Introduction

Teething [Odontiasis] is a term limited to eruption of primary dentition or milk teeth. It is also refereed as cutting of the teeth through gums. It usually begins in the 4th - 6th month of a child’s life and full set of 20 primary teeth erupts by 2½ or 3 years of age. The appearance of teeth is eagerly awaited by the parents since it represents an important early milestone in child’s development. In most children, eruption of primary teeth is preceded by increased salivation and child will frequently put his hand and fingers in mouth. Once the teeth starts erupting the child will be teething off and on and the parents should be aware of the sequence of tooth eruption.

Tooth Eruption chart

Natal and neonatal teeth

When teeth are present at birth or erupt during first 30 days of life in lower front gum region, they are termed as Natal and neonatal teeth respectively. These are primary mandibular incisor which erupts prematurely. These teeth require no intervention unless they are loose and child is at risk of inhaling them or cause problems in feeding.

Features seen during teething

Discomfort during few days before eruption of teeth may vary from child to child and the type of tooth erupting. Some babies are bothered more. Due to shape of molars they are more likely to cause teething discomfort then front teeth.

Local Signs:

1. Increased drooling of saliva
2. Hyperaemia or swelling of the mucosa overlying the erupting teeth
3. Patches of erythema (redness) on the cheeks due to rubbing of cheek or ear as a consequences of referred pain during eruption of molars
4. Irritation or mild to severe pain in the region of the erupting tooth
5. Taking finger and hand in mouth

Systemic Signs:

1. General irritability and crying
2. Loss of appetite because of soreness of gum region
3. Sleeplessness and restlessness due to gum discomfort
4. Increased salivation and drooling of saliva
5. Increased Thirst
6. Circumoral rash

Associated problems:

Systemic

1. Fever: Tooth eruption will never cause fever. Due to irritability of gums child will pick anything from floor or chew on whatever he gets which might be infected, thus causing infection and fever.
2. Diarrhoea and Vomiting: Intestinal infections can occur due to chewing on unhygienic objects picked up by child thus leading to diarrhoea or vomiting.
3. Cough

Local

1. Eruption hematoma or Eruption cyst: A bluish purple elevated area of tissue formed before the eruption of tooth. It is self-limiting and subsides as and when the tooth breaks through the tissue and erupts.
2. Eruption sequestrum: A tiny spicule of non-viable bone overlying the crown of an erupting permanent molar just before or immediately after the emergence of tips of the cusps through the oral mucosa.
3. Riga-fede disease: This is an inflammatory disorder characterized by ulceration of oral mucosa especially located on tongue, caused by repeated trauma by natal or neonatal teeth.

How to get rid of teething problems

Preventive Measures

1. Maintain the child’s oral and general body hygiene. Wipe the child’s mouth for drooling saliva and keep it clean and dry.
2. Gums should be wiped after each meal with wet muslin cloth or cotton soaked in a weak antiseptic like 1:100 potassium permanganate solution.
3. Adequate quantity of vitamins, minerals and proteins should be given to the child so that the body resistance is increased.
4. Parents need to spend more time playing games with children to distract them and help them to overcome their irritable nature.

Home remedies for teething pain

A variety of objects differing in size, shape and composition have been advocated to satisfy the natural desire of the infant to chew on hard objects during teething. These objects also have an added advantage of stimulating the gum pads for the smooth and painless eruption of the teeth.

1. Gentle rubbing gums with a clean finger for two minutes at a time or let child bite on a clean washcloth.
2. Use of cold objects reduces inflammation.
3. Hard, non-sweetened rusks or toasted bread helps in providing gingival stimulation as well as increases the blood supply to the area.
4. Use of hard fruits such as apple or guava which also helps in developing taste for fruits.
5. Use of specially manufactured objects such as teething rings and keys is also recommended.
6. Teething necklaces (a rectangular shaped nursery food) and pacifiers which release preventive agents such as sodium fluoride and xylitol into the mouth has been advocated.

Medical Management

1. Topical application of glycerine which acts as a protective demulcent and mild antiseptic.
2. Topical application of lignocaine hydrochloride which provides relief in the interval before the analgesic is effective.
3. The aperients (mild purgatives) like castor oil, phenolphthalein, calomel and milk of magnesia can also be used in the treatment of teething.
4. Acetaminophen or ibuprofen can be prescribed for young children [not younger than 6 months] for the relief of pain associated with the erupting primary dentition.
5. A safe and effective hypnotic which is popular in paediatric practice for the treatment of teething is chloral hydrate. This is dispensed either as a mixture or as an elixir. Undoubtedly for infants and young children the elixir is easier to administer.
6. In homeopathy use of the preparation Chamomilla has been used for teething.

Surgical treatment

Surgical treatment is sometimes recommended for the relief of pain from an eruption cyst or a hematoma, which may have occurred in connection with an erupting primary tooth. The technique most often advocated involves surgical removal of the tissue overlying the unerupted tooth.

You should remember

1. Many symptoms are ascribed to teething, but any association with fever, upper respiratory infection, or systemic illness is probably coincidental rather than related to the eruption process. Attributing fever to teething without thorough diagnostic evaluation for other sources has resulted in missing serious organic disease.
2. The most common and popular treatment for teething pain is the application of low dose topical anaesthetics or teething gels, available over the counter. Most of these agents contain benzocaine or less commonly lidocaine. If improperly used, they can cause numbness of the entire oral cavity and pharynx and suppression of the gag reflex which can be a serious side effect.
3. Caution must be exercised while using topical anaesthetics, especially for infants, as their systemic absorption is rapid and toxic doses may occur if misused. FDA issued warning in May 2011 for avoidance of benzocaine to be used as topical applicant as there is association with methemoglobinemia, a rare but serious complication which limits the ability of red blood cells to transport oxygen throughout body.
4. Systemic analgesics such as acetaminophen or ibuprofen are safer and more effective. Aspirin should not be given to the child as it can cause Reye syndrome.
5. Chewing on a teething object can be beneficial as it hastens the eruption process.

References

1. Current Diagnosis & Treatment: Pediatrics, Nineteenth Edition. William W. Hay, Jr.,Myron J. Levin, Judith M. Sondheimer,Robin R. Deterding. The McGraw-Hill Companies, Inc. ISBN 978-0-07-154433-7.
2. Textbook of Pedodontics, Second Edition. Shobha Tandon, Paras Medical Publisher, ISBN 978-81-8191-241-1.
3. Dentistry for the Child and Adolescent, Ninth Edition. Jeffrey A. Dean, David R. Avery, Ralph E. McDonald. Elsevier Inc. ISBN 978-0-323-05724-0