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Summary box:
In this article you will learn:
- The timeline and symptoms associated with eruption of primary teeth
- The available pharmacological and non-pharmacological options for the management of teething
- Practices not advisable
Teething is the process whereby the teeth emerge through the gums. The first primary teeth to erupt in babies, commonly referred to as milk teeth, are already formed under the gums prior to birth.
The age of teething varies from child to child. In general, the first teeth begin to erupt when the baby is around six to nine months old. The full set of 20 deciduous teeth has usually erupted into the mouth by three years of age. The formation of the roots of teeth is a process that is not normally completed until three to five years after the eruption of the crown of the teeth.
Primary teeth
The first primary teeth to erupt are usually the lower central incisors (see ‘Photo guide: tooth eruption in children’).
Although there is natural variation, the average age for eruption is seven months. Occasionally, one or more teeth may be present at birth, or erupt in the first month of life. These teeth, which tend to be in the lower incisor region, may be part of the primary dentition or anomalous tooth-like structures. Natal teeth, which do not form part of the primary dentition, may need to be extracted if there is a danger of detachment and inhalation, difficulties in feeding or ulceration of the undersurface of the tongue (see ‘Photo guide: tooth eruption in children’).
Generally, both primary and permanent teeth erupt in pairs, with the process starting with the lower primary central incisors erupting two or more weeks ahead of the upper primary central incisors. Primary teeth look smaller and are whiter than their permanent successors. For details of the timing of the eruption of primary teeth, see ‘Eruption and exfoliation of primary teeth’.
| Eruption and exfoliation of primary teeth | |
|---|---|
| Upper primary teeth | Eruption (months) |
| Central incisor | 8–12 |
| Lateral incisor | 9–13 |
| Canine | 16–22 |
| First molar | 13–19 |
| Second molar | 25–33 |
| Lower primary teeth | Eruption (months) |
| Central incisor | 6–10 |
| Lateral incisor | 10–16 |
| Canine | 17–23 |
| First molar | 14–18 |
| Second molar | 23–31 |
A child should start to lose their primary teeth between six and seven years of age. It is important to preserve and care for the primary teeth as they save a space for their permanent successors and, in the absence of any decay and subsequent infection, help to give the permanent teeth a healthy start. Primary teeth give a child a normal facial appearance, aid speech and enable the child to enjoy a varied, balanced diet.
Photo guide: tooth eruption in children
Images courtesy of Richard Welbury
1) Primary dentition: lower central incisors within days of eruption in a child aged six to ten months.
2) Two natal teeth that require extraction to prevent further ulceration to the underside of the tongue.
Teething
The eruption of primary teeth in children can be distressing for the child and the child’s parents (see ‘Signs and symptoms of teething’).
| Signs and symptoms of teething |
|---|
| Pain |
| Inflammation |
| General malaise |
| Disturbed sleep |
| Facial flushing |
| Drooling |
| Gum rubbing/biting/sucking |
| Bowel upset |
| Loss of appetite |
Considerable variation exists in the presence or absence, and severity, of the symptoms associated with teething. Some babies will experience a variety of symptoms, others may just experience one[1]
. Pain is reported by most parents.
Systemic upset and pain
The majority of children aged 6–12 months are susceptible to a wide range of minor ailments and infections. As such, it may be difficult to separate the signs and symptoms of teething from those of a concurrent condition, possibly aggravated by the teething process. Teething has been found to occur in an eight-day window in which the tooth emerges; four days before through to three days afterwards[2]
.
The pain associated with teething is generally considered a constant, dull pain of growing intensity in the four days leading up to the emergence of the tooth, and then rapidly diminishing, unless the eruption is associated with marked inflammation, which may take several days to resolve.
Management of teething
There are various methods of managing teething (see ‘Methods for management of teething’).
| Methods for management of teething |
|---|
| Chilled teething rings |
| Hard sugar-free teething rusks/breadsticks |
| Frozen fruit and vegetables |
| Pacifier (chilled) |
| Reassurance |
| Rubbing gums with chilled spoon/clean finger |
| Analgesics |
| Antipyretics |
| Topical anaesthetic agents |
Non-pharmacological management
Teething rings can provide temporary pain relief. Maximal relief can be achieved when the ring is chilled to freezing temperatures first. Teething rings should be attached to the child’s clothes, not around the neck, to avoid risk of strangulation and the ring being repeatedly lost in bedding or being dropped. Solid silicone rings are preferable to fluid filled rings that may leak[3]
. Teething ring packaging should be checked to confirm that the ring comprises inert substances only. Many parents have fixed views and opinions about the use of pacifiers.
Excess production of saliva and associated drooling often causes the child’s circumoral skin, typically the lower lip and chin, to become soaked in saliva. This should be wiped away, as and when necessary, to avoid the corner of the mouth fissuring and a rash forming. This rash may be considered diagnostic of teething[4]
.
