> Table of Contents > Teething
Teething
Dana Nguyen, MD, FAAFP
Katrina E. Walters, MD, FAAFP, FM
image BASICS
DESCRIPTION
  • Teething is the eruption of the primary or deciduous teeth, which most children experience without difficulty. It is a natural, gradual, and predictable process, with normal variation among infants (1,2).
  • Primary (deciduous) teeth
    • Primary tooth eruption usually begins at 5 to 7 months of age.
    • The order of primary tooth eruption and average age is the following:
      • Central mandibular incisors (5 to 7 months)
      • Central maxillary incisors (6 to 8 months)
      • Lateral mandibular incisors (7 to 10 months)
      • Lateral maxillary incisors (8 to 11 months)
      • Cuspids (16 to 20 months)
      • 1st molars (10 to 16 months)
      • 2nd molars (20 to 30 months)
    • Delayed eruption may be familial or due to systemic syndromes or nutritional deficiencies. Delayed eruption may also be seen with cleft palate and lower birth weight (3,4,5).
    • Tooth eruption in premature infants occurs according to postconceptual age rather than age since birth (chronologic age) (2).
    • Natal/neonatal teeth
      • Natal teeth (present at birth) occur in 1/2,000 neonates.
      • Neonatal teeth erupt in the 1st month of life.
      • Natal/neonatal teeth are most often prematurely erupted primary (deciduous) teeth but may be supernumerary.
      • 15-20% of cases are familial; also may be secondary to a syndrome or congenital anomalies of the head and neck.
      • Natal/neonatal teeth may be loose, but most are the normal deciduous lower central incisors and can persist.
      • Natal/neonatal teeth may be removed if there is an aspiration risk or if they cause trauma to the infant or to the mother (breastfeeding) (2).
EPIDEMIOLOGY
Incidence
Predominant age: birth to 3 years of age
ETIOLOGY AND PATHOPHYSIOLOGY
Teething symptoms are more common with eruption of the primary incisors (6).
Genetics
Both premature and delayed tooth eruption may be familial. Primary failure of eruption has been linked to mutations of the PTHR1 gene (5).
COMMONLY ASSOCIATED CONDITIONS
Teething may be coincident with other common childhood conditions, causing local or systemic signs and symptoms (e.g., fever, GI disturbance, fussiness, drooling, rash, and sleep disturbance). No pattern of symptoms that distinguishes teething from any other cause. Other possible causes of systemic symptoms should be ruled out prior to attributing them to teething (7).
image DIAGNOSIS
PHYSICAL EXAM
  • Infants may have no signs or symptoms of teething, although symptoms are present in most children.
  • Excessive drooling and chewing on fingers begins at 3 to 4 months of age. This is also the time that normal hand to mouth stimulation increases salivation.
  • Discomfort may be observed more commonly with the eruption of the first tooth, the molars, and/or with the simultaneous eruption of multiple teeth (11)[B].
  • Minor signs and symptoms of biting or chewing, drooling, irritability, facial rash, and low-grade fever (<101.9°F; 38.9°C) have been reported in association with teething, although no evidence identifies specific signs/symptoms caused by teething (9)[B].
  • Serious signs and symptoms (e.g., fever >101.9°F; 38.9°C, dehydration) are not caused by teething and warrant evaluation for organic disease (7)[A].
  • A small red or white spot may appear over the swollen gingivae just prior to tooth eruption.
  • Local inflammation, swelling, or hematoma (bluish swelling) can be found on the involved gingivae overlying the erupting tooth. Gingival irritation was present in 96% of infants in one study (11)[B].
DIFFERENTIAL DIAGNOSIS
Herpetic gingivostomatitis: Infants with fever, irritability, sleeplessness, and difficulty feeding may have underlying infection caused by herpes simplex virus. Some infants with positive culture may not have evidence of inflammation or ulceration expected in gingivostomatitis.
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
Radiographs can distinguish prematurely erupted primary teeth from supernumerary teeth.
image TREATMENT
GENERAL MEASURES
  • Education of parents regarding common symptoms of teething and management options resulted in decreased use of pharmacologic treatment and increased use of other methods such as rubbing the gums (12)[B].
  • Prospective trials show the strongest effectiveness evidence supporting teething rings, followed by cuddle therapy, followed by rubbing the gums to reduce symptoms (13)[B].
  • Provide the infant with a safe, one-piece teething ring, clean cloth, or pacifier for gumming.
  • Apply pressure over involved swollen gingivae with a clean finger or piece of wet gauze.
  • May use cool (but not frozen) fluids, cold teething rings, or cold vegetables such as a peeled cucumber
  • Avoid the use of alcohol (historically rubbed on gingivae for an analgesic effect).
  • Gingival hematomas that erupt appear as blue cysts. Most do not require medical intervention. Be sure there are no other signs of a bleeding disorder.
  • Avoid the following:
    • Dipping a pacifier or teething ring in sugar or honey
    • Giving an infant a bottle in bed
    • Using fluid-filled teething rings (contents may leak)
    • Using frozen foods or teething rings (these could cause thermal damage to the tissues)
    • Tying a teething ring around infant's neck (14)[C]
MEDICATION
First Line
  • Initial treatment with medications is not recommended.
  • For an infant with low-grade fever, irritability, and/or inflamed gingivae (where other comforting measures have not been of help); acetaminophen in proper doses (15 mg/kg/dose q4-6h PRN) can be used.
Second Line
  • These are of questionable benefit because they are washed off quickly by saliva, and the benefit may be due in part to the pressure placed on the gingivae when applied.
    • FDA issued a warning about possible serious harm, to include death (15)[A].
P.1015

ISSUES FOR REFERRAL
  • Parents should establish a dental home for infants by 12 months of age. Dental caries remain the most prevalent infectious disease in children in the United States. Preventative care and anticipatory guidance offered in a dental home help prevent early childhood caries (16)[A].
