The ofcial journal of the Australian Dental Association

Australian Dental Journal

Australian Dental Journal 2013; 58: 371372 doi: 10.1111/adj.12077

Perioral dermatitis from high uoride dentifrice: a case report 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 corticosteroids with occasional reports of inhaled corticosteroids and decreased personal hygiene. We present a case of a 45-yearold female with a one-year history of perioral dermatitis related to the use of highly uoridated toothpaste commenced to control dental caries.
Keywords: Dermatology, adverse reaction, uoride. (Accepted for publication 28 October 2012.)

CASE DESCRIPTION Our patient, a 45-year-old female, had been commenced on a high concentration sodium uoride toothpaste, NeutraFluor 5000 Plus (Colgate) for the control of dental caries. Following ve years of use, she began to note the presence of a papulopustular eruption in the perioral region. She was not on any other medications and did not regularly use makeup on her face, although she did use daily lipstick. Her face washing habits were unremarkable. Following consultations with her dentist and general practitioner, and based upon suspicions that the high uoride toothpaste could be a contributing factor (she was not taking other prescription or over-the-counter medication), she ceased the high uoride toothpaste and was commenced on a regularly uoridated toothpaste (Macleans Protect (GSK)) with improvement but not resolution of her symptoms (Fig. 1). Retrial of her high uoride toothpaste saw a subsequent are up of her perioral dermatitis, leading to cessation of the use of the high uoride toothpaste and referral to a dermatologist. Upon presentation, the perioral dermatitis had continued to improve, however there remained several small, persistent regions on her right cheek. At no time were the lips or the oral cavity affected and the patient denied the use of any potent topical or inhaled corticosteroids. The patient was commenced on eryacne (topical 2% erythromycin) and topical azeliac acid to control symptoms associated with her dentists choice of toothpaste which resulted in an improved outcome.
2013 Australian Dental Association

Fig. 1 Persistent pustular lesion continuing after switching from high to regular uoridated toothpaste. These lesions were widespread when using the high uoridated toothpaste.

Investigations into the source of the perioral dermatitis indicated the role of the toothpaste that was being used at the time, as the patient was not on any other systemic or topical medications. Colgate Neutrouor 5000 Plus is a high uoride toothpaste, available in Australia as a pharmacy only product. The active ingredient in this toothpaste is 1.1% sodium uoride, whereas the sodium uoride contained within Macleans Protect is 1024 PPM (Table 1). Perioral dermatitis has also been reported from tartar controlled toothpaste with a case series presented by Beacham et al.1 which concluded that the circumoral dermatitis noted appeared to be brush
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P Peters and C Drummond Table 1. Dentifrices used and active ingredients contained
Toothpaste Colgate Neutrouor 5000 Plus Macleans Protect PPM 5000 ppm 1024 ppm Active ingredient 1.1% neutral sodium uoride 0.22% sodium uoride

perioral dermatitis but included stomatitis, cheilitis, glossitis, gingivitis and immediate hypersensitivity. CONCLUSIONS Due to the well documented benets to public health from the use of uoride in toothpastes and its addition to the water supply, an adverse reaction such as our presented case should not lead to a cessation of uoride containing dentifrices but should encourage dental and medical practitioners to explore how uoride can best be delivered to enable continued good oral health whilst minimizing potential adverse reactions. If such high uoride dentifrices are required, the benets need to outweigh the side effects, or at least the side effects to be manageable. REFERENCES
1. Beacham BE, Kurgansky D, Gould WM. Circumoral dermatitis and cheilitis caused by tartar control dentifrices. J Am Acad Dermatol 1990;22:10291032. 2. Ferlito TA. Tartar-control toothpaste and perioral dermatitis. J Clin Orthod 1992;26:4344. 3. Mellette JR, Aeling JL, Nuss DD. Letter. Fluoride tooth paste: a cause of perioral dermatitis. Arch Dermatol 1976;112:730731. 4. Blasik LG, Spencer SK. Fluoroderma. Arch Dermatol 1979; 115:13341335. 5. Andermann I. Acne caused by uorine. Dermatol Wochenschr 1956;10:245247. 6. Camarasa JG, Serra-Baldrich E, Lluch M, Malet A. Contact urticaria from sodium uoride. Contact Dermatitis 1993;28:294. 7. Sainio EL, Kanerva L. Contact allergens in toothpastes and a review of their hypersensitivity. Contact Dermatitis 1995; 33:100105.

dependent (worse with repeated brushing) and related to pyrophosphate compounds. A further report by Ferlito2 did not nominate a presumed causative agent. Mellette et al.3 reported two cases of perioral dermatitis with a cause and effect noted where upon discontinuation of the uoridated toothpaste, nil further episodes of perioral dermatitis were noted, indicating a potential causative role of uoride. However, the case we are presenting is one in which the concentration of uoride reects the nature and presentation of the perioral dermatitis which would give stronger credence to the role of uoride in the perioral dermatitis. Blasik4 reported a case of uoroderma in which two female patients applying a uoride gel 45 times in a specially moulded tray daily whilst undergoing radiotherapy developed pustular lesions over the head and neck region. Plasma levels of uoride were mildly increased in these patients, indicating systemic absorption and leading to a halogenoderma-like reaction. Andermann5 reported a case of uorakne in a patient working with hydrogen uoride in a stained glass factory. The patients acneiform eruption cleared after a change of employment and recurred on resuming her previous job. Urticarial reactions have been reported, with several reported cases of a contact dermatitis occurring as a result of ingredients contained within toothpaste.6 A 1995 Finnish study7 of domestic toothpastes found 50% of the products available on the market contained 30 compounds widely recognized as contact allergens, mostly included as avours (aldehyde, cinnamon oil and peppermint). Reactions from the use of these toothpastes were not just limited to

Address for correspondence: Dr Peter Peters Dermatology Department The Canberra Hospital Garran ACT 2904 Email: petersderm@email.com

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2013 Australian Dental Association