Teething is the process by which an infant's first teeth sequentially appear
by emerging through the gums, typically arriving in pairs. Teething may start as
early as six months or as late as eight months. The first 10 teeth typically
appear between six and nine months. It can take several years for all 20 teeth
to complete the tooth eruption. Though the process of teething is sometimes
referred to as "cutting teeth", when teeth emerge through the gums they do
not cut through the flesh. Instead, hormones are released within the body
that cause some cells in the gums to die and separate, allowing the teeth to come
through. Teething may cause a slightly elevated
temperature, but not rising into the febrile range, 100–101 °F. Higher
temperatures during teething are due to some form of infection, such as a herpes
virus, initial infection of which is extremely widespread among children of
teething age. History
Teething used to be considered a cause of death, as many children died in the
first years of life, at the same time as teething occurs. "The tendency in the
past to attribute serious disease to teething was so prevalent that in 1842
teething was the registered cause of death in 4.8% of all infants who died in
London under the age of 1 year and 7.3% of those between the ages of 1 to 3
years according to the Registrar General's report."
Ironically, while teething is a natural process which creates little more than
discomfort, some methods for relieving teething pain have caused serious harm
and even death. Old remedies for teething include "blistering, bleeding,
placing leeches on the gums, and applying cautery to the back of the
head". In the sixteenth century the French surgeon Ambroise Paré introduced
the lancing of gums using a lancet, in the belief that teeth were failing to
emerge from the gums due to lack of a pathway, and that this failure was a
cause of death. This belief and practice persisted for centuries, with some
exceptions, until towards the end of the nineteenth century lancing became
increasingly controversial and was then abandoned, although as late as 1938 an
Anglo-American dental textbook advised in favour of lancing, and described the
procedure. In the first half of the twentieth century, teething powders in
the English-speaking world often contained calomel, a form of mercury. It
was removed from most powders in 1954 when it was shown to cause "pink
disease", a form of mercury poisoning. Teething toys have a long history. In
England in the 17th–19th centuries, a coral meant a teething toy made of
coral, ivory, or bone, often mounted in silver as the handle of a rattle. A
museum curator has suggested that these substances were used as "sympathetic
magic" and that the animal bone could symbolize animal strength to help the
child cope with pain. Sequence of appearance
The infant teeth tend to emerge in pairs - first one lower incisor emerges then
the other lower incisor emerges before the next set begin to emerge. The
general pattern of emergence is: Lower central incisors at approximately
6 months Upper central incisors at approximately
8 months Upper lateral incisors at approximately
10 months Lower lateral incisors at approximately
10 months First molars at approximately 14 months
Canines at approximately 18 months Second molars at approximately 2–3 years
Milk teeth tend to emerge sooner in females than in males. The exact pattern
and initial starting times of teething appear to be hereditary. When and how
teeth appear in an infant has no bearing on the health of the child.
Symptoms The level of pain that a baby can handle
will be different for each child. Some may be a lot fussier than others while
they are teething. The soreness and swelling of the gums before a tooth
comes through is the cause for the pain and fussiness a baby experiences during
this change. These symptoms usually begin about three to five days before
the tooth shows, and they disappear as soon as the tooth breaks the skin. Some
babies are not even bothered by teething.
Common symptoms include drooling or dribbling, mood changes, irritability or
crankiness, and swollen gums. Crying, sleeplessness, restless sleep at night,
and mild fever are also associated with teething. Teething can begin as early as
3 months and continue until a child's third birthday. In rare cases, an area
can be filled with fluid and appears over where a tooth is erupting and cause
the gums to be even more sensitive. Pain is often associated more with large
molars since they cannot penetrate through the gums as easily as the other
teeth. Some noticeable symptoms that a baby has
entered the teething stage include chewing on their fingers or toys to help
relieve pressure on their gums. Babies might also refuse to eat or drink due to
the pain. Symptoms will generally fade on their own, but a doctor should be
notified if they worsen or are persistent. Teething may cause signs and
symptoms in the mouth and gums, but does not cause problems elsewhere in the
body. Pulling on the ears is another sign of
pain; the pain in the mouth throbs throughout the baby's head so they pull
their ears believing that it will provide relief. Mild rash can develop
around the mouth due to skin irritation that is caused by excessive drooling or
dribbling. = Misdiagnosis as teething =
Teething has not been shown to cause fever or diarrhea; however the belief
that teething causes fever is extremely common among parents. Whilst there is
some evidence that teething can cause an elevated temperature, it does not cause
fever. One small 1992 study found a significant rise in temperature on the
day of eruption of the first tooth. Another study in 2000 found "mild
temperature elevation," but not fever over 102 °F.