  • Other medical problems may delay tooth eruption. It is reasonable to refer a child who has not erupted a tooth by 18 months of age to a dentist, if he or she is not seeing one already (5)[C].
ADDITIONAL THERAPIES
Infants who bite or chew while breastfeeding can be trained not to bite by withdrawing the child from the breast for a moment, and then resume. Resist urge to startle the infant.
COMPLEMENTARY & ALTERNATIVE MEDICINE
Homeopathy is used to treat teething. Chamomilla is one reported treatment, but no efficacy or safety studies have been published (17)[C].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Outpatient
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
No restrictions
DIET
Breastfeeding can continue during and after teething. Otherwise, no special diet required.
PATIENT EDUCATION
  • Parents should be cautioned not to misinterpret teething as the cause of any systemic manifestation. The health provider should be consulted for any systemic complaints.
  • American Dental Association, Mouth Healthy Web site: http://www.mouthhealthy.org/en/babies-and-kids/
  • Teething Tots: http://kidshealth.org/parent/pregnancy_newborn/common/teething.html
PROGNOSIS
Normal progression through the teething process without illness
REFERENCES
1. Aktoren O, Tuna EB, Guven Y, et al. A study on neonatal factors and eruption time of primary teeth. Community Dent Health. 2010;27(1): 52-56.
2. Cunha RF, Boer FA, Torriani DD, et al. Natal and neonatal teeth: review of the literature. Pediatr Dent. 2001;23(2):158-162.
3. Kobayashi TY, Gomide MR, Carrara CF. Timing and sequence of primary tooth eruption in children with cleft lip and palate. J Appl Oral Sci. 2010;18(3):220-224.
4. Sajjadian N, Shajari H, Jahadi R, et al. Relationship between birth weight and time of first deciduous tooth eruption in 143 consecutively born infants. Pediatr Neonatol. 2010;51(4):235-237.
5. Stellzig-Eisenhauer A, Decker E, Meyer-Marcotty P, et al. Primary failure of eruption (PFE)—clinical and molecular genetics analysis [in English, German]. J Orofac Orthop. 2010;71(1):6-16.
6. Noor-Mohammed R, Basha S. Teething disturbances: prevalence of objective manifestations in children under age 4 months to 36 months. Med Oral Patol Oral Cir Bucal. 2012;17(3): e491-e494.
7. Tighe M, Roe MF. Does a teething child need serious illness excluding? Arch Dis Child. 2007;92(3):266-268.
8. Feldens CA, Faraco IM, Ottoni AB, et al. Teething symptoms in the first year of life and associated factors: a cohort study. J Clin Pediatr Dent. 2010;34(3):201-206.
9. Macknin ML, Piedmonte M, Jacobs J, et al. Symptoms associated with infant teething: a prospective study. Pediatrics. 2000;105(4, Pt 1):747-752.
10. Wake M, Hesketh K, Lucas J. Teething and tooth eruption in infants: a cohort study. Pediatrics. 2000;106(6):1374-1379.
11. Kiran K, Swati T, Kamala BK, et al. Prevalence of systemic and local disturbances in infants during primary teeth eruption: a clinical study. Eur J Paediatr Dent. 2011;12(4):249-252.
12. Plutzer K, Spencer AJ, Keirse MJ. How first-time mothers perceive and deal with teething symptoms: a randomized controlled trial. Child Care Health Dev. 2012;38(2):292-299.
13. Memarpour M, Soltanimehr E, Eskandarian T. Signs and symptoms associated with primary tooth eruption: a clinical trial of nonpharmacological remedies. BMC Oral Health. 2015;15: 88-95.
14. McIntyre GT, McIntyre GM. Teething troubles? Br Dent J. 2002;192(5):251-255.
15. U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA recommends not using lidocaine to treat teething pain and requires new Boxed Warning. http://www.fda.gov/Drugs/DrugSafety/ucm402240.htm. Published June 26, 2014. Updated October 9, 2014.
16. American Academy of Pediatric Dentistry. Clinical Affairs Committee—Infant Oral Health Subcommittee. Guideline on infant oral health care. Pediatr Dent. 2012;34(5):148-152.
17. Thompson EA, Bishop JL, Northstone K. The use of homeopathic products in childhood: data generated over 8.5 years from the Avon Longitudinal Study of Parents and Children (ALSPAC). J Altern Complement Med. 2010;16(1):69-79.
18. Clark MB, Slayton RL, Segura A, et al. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2014;134(3):626-633.
Additional Reading
&NA;
  • American Academy of Pediatrics. Children's Oral Health Web site: http://www2.aap.org/commpeds/dochs/oralhealth/index.html.
  • American Academy of Pediatrics Oral health initiative. Protecting all children's teeth (PACT): a pediatric oral health training program: http://www2.aap.org/oralhealth/pact/pact-home.cfm.
  • Williams GD, Kirk EP, Wilson CJ, et al. Salicylate intoxication from teething gel in infancy. Med J Aust. 2011;194(3):146-148.
Codes
&NA;
ICD10
K00.7 Teething syndrome
Clinical Pearls
&NA;
  • Parents and caregivers should follow the American Academy of Pediatrics' recommendations for treating teething pain.
    • Use a teething ring chilled in the refrigerator (not frozen).
    • Gently rub or massage the child's gums with your finger to relieve the symptoms.
    • Topical pain relievers and medications that are rubbed on the gums are not necessary or even useful because they wash out of the baby's mouth within minutes, and they can be harmful.
  • Teething may cause discomfort but does not cause significant fevers.
  • Teething babies can still breastfeed. Babies can be taught not to bite, and breastfeeding may continue past 12 months of age without difficulty.