Last month, as 8-year-old Molly Statt stood in the bathroom brushing her teeth, something on the back of the tube of Crest caught her attention. She stopped brushing. Looking up at her father standing beside her, she asked, “Is this poison?”
“Of course not,” Paul Statt reassured his daughter. “Then why does it say ‘poison’ on it?” she asked.
Statt looked more closely at the label. 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.”
Like most people, the Petersborough, N.H., resident assumed that an over-the-counter health-care product like toothpaste 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.
“When I receive the fluoride here, it has a skull-and-bones on it,” Regina Miskewitz says of the containers of the chemical at the Princeton, N.J., laboratories of Church & Dwight Co. Inc., maker of Arm & 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 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 diarrhetic. But the fluoride poses the most danger if too much toothpaste is swallowed – particularly by younger children.
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 – ADA’s general warnings along with the new FDA-required statement that starts with:”Keep out of 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 – 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 Georgia School of Dentistry found that about half of 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 use 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, which 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.
“It is always kind of a trade-off,” 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. The company recently began marketing a new line of natural toothpastes for children which eliminates synthetic sweetners but contains fluoride.
“We made a decision to have only fluoride toothpaste for children because that has been proven to be the overall benefit of toothpaste for children,” Rosenzweig says. “We feel the benefit outweighs the negative.”
In fact, many in the toothpaste industry feel the new FDA warnings may be overstating the risks.
“Our position was that they went a little too far” says Clifford Whall, director of product evaluations on the ADA’s Council on Scientific affairs. “There wasn’t really a need for the cautionary statement about the danger of poisoning if you’ve ingested too much.”.
While Whall concedes that poison control centers do receive reports of fluoride “poisonings” every year, he says the ADA isn’t aware of any of those cases resulting in adverse affects. “It just hasn’t proven to be that kind of problem….we didn’t think you needed a label like that because it could unnecessarily scare consumers into not using toothpaste.”