UC Irvine Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health
Title I Can't Believe It's Not Toothpaste! Poison Control Center Calls Regarding Dental and Oral- Care Products
Permalink https://escholarship.org/uc/item/4hk3w2gx
Journal Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 4(1)
ISSN 1936-900X
Author Suchard, Jeffrey R
Publication Date 2003
Peer reviewed
eScholarship.org Powered by the California Digital Library University of California Page 10 The California Journal of Emergency Medicine IV: 1.Jan-Mar 2003
ORIGINAL RESEARCH INTRODUCTION Poison Control Centers receive many calls regarding I Can't Believe It's Not Toothpaste! personal care products. In 2001, the American As- Poison Control Center Calls sociation of Poison Control Centers noted 288,17 1 Regarding Dental and Oral-Care exposures to personal care and cosmetic products, Products including 27,559 exposures to dental care products (denture cleaners, toothpastes, and "other") and Jeffrey R. Suchard, MD 17,965 exposures to mouthwashes.' More than 99% Department of Emergency Medicine of these exposures resulted in minor or no reported University of California Twine Medical adverse effects, because many of the exposures in- Center volved hivial amounts of product or because the prod- ucts were esseiltially noii-toxic as commonly encoun- 101 The City Drive, Route 128 tered. Orange, CA 92868 E-mail: jsuchard@ uci.edu During a routine quality assurance review of calls to the Sainaritan Regional Poison Center (Phoenix, AZ) ABSTRACT in December 1997, an unusual cluster of incidents was Background; A cluster of incidents in which non-tootli- noted: three callers in one day reported brushing their paste products were used to brush teeth prompted a review teeth with a product that was not toothpaste. This of all calls to one Poison Control Center (PCC) regarding event raised two questions of which products are eas- exposures to dental and oral-care products to determine if any resulted in significant toxicity. ily mistaken for toothpaste, and could such exposures Methods; Retrospective review of 65.849 calls to one BCC result in any significant toxicity. during one calendar year. All inquiries about exposures to substances used as dental or oral-care products were ana- lyzed by a single reviewer for reported adverse effects; in- Early in the course of this review, it became evident cluding hospital admission or PCC referral for emergent that the PCC received a large number of calls about medical evaluation. various dental and oral-care products, reprerenting Results; 798 calls involved exposure to dental or oral-care products, comprising 1.21 % of all calls received. many potential toxicities. The review was then ex- 7rootlibrushing incidents with non-toothpaste products (122 panded to: I) characterize the volume and nature of all cases) did not result in any significant recognized toxicity. dental and oral-care product calls, 2) determine how Twenty-four patients were either referred for emergent medi- cal evaluation (14) or were admitted to the hospital (10). In many of these cases resulted in significant toxicity, and 23 of these patients (96%), the toxic agent was either an 3) discover which non-toothpaste products people in- over-the-counter analgesic or a local anesthetic used to advertently use to brush their teeth. treat dental pain. Gonc8usions: Among PCC calls received regarding dental and oral-care products, over-the-counter analgesics and METHODS local anesthetics used for dental pain resulted in the most Calls received by the Samaritan Regional Poison frequent need for emergent medical evaluation or for hospi- tal admission. Center are concurrently logged into a computel-szed database; DOTLAB - PCC Patient Management & Data Collection, Version 4. l a was used at the time of this study. The author retrospectively reviewed all calls received during the calendar year 1997. hcluded cases were those in which the caller reposted an ex post~eto, or 'aaad a question regapding the use or mis- rrable I. Non-Toothpaste Products Used to Brash Teeth use of any dental or oral-care product. Cases in- volving the use ofanalge\ics or local anesthetics spe- Substance Number of Cases cifically for dental pain were also included, as were Analgesics nnedications prescrikd or recornmended by a den- capsaicin local anesthetics 1 antipruritics tist or oral wrgeon. Exposure to hydrogen peroxide, benzocaine if used as a gargle or mouth rinse, and inadvertent or tripelennarnine rnenthol intentional misuse of other substances as dental or menthol + capsaicin oral-care products (e.g. brushing teeth with a non- menthol + other essential oils methyl salicylate (MeSAL) toothpaste prodract) vv'ere also included. MeSAL + menthol MeSAL + menthol + ca~nphor MeSAL + menthol + other essential oil Standard PCC practice is to perform telephone fol- MeSAL alonc low-up in cases when potentially conceri~ingsymp- rriethanolamine salicylate toms are reported or when delayed toxic effect\ may Antibiotics occur. The Certified Specialists in Poi5ol-r Infomn~a- antibacterial bacitracin 2 tion (CSPls) taking calls in the PC@typicdiy foilow- gentamicin I UP every few hours, depending or1 the sex erity of neornycin / polymyxin 1 bacitracin 1 symptoms and estirraated risk for morhd~~/~nortali~. antif~iingai c!o:rimazole 2 Among paticats admitted to Il-ie hospital m ho have miconarole been stabilized, follow-up may occur less frequzmtly, Ho~~seholdChemicals often once per d'ly. Because the ?real majority of anionic / nonionic detergents 4 (2") hycirogen peroxide (538) 3 call reported to PCG3 result li: vei-2 miid or a~otoxic isopropanol 1 effects, the need for Lelephone i'ktllov#-~npis deter~~ed sodiiirn hypochlorite (bleach) 5 (4 :': ) bj the CSPZ on a cahe-by-case basis. soidering flux 1 ': water (caller believed was contaminated) 1