Pharmacological management
For a list of available products, see ‘Teething medicaments’.
| Teething medicaments | |
|---|---|
| Local anaesthetics | Dentinox teething gel (lidocaine hydrochloride 0.33%, cetylpyridinium chloride 0.1%) Rinstead teething gel (lidocaine hydrochloride 0.5%, cetylpyridinium chloride 0.1%) Woodward’s teething gel (lidocaine 0.5%, cetylpyridinium chloride 0.0025%, ethanol 30%) Anbesol teething gel (lidocaine hydrochloride 0.9%, chlorocresol 0.1%, cetylpyridinium chloride 0.02%) |
| Minor analgesics | Choline salicylate dental gel Bonjela Teejel (Choline salicylate 8.7%, cetalkonium 0.01%. Note, the use of salicylates is the subject of debate, see ‘Choline salicylate-based products’). |
| Paracetamol-based preparations (120mg/5ml) | Paracetamol oral suspension Infadrops Calpol Infant (sugar-free) Disprol Infant Suspension Panadol Baby and Infant Suspension Medinol Under 6 Paneleye Junior |
Topical agents include local anaesthetics, normally lidocaine-based preparations, and minor analgesics (such as choline-salicylate based preparations, although the use of these is the subject of debate; see ‘Choline salicylate-based products’). Lidocaine hydrochloride is rapidly absorbed through mucous membranes, giving rapid, albeit temporary, pain relief[5]
.
Regarding application, by way of example, around 0.75ml of Anbesol should be placed on a clean finger or cotton bud and applied by rubbing gently on to the painful area. Around 20 minutes should elapse between applications, however, only six applications should be made each day to avoid systemic effects.
Systemic analgesics can also be used. Sugar-free paracetamol liquid is the systemic medication of choice for teething infants, given its action in reducing pain and pyrexia. The doses can be repeated at four-hourly to six-hourly intervals, with a maximum of four doses a day[5]
.
Ibuprofen, which can be given to children aged over one year, is not recommended in the management of teething.
Choline salicylate-based products provide analgesia and also have anti-inflammatory and antipyretic effects, which reduce swelling.
The use of salicylates in children is the subject of debate. The Medicines Healthcare products Regulatory Agency (MHRA) contraindicates the use of salicylates for topical oral pain relief in children aged under 16 years because of a probable case of salicylate toxicity and a theoretical risk of Reye’s syndrome, which has been linked with the use of aspirin after viral infections[6]
. However, choline salicylate is a derivative of aspirin and the relationship between aspirin and Reye’s syndrome is not proven to extend to non-aspirin salicylates. Many paediatricians and pharmacists advocate the avoidance of choline salicyclate products in teething.
For children aged over four months, the recommendation is to gently massage 0.75ml of gel on to the painful area, not more than once every three hours, with a maximum of six applications each day.
Frequent applications of choline salicylate to the oral mucosa may result in a chemical burn[7]
.
Practices not advisable
Adding honey, jam or sugar to a feeding bottle, or dipping a pacifier in a sugary food substance, is to be discouraged. These remedies have no pain-relieving effect and can cause dental decay and pain. A feeding bottle in bed — in particular one containing a sugary fluid — should also be discouraged, as the teeth are constantly bathed in sugar and, even in low concentrations, this increases the risk of dental decay and subsequent pain and infection. The application of alcohol to the mucous membrane of an infant should also be discouraged as it has no pain-relieving effect.
General advice
Only inert teething objects and/or recommended sugar-free medications should be used during teething. Teething preparations should be kept out of reach of children to eliminate the chance of overdose. Medicines for teething should not be added to a feeding bottle or food because it is difficult to monitor the dose given. Additionally, the active ingredient of the medication could interact with food.
Breastfeeding and primary teeth
Biting should not be a reason to stop breastfeeding. While breastfeeding, the tongue covers the lower teeth, so it is impossible for a baby to nurse and bite at the same time. Babies bite for various reasons, which vary with the age of the child. A newborn may clamp down, or if any teeth are present, bite, simply in response to a change in position, or in a bid to slow down the flow of milk if it is too fast[2]
. Biting is more common when a baby is teething, but it is usually a short-term problem and requires perseverance from the mother to find a solution. Every baby is different and the solution depends on the age and temperament of the baby. Many mothers faced with this problem find a teething toy, or feeding in a different position, to be of assistance.
- When published, this article incorrectly stated the dosage of paracetamol for a 1–2 year old child as 12mg/5ml. It was corrected to 120mg/5ml on 23 November 2015 at 13:25.
Christine Lyttle, BSc MFDSRCPS and Fleur Stoops, BSc MFDSRCPS, are core trainees in paediatric dentistry, Glasgow Dental Hospital. Richard Welbury, PhD FDSRCPS is professor of paediatric dentistry, University of Glasgow. Nairn Wilson, PhD FDS, is honorary professor of dentistry, King’s College London.
References
[1] McIntyre GI & McIntyre GT. Teething troubles? Br Dent J 2002;192(5):251–255. doi:10.1038/sj.bdj.4801349
[2] Smith A. Teething and biting. September 2013. Available at: http://www.breastfeedingbasics.com/articles/teething-and-biting (accessed October 2015).
[3] Macknin ML, Piedmonte M, Jacobs J et al. Symptoms associated with infant teething: A prospective study. Pediatrics 2000;105(4):747–752. doi:10.1542/peds.105.4.747
[4] Seward MH. The treatment of teething in infants: A review. Br Dent J 1972;132(1):33–36. PMID: 4552275
[5] British National Formulary March 2015. British Medical Association, London.
[6] MHRA. Oral salicylate gels: not for use in those younger than age 16 years. Drug Safety Update June 2009. Available at: https://www.gov.uk/drug-safety-update/oral-salicylate-gels-not-for-use-in-those-younger-than-age-16-years#fn:1 (accessed 9 October 2015).
[7] Paynter AS & Alexander FW. Salicylate intoxication caused by teething ointment. Lancet 1979;314(8152):1132. doi:10.1016/s0140-6736(79)92528-5