There is a risk that fever around the age of teething is dismissed as due to
teething when it is actually due to illness, particularly infection by
herpes viruses. "Coincidentally, primary tooth eruption begins at about the time
that infants are losing maternal antibody protection against the herpes
virus. Also, reports on teething difficulties have recorded symptoms
which are remarkably consistent with primary oral herpetic infection such as
fever, irritability, sleeplessness, and difficulty with eating." "Younger
infants with higher residual levels of antibodies would experience milder
infections and these would be more likely to go unrecognized or be
dismissed as teething difficulty." Herpes virus infection may take the form
of primary herpetic gingivostomatitis or of infection by human herpesvirus 6,
which infects 90% of children by age 2. "The symptoms of elevated temperature
and facial rash could be explainable by infection with the HHV-6 agent, which is
ubiquitous among infants of teething age." Other viruses may also cause
fevers which may be misattributed to teething, but the oral involvement that
may occur with herpes viruses makes misdiagnosis a particular risk for such
infections. Treatment
Before treating a baby for teething, it is important to know what is causing the
baby to be upset. Rubbing a finger gently along the gums in search for
swollen ridges or the feel of a tooth below the gums is one way to be certain.
If unsure, it is recommended that the child be seen by a pediatrician before
treatment is administered. A teething ring is generally a soft
plastic device that can be chewed on and allows the baby to break down some of
the gum tissue which promotes the growth of the teeth out of the gum. Some
teething rings can easily be broken or damaged, so other types of teething
devices can be made from household items. Placing a wet washcloth in the
freezer for a few minutes and then applying it gently to the gums can be
effective, but care must be taken not to expose a baby's gums to coldness for too
long. Infants chew on objects to aid in the
teething process. This can be dangerous if the baby is allowed to chew on
objects which are small enough to be swallowed or which could break while
being chewed and cause choking. Teething rings and other toys, called teethers,
are often designed with textures that will appeal to an infant during
teething. Drawing water into a pacifier and freezing it as another way to offer
a teething child relief. The cold pressure on the gums gives relief
without making the child’s fingers cold. Some infants gain relief from chewing on
cold objects. Some children respond well to chilled foods. Suggestions for
chilled foods that might appeal to a baby include applesauce, yogurt, and
pureed fruits. Dentists recommend brushing infants'
teeth as soon as they appear. It is not advisable to wait for the teething
process to be complete. Dentists may recommend against the use of fluoride
toothpaste during teething. = Medication =
In cases where the infant is in obvious pain, some doctors recommend the use of
non-steroidal anti-inflammatory drugs or child-safe pain-relief treatments
containing benzocaine, lidocaine, or choline salicylate. Benzocaine must be
used cautiously because it can cause methemoglobinemia; choline salicylate is
related to aspirin and "may cause Reye's syndrome in susceptible children,
especially those with or recovering from viral infections, or when used in
combination with other NSAIDs". 5% lidocaine gel produces anaesthesia
within 2–5 minutes, lasting for 10–20 minutes. However, one author concludes
that, "Overall, the risks and adverse effects from inappropriate or prolonged
use of pharmacological agents outweigh their potential benefits." She points
out that "the psychological trauma involved in administering medications or
applying topical preparations to infants must be considered", and argues that
"the placebo effect must not be overlooked. For example, applying a gel
of 20% benzocaine in polyethylene glycol may give only a modest benefit over
applying the placebo, which gives an efficacy of 60% compared with 90% for
the active preparation." Medicines are often applied to the
babies' gums to relieve swelling and pain. These gels are similar to the
toothache gel that is used by adults for sore gums and toothaches, but is
administered in much smaller doses. Teething gels work as a numbing agent to
dull the nerves in the gums so that the pain is less noticeable. It is important
to follow the directions on the package to ensure that the correct amount of
medication is administered and that proper techniques are used to reduce the
risk for infection. It is important not to let the medicine numb the throat as
it may interfere with the normal gag reflex and may make it possible for food
to enter the lungs. Similar medicines are also available in powder form, as
"teething powder". Acetaminophen and ibuprofen are also
recommended to treat the pain and swelling that babies experience. It
should only be used a few times a day so that it does not mask symptoms that are
being experienced due to other medical conditions and not because of teething.
Products that contain aspirin should never be given to a child unless
directed by a pediatrician, due to the risk of Reye's syndrome.
Some traditional medicine used to treat teething pain has been found to be
harmful due to high lead content, with effects including toxic encephalopathy.
"Surma" or "kohl" has traditionally been used in the Middle East and Indian
subcontinent as a teething powder, as have the Middle Eastern
"saoott"/"cebagin". "Santrinj" - a 98% lead oxide product otherwise used as a
paint primer - is also used in the Middle East as a home remedy for
teething. See also
Tooth eruption Deciduous teeth
Permanent teeth Dentition
References External links
NHS Choices Birth to Five Planner: Teething
NHS Choices Health A-Z: Teething "Personal View: It's only teething... A
report of the myths and modern approaches to teething", M P Ashley,
British Dental Journal 191, 4 - 8 Published online: 14 July 2001 |
doi:10.1038/sj.bdj.4801078. ttp:www.nature.comjournaln14801078a.html
Tlismi Moti : Tilasmi Moti for painless teething: tlismi moti