Prevention---- 5th class Prof. Dr.

Ban Sahib

Lecture- 11 Toxicity of fluoride

For more than 6 decades, fluoride has been the first line of defense against caries.
After years of laboratory research, animal experiments, and clinical trials, researchers
now have a good idea how fluoride works to prevent tooth decay. They have also
learned more about how fluoride interferes with a number of host biological
processes.
Clinicians should be aware of the total daily fluoride intake to which their patients
are exposed. Once the background exposure is known, side effects can be minimized
while ensuring maximum anti-caries benefit is attained
Fluoride toxicity: refers to excess fluoride ingestion involving acute or chronic form.
Sources of excess systemic fluoride
Water, beverages, and food: Fluoride is the thirteenth most abundance element in
the earth’s crust and occurs naturally in ocean water at levels of about 1.3 ppm , up
to15 ppm in groundwater, and up to 2,000 ppm in soil. Certain foods contain more
fluoride than others. Dark tea, for example, is enriched in fluoride and can range
between 3 and 6 ppm. Accidental fluoridation overfeeds have resulted in acute
fluoride poisoning, and could result in death in addition there have been accidental
exposures of the concentrated fluoridation chemicals that have resulted in severe
acute fluoride chemical burns and life-threatening squeal. In past years, skin burns of
this type were common for many water engineers who emptied drums of fluoride
agents into the hoppers feeding water supplies.

Medicines: In addition to fluoride supplements, many common pharmaceuticals used

in medicine are fluorinated. The more common ones include Celebrex, Cipro,
Diflucan, Prozac, Dalmane, Lipitor, and nearly all of the halogenated general
anesthetics. Depending on the molecular formula, these drugs contain from 3–17%
fluorine by weight. Some have been shown to lose free fluoride from defluorination
by cytochrome P450 enzymes.

Pollution: Increased fluoride intake can occur from inhaling fluoride-polluted air.
Ample were much higher near steel plants. The highest fluoride levels found in air
have been documented in area where coal is burned extensively for industrial power
generation. In some areas, where dental fluorosis has been documented to be quite
severe and skeletal fluorosis has been observed, the concentration of fluoride in
ambient can be as high as 11 μg/m3.
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(1 PPM = 1,000 microgram per meter cubed. Similarly, 1 microgram per meter cubed = 0.001 PPM).
Acute toxicity—clinical signs, diagnosis, treatment

Acute toxicity occurs due to single ingestion of a large dose of fluoride at one time.
The severity depends on the amount and form of fluoride ingested, age and weight of
person as well as the rate of absorption.

The FDA and occupational safety health legislation carefully regulates the handling
of fluorides in industry and in the marketplace. Commercial dental fluoride products
and professional practices can be toxic and even lethal when used inappropriately

Every parent (and health care professional) should be aware of the potential
emergency that could result from an ingestion of a sizable amount of fluoride. The
investigators have recommended a probable toxic dose (PTD) standard based on body
weight as a more practical approach to making treatment decisions. They defined the
probably toxic dose (PTD) as: the minimum dose that could cause toxic signs and
symptoms, including death, and that should trigger immediate therapeutic
intervention and hospitalization and that dose with it, the urgency for first aid and
more definitive emergency treatment can be determined rapidly.

The PTD approach, first reported bases the level and urgency of treatment on the
number of multiples of 5 mg/kg of fluoride ingested.
For example the sources of a probably toxic dose in low weight 28-month toddler
weighing 10 kg (22 pounds) are listed in Table below. This table can be used for
quickly judging whether or not toddlers or children weighing more than 10 kg have
consumed a toxic dose of fluoride.

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Excessive exposure to fluoride results in four general reactions:

(1) when a concentrated fluoride salt contacts moist skin or mucous membrane,
hydrofluoric acid forms, causing a chemical burn ( ulceration and necrosis can occur)
(2) inhibition of enzyme systems
(3) binding calcium needed for nerve action
(4) hyperkalemia (excessive amount of potassium in the bloodstream) contributing to
cardiotoxicity (damage to the heart muscle).

Following excessive ingestion of fluoride, nausea and vomiting can occur. The
vomiting is usually caused by the formation of hydrofluoric acid in the acid
environment of the stomach, causing damage to the lining cells of the stomach wall.
Local or general signs of muscle tetany (intermittent, prolonged spasms) ensue from a
drop in blood calcium (hypocalcemia). Abdominal pain can accompany this effect.
Finally, as the hypocalcemia and hyperkalemia intensify, the severity of the condition
becomes ominous with the onset of the three C’s that can indicate death
(coma, convulsions, and cardiac arrhythmias (irregular heartbeat)).

Emergency treatment for fluoride over dose: (briefly)

 If the amount ingested is less than 5 mg/kg, the office use of available calcium,
aluminum, or magnesium products as first aid antidotes should suffice.
 If the amount is more than 5 mg/ kg, first aid measures should be expeditiously
applied followed by hospital observation for the need for further care.
 Finally, if the amount of fluoride ingested approaches or exceeds 15 mg/ kg, the
immediate first aid treatment should be followed by a most urgent action to move
the patient swiftly into a hospital emergency room where cardiac monitoring,
electrolyte evaluation, and shock support are available. Ingestion of 15 mg/kg
fluoride can be lethal

The blood level of fluoride reaches its maximum from one‐half to 1 hour after the
fluoride is ingested; by that time treatment could be too late.

