Sources of excess systemic fluoride

1.
2.
3.
4.
5.

Water, beverages and food ( halo effect )

Fluoride supplements ( eg. 2.2mg NAF )
Medicines ( eg. ( Prozac )
Pollution of drinking water
Fluoridated salt ( range from 90mg/kg to 350mg/kg )

DIETARY FLUORIDE SUPPLEMENTATION SCHEDULE

Age
<0.3 ppm F
>0.6 ppm F
Birth-6 months
0
0
6 mo-3 years
0.25 mg
0
3-6 years
0.50 mg
0
6 y up to at least 16 years
1.00 mg
0

0.3-0.6 ppm F
0
0
0.25 mg
0.50 mg

Pharmacology of Fluoride ( Recognition and Management of Fluoride Toxicity

Toxipedia, John Doull 2009 )
Absorption :
Fluoride ions convert to HF ( hydrofluoric acid ) at pH 1.0-2.0 in the gut and rapidly
absorbed.
Excretion :
Approximately 50% of ingested fluoride is excreted in the urine, a small amount is excreted
in the feces, saliva and sweat.

Mode of action ( bone ) :

Fluoride exchanges with the hydroxyl groups of existing hydroxyapatite crystal in bone to
form FA ( fluorapatite ), which is less soluble in acid.

Factors that may affect absorption :

1. Hardness of water ( mg/l of calcium or calcium carbonate ) effect very small
2. Trace metals to fluoride concentration of 1ppm ( Aluminium, iron, copper, lead ) low
pH, fluoride complexes with Aluminium; no effect on solubility of iron, copper and
lead.

Calculation of fluoride toxicity in dental / supplement products ( Estimated

probably toxicity : 5mgF/kg )
Fluoride
Source

Concentrati
on

Amount
Usually Used

Amount
Containing A
Probably
Toxic Dose for
a 10 kg
toddler

Amount
Containing A
Probably
Toxic Dose
for a 20 kg
toddler

Fluoride

0.25 mg F

1 tab/day

200

400

Supplement

s
Fluoride

0.5 mg F

1 tab a day

100

200

1.0 mg F

1 tab a day

50

100

Fluoridated

NaF 0.22%

50cc (1/5 of

100 cc

1L

Toothpaste

( 990 PPM )

tube)

Fluoridated

MFP 0.76%

same

same

same

Toothpaste

( 1000 PPM )

Fluoridated

SnF2 0.4%

same

same

same

Toothpaste

( 2430 PPM )

Overfeed of

e.g. 0.1 mg

1 L/day

500ml

1L

Fluoridated

fluoride/ml

Water

(100 ppm)

Fluoridated

NaF 0.05%

Mouthful/day

One cup (218

435 ml

Mouthrinse

( 230 PPM =

Supplement
s
Fluoride
Supplement
s

ml)

0.23 F/ml )
Fluoridated

NaF 0.2%

Mouthrinse

( 900 PPM =

Mouthful/week

Approx. one

112 ml

capful (56ml)

0.9F/ml )
Professional

2.2% NaF

5 ml every 6

Fluoride Gel

gel

months

5 ml

10 ml

4 ml

8 ml

( 226000
PPM =
226F/ml )
Professional

APF 1.23% F

5 ml every 6

Fluoride Gel

( 12300PPM

months

= 12.3F/ml )

Eg. :
Estimated probably toxicity for children is 5mg/kg, for a 10kg child , application of 2.26%
NAF
2.26% NaF contains 226000 PPM = 226F/ml, an amount of (226/50) 4.5ml of 2.2%NaF
swallowed will consider toxic to a 10kg child.

Acute toxicity symptoms :

Excess salivation, tremors, weakness, convulsion, shallow breathing, nausea, vomiting,

abdominal pain, diarrhea and eventually shock.
In human, death from an oral dose usually occurs within 4 hours. (Effect of fluoride on soft
tissues in vertebrates a review by PA Monsour, BJ Kruger, International Society for fluoride
research Vol18 no 1, January 1985 )

Chronic toxicity symptoms :

Severe joint pain, radiographic show osteosclerosis and increased bone density

Systemic effects :
National Research Council National Academy of Science Committee on Toxicology 1993 :
Health effects of ingested fluoride. Washington DC : National Academy Press; World Health
Organisation Expert Committee on oral health status and fluoride use 1994 : Fluorides and
Oral Health. WHO Technical Report Series No.846. Geneva : WHO )
(

Bone :
There is no evidence of harm to human health from water-borne fluoride even in
populations where the level of fluoride in drinking water is in excess of that known to be
optimal for dental health (1ppm).
Severe forms of fluorosis, common in India and China, where the fluoride levels in the
underground water supplies can vary from 10-20ppm.
Bone fluorosis may cause Bone fracture (Alarcon-Herrera et al 2001), and high daily doses
of fluoride usually fail to successfully treat osteoporosis (Riggs et al 1987)
Classification of Skeletal fluorosis Preclinical phase (3,500-5,500mg F/kg), Clinical phase I
(6,000-7,000mg F/kg), Clinical phase II (7,500-9,000mg F/kg), Clinical phase III Crippling
Fluorosis ( >8,400mg F/kg)
Endocrine system :
1. Adrenal epinephrine increase and hyperglycemia
2. Parathyroid hormone increase
Urinary system large dose of fluoride will cause necrosis of convoluted tubules and
inflammation of glomeruli.
Digestive system fluoride interferes with the normal functioning of the liver and causes
disruption of hepatocytes.
Cardiovascular system calcification of arteries is an integral feature of skeletal fluorosis.
Central Nervous system no conclusion
There is no credible evidence that water fluoridation is associated with any health effects.
( The effective use of fluoride in public health by Sheila Jones et al, Buletin of the World
Health Organization September 2005, 83(9)).

Treatment of acute fluoride toxicity ( Topical fluoride therapy: discussion of some aspects of
toxicology, safety and efficacy by E. Newbrun, 63 rd General Session of the International
Association of Dental Research, March 1985 ).
1. <5.0mg/kg oral administration of calcium in the form of milk or lime water,
observation for 4 hours
2. 5mg/kg-15mg/kg hospitalization for gastric lavage,vital signs, oral calcium
gluconate
3. >15mg/kg hospitalization for gastric lavage and further management

Prepared by
P66136
13 May 2013