Abstract/Text
The accuracy of signs and symptoms as predictors of the presence and severity of esophageal injury was evaluated in 378 children admitted to three pediatric hospitals between 1970 and 1980. The signs and symptoms analyzed included nausea, vomiting, dysphagia, refusal to drink, abdominal pain, increased salivation, oropharyngeal burns, and abdominal tenderness. The severity of lesions found at esophagoscopy in 378 children was graded from grade 0, no lesion, to grade 3, perforation. Of the 298 patients demonstrating signs or symptoms, 243 (82%) had a grade 0 or 1 lesion, 55 (18%) had a grade 2 lesion, none had a grade 3 lesion, and five (2%) developed a stricture of the esophagus. Among the 80 patients without signs or symptoms, 70 (88%) had a grade 0 or 1 lesion, ten (12%) had a grade 2 lesion, none had a grade 3 lesion, and one (1%) developed a stricture of the esophagus. When individual signs or symptoms were correlated with the severity of esophageal lesion, vomiting (33%) followed by dysphagia (25%), excessive salivation (24%), and abdominal pain (24%) were most frequently associated with a grade 2 or 3 esophageal lesion. A similar percentage of a grade 0 or 1 (82% v 85%), a grade 2 (18% v 15%), and a grade 3 (0%) esophageal lesion followed the ingestion, respectively, of an alkali (324 patients) or an acid (54 patients). In six patients (2%) stricture occurred only following an alkali ingestion. These data demonstrate that signs and/or symptoms do not adequately predict the presence or severity of an esophageal lesion following the ingestion of a caustic substance.
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The relationship between absence or presence of grossly visible lesions in the cheeks, lips, and oropharynx (C.L.O. burns) and the incidence, site, and degree of visceral burns was evaluated in all children referred to our hospital for a suspected caustic ingestion during a 10-year period. All children underwent eso-gastro-duodenoscopy within 24 hours. Of the 156 children, 96 (61.6%) showed no visible signs of contact with the caustic substance; however, in 36/96 (37.5%), endoscopy revealed burns in one or more visceral sites. Eight of 36 children (22.2%) sustained potentially dangerous lesions (second to third degree). Sixty of 156 children (38.4%) showed visible lesions; in 30/60 (50%), endoscopy revealed other burns in one or more visceral sites. Fourteen of 30 patients (46.6%) sustained potentially dangerous lesions (second to third degree). A total of 50 esophageal burns have been recorded: first degree (E1), 32; second degree (E2), 12; third degree (E3), 6. Two of 12 patients with E2 lesions and 6/6 with E3 lesions developed esophageal stenosis. One patient in this latter group died because of complications related to a tracheostomy. A total of 31 gastric burns have been recorded: G1 (22), G2 (6), G3 (3). One gastric perforation was observed in the G3 group, whereas the remaining two lesions healed with residual asymptomatic scarring. Minimal scarring was observed in two of six patients with G2 burns. A total of eight lesions have been recorded in the larynx [L1 (3), L3 (1)] and in the duodenum [D1 (2), D2 (2)].(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract/Text
PURPOSE: Quickly differentiating patients who need emergency salvage operation for caustic ingestion injury from those who do not remains difficult. We thus conducted a retrospective study to assess whether arterial blood gas (ABG) analysis is helpful for deciding on the best management plan.
METHODS: We divided 129 patients with caustic ingestion injuries into two groups according to treatment. Group 1 consisted of 30 patients who underwent surgery and two who should have. Group 2 consisted of 97 patients treated conservatively. The 30 operated patients in group 1 were further divided into two groups according to whether they survived (group 3) or died (group 4). We analyzed and compared ABG data between groups 1 and 2, and between groups 3 and 4.
RESULTS: In groups 1 and 2, the mean pH was 7.22 +/- 0.12 and 7.38 +/- 0.06, respectively, and the mean base excess (BE) was -12.0 +/- 5.2 and -1.8 +/- 3.7, respectively. Both these values were significantly different between groups 1 and 2 (P < 0.001). In groups 3 and 4, the mean pH was 7.27 +/- 0.09 and 7.11 +/- 0.11, respectively, and the mean BE was -10.3 +/- 4.7 and -16.1 +/- 4.6, respectively. Both these values were significantly different between groups 3 and 4 (P < 0.001 and P < 0.005, respectively). CONCLUSIONS. ABG data can help make the right decision about treatment. An arterial pH lower than 7.22 or a BE lower than -12.0 indicates severe injury, and an emergency salvage operation should be seriously considered.
