Accidental fluoride toothpaste ingestion
People aren’t meant to swallow toothpaste, but accidental ingestion of small amounts is common. Large or repeated ingestion can cause harm, so it’s important to know safe limits and how to assess risk.
Safe daily fluoride intake
There are no recommended safe levels of fluoride ingestion in the UK. The European Food Safety Authority (EFSA) set safe daily intake limits for fluoride in 2025. These vary by age:
- 1mg per day for infants under 1 year
- 1.6mg per day for toddlers aged 1 to 3 years
- 2mg per day for children aged 4 to 8 years
- 3.3mg per day for children over 8 years, adults and pregnant women
Toothpaste manufacturers recommend a maximum of 0.05mg/kg body weight per day from all sources (not exceeding 1mg per day). The manufacturer’s recommendation differs from EFSA guidelines.
Fluoride toothpaste
Fluoride strength is measured in parts per million (ppm). 1ppm means each 100g of toothpaste contains 0.1mg of fluoride.
Toothpaste manufacturers may use sodium fluoride, sodium monofluorophosphate, stannous fluoride, or a combination of these. There is currently no evidence that any form is more effective than another.
Non-prescription toothpaste
Non-prescription toothpaste products can contain up to 1500ppm (150mg per 100g).
2800ppm POM toothpaste
Prescribe generically as Sodium fluoride toothpaste 0.619% DPF or Sodium fluoride 0.619% dental paste, sugar-free.
Indicated for the prevention and treatment of dental caries in adults and children aged 10 years and older.
Recommended daily dosage is a 1cm ribbon (weighing approximately 1g and containing 2.8mg of fluoride), to be used twice a day, spitting out after use.
Each tube contains 75ml, weighs 100g, and contains 280mg of fluoride ions.
5000ppm POM toothpaste
Prescribe generically as Sodium fluoride toothpaste 1.1% DPF or Sodium fluoride 1.1% dental paste, sugar-free.
Indicated for the prevention of dental caries in adolescents and adults, particularly amongst patients at risk from multiple caries, aged 16 years and over.
Recommended daily dosage is a 2cm ribbon (weighing 0.6-1g and containing 3-5mg of fluoride), to be used three times a day, spitting out after use.
Each tube weighs 51g and contains 225mg of fluoride ions.
Other sources of fluoride
Before prescribing high-strength fluoride toothpaste or assessing accidental ingestion, consider all fluoride sources your patient has access to.
Other sources include drinking water, fluoridated salt, other fluoride-containing medicines, fluoride supplements, and other dental products.
Fluoride in drinking water
The most common source of fluoride is drinking water, where it occurs naturally at low levels in most areas of England.
A small number of areas artificially raise the fluoride level in drinking water to 1mg/L as a public health measure to prevent tooth decay.
However, the overwhelming majority of areas have fluoride levels below 1mg/L, with most being below 0.49mg/L.
The maximum permitted level of fluoride in drinking water is 1.5mg/L.
The Drinking Water Inspectorate website provides typical fluoride levels and locations of fluoridated water in England and Wales.
Fluoride toxicity
Excessive fluoride ingestion from high-strength toothpaste when used as prescribed is very rare in adults.
Acute toxicity of fluoride
Ingestion of more than 5mg/kg of fluoride requires urgent medical assessment.
Fluoride toxicity can range from mild gastrointestinal symptoms to systemic complications of hypocalcaemia and hyperkalaemia. Severe fluoride toxicity is very rare.
People who ingest less than 5mg/kg body weight are unlikely to show symptoms.
Chronic toxicity of fluoride
Repeated high fluoride intake (usually from very fluoridated water or supplement use) may cause fluorosis.
In children, as their teeth are developing, this can cause dental fluorosis, a cosmetic condition characterised by flecking, discolouration, and pitting of tooth enamel.
In both children and adults, severe cases can lead to skeletal fluorosis, which can cause bone fragility, bony outgrowths and calcification of ligaments and tendons. Kidney and thyroid problems may also develop.
Assessing accidental ingestion
To determine if dangerous levels of fluoride have been or could be accidentally ingested, consider:
- the patient’s age and weight
- the strength of the fluoride-containing toothpaste
- the amount of toothpaste involved, be aware that the tubes of different strengths of POM toothpastes produce different ribbon thickness when squeezed
- the patient’s other fluoride sources (such as drinking water)
Example scenarios
The following case studies illustrate situations where fluoride ingestion must be considered.
Accidental toddler exposure
A parent has been accidentally using 5,000ppm fluoride toothpaste to brush their 2-year-old’s teeth. They apply the correct amount of toothpaste (a 0.1g smear) twice daily. The child accidentally ingests about a quarter of each application. There are no other fluoride sources. Consider the following:
- the safe daily limit of fluoride for a 2-year-old is 1.6mg
- each 0.1g smear of 5,000ppm toothpaste contains 0.5mg fluoride
- estimated accidental ingestion per smear is 0.125mg (one quarter)
- total daily exposure from twice daily use of toothpaste is 0.25mg
As ingestion of 0.25mg of fluoride is within the safe daily limits, no action is needed.
Entire tube ingestion
An 8-year-old child (25kg body weight) has eaten an entire tube of 2,800ppm fluoride toothpaste. They report they are now feeling nauseous. Consider the following:
- ingestion of more than 5mg/kg of fluoride requires medical attention
- for a child weighing 25kg, this would be more than 125mg of fluoride
- as each tube of 2800ppm toothpaste weighs 100g and contains 280mg of fluoride, more than twice the child’s safe daily maximum dose
As the child has ingested more than 125mg of fluoride and is symptomatic, they should be taken to hospital for assessment.
Use in a fluoridated area
A 49-year-old patient living in an area with fluoridated drinking water (1 mg/L) is prescribed 5,000ppm fluoride toothpaste. They drink 2 litres of water daily. Consider the following:
- the safe daily limit for a 49-year-old adult is 3.3mg of fluoride per day
- they receive 2mg from their drinking water (1mg from each litre)
- therefore, the remaining safe allowance from other sources is 1.3mg
- each 1g of 5000ppm toothpaste contains 5mg of fluoride; 0.26g will provide 1.3mg
Therefore, if the patient accidentally ingests no more than 0.26g of toothpaste a day, they will not exceed their safe daily intake of fluoride. This equates to approximately 0.5 to 0.8cm of toothpaste.