Basics
Description
Teething is the normal developmental process of primary tooth eruption whereby the tooth moves from its position in the alveolar bone through the mucosa into the mouth. Parents/caregivers, physicians, and dentists often associate many localized and systemic symptoms with the teething process, including mouthing/biting, drooling, changes in appetite, and fever.
Diagnosis
Consider the following diagnostic approach when evaluating an infant or toddler who presents with chief complaint of teething:
- Careful history and physical exam
- Evaluation of signs/symptoms inconsistent with teething (fever >102 °F/38.8 °C, irritability, diarrhea) and treatment of possible illness
- If teething is suspected or confirmed and serious illness ruled out, offer education and advice for parents/caregivers around the management of teething symptoms.
History
Teething is a normal developmental process for which anticipatory guidance should be offered at appropriate well visits. The following questions will be helpful for providers in determining if teething should be considered in the differential diagnosis.
- Is teething likely to be occurring at the child 's age?
- First tooth appears by 6 months of age; however, 1% of children will get their first tooth before 4 months old and 1% after 12 months old.
- Completion of a set of 20 deciduous/primary teeth by 30 months of age
- Teeth emerge in pairs, with lower central incisors usually appearing first.
- Rule of thumb: age (in months) ¢ 6 = average number of teeth (until 24 months old)
- Has the child had fever?
- General consensus is that temperature >102 °F or 38.8 °C should not be attributed to teething.
- One prospective longitudinal study showed an association between mild tympanic temperature elevations (with maximum 36.8 °F) and day of tooth eruption.
- Another study showed mild temperature elevation in the 8-day teething period.
- Does the child have one or more symptoms often attributed to teething?
- Common symptoms parents often attributed to teething include biting, drooling, gum rubbing, irritability, sucking, wakefulness, ear rubbing, facial rash, and decrease in appetite for solids.
- One prospective study showed an increase of the above symptoms in the period from 4 days prior to 3 days after tooth eruption, considered to be the 8-day window of teething.
- There is no consensus in the medical literature about the association of teething and these minor symptoms.
- Is the child irritable?
- Irritability with an inability to console is concerning and must not be attributed to teething.
- Is the child exhibiting changes in sleep pattern?
- Teething should not cause significant sleep disturbances.
- Further history should be obtained regarding the nature of the sleep changes, some of which are common in children between 6 and 12 months old.
- Are there changes in the mouth which make the parent think the child may be teething?
- Swelling of the gums may be noted prior to tooth eruption.
- An area of gum swelling with discoloration may represent an eruption cyst for which no treatment is required.
Alert
Fever >38.8 °C/102 °F, irritability, or diarrhea should NOT be attributed to teething and should prompt a careful history, physical exam, and investigation for possible etiology, including otitis media, meningitis, serious bacterial illness, or viral infection.
Differential Diagnosis
- Infectious
- Gingivostomatitis causing pain or drooling
- Viral or bacterial illnesses causing pain, fever, fussiness, or change in behavior
- Toxic ingestion causing drooling
- Trauma or burn to the mouth
- Normal developmental behaviors: Drooling, gum rubbing, and finger sucking may be consistent with typical development.
Physical Exam
- Often, there are no pertinent findings on physical exam.
- Gum swelling and eruption cysts are both normal findings.
Diagnostic Tests & Interpretation
No laboratory tests are indicated in the otherwise healthy child with teething.
Treatment
General Measures
- Nonpharmacologic
- Application of cold/frozen objects onto the gums causes vasoconstriction and reduces inflammation.
- Biting on teething rings or other objects can offer relief by applying pressure to the gums.
- Objects used for this purpose include teething rings, pacifiers, cold spoons, frozen bagels or bananas, or a cold washcloth.
- Teething rings can be placed in the refrigerator but not the freezer, which could disrupt the integrity of the plastic cover.
- Discard teething rings made prior to 1998, as they may contain diisononyl phthalate, a plastic softening agent which was later found to be toxic and potentially carcinogenic.
- Do not attach a teething ring to a tether around the child 's neck, as that may cause strangulation.
- Care should be taken to not give the child an object which could be a potential choking hazard.
- Pharmacologic management
- Acetaminophen (15 mg/kg PO q 4 " 6 hours) or ibuprofen (10 mg/kg PO q 6 " 8 hours) may be used for pain relief as needed but should not be given around-the-clock so as not to mask fever.
- Over-the-counter teething preparations containing benzocaine have been associated with methemoglobinemia and are not recommended. The FDA released a Drug Safety Communication in 2011 to inform the public of this potentially fatal adverse effect.
- Homeopathic remedies include belladonna, clove oil, olive oil, fennel, green onion, ginger, vanilla, and chamomile. Depending on the amount ingested and the size of the child, toxicity may be a concern.
