpastes with significantly lower levels of fluoride (250 - 500 ppm) than adult brands (1,000 ppm+). In the US, meanwhile, the vast majority of children's toothpastes continue to have the same concentration of fluoride (1,000 ppm+) as adult toothpastes (1,000 ppm+).

Interestingly, "despite" the fact that the vast majority of western Europe does not fluoridate its water, and despite the fact that children's toothpaste with lower fluoride levels are more common, Europe's tooth decay rates are as low - if not lower - than the tooth decay rates in the heavily fluoridated United States.

References:

Akiniwa, K. (1997). Re-examination of acute toxicity of fluoride. Fluoride 30: 89-104.

Gessner BD, et al. (1994). Acute fluoride poisoning from a public water system. New England Journal of Medicine 330:95-9.

Levy SM, Guha-Chowdhury N. (1999). Total fluoride intake and implications for dietary fluoride supplementation. Journal of Public Health Dentistry 59: 211-23.

Spak CJ, et al. (1990). Studies of human gastric mucosa after application of 0.42% fluoride gel. Journal of Dental Research 69:426-9.

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.

Whitford GM. (1987). Fluoride in dental products: safety considerations. Journal of Dental Research 66: 1056-60.