Despite all precautions, potential for signs and symptoms of acute fluoride toxicity
could exist in dental office misuse of excess amounts of professionally applied topical
fluoride. To be prepared for such an unlikely emergency, the professional staff should
be trained to institute emergency procedures if necessary

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Actions are especially significant in treating fluoride poisoning (If the amount is
more than 5 mg/ kg ):

Induced vomiting is beneficial and often occurs spontaneously. When vomiting does
occur, the majority of the ingested fluoride is often expelled.

Protection of the stomach by binding fluoride with orally administered milk or, better
yet, milk and eggs should be given, for two reasons: (1) as demulcents, they help
protect the mucous membrane of the upper gastrointestinal tract from chemical burns
and (2) they provide the calcium that acts as a binder for the fluoride. Calcium
hydroxide or an aluminum preparation can be ingested to accomplish the same
purpose. Plenty of fluid, preferably milk, should be ingested to help dilute the
fluoride compound in the stomach. Preferably, the patient should be taken directly to
a hospital emergency room.

Urgent and decisive treatment is mandatory once the PTD of 15 mg/kg has been
approached or exceeded. Once in a well‐equipped medical facility, several options are
possible, such as gastric lavage (use of a fluid to wash fluoride out of the stomach),
blood dialysis (diffusion of blood across a semipermeable membrane to remove the
fluoride) or intravenous delivery of calcium gluconate to maintain blood calcium
levels. Every effort should be made to rid the body rapidly of the fluoride or to negate
its toxicity before refractory (resistant to treatment) hyperkalemia and cardiac
fibrillation (rapid, irregular contraction of muscle fibers in the heart) become a more
serious problem than the fluoride intoxication.

Generally, death from ingestion of excessive fluoride occurs within 4 hours; if the
individual survives for 4 hours, the prognosis is guarded to good.

General factors affecting acute toxicity:

 Form of administration: Fluoride toxicity from solution type is greater because
of rapid absorption.
 Age: Younger age is severely affected by fluoride toxicity.
 Rate of absorption is high when empty stomach.
 Type of fluoride ion as stannous fluoride is slightly more toxic than others.
Chronic Excessive Fluoride Exposure (toxicity):
Non-dental clinical signs
Excess fluoride ingestion can lead to joint pain and bone problems. This is a major
problem in areas of endemic fluorosis. Dentists should be aware that administration

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of too much fluoride for home use may put the patient at risk for joint pain or bone
problems.
The exceedingly high level of continual intake of fluoride for 10 to 20 years resulted
in a severe skeletal fluorosis characterized by osteosclerosis (abnormal increase in
thickness and density of bone), calcification of the tendons, and the appearance of
multiple exostoses (bony growths that arise from the bone’s surface) and often
accompanying osteoporosis, osteomalacia, or osteopenia .
Other factors that increase the severity of skeletal fluorosis are high temperatures
with a concomitant increase in drinking episodes, an elevated intake of fluoride in
food, nutritional diseases (low vitamin D and calcium diets)
Briefly the severity of toxicity depends on:
 The duration of fluoride intake.
 Age of individuals.
 Total amount of fluoride ingested.
 Concentration of fluoride.
If a dentist suspects excess chronic fluoride intake, it would be prudent to refer to a
physician with some knowledge in fluoride toxicity. Fluoride tests are not routine in
family practice, and referral to a physician or hospital with experience in dealing with
fluoride poisoning should be considered.
Medical management of chronic fluoride toxicity
Chronic fluoride poisoning is more difficult to recognize and manage. When
everyone in an entire community appears to have symptoms of nausea and vomiting,
fluoridation overfeed, especially in small communities, should be considered as a
potential cause, and the public health department should be alerted.
Bottle-fed infants that do not tolerate formula may improve with straight formula or
formula reconstituted with distilled water or that treated by reverse osmosis (RO).
Patients who consume large quantities of water or who have renal problems should
avoid fluoridated water altogether.
Physicians should at least consider that some joint pain complaints may simply be the
result of exposure to too much fluoride and reduce the fluoride intake.

Home Security of Fluoride Products

The lack of secure home storage of (OTC) medications (also known as

nonprescription medication) and prescription fluoride products poses hazards to
consumers. As presently packaged, the fluoride content of OTC fluoride products can
exceed the probable toxic dose (PTD) for children. Clearly, parents need to be
educated about the hazards of fluoride‐containing dental products.
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Dentifrices, mouth rinses, and fluoride supplements need to be securely stored when
young children are in the home. Also, health professionals need to be educated about
the emergency treatment protocol for excessive intake of fluoride.
Recommendations to avoid toxicity:
 Parent supervision.
 Using of small amount of fluoride professionally.
 Keep fluoride products out of reach of children