mSULTS Personal Care Products dental or oral-care products !other than toothpaste) Of 65,849 calls logged into the PCC computer data- rnouthv~ash base, 798 ( 1.2 1 %) met inclusion criteria for further sorbitoilpropylene glycol (infant tooth & gum cleaner) analysis. A total of 1 42 cares involved bnx~shingteeth hair relaxer with a non-toothpaste product (See Table 1). In 1 15 hemorrhoidal cream skin care products of these cases the non-toothpaste product was used benzoyl peroxide cream unintentionally. Generally, the prod~~ctused in these coal tar extract 1 ailantoin cream diphenhydramine ointment (2%) cases resembled toothpaste, ahad the blusher assumed hand lotion it was toothpaste until the ~stc&enidentity was dis- hydrocortisone cream salicylic acicl covered. If the caller reported using a toothbrush tretinoin (0.25-0.596) that had been contamiraated with or previously used witch hazel zinc oxide with a non-toothpaste prod~~ct(eight cases), this was diaper rash ointment (40%) also considered unintentional use of a non-toothpaste skin rash ointrnent 113 product. the rernainillg seven cases, a prodtact was * = Number of Cases where toothbrush contaminated with or used intentionally (is. the brusher Lmew it wasn't tooth- previously paste before they started) beat the PC63 was called used with listed substance regarding actual or potential side effects. The substances most co only nlistden for tooth- in one patient who repeatedly used 3% hydrogen paste were methyl salicylaie-conpaining muscle rdbs peroxide to brush their teeth. Effects assessed as (38 casec), corticosteroid creams (1 8), zinc oxide unlikely to be related to the exposure included d~au- diaper-rash oint~nenlts(1 6)- and capsc2icin-contain@ rhea, headache, peripheral n~mbnessand tingling, md arthritis creams (8). Among 1 16 cases where the decreased appetite. time of a single, acute exposure was reported, distri- bution was generally bimodal with respect to the time Only one recommendation for emergent medical of day: the larger peak occurred between 6-8 a.m. e~~al~rationwas made by the PCC after toothbrushing and the second peak bctvk~een8- B 0 y .m. There was with a non-tooll-mpasteproduct. In this case, a three- no evident clustering by time of yex9with a rmge of year-old cMd smeared her skin with, bmskd her teeth 4- 44 cases per month. Out of 1 1 8 cases where the with. and possiuly ingested the contents of two tubes age of the toothbn~sherwas reported, 65 (52%) oc- of methyl salicylate (MeSAk) cream, one tube con- curred in children aged six years or less. taining 30% MeSAL and the other 10% MeSAE. The maximum potelatial ingestion of salicylate was A minoriq sf cdiilers repotted a&erse effects tkdt were 65115 rng (436 mglkg), which could be expected to recorded in the database. Adverse effects assessed cause serious toxicity. Despite the PCC's recom- as likely to be related to the exposure included tran- mendation for acute evaluation in an Emergency De- sient mucous menabrane irritation, bad taste, nausea, partment, the parent declined to transport the child, citing both a lack of insurance and lack of syrnptolns
Class of Substances Number of Calls
Local anesthetics Home dental rinses with fliloride Analgesics for oclontalgia Fluoride supplelnents Dentures and denture-related products
Teething medications Hydrogen peroxide Medications prescribed or used by dentist (already included above: 7 analgesics; 3 local anesthetics) Breath fresheners Oral thrush medications Car;bamide peroxide Mistaken product ideiitity (excluding products mistaken for tootl~paste) Swallowed tooth, filling, or dental prosthesis Question regarding health risks of mercury amalgam Question regarding bleach rinse by dentist Other questions / exposures In the child. A follow-up call 2 hours later found that DISCUSSION the child remained asy mptomadc, arid it tvas felt that NIost pn-eviozas studies regarding dental and oral-care this child had absorbed considerably less salicylate product poisoning have focused on one specific toxic than calcrxlated in the ""worst case scenario". effect from a narrow range of products, such as Ruo- ride toxicity from toothpaste, ',' dietary supplements, The re~azaining676 calls regarding other dental and OF home denial ~inses," or zthanol poisoning from oral-care prod~hctsrepresented 1 .02L?cof all calls re- mo~rthwashingestions.Vase reports of other ceived (See Table 2), The most common products dental]y-related poisoa~ingsinclude an m8-icholinergic involved were toothpaste (166 ca18s), anonthwash toidrome horn Datum-coneailking honmade tooth- (I1 I). locd mesthetics (XI),hoaiseholcl fluoride rinses paste5 and methemoglobinemia from local anesthet- (49, analgesics for odonbdlgia (4M),and oral fluoride ic~.~ supplements (36). The vast majority of these calls Our revie% of exposures to dental and oral-care prod- resulted in no reported adverse effects. ucts confvms the expectation that 2t1e mzio~+tyof cases will not result in any significant "rsxi~lty.~Although Ten patients, howevel; were admitied to the horpital: tootl~pasteand nlaouthwash were the subjects of most four for
CONSLUSIONS Toothbrushing with non-toothpaste products did not result in significant recognized toxicity. However, the