USGS Workforce Planning Data Analysis
بسم الله الرحمن
الرحيم
صدق الله العلي العظيم
Toxicity of fluoride
Dr. Rihab Abdul Hussein Ali
B.D.S , M.Sc. , PhD.
•
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
to
15
ppm in
ground water
, 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
. 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.
(
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.
Some sources of fluoride poisoning- A guide to probable toxic doses for a small toddler
•
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:
•
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
efficiently
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.
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
.
(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
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:
1- The
duration
of fluoride intake.
2-
Age
of individuals.
3-
Total amount
of fluoride ingested.
4-
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 medications
(also known as
nonprescription
medication) and
prescription
fluoride products poses
hazards
to
consumers. As presently packaged, the
fluoride
content
of 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.
•
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
Emergency Treatment for Fluoride Overdose
Symptoms and treatment of acute fluoride poisoning
Utilize USGS Workforce Data Standards and Resources to access and analyze workforce demographics through the USGS Workforce Demographics Dashboard. Gather insights for strategic planning and decision-making.
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Presentation Transcript
Toxicity of fluoride Dr. Rihab Abdul Hussein Ali B.D.S , M.Sc. , PhD.
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 ground water, 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. 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 g/m3. (1 PPM = 1,000 microgram per meter cubed. Similarly, 1 microgram per meter cubed = 0.001 PPM).
Acute toxicityclinical 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.
Some sources of fluoride poisoning- A guide to probable toxic doses for a small toddler
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: 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 efficiently 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.
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.
(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 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: 1- The duration of fluoride intake. 2- Age of individuals. 3- Total amount of fluoride ingested. 4- 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 medications (also known as nonprescription medication) and prescription fluoride products poses hazards to consumers. As presently packaged, the fluoride content of 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.
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
