Australian Dental Journal

The official journal of the Australian Dental Association

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 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 commenced
to 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 control
of dental caries. Following five years of use, she began
to note the presence of a papulopustular eruption in
the 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 washing
habits were unremarkable. Following consultations
with her dentist and general practitioner, and based
upon suspicions that the high fluoride toothpaste could
be a contributing factor (she was not taking other pre- Fig. 1 Persistent pustular lesion continuing after switching from high to
regular uoridated toothpaste. These lesions were widespread when using
scription or over-the-counter medication), she ceased the high uoridated toothpaste.
the high fluoride toothpaste and was commenced on a
regularly fluoridated toothpaste (Macleans Protect
(GSK)) with improvement but not resolution of her Investigations into the source of the perioral derma-
symptoms (Fig. 1). Retrial of her high fluoride tooth- titis indicated the role of the toothpaste that was
paste saw a subsequent flare up of her perioral dermati- being used at the time, as the patient was not on any
tis, leading to cessation of the use of the high fluoride other systemic or topical medications. Colgate Neu-
toothpaste and referral to a dermatologist. Upon pre- trofluor 5000 Plus is a high fluoride toothpaste,
sentation, the perioral dermatitis had continued to available in Australia as a pharmacy only product.
improve, however there remained several small, persis- The active ingredient in this toothpaste is 1.1%
tent regions on her right cheek. At no time were the lips sodium fluoride, whereas the sodium fluoride con-
or the oral cavity affected and the patient denied the tained within Macleans Protect is 1024 PPM
use of any potent topical or inhaled corticosteroids. (Table 1).
The patient was commenced on eryacne (topical Perioral dermatitis has also been reported from
2% erythromycin) and topical azeliac acid to control tartar controlled toothpaste with a case series pre-
symptoms associated with her dentists choice of sented by Beacham et al.1 which concluded that the
toothpaste which resulted in an improved outcome. circumoral dermatitis noted appeared to be brush
2013 Australian Dental Association 371
P Peters and C Drummond
Table 1. Dentifrices used and active ingredients
contained
Toothpaste PPM Active ingredient
Colgate Neutrofluor 5000 5000 ppm 1.1% neutral sodium
Plus fluoride
Macleans Protect 1024 ppm 0.22% sodium fluoride
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 derma-
titis with a cause and effect noted where upon discon-
tinuation of the fluoridated toothpaste, nil further
episodes of perioral dermatitis were noted, indicating
a potential causative role of fluoride. However, the
case we are presenting is one in which the concentra-
tion of fluoride reflects the nature and presentation of
the 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 two
female patients applying a fluoride gel 45 times in a
specially moulded tray daily whilst undergoing radio-
therapy developed pustular lesions over the head and
neck region. Plasma levels of fluoride were mildly
increased in these patients, indicating systemic absorp-
tion and leading to a halogenoderma-like reaction.
Andermann5 reported a case of fluorakne in a
patient working with hydrogen fluoride in a stained
glass factory. The patients acneiform eruption cleared
after 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 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 flavours (aldehyde,
cinnamon oil and peppermint). Reactions from the
use of these toothpastes were not just limited to
372
perioral dermatitis but included stomatitis, cheilitis,
glossitis, gingivitis and immediate hypersensitivity.
CONCLUSIONS
Due to the well documented benefits to public health
from the use of fluoride in toothpastes and its addi-
tion to the water supply, an adverse reaction such as
our presented case should not lead to a cessation of
fluoride containing dentifrices but should encourage
dental and medical practitioners to explore how fluo-
ride can best be delivered to enable continued good
oral health whilst minimizing potential adverse reac-
tions. If such high fluoride dentifrices are required,
the benefits 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 fluorine. Dermatol Wochenschr
1956;10:245247.
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 a
review of their hypersensitivity. Contact Dermatitis 1995;
33:100105.
Address for correspondence:
Dr Peter Peters
Dermatology Department
The Canberra Hospital
Garran ACT 2904
Email: petersderm@email.com
2013 Australian Dental Association