- Remedies used in the past that are no longer recommended include alcoholic liquors, honey, emetics, purgatives, and lancing of the gums.
Issues for Referral
- Children should have a dental home by the age of 12 months.
- Children who have delayed eruption of their first primary tooth beyond 15 months should be evaluated. The following conditions have been associated with delayed eruption: anodontia, impacted teeth, hypothyroidism, hypopituitarism, calcium/phosphorus metabolism problems, ectodermal dysplasias, Gaucher disease, osteopetrosis, Apert syndrome, cleidocranial dysplasia, and Down syndrome.
- Referral to a dentist should be considered for children with significant variation in eruption caused by dental infections, additional teeth in the path of eruption, insufficient space in the dental arch, and/or ectopic placement of teeth.
- Presence of or risk for dental caries at an early age should prompt a dental evaluation.
- Natal teeth should be evaluated only if they are loose and pose an aspiration risk or if they interfere with breastfeeding.
Patient Education
- Information available at http://www.ada.org/en/Home-MouthHealthy/aztopics/t/teething
- Parent handout available at http://patiented.solutions.aap.org/handout.aspx?resultClick=1&gbosid=166311
Additional Reading
- American Academy of Pediatrics. A pediatric guide to children 's oral health. http://www2.aap.org/oralhealth/docs/oralhealthfcpagesf2_2_1.pdf. Accessed March 15, 2015.
- Anderson J. "Nothing but the tooth " : dispelling myths about teething. Contemp Pediatr. 2004;21:75 " 87.
- Ashley MP. It 's only teething " ¦ a report of the myths and modern approaches to teething. Br Dent J. 2001;191(1):4 " 8. [View Abstract]
- Lehr J, Masters A, Pollack B. Benzocaine-induced methemoglobinemia in the pediatric population. J Pediatr Nurs. 2012; 27(5):583 " 588. [View Abstract]
- Macknin ML, Piedmonte M, Jacobs J, et al. Symptoms associated with infant teething: a prospective study. Pediatrics. 2000;105(4, Pt 1):747 " 752. [View Abstract]
- Markman L. Teething: facts and fiction. Pediatr Rev. 2009;30(8):e59 " e64. [View Abstract]
- Ramos-Jorge J, Pordeus I, Ramos-Jorge M, et al. Prospective longitudinal study of signs and symptoms associated with primary tooth eruption. Pediatrics. 2011;128(3):471 " 476. [View Abstract]
- Sood S, Sood M. Teething: myths and facts. J Clin Pediatr Dent. 2010;35(1):9 " 14. [View Abstract]
- Wake M, Hesketh K, Lucas J. Teething and tooth eruption in infants: a cohort study. Pediatrics. 2000;106(6):1374 " 1379. [View Abstract]
Codes
ICD09
ICD10
SNOMED
- 8004003 teething syndrome (disorder)
- 247349000 painful teething (finding)
FAQ
- Q: When does a child need to see the dentist?
- A: Every infant should receive an oral health assessment from the primary care provider by 6 months of age to assess the patient 's risk for oral disease or caries. Parents should be provided education on infant oral health and evaluation of fluoride supplementation. The AAP and the AAPD recommend that the patient establish a dental home by 1 year of age or sooner if with concern for dental caries, trauma, teeth staining, or family history of early dental caries.
- Q: What is the proper care of newly erupted teeth?
- A: Brushing with a toothbrush helps reduce bacterial colonization and should be done by a parent twice daily using a soft toothbrush of age-appropriate size. Never put the baby to bed with a bottle due to increased risk for early childhood dental caries.
- Q: Will thumb sucking affect my baby 's teeth?
- A: Thumb sucking is a normal part of infancy but, if allowed to continue into early childhood, can cause problems with the child 's bite. If it continues past the age of 3 years, the primary care or dental provider should counsel parents on strategies to reduce the behavior.
- Q: Is there a cluster of symptoms that can predict when teeth will emerge?
- A: Studies have failed to show a group of symptoms which is predictive of tooth eruption.
- Q: What are natal and neonatal teeth?
- A: Natal teeth are teeth present at birth, most often representing the premature eruption of primary teeth but occasionally can be a third set of teeth. They are usually left in place unless they cause difficulty with nursing or are loose and pose an aspiration risk. Neonatal teeth, however, erupt in the 1st month of life. Occurring in approximately 1 in 2,000 children, natal and neonatal teeth are not usually pathologic but have been associated with various syndromes, including Hallermann-Streiff syndrome, Ellis-van Creveld syndrome, craniofacial dysostosis, congenital pachyonychia, Pierre Robin, adrenogenital syndrome, and Sotos syndrome.