53

Australian Dental Journal, February, 1979

FEBRUARY. 1979 ROBERTHARRIS,M.B.E., M.D.s.,

D.D.SC.,

Editor

Volume 24 : : N o . 1

TRALIAN

DENTAL JOlJRNAL

Published by the Australian Dental Association Incorporated 116 Pacific Highway, North Sydney, N.S.W. 2060

THREE STEPS TO TRAGEDY

The fact that fluoridation of community water supplies is effective as a public health measure for the maximum reduction of dental caries and does not require co-operation by the individual recipient of the benefit has been widely demonstrated. Furthermore, the demonstration has continued for many years without any proven deleterious effects. It is ironic that opposition, often vehement opposition, continues by supposedly knowledgeable people. Such a situation is by no means unique for it was the fate which befell and prolonged the ultimate acceptance of pasteurization of milk, vaccination against small-pox, and of the Salk vaccine against poliomyelitis. Opponents attack fluoridation on the basis of its safety, economy, and infringement of personal liberty in the choice of a health measure. The question of safety is of paramount importance. A large number of reports of investigations in various countries are overwhelming in their endorsement of the safety of fluoridation of water supplies to a concentration of 1 ppm. In 1974, Ericsson' summarized a great deal of extensive material on the subject and concluded that the safety of fluoridation at the level of 1 ppm has the support of a large volume of scientific and clinical data such that any health hazard associated with the practice is extremely improbable. The emphasis here is that fluoride concentration in the range of about 1 ppm in the drinking water is perfectly safe. Alternative methods of bringing fluoride to tooth enamel have been demonstrated to have a clinically significant effect in reducing dental caries. Some of these methods have been used in rural areas without access to community water supplies. They are of two basic types : the application of fluoride-containing substances directly to the tooth or the ingestion of fluoride. All suffer from the same disadvantages. Their use requires the conscious effort of the patient or parent to purchase a product or seek a service. Fluoridated drinking water provides both methods of protection in a widespread passive manner; and, by reducing caries, is an economic saving to the community. 1

Caries Research Suppl., 8 : 16, 1974.

Australian Dental Journal, February, 1979

54

Although small amounts of ingested fluoride are safe and essential in promoting good dental health, extreme amounts are poisonous. Martindale notes* that for adults oral doses in excess of 250 mg cause great distress and larger doses can be rapidly fatal. It is important, therefore, when using or prescribing fluorides that every care is taken to ensure that only recommended amounts and recommended concentrations of the chosen agent are used and that the method is suitable to the age of the patient. A fatality followed the use of stannous fluoride in a preventive procedure for a three year-old boy. Horowitz3 discussed this in a commentary, Abusive Use of Fluoride. The child was healthy and a dental examination showed that he was caries free. He was referred for fluoride prophylaxis. A dental ancillary prepared a four per cent solution of stannous fluoride and with it prepared a slurry with a pumice mixture. The slurry was applied to the child’s teeth and then, after a cleaning procedure, it was removed by means of cotton swabs saturated with the stannous fluoride solution. He was then shown how to rinse his mouth and given a half-cupful (Lily) of the stannous fluoride solution. Five minutes later he vomited and had a convulsive seizure. A physical examination showed that he was in a state of shock. Emergency treatment was applied and he was taken to hospital and promptly admitted to the Intensive Care Unit of the paediatric ward. He suffered respiratory and cardiac failure and died three hours after the ingestion of the stannous fluoride. It was estimated that the solution in the cup contained about 435 mg of fluoride. The tragedy is that a healthy, caries-free child was referred for additional preventive treatment and died because of it. Three things were unacceptable in this situation : the use of concentrated slurry of stannous fluoride and pumice, the removal of the slurry with concentrated stannous fluoride solution, and the use of a concentrated stannous fluoride solution for a mouth rinse. None of these procedures can be recommended for a three-year-old child. At such an age he cannot master mouth-rinsing or control the swallow reflex and hence there is a grave risk that a dangerous amount of fluoride will be absorbed. Myers4 has devoted a major portion of his assessment of fluorides to the aspect of fluoride intake and Forsman has reported5 that the caries rate was similar for a 0.025 and a 0.2 per cent rinse with 7 ml of the solution used for one half minute. Six points should be remembered when fluoride is used. They are:1. Fluoride in recommended amounts in various vehicles is effective. In excess it is a poison. 2. Because some quantity of a preventive agent is good, more is not necessarily better. 3. All who undertake preventive procedures must use accepted and acceptable methods. 4. Only recommended concentrations, amounts, and methods of delivery should be used. The same result could have occurred if other fluorides had been used in the same fashion. 5. All agents must be used with care and reference to appropriate authority must always be made if any change in procedures is contemplated. 6. Personnel who have a limited knowledge of pharmacology and toxicology and dispense or use fluoride solutions must at all times be carefully supervised. Parents who participate in such procedures must be carefully selected and fully Martindale, The Extra Pharmacopocia, 27th Edition, 1977

’ Journal Public Health Dentistry, Spring, 1977.

Fluorides and dental fluorosis, 1978. Community Dent. Oral Epidemiol., 2. 58, 1974.

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Australian Dental Journal, February, 1979

informed on the need to follow instructions meticulously and to supervise the mouth rinsing practices of their children. This subject has been discussed at some length because of its importance and of the need to exercise constant vigilance, even when dealing with what would seem to be a simple procedure. It is claimed that “this is the first reported case of death from fluoride poisoning from dental treatment”. The tragedy should never have occurred and must never occur again.

THE JOURNAL Delays in the delivery of the Journal have been a matter of considerable concern to the editorial staff and the Journal Committee. Despite every endeavour to overcome the difficulty success has not been consistently achieved. Factors causing delays have been beyond the control of the staff and a change in printers has been made. Readers will note some changes in the style of presentation of the material in this issue of the Journal. Apart from a better quality of paper the end result has been achieved by a change from letterpress to offset printing the standard of which is now acceptable for our requirements. The advertisers, especially those with overseas associations, will find the technical requirements will simplify the transfer of material. With the increase in the number of editorial assistants, the reading and selection of papers has been greatly facilitated, and delays in responding to submissions have been reduced. Wherever possible the number of pages of clinical and technical material will be maintained so that the time between acceptance and publication will be kept to a minimum. The flow of papers is not a constant, regular procession and one of the tasks is, hopefully, to maintain the number and variety of articles in each issue. The co-operation of authors has made possible the success of the Journal and our appreciation is extended to all who have laboured over the years in providing reviews of books, information from State Branches of the Association, and to the international correspondents who have kept us informed on dental matters in the United Kingdom, New Zealand, and the United States. The support of our readers, contributors, and advertisers is greatly appreciated. It is a measure of this appreciation that the Executive Officers have approved the changes so that our service to members and to the profession can be maintained at the highest level.

Three steps to tragedy.

53 Australian Dental Journal, February, 1979 FEBRUARY. 1979 ROBERTHARRIS,M.B.E., M.D.s., D.D.SC., Editor Volume 24 : : N o . 1 TRALIAN DENTAL J...
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