Perioral dermatitis from high fluoride dentifrice: a casereport and review of literature

P Peters,*† C Drummond*

*Dermatology Department, The Canberra Hospital, ACT Health.†School of Medicine, The University of Queensland.

ABSTRACT

Perioral dermatitis is a papulopustular eruption, commonly related to the inappropriate application of topical corticoster-oids with occasional reports of inhaled corticosteroids and decreased personal hygiene. We present a case of a 45-year-old female with a one-year history of perioral dermatitis related to the use of highly fluoridated toothpaste commencedto control dental caries.

Keywords: Dermatology, adverse reaction, fluoride.

(Accepted for publication 28 October 2012.)

CASE DESCRIPTION

Our patient, a 45-year-old female, had been com-menced on a high concentration sodium fluoride tooth-paste, NeutraFluor 5000 Plus (Colgate) for the controlof dental caries. Following five years of use, she beganto note the presence of a papulopustular eruption inthe perioral region. She was not on any other medica-tions and did not regularly use makeup on her face,although she did use daily lipstick. Her face washinghabits were unremarkable. Following consultationswith her dentist and general practitioner, and basedupon suspicions that the high fluoride toothpaste couldbe a contributing factor (she was not taking other pre-scription or over-the-counter medication), she ceasedthe high fluoride toothpaste and was commenced on aregularly fluoridated toothpaste (Macleans� Protect(GSK)) with improvement but not resolution of hersymptoms (Fig. 1). Retrial of her high fluoride tooth-paste saw a subsequent flare up of her perioral dermati-tis, leading to cessation of the use of the high fluoridetoothpaste and referral to a dermatologist. Upon pre-sentation, the perioral dermatitis had continued toimprove, however there remained several small, persis-tent regions on her right cheek. At no time were the lipsor the oral cavity affected and the patient denied theuse of any potent topical or inhaled corticosteroids.The patient was commenced on eryacne (topical

2% erythromycin) and topical azeliac acid to controlsymptoms associated with her dentist’s choice oftoothpaste which resulted in an improved outcome.

Investigations into the source of the perioral derma-titis indicated the role of the toothpaste that wasbeing used at the time, as the patient was not on anyother systemic or topical medications. Colgate� Neu-trofluor� 5000 Plus is a high fluoride toothpaste,available in Australia as a pharmacy only product.The active ingredient in this toothpaste is 1.1%sodium fluoride, whereas the sodium fluoride con-tained within Macleans� Protect is 1024 PPM(Table 1).Perioral dermatitis has also been reported from

tartar controlled toothpaste with a case series pre-sented by Beacham et al.1 which concluded that thecircumoral dermatitis noted appeared to be brush

Fig. 1 Persistent pustular lesion continuing after switching from high toregular fluoridated toothpaste. These lesions were widespread when using

the high fluoridated toothpaste.

© 2013 Australian Dental Association 371

Australian Dental Journal 2013; 58: 371–372

doi: 10.1111/adj.12077

Australian Dental JournalThe official journal of the Australian Dental Association

dependent (worse with repeated brushing) and relatedto pyrophosphate compounds. A further report byFerlito2 did not nominate a presumed causative agent.Mellette et al.3 reported two cases of perioral derma-titis with a cause and effect noted where upon discon-tinuation of the fluoridated toothpaste, nil furtherepisodes of perioral dermatitis were noted, indicatinga potential causative role of fluoride. However, thecase we are presenting is one in which the concentra-tion of fluoride reflects the nature and presentation ofthe perioral dermatitis which would give stronger cre-dence to the role of fluoride in the perioral dermatitis.Blasik4 reported a case of fluoroderma in which twofemale patients applying a fluoride gel 4–5 times in aspecially moulded tray daily whilst undergoing radio-therapy developed pustular lesions over the head andneck region. Plasma levels of fluoride were mildlyincreased in these patients, indicating systemic absorp-tion and leading to a halogenoderma-like reaction.Andermann5 reported a case of ‘fluorakne’ in apatient working with hydrogen fluoride in a stainedglass factory. The patient’s acneiform eruption clearedafter a change of employment and recurred on resum-ing her previous job.Urticarial reactions have been reported, with several

reported cases of a contact dermatitis occurring asa result of ingredients contained within toothpaste.6

A 1995 Finnish study7 of domestic toothpastes found50% of the products available on the marketcontained 30 compounds widely recognized as contactallergens, mostly included as flavours (aldehyde,cinnamon oil and peppermint). Reactions from theuse of these toothpastes were not just limited to

perioral dermatitis but included stomatitis, cheilitis,glossitis, gingivitis and immediate hypersensitivity.

CONCLUSIONS

Due to the well documented benefits to public healthfrom the use of fluoride in toothpastes and its addi-tion to the water supply, an adverse reaction such asour presented case should not lead to a cessation offluoride containing dentifrices but should encouragedental and medical practitioners to explore how fluo-ride can best be delivered to enable continued goodoral health whilst minimizing potential adverse reac-tions. If such high fluoride dentifrices are required,the benefits need to outweigh the side effects, or atleast the side effects to be manageable.

REFERENCES

1. Beacham BE, Kurgansky D, Gould WM. Circumoral dermatitisand cheilitis caused by tartar control dentifrices. J Am AcadDermatol 1990;22:1029–1032.

2. Ferlito TA. Tartar-control toothpaste and perioral dermatitis.J Clin Orthod 1992;26:43–44.

3. Mellette JR, Aeling JL, Nuss DD. Letter. Fluoride tooth paste: acause of perioral dermatitis. Arch Dermatol 1976;112:730–731.

4. Blasik LG, Spencer SK. Fluoroderma. Arch Dermatol 1979;115:1334–1335.

5. Andermann I. Acne caused by fluorine. Dermatol Wochenschr1956;10:245–247.

6. Camarasa JG, Serra-Baldrich E, Lluch M, Malet A. Contact urti-caria from sodium fluoride. Contact Dermatitis 1993;28:294.

7. Sainio EL, Kanerva L. Contact allergens in toothpastes and areview of their hypersensitivity. Contact Dermatitis 1995;33:100–105.

Address for correspondence:Dr Peter Peters

Dermatology DepartmentThe Canberra Hospital

Garran ACT 2904Email: petersderm@email.com

Table 1. Dentifrices used and active ingredientscontained

Toothpaste PPM Active ingredient

Colgate Neutrofluor 5000Plus

5000 ppm 1.1% neutral sodiumfluoride

Macleans Protect 1024 ppm 0.22% sodium fluoride

372 © 2013 Australian Dental Association

P Peters and C Drummond