The Washington Post
Consummate Consumer
Toothpaste: How Safe?
By Don Oldenburg / Washington Post June 16, 1997

Last month, as 8-year-old Molly Statt stood in the bathroom brushing her teeth, something on the back of a large-size tube of Crest caught her attention. She stopped brushing.

Looking up at her father standing beside her, she motioned to the toothpaste and asked, "Is this poison?"

"Of course not," Paul Statt reassured his daughter.

"Then why does it say 'poison' on it?" she asked.

Statt looked closer on the label at the back of the tube. In small print were warnings he hadn't noticed before, including one that read: "If you accidentally swallow more than used for brushing, seek professional help or contact a poison control center immediately."

Caught off guard, he didn't have a good answer for Molly. For a week or so afterward she didn't want to brush with toothpaste. Now she is back to using it, but Statt worries that she's confused about the safety of toothpaste and about the truth of poison labels. "When did they start putting a poison warning on toothpaste tubes?" he asks.

Like most people, the Petersborough, N.H., resident assumed that an over-the-counter health care product like toothpaste, which we are encouraged to put in our mouths "at least twice daily," must certainly be as safe as the water we drink. But it's not. And that's the message of the new warning labels required by the Food and Drug Administration on all fluoride toothpastes and dental care products shipped as of April 7.

None of the caveats that began appearing on toothpaste tubes in 1991 so candidly broached the risks of ingesting too much fluoride. General warnings on toothpaste products that display the American Dental Association seal of approval heretofore cautioned: "Don't swallow -- Use only a pea-sized amount for children under six," and "Children under 6 should be supervised while brushing with any toothpaste to prevent swallowing." The word "poison" wasn't used.

"When I receive the fluoride here, it has a skull and bones on it," Regina Miskewitz says of containers of the chemical at the Princeton, N.J., laboratories of Church and Dwight Co. Inc., maker of Arm and Hammer products where she is director of research and development for oral and personal care.

"If a child was to take a big spoonful of this fluoride, I don't think he could swallow it," she says, "but if he did get it down, it is a poison and the child could die. If a child ingested a whole tube of toothpaste, he should be taken right to the emergency room and he would either get his stomach pumped or get some kind of antidote."

Three ingredients found in most toothpastes pose health risks if too much is ingested, according to Miskewitz. Sorbitol, a liquid that keeps toothpaste from drying out, is a laxative that could cause diarrhea in children. Sodium lauryl sulfate, an ingredient that makes toothpaste foam, can also be a diarrheic. But the fluoride poses the most danger if too much toothpaste is swallowed -- particularly to younger children.

"Small amounts of this material go a long way in causing disruption in their bodies because they are so small," Miskewitz says. "The fluoride in toothpaste is considered a drug. Even though it is an over-the-counter drug, we are altering the body when we brush our teeth with a fluoride toothpaste or gel . . . As normal consumers, you're not aware of these things. But, I'm sure our 800 number is going to get more calls as products with the new warnings show up on store shelves."

This summer, as toothpaste shipments with the new labeling replace older inventories, consumers will see nearly twice the warnings displayed on the back of tubes and cartons -- the ADA's general warnings along with the new FDA-required statement that starts with: "Keep out of the reach of children under 6 years of age."

Research has shown that because they aren't yet in control of their swallowing reflex, children 4 to 6 years old typically swallow toothpaste when brushing. "That's why it's recommended that kids get only a pea-sized amount of toothpaste," says Miskewitz, "because most of that goes down their throats."

A 1995 study at the Medical College of Georgia School of dentistry found that about half the children this age don't spit out or rinse out -- they swallow the toothpaste instead. Making matters worse, they tend to use too much toothpaste on their own - especially when they used flavored children's toothpastes.

While the cavity-preventing effectiveness of fluoride has been demonstrated, too much fluoride not only can be dangerous, it can cause a condition known as fluorosis that discolors or spots developing teeth. Research conducted by the School of Dental Medicine at the University of Connecticut Health Center concluded that brushing with more than a pea-size amount of toothpaste more than once daily contributed to most of the fluorosis cases it observed in young children. In areas where the drinking water contains fluoride, children who swallow even the pea-size amount of toothpaste are getting too much fluoride and are at risk for fluorosis.

"I haven't heard of problems beyond fluorosis, but that's a valid concern. There are some kids getting too much fluoride," says Nancy Rosenzweig, vice president of corporate communication and market development at Tom's of Maine, which in 1975 introduced the first "natural" toothpaste on the market.

"That's why Tom Chappell started making toothpaste. He was in his bathroom reading ingredient labels and saying, 'You know, there's a lot of stuff in here that you really shouldn't be putting in your mouth.'"

Besides its natural toothpastes that contain fluoride, the small Kennebunkport-based company makes a nonfluoride toothpaste in flavors including "cinnamint" and "fennel." When Tom's recently began marketing its new line of natural toothpaste for children, it left out the synthetic sweeteners, the neon colors and the bubble gum flavors. But the tootpastes called Silly Strawberry and Outrageous Orange, contain the same levels of fluoride as competitors' toothpastes . . .

Emphasis provided and retyped for clarity by Clinton Ray Miller, President, National Committee Against Flouridation 704-924-8615.