Teething
Exam Tips
- In OSCEs, frame teething as a diagnosis of exclusion: no single symptom cluster is diagnostic.
- A temperature >=38 C, systemic toxicity, poor perfusion, persistent reduced intake, or severe inconsolability should prompt urgent assessment for infection/sepsis.
- Quote eruption timing: usually starts around 6 months (range 4-36 months), with considerable normal variation.
- Counselling station pearl: first-line treatment is non-pharmacological comfort; use sugar-free paracetamol/ibuprofen in licensed doses only if needed.
- Safety point often examined: avoid recommending homeopathic/unlicensed teething products; lidocaine gels are restricted and not licensed under 5 months; Bonjela Junior is not licensed for teething.
- See Figure: eruption sequence of primary dentition and age bands (common paediatric dentistry exam image).
Definition
Teething is the normal physiological eruption of primary (deciduous) teeth through the gingiva in infants and young children, usually causing mild, local oral discomfort rather than systemic illness. It is a diagnosis of exclusion in children up to about 3 years, made only after other causes of distress, fever, or reduced feeding have been assessed and deemed unlikely.
Pathophysiology
Primary teeth develop within the alveolar bone and then migrate occlusally as surrounding bone and overlying soft tissue remodel, allowing crown emergence through the gingiva. Local inflammatory mediator release around erupting teeth can produce transient gum tenderness, swelling, drooling, and increased mouthing/biting behaviour. Evidence does not support teething as a reliable cause of significant systemic upset (for example high fever or diarrhoea), so marked systemic features should prompt assessment for alternative pathology. Typical eruption order is central incisors, lateral incisors, first molars, canines, then second molars, with most children beginning around 6 months and completing the primary dentition by 2-3 years. See Figure: standard primary tooth eruption chronology chart (paediatric dentistry text).
Risk Factors
- Age window of eruption (commonly 4-36 months; most start near 6 months)
- Multiple teeth erupting together (can increase local irritability/discomfort)
- Very early eruption (natal/neonatal teeth) in a small minority
- Delayed eruption associated with endocrine/systemic conditions (for example hypothyroidism, hypopituitarism, hypoparathyroidism, growth hormone deficiency)
- Genetic/syndromic or haematological associations with delayed eruption (for example Down syndrome, sickle cell disease, hypophosphataemic rickets)
Clinical Features
Symptoms
- Gum discomfort/pain (often starts 3-5 days before eruption)
- Increased biting, chewing, or gum-rubbing
- Drooling
- Irritability/fussiness
- Disturbed sleep or increased wakefulness
- Reduced appetite or feeding reluctance
- Ear-rubbing
- Mild temperature elevation only (typically <38.0 C)
Signs
- Visible erupting tooth or imminent eruption
- Localized gingival swelling, erythema, and tenderness over eruption site
- Facial flushing
- Perioral/facial irritation from saliva
Investigations
Management
Lifestyle Modifications
- Reassure carers that teething is usually mild and self-limiting
- Gently rub gums with a clean finger
- Use clean cool teething aids (for example chilled teething ring or cold wet flannel; not frozen hard objects)
- For weaned infants, supervised chilled soft fruit/vegetable pieces (for example banana or cucumber) while avoiding choking hazards
- Wipe excess saliva to reduce facial rash
- Provide comfort measures (cuddling, soothing, sleep support)
- Start twice-daily toothbrushing with fluoride toothpaste as soon as teeth erupt and arrange first dental visit by first birthday
Pharmacological Treatment
Simple analgesic
- Paracetamol oral: 15 mg/kg per dose every 4-6 hours when required (max 4 doses in 24 hours; max 60 mg/kg/day)
- Age-banded examples commonly used in UK products: 3-5 months 60 mg per dose; 6-23 months 120 mg per dose; 2-3 years 180 mg per dose (check product strength)
Use only if non-drug measures are insufficient. Dose by age/weight and licensed product instructions; avoid duplicate paracetamol-containing medicines.
NSAID
- Ibuprofen oral (>=3 months and >=5 kg): 5-10 mg/kg per dose every 6-8 hours when required (max 30 mg/kg/day)
Avoid in dehydration, active GI ulceration, significant renal impairment, known NSAID hypersensitivity, or aspirin/NSAID-exacerbated asthma. Use caution in varicella because of severe skin/soft-tissue complication risk.
Topical local anaesthetic (restricted use)
- Lidocaine oral teething gels (for example products containing lidocaine such as Calgel, Dentinox, Anbesol): only under pharmacist supervision; not licensed under 5 months
Not first line; consider only for significant distress after non-pharmacological and simple oral analgesic options. Strictly follow licensed dose/frequency to avoid toxicity.
Complications
- Misattribution of serious illness to teething (for example otitis media, UTI, meningitis, sepsis) causing delayed diagnosis
- Irritant facial dermatitis from persistent drooling
- Secondary gingival inflammation/plaque-related issues if oral hygiene is poor after eruption
- Choking risk from inappropriate teething objects or unsupervised food items
- Adverse drug effects from incorrect analgesic dosing or inappropriate topical/oral preparations
Prognosis
Excellent. Symptoms are typically mild, intermittent, and settle as each tooth erupts; most primary teeth are present by 2-3 years. Persistent distress, systemic unwellness, or prolonged symptoms should trigger reassessment for non-teething causes.
Sources & References
✅NICE Guidelines(1)
- Teething[overview]