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We prospectively evaluated the role of fiberoptic esophagogastroduodenoscopy in the management of 81 patients with corrosive ingestion. A total of 381 endoscopic examinations were performed: 88 within 96 hours following corrosive ingestion, 108 between the third and ninth week, and 185 during the period of follow-up after bougie dilation of esophageal strictures. The customary endoscopic classification of burns (grades 0 to 3) was modified by subdividing grade 2 burns into 2a and 2b, and grade 3 burns into 3a and 3b for prognostic and therapeutic implications. There was no significant correlation between oropharyngeal and upper gastrointestinal tract injury. Early major complications and deaths were confined to patients with grade 3 burns. All patients with grade 0, 1, and 2a burns recovered without sequelae. The majority of patients (71.4%) with grade 2b injury and all survivors with grade 3 injury developed esophageal or gastric cicatrization, or both, which needed endoscopic or surgical treatment. There were no complications related to endoscopy. We conclude that early endoscopy is not only a safe, reliable, and accurate diagnostic tool in such patients, but also is of crucial importance in management and prognosis.
Abstract/Text
BACKGROUND: The ingestion of caustic substances induces an extensive spectrum of injuries to the aerodigestive tract which include extensive necrosis and perforation of the esophagus and stomach. The gold standard of safely assessing depth, extent of injury, and appropriate therapeutic regimen is esophagogastroduodenoscopy (EGD). The objective of this study was to report our clinical experience and to evaluate the role of a 6-point EGD classification system of injury in predicting outcomes in adult patients diagnosed with caustic agent ingestion.
METHODS: The study was a retrospective medical chart review from 273 patients admitted to the Chang Gung Memorial Hospital in Tao-Yuan, Taiwan between June 1999 and July 2006 for treatment of caustic ingestion. The patients underwent EGD within 24 hours of admission and mucosal damage was graded using Zagar's modified endoscopic classification scheme. After treatment, patients were followed in the outpatient clinic for a minimum of 6 months.
RESULTS: A total of 273 patients were included for analysis. Grade 3b injury was the most common caustic injury (n = 82, 30.03%), followed by grade 2b injuries (n = 62, 22.71%). Stricture was the most common complication (n = 66, 24.18%), followed by aspiration pneumonia (n = 31, 11.36%), and respiratory failure (n = 21, 7.69%). Compared to grade 3a mucosal injury, grade 3b mucosal injuries were at greater risk of prolonged hospital stay (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.25-4.80), ICU admission (OR: 10.82; 95% CI: 2.05-200.39), and gastrointestinal (OR: 4.15; 95% CI: 1.55-13.29) and systemic complications (OR: 4.07; 95% CI: 1.81-14.07).
CONCLUSION: In patients with caustic ingestion, EGD should be performed within 12 to 24 hours and categorized according to a 6-point scale. Patients with grade 3b burns identified on endoscopy have high rates of morbidity. The 6-point scale is useful for predicting immediate and long-term complications, and guiding appropriate therapy.
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BACKGROUND: It is controversial whether treatment with corticosteroids reduces stricture formation in the esophagus after the ingestion of caustic material.
METHODS: We conducted a prospective study over an 18-year period in which 60 children (median age, 2 years) with esophageal injury from the ingestion of caustic material were assigned randomly to treatment either with or without corticosteroids. The corticosteroids were given initially as prednisolon (2 mg per kilogram of body weight per day intravenously) and then as prednisone orally to complete a three-week course. All patients were evaluated by esophagoscopy within 24 hours of the ingestion. Those with moderate or severe esophageal injury had repeat esophagoscopy and barium swallow at follow-up.
RESULTS: Esophageal strictures developed in 10 of the 31 children treated with corticosteroids and in 11 of the 29 controls (P not significant). Four children in the steroid group and seven in the control group eventually required esophageal replacement (P not significant). All but 1 of the 21 children with strictures had severe circumferential burns on initial esophagoscopy.
CONCLUSIONS: There appears to be no benefit from the use of steroids to treat children who have ingested a caustic substance. The development of esophageal stricture was related only to the severity of the corrosive injury.
