Teething
Julie A. Boom, MD
Teething - BASICS
Teething - description
Teething is the normal developmental process of primary tooth eruption, often characterized by parental reports of fever, fussiness, increased drooling, increased finger sucking, alterations in bowel pattern, and/or decreased appetite.
Teething - DIAGNOSIS
The overall goal is to determine if the infant has any other signs or symptoms of another illness that would require additional investigation (e.g., fever 38.8°C [102°F], diarrhea, or irritability); avoid overdiagnosing teething, which might delay diagnosis of a more serious illness.
- Phase 1: Careful history and physical
- Phase 2: Workup of specific signs or symptoms that are not consistent with teething
- Phase 3: Provide relief of discomfort for the child who is teething.
Teething - signs & symptoms
Of note, fever >38.8°C (102°F), irritability, or diarrhea should not be attributed to teething, and other etiologies should be considered, such as acute otitis media, urinary tract infection, septicemia, meningitis, septic arthritis, or viral infection.
Teething - history
- Age: The average age for the eruption of the 1st tooth is ~6 months.
- 1% of infants acquire the 1st tooth before 4 months of age, and 1% after 12 months of age.
- Rule of thumb: Age (months) – 6 = average number of teeth (up to 2 years of age).
- Eruption usually begins with the lower central incisors.
- Swelling or bluish discoloration of the gums:
- Primary tooth eruption is frequently associated with swelling of the gums.
- A bluish area of gum swelling may represent an eruption cyst secondary to a hematoma. This condition requires parental reassurance only.
- Consolability:
- Infants who are teething may be fussy but should be consolable.
- An infant who is irritable and not consolable should be evaluated for serious systemic illness such as septicemia, meningitis, septic arthritis, or UTI.
- Fever: Several studies suggest that mild temperature elevation can occur 1–3 days before tooth eruption.
- Other symptoms:
- One recent study found that the following symptoms may be seen during the 4 days before and the 3 days after tooth eruption: Increased biting, drooling, gum rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite for solid foods, and mild temperature elevation.
- In this study, congestion, sleep disturbance, stool looseness, increased stool number, decreased interest in drinking, cough, nonfacial rashes, vomiting, and fever >38.8°C (102°F) were not associated with the teething period. Another recent study did not validate these findings.
- Sleeping habits:
- A teething child should be able to sleep with minimal disturbance.
- Changes in sleeping habits, such as frequent nighttime awakening, should suggest common problems with sleep associations often seen in young children 6–12 months old.
- Illness in the home: An acute illness should be investigated as the cause of the child’s symptoms.
Teething - physical exam
- Swelling with slight pallor over the gum where the tooth will erupt: Normal finding
- Bluish discoloration overlying the gum where a tooth is expected: This represents a hematoma, known as an “eruption cyst,” which is a normal finding.
- Irritability: Irritability on physical examination suggests a more serious illness than teething. In addition to the infectious etiologies noted, the child should be evaluated for hair tourniquet syndrome and/or corneal abrasion.
- Oral ulcers: Viral enanthems, such as herpes or coxsackie, should be considered.
- Presence of cervical lymphadenopathy: Oral, dental, or pharyngeal infections should be considered.
- Signs of dehydration, such as dry mucous membranes, absent tears, sunken fontanel, or tenting of the skin: Infectious etiologies that result in poor oral intake or diarrhea should be considered.
- Oral erythema and abrasions with excessive drooling: The possibility of caustic ingestion should be explored.
Teething - tests
No laboratory tests are indicated in the otherwise healthy child with teething.
Teething - differencial diagnosis
- Congenital/Anatomic:
- Natal teeth, neonatal teeth
- Gastroesophageal reflux resulting in esophagitis with decreased appetite
- Infectious:
- Primary herpes gingivostomatitis causing pain or drooling
- Human herpesvirus 6 causing fever
- Coxsackievirus oral infection causing fever or drooling
- Epiglottitis causing severe drooling with fever
- Viral illness causing fever >38.3°C (101°F), diarrhea, or upper respiratory symptoms
- Toxic ingestion causing drooling
- Trauma:
- “Lancing” of gums (i.e., incising the gum to expose the erupting tooth) causing pain
- Hair tourniquet syndrome causing pain and irritability
- Corneal abrasion causing pain
- Miscellaneous: Drooling, gum rubbing, and finger sucking may be normal developmental behaviors.
Teething - TREATMENT
- Application of cold/frozen objects locally onto the gums: Many find that cold objects work well, but care must be taken because direct contact with a frozen object may result in local irritation.
- Objects for chewing: Choking hazards, such as raw carrots, must be avoided.
- Teething rings should not be placed around the child’s neck, as they represent a strangulation hazard. Teething rings made prior to 1998 should be discarded as they might contain diisonoyl phthalate, a softening agent now thought to be toxic.
