Changes in referral rates for acute toothpaste ingestions reported to the NPIS

Objective: In June 2010, the management advice on TOXBASE^® (the UK poisons database) for toothpaste ingestion changed, from advising medical assessment in patients developing anything other than minor gastrointestinal symptoms to advising observation in patients ingesting over 5 mg/kg fluoride, and further management in those ingesting over 10 mg/kg fluoride. We investigated the amounts ingested, features present, and advice given in cases of acute toothpaste ingestion reported to the UK National Poisons Information Service (NPIS) before and after this change.

Methods: Using data extracted from UKPID, a centralised NPIS telephone enquiry database, we reviewed cases involving toothpaste ingestion from 21/06/2007 to 20/06/2012. Data from the three years prior to TOXBASE^® advice changing, and the following two years were compared.

Results: The NPIS received 355 calls regarding acute toothpaste ingestion over the 5 years: 158 in 2007–2010, and 197 in 2010–2012; an 86.9% increase in annual calls. Over the same period, total calls received by NPIS fell by 8.8%. The number of calls from NHS Direct/NHS24 (public access services) increased from 47 (29.7% of all toothpaste calls) in 2007–2010 to 89 (45.2%) in 2010–2012; a 183% increase in annual calls. 299/355 (84.2%) patients were aged under 4 years. 256/355 patients (72.1%) had remained asymptomatic since ingestion (117/158 [74.1%] in 2007–2010; 139/197 [70.6%] in 2010–2012). 83/355 (23.4%) had minor symptoms, most commonly vomiting (31/83 [37.3%]) and abdominal pain (21/83 [25.3%]). 7/83 patients (8.4%) had persistent vomiting, constituting moderate severity. The mean reported volume of toothpaste ingested was 35.4 mL in 2007–2010, and 38.4 mL in 2010–2012. The mean fluoride dose in asymptomatic and symptomatic patients was 3.89 mg/kg and 4.78 mg/kg respectively. The lowest dose associated with symptoms was 1.6 mg/kg. 38/355 patients (10.7%) were referred for medical assessment; 5/158 (3.2%) in 2007–2010, 33/197 (16.8%) in 2010–2012. The mean reported fluoride dose in referred patients was 6.96 mg/kg in 2007–2010 and 6.95 mg/kg in 2010–2012.

Conclusion: Changes to TOXBASE^® management advice for toothpaste accurately reflected the potential for moderate symptoms to occur following ingestion. Similar amounts of toothpaste/fluoride were ingested before and after June 2010; however more than 5 times as many patients were referred after management advice changed.