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The most serious complication of corrosive damage to the oesophagus besides perforation is stricture formation. The role of corticosteroids in preventing corrosive-induced strictures is controversial. This review evaluates the usefulness of corticosteroid treatment by critically assessing clinical reports published between 1991 and 2004 in the English, German, French and Spanish literature. Inclusion criteria were the presence of second- or third-degree oesophageal injuries documented by endoscopy and management involving either at least an 8-day course of corticosteroids or no steroid therapy. Ten studies with a total of 572 patients fulfilled the inclusion criteria: six studies employed corticosteroids, two studies did not use corticosteroids, and two studies compared the outcome with and without corticosteroid treatment. In those patients with second-degree burns, the incidence of stricture in the corticosteroid-treated patients was 13.8% and in the non-corticosteroid-treated patients was 6.3%. In those patients with third-degree burns, significantly worse results were found in the corticosteroid-treated group (71.0%) than in the non-corticosteroid-treated group (23.1%). As all studies did not separate second- and third-degree burns, re-analysis of the outcome was undertaken. In the 305 patients treated with corticosteroids, 35.1% developed strictures, whereas 33.3% of the 267 non-corticosteroid-treated patients developed strictures. These data suggest that systemic corticosteroids are not beneficial for second- and third-degree corrosive oesophageal burns. Therefore, the use of corticosteroids in the management of corrosive ingestions should be abandoned as they do not prevent the development of strictures and may lead to the development of serious adverse effects.
Abstract/Text
Five hundred and nineteen NaOH ingestion cases were admitted to our department between 1975 and 1994, and examined via esophagoscopy in the first 48 hours. Two hundred and forty-six patients in this series were diagnosed as severe burns endoscopically. This group of 246 patients were evaluated in a retrospective study to determine whether systemic steroid treatment had any place in preventing stricture formation following severe esophageal burns. Seventy-nine patients in this group were divided into three subgroups and they received methyl prednisolone parenterally in three different regimens. The control group consisted of 167 patients admitted between the years 1986 and 1994 who did not receive any form of steroid treatment. There were no statistically significant differences between the healing rates of the subgroups and the control group (p > 0.01). The authors concluded that systemic steroid treatment has no beneficial effect on esophageal wound healing following caustic esophageal burns.
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OBJECTIVES: We sought to present our experience in the management of esophageal burns.
METHODS: From April 1976 through October 2003, 149 patients with corrosive esophageal burns were included in this study. Treatment modalities consisted of modified intraluminal stenting in 28, colon interposition in 71, gastric transposition in 25, repair of cervical stricture with platysma myocutaneous flap in 17, and miscellaneous operations in 12 patients. Eleven of these patients underwent the above procedures twice at our institute. The remaining 7 patients were treated with conservative therapy.
RESULTS: Twenty-three patients recovered from intraluminal stenting, and 5 experienced stricture after stent removal. One of the 5 patients with failed stents responded to bougienage, and the remaining 4 patients required esophageal reconstruction later. Of the 71 colon interpositions, 5 patients died postoperatively, and complications consisted of proximal anastomotic fistula in 17, anastomotic stenosis in 6, and abdominal incision dehiscence in 2 patients. Postoperative complications in the 25 patients with gastric transpositions comprised anastomotic stricture in 2 patients and empyema in 1 patient. There was a cervical leak in 1 of the 17 patients undergoing the repair of cervical esophageal or anastomotic stricture with a platysma myocutaneous flap. One of the patients in the group undergoing 12 miscellaneous procedures died 8 months after surgical intervention. All the survivors currently eat regular diets.
CONCLUSIONS: Intraluminal stenting can prevent the formation of caustic esophageal stricture. The location of the cicatricial esophagus dictates whether to perform concomitant esophagectomy during esophageal reconstruction. Platysma myocutaneous flap repair is an excellent method for the treatment of severe cervical esophageal or anastomotic stricture.
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OBJECTIVE: We sought to present our experience in preventing esophageal stricture formation using modified intraluminal stenting in patients with caustic burns.
METHODS: Between April 1976 and June 2005, 33 of 162 patients with corrosive esophageal burns were included in this study. Endoscopy was performed to define the degree of injury in all the patients but one. Among the 33 patients, 31 underwent modified esophageal intraluminal stenting through laparotomy 2-3 weeks after ingestion of corrosive agent and the remaining 2 patients underwent immediately after experiencing esophageal perforation.