- Acetaminophen (15 mg/kg PO q4h) or ibuprofen (10 mg/kg PO q6h) may be used for pain relief as needed, but should not be given round-the-clock to mask fever.
- Home remedies or treatments given by parents:
- Most over-the-counter preparations marketed for the relief of teething symptoms contain 7.5–10% benzocaine as the active ingredient. Excessive use of benzocaine preparations has been associated with methemoglobinemia.
- Homeopathic remedies may contain a variety of ingredients including belladonna alkaloids, chamomile, and ground coffee. Depending on the size of the child and the amount of medication or herb ingested, toxicity is possible.
- Remedies that have been used in the past and are no longer recommended include: Alcoholic liquors, paregoric, 2% lidocaine solution (excess may result in seizures), lancing the gums, and rubbing the gums with a thimble until the tooth breaks through the gum.
Teething - FOLLOW UP
Teething - disposition
Teething - issues for referral
- Children who have delayed eruption of their 1st primary tooth beyond 12 months require additional investigation for the following: Adontia, hypothyroidism, hypopituitarism, rickets, and multiple syndromes such as osteodystrophies, Apert syndrome, and Down syndrome. Most of these conditions require referral to a specialist for management.
- Children with premature eruption may have a familial cause; however, referral for evaluation of hyperpituitarism should be considered.
- 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.
- Natal teeth that are stable and do not interfere with breastfeeding may remain. Loose natal teeth may need to be removed to prevent choking and aspiration. Natal teeth can interfere with breastfeeding and cause ulceration, which is another indication for removal.
Teething - bibliography
- 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;191:4–8.
- Cunha RF, Boer FA, Torriana DD. Natal and neonatal teeth: Review of the literature. Pediatr Dent. 2001;23:158.
- Hilgers KK, Akridge M, Scheetz JP, et al. Childhood obesity and dental development. Pediatr Dent. 2006;28:18–22.
- Jaber L, Cohen IJ, Mor A. Fever associated with teething. Arch Dis Child. 1992;67:233–234.
- Macknin ML, Piedmonte M, Jacobs J, et al. Symptoms associated with infant teething: A prospective study. Pediatrics. 2000;105:747–752.
- Viscardi RM, Romberg E, Abrams RG. Delayed primary tooth eruption in premature infants: Relationship to neonatal factors. Pediatr Dent. 1994;16:23–28.
- Wake M, Hesketh K, Lucas J. Teething and tooth eruption in infants: A cohort study. Pediatrics. 2000;106:1374–1379.
Teething - CODES
Teething - icd9
520.7 Teething syndrome
Teething - PATIENT TEACHING-MED
- Information available at www.ada.org/public/topics/ tooth_eruption.asp
- Parent handout available at http://contpeds.adv 100.com/contpeds/data/articlestandard/contpeds/332004/112042/article.pdf
Teething - FAQ
- Q: What is the difference between natal teeth and neonatal teeth?
- A: Natal teeth are present at birth, whereas neonatal teeth erupt during the 1st month of life. The incidence of natal teeth is 1:2,000–6,000 live births and usually involves the lower central incisor. Natal teeth can be associated with various conditions including Pierre Robin sequence, cleft lip and/or palate, chondroectodermal dysplasia, and Hallerman–Streiff, Ellis-van Creveld, and Sotos syndrome. There is often a familial history of natal or neonatal teeth. 95% of natal teeth are normal primary incisors that may have formed superficially and erupted early. Only 5% of natal teeth are supernumerary (extra) teeth. Therefore, if a natal tooth is removed, a primary tooth will not erupt in its place in most cases. Because primary teeth act as space holders for the secondary teeth, early loss of a primary tooth may result in significant crowding of the secondary teeth.
- Q: Does primary tooth eruption in preterm infants occur at the same time as in full-term infants?
- A: In healthy preterm infants who had relative uneventful neonatal courses, the 1st primary tooth erupts at the usual chronological age. Premature infants requiring prolonged oral intubation and/or who experience inadequate nutrition due to the severity of neonatal disease may have delays in tooth eruption. The initial eruption sequence remains the same (lower central incisors 1st).
- Q: Does obesity effect dental development?
- A: Obese children, ages 8–15, have been shown to have advanced dental development compared to their nonobese peers. This can have important implications for planning the timing of orthodontic treatment.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
Other Book Chapters Related to Loose tooth
Read excerpts from these other book chapters related to Loose tooth:
Medical Books Excerpts
- TOOTHACHE
- "Differential Diagnosis in Primary Care" (2007)
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- TOOTHACHE
- "Differential Diagnosis in Primary Care" (2007)
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Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.
More About Causes of Loose tooth
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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