Too Much of a Good Thing: A Case of Acute Fluoride Ingestion

A protective effect of fluoride for the prevention of dental caries was observed in communities that consumed naturally fluoridated water compared to non-fluoridated water. Subsequently, fluoride began to be added to the drinking water in various countries as a means of caries prophylaxis. Dentistry began to develop the use of fluoride as an additive to toothpastes and mouth rinses as well as in the form of sodium fluoride powder. Fluoride gels, tablets, and powders can be used safely but can lead to acute ingestions. Here we present the case of a 36-year-old male patient with a history of depression and a previous salicylate overdose who presented to the emergency department (ED) with nausea, vomiting, and diffuse abdominal discomfort. He denied any prescription medications. On specific questioning concerning supplements obtained in a store or by the internet, he stated that he had ingested sodium fluoride powder. The patient said that he had been brushing with the powder for several days for dental pain. He stated that he ingested "a large amount" of the powder approximately eight hours prior to presentation at the ED. The powder had been purchased from the internet. He denied suicidal ideation. He stated that he brushed "a lot" in the eight hours prior to presentation at the ED and used half of the bottle of the powder. According to the patient and his family, the patient had an episode of hematemesis just prior to him presenting at the ED. The patient was found to have hypocalcemia and hypomagnesemia as well as hypotension and tachycardia. Gastroenterology performed an emergency esophagogastroduodenoscopy (EGD), which showed mild esophagitis and gastritis secondary to caustic injury. This case illustrates the importance of taking a complete medical history, including all non-prescription medications and supplements. It also illustrates that fluoride ingestion can present with tachycardia and hypotension as well as an elevated lactate, creating a sepsis-mimic picture. The importance of early repletion of electrolytes and consultation with gastroenterology is also illustrated by this case.