RESULTS: There was no death in this series. A 1-year-old child had aspiratory pneumonia because of poor compliance. The stent was removed without requiring anesthesia after it had been in situ for 4-6 months in the 33 patients. All the patients had a normal intake of food after removal of the stents, and stricture was not found on barium swallow. However, five patients had esophageal stenosis from 2 to 3 months during follow-up. One of them responded to esophageal bougienage, the remaining four patients required esophageal reconstruction and had a normal diet postoperatively. Twenty-four-hour pH monitoring in five patients showed that there was no gastroesophageal reflux.
CONCLUSION: The modified esophageal intraluminal stent is able to prevent the formation of caustic esophageal stricture.
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BACKGROUND: A benign condition is a relative contraindication to the use of self-expanding metallic stents, because these devices usually are not retrievable. The self-expanding plastic stent is removable and induces less tissue hyperplasia. This study prospectively evaluated the use of a self-expanding plastic stent to treat benign esophageal conditions.
METHODS: Over 4 years, 21 patients underwent self-expanding plastic stent placement for various benign esophageal disorders, including refractory peptic (n = 2), caustic (n = 3), post-radiotherapy (n = 3), and anastomotic (n = 4) stenoses; hyperplastic (n = 5) stenosis within a previously implanted metallic stent; and anastomotic leak (n = 4) after esophagectomy. The self-expanding plastic stent was removed from all patients. Patients were followed for at least 8 months after stent removal.
RESULTS: Implantation was successful in all cases. Temporary self-expanding plastic stent placement was curative in 17/21 patients, especially those with caustic and hyperplastic strictures and anastomotic fistula, all of which were treated successfully without re-intervention. Median follow-up was 21 months (range 8-39 months) after stent removal. Moreover, by inducing tissue ischemia, self-expanding plastic stent allowed delayed removal of metallic stents. Only one severe complication (tracheal compression) was encountered, and this resolved after stent removal.
CONCLUSIONS: A range of benign stenosing disorders of the esophagus can be treated safely with a self-expanding plastic stent. Because the long-term results were highly favorable, self-expanding plastic stent placement could be used as the initial treatment for various conditions. Self-expanding plastic stent insertion within an esophageal self-expanding metallic stent allowed removal of the latter, theoretically unretrievable, stent.
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OBJECTIVE: Oesophageal carcinoma is a well-known late complication of caustic ingestion, occurring in up to 7% of cases. We report a large series of patients with oesophageal scar cancer (SC), investigating the association between fibrosis and survival.
METHODS: A total of 25 patients with a history of oesophageal SC (1979-2005) were retrospectively studied. The amount of intra- and peri-tumoral fibrotic tissue was measured with Azan-Mallory staining. A control group of patients with non-SC was used for comparison.
RESULTS: Twenty-five patients (16 males:9 females, median age 59 years), presented with SC. The histotype was squamous cell carcinoma (SCC) in 20 (80%) patients, adenocarcinoma (AC) in three (12%) and verrucous carcinoma in two (8%). Oesophageal resection was performed in 17 of 25 (68%) patients; in eight (32%), only a palliative treatment (endoscopic/surgical) was possible. Mortality and morbidity rates were 4% and 40%, respectively. One-, 3- and 5-year overall actuarial survival rates for SC patients were 72%, 56% and 52%, respectively. The amount of fibrotic tissue around/within the tumour was significantly higher in SC patients (34.5% vs 5.9% non-SC, p=0.01); these patients had also a higher prevalence of tumours limited to the muscular wall (pT1-T2) (76% vs 28% non-SC, p<0.0001) and less lymph node metastases in T1-T2 cases (8% vs 34% non-SC, p=0.07). The 5-year survival was significantly better in SC patients: 71% versus 24% for resected cancers (p<0.0001), and 52% versus 15% for all observed patients (p=0.0001).
CONCLUSIONS: The presence of fibrotic tissue around/within the tumour is associated with a better prognosis in SC. Fibrosis might offer a protection against both local spread and nodal dissemination.
Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
Pietro Betalli, Diego Falchetti, Stefano Giuliani, Alessandro Pane, Luigi Dall'Oglio, Gian Luigi de Angelis, Mariano Caldore, Claudio Romano, Piergiorgio Gamba, Vincenzo Baldo, Caustic Ingestion Italian Study Group
Caustic ingestion in children: is endoscopy always indicated? The results of an Italian multicenter observational study.
Gastrointest Endosc. 2008 Sep;68(3):434-9. doi: 10.1016/j.gie.2008.02.016. Epub 2008 Apr 29.
Abstract/Text
BACKGROUND: The ingestion of caustic substances can represent a serious medical problem in children.
OBJECTIVE: Whether or not an urgent endoscopy should be performed is still a matter of debate, particularly in asymptomatic patients.
DESIGN: We conducted a multicenter observational study to investigate the predictive value of signs and symptoms in detecting severe esophageal lesions.
SETTING AND PATIENTS: The records of 162 children who presented with accidental caustic substance ingestion were analyzed.
INTERVENTIONS: Signs and symptoms were divided into minor (oral and/or oropharyngeal lesions and vomiting) and major (dyspnea, dysphagia, drooling, and hematemesis). An endoscopy was performed in all patients within 12 to 24 hours of the substance being ingested.
MAIN OUTCOME MEASUREMENTS: The types of substance ingested, signs and symptoms, age, sex, and severity of esophageal injury were correlated.
RESULTS: Mild esophageal lesions were identified in 143 of 162 patients (88.3%), and severe (third degree) esophageal lesions in 19 patients (11.7%). The risk of severe esophageal lesions without signs and/or symptoms was very low (odds ratio [OR] 0.13 [95% CI, 0.02-0.62], P = .002). Indeed, the presence of 3 or more symptoms is an important predictor of severe esophageal lesions (OR 11.97 [95% CI, 3.49-42.04], P = .0001). Multivariate analysis showed that the presence of symptoms is the most significant predictor of severe esophageal lesions (OR 2.3 [95% CI, 1.57-3.38], P = .001).
CONCLUSIONS: The results demonstrated that the incidence of patients with third-degree lesions without any early symptoms and/or signs is very low, and an endoscopy could be avoided. The risk of severe damage increases proportionally with the number of signs and symptoms, and an endoscopy is always mandatory in symptomatic patients.
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BACKGROUND AND STUDY AIMS: Despite the increasing use of early esophagogastroduodenoscopy, the prognostic evaluation and triage of patients who have ingested caustic material is challenging. We evaluated the usefulness of selected clinical and endoscopic parameters in predicting the risk of death after ingestion of caustic substances.
PATIENTS AND METHODS: Clinical and endoscopic parameters were obtained from the records of all the patients admitted to our endoscopy unit because of ingestion of caustic material between 1 March 1982 and 30 June 1999. Parameters significantly associated with the risk of death by univariate analysis were entered into a multivariate logistic model. The independent predictors of death by multivariate analysis were used to build a risk score system.
RESULTS: Out of 210 patients, 13 underwent emergency surgery (6.2 %) and 25 died (11.9 %). Multivariate analysis identified the following as independent predictors of death: age (10-year intervals; odds ratio [OR] 2.4; 95 % confidence interval 1.4 - 4.1), ingestion of strong acids (OR 7.9; 1.8 - 35.3), white blood cell count at admission > or = 20 000 units/mm3 (OR 6.0; 1.3-28), deep gastric ulcers (OR 9.7; 1.4 - 66.8), and gastric necrosis (OR 20.9; 4.7 - 91.8). The values of the risk score system devised from the results of the multivariate analysis ranged from 1 to 16. No patient scoring < 10 points died and just one of the patients scoring > 14 points survived.
CONCLUSION: Age, ingestion of a strong acid, leucocytosis, deep gastric ulcers, and gastric necrosis are predictive of death after caustic ingestion. A risk score system including these predictors may be useful in prognostic evaluation.
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Significant local and systemic toxicity may occur from hydrofluoric acid by all routes of exposure. Prompt decontamination by removal from the source and copious irrigation of eyes and skin are essential to reduce morbidity and mortality. Ingestion of small amounts of HF can lead to rapid systemic poisoning and death. Calcium gluconate therapy has become the preferred method of detoxifying the fluoride ion, although its efficacy is based mainly on anecdotal reports and poorly controlled clinical studies. Therefore, more basic research is needed to elucidate the pathophysiology of local toxicity and the best therapeutic modalities to limit injury. All significant exposures should be evaluated by health care personnel familiar with the potential toxicity of this compound.
