Teething

Teething is the eruption of primary (deciduous) teeth through the gums. First teeth (lower central incisors) usually erupt at about 6 to 10 months (range 3 to 15 months), followed by upper central incisors (8 to 12 months), lateral incisors (9 to 13 months), first molars (13 to 19 months), canines (16 to 23 months) and second molars (23 to 33 months). All 20 teeth are present by about 30 months.

• Natal teeth (present at birth) and neonatal teeth occur in about 1 in 2000 to 3000 births.
• Physiological process; symptoms are mild and local. Many perceived "teething symptoms" are coincidental, as the 6 to 24 month period is also when maternal antibodies wane and infections are frequent.
• Local effects: gum swelling and tenderness, eruption cysts or haematomas (bluish translucent swelling over the erupting tooth), drooling, mouthing and chewing.
• Early eruption variation is normal; delayed eruption (no teeth by 15 months) is evaluated for hypothyroidism, rickets or genetic syndromes (ectodermal dysplasia, cleidocranial dysplasia, Down syndrome).

• Increased drooling, gum swelling and redness, gnawing and biting on objects, irritability, mild sleep disturbance, mildly decreased appetite, rubbing of cheeks or ears, occasionally a low grade temperature (below 38.0 C) and mild facial rash from drool.
• Not caused by teething: high fever (38.0 C and above), significant diarrhoea, vomiting, seizures, severe rash, cough, ear infection, refusal to feed, lethargy, or marked distress; look for other causes.
• Examination: gums (swelling, translucent eruption cyst), tooth position, oral thrush, herpetic gingivostomatitis (ulcers, fever), hand, foot and mouth disease, ear, throat, chest, hydration, general appearance, growth.
• Red flags: fever over 38.0 C, lethargy, poor feeding, signs of dehydration, persistent diarrhoea, rash, drooling with stridor or inability to swallow, mouth ulcers with fever, neck swelling, lack of any teeth by 15 to 18 months, dental abscess.

• Clinical. No investigations. Seek other causes when systemic features appear.
• Evaluate delayed eruption: thyroid function, calcium, phosphate, vitamin D, alkaline phosphatase, and dental review if no tooth by 15 to 18 months.

• Reassure parents that teething causes mild symptoms and does not cause significant fever, diarrhoea, seizures or illness.
• Comfort measures:
  • Gentle gum massage with a clean finger.
  • Chilled (not frozen) teething rings, cold clean washcloth, or a cold (not frozen) firm raw fruit or vegetable such as a chilled carrot or cucumber under supervision in infants of weaning age (choking risk).
  • Wipe drool and apply a barrier cream (petroleum jelly) to protect facial skin.
  • Cuddle, distraction, regular routines.
• Analgesia for distress or poor sleep (short term, as needed): paracetamol 15 mg/kg orally every 4 to 6 hours, maximum 4 doses in 24 hours; or ibuprofen 5 to 10 mg/kg orally every 6 to 8 hours with food (age over 3 months and weight over 5 kg), maximum 30 mg/kg per day.
• Avoid:
  • Teething gels containing benzocaine (risk of methaemoglobinaemia), lidocaine (risk of toxicity and swallowing impairment), choline salicylate (risk of Reye syndrome; not recommended under 16 years), and homeopathic teething tablets or gels containing belladonna (atropine toxicity and seizures).
  • Amber necklaces and bracelets, frozen teething rings, hard biscuits (choking and strangulation risks), alcohol, sweetened drinks, honey for gums.
• Dental care: after the first tooth appears, brush twice daily with a smear (grain of rice size) of fluoride toothpaste 1000 ppm (1350 to 1500 ppm is also used) and a soft infant brush; avoid prolonged bottle or sippy cup use, sleeping with a bottle, and sugary drinks; arrange the first dental visit by age 1 year.
• Eruption cyst or haematoma: no treatment (resolves spontaneously on eruption).
• Natal teeth: dental review; extraction if loose with aspiration risk or if they interfere with feeding.
• Review if systemic symptoms, persistent fever or delayed eruption.