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Hydrofluoric acid is used for different purposes in industry and in the home as a rust remover. Most exposures are accidental and may result in severe superficial and deep tissue injury as well as systemic toxicity. There is uncertainty regarding the optimal treatment of hydrofluoric acid eye injury. A patient in whom a solution of 49% hydrofluoric acid induced a large corneal erosion is described. Repeated instillation of 1% calcium gluconate eye drops combined with the conventional treatment of acid eye burns resulted in a complete and quick recovery.
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Hydrofluoric acid (HF) produces a unique chemical burn due to tissue penetration by fluoride ion. Fluoride ion interferes with calcium activity in a variety of cell membranes and calcium-dependent processes, resulting in severe pain and deep tissue destruction. The currently accepted methods of treating HF burns include application of topical soaks or ointments with calcium or magnesium salts for minor burns and local injection of calcium gluconate for more severe burns. Digital burns also may require nail removal and direct injection into the nail bed. We present the cases of a series of patients with moderate to severe HF burns involving one or more fingers who were treated with selective intraarterial calcium infusion of dilute (1.66%) calcium salts. All patients had excellent relief of symptoms and marked improvement of the burn lesions following one to three four-hour infusions of calcium chloride or calcium gluconate. One patient required subsequent surgical intervention for grafting of a full-thickness burn, and one patient developed transient spasm at the site of percutaneous arterial line insertion. Intraarterial calcium infusion for the treatment of HF burns of the fingers provides many therapeutic advantages, including elimination of painful calcium injection directly into fingertips, avoidance of debilitating procedures such as fingernail removal, and assurance that all affected cells are receiving adequate amounts of calcium to replenish depleted stores and to complex with remaining free fluoride ion.
Abstract/Text
STUDY OBJECTIVE: To describe regional intravenous infusion of calcium gluconate as a therapy for hydrofluoric acid (HF) burns of the forearm, hand, or digits.
METHODS: This study describes seven patients with HF burns. Calcium gluconate, 10 mL of 10% solution with 30 to 40 mL normal saline solution, was injected intravenously into the affected limb using a Bier block technique. Ischemia was maintained for 20 to 25 minutes. Therapy was considered successful if significant reduction of pain and tenderness was noted after tourniquet release.
RESULTS: Seven patients were treated. HF concentration varied from 5% to 49%. Exposure sites included the forearm (two cases), thenar eminence and digits (two cases), or digits only (three cases). Complete pain resolution occurred on tourniquet release in four patients (two with burns to the forearm, two with burns to digits only). One patient had partial relief (thenar but not digital exposure site), and two had no relief of symptoms. Intraarterial calcium gluconate perfusion was subsequently administered to the three patients with persistent subungual and pulp, or thenar pain. Recovery was complete in all cases. No adverse effects were noted.
CONCLUSION: Regional intravenous infusion of calcium gluconate should be considered a therapeutic option in HF burns of the forearm, hand, or digits when topical therapy fails.
Abstract/Text
BACKGROUND: Some hydrofluoric acid burns appear initially as only a slight wound, but patients may show dramatic changes within several hours. The extent of such burns are directly related to the concentration, amount, and duration of exposure.
CASE REPORT: A 64-year-old man sustained 44% total body surface burns after exposure to 30% hydrofluoric acid. Approximately 5 h after injury, he developed recurrent ventricular tachycardia and ventricular fibrillation which occurred in conjunction with long QT syndrome. In this case, the occurrence of hypocalcemia and especially hypomagnesemia played an important role in the development of long QT syndrome.
Abstract/Text
A patient with hydrofluoric acid burns involving only 8% of his body surface area died from intractable cardiac arrhythmia secondary to the depletion of ionized calcium by fluoride ion. For burns of this type, immediate subcutaneous injection of 10% calcium gluconate into the burn wound is recommended and the dose given should be titrated to the relief of local pain. Immediate debridgement of the burn wound also can decrease the treacherous aspect of the circulating fluoride ion, which binds to calcium to form an insoluble salt, effectively removing the calcium ion from any physiologic interaction.
