HOW TO MANAGE TEETHING PROBLEMS IN CHILDREN

Teething or tooth eruption is a physiologic process that involves the emergence of a tooth in the oral cavity. Usually, teeth begin to appear in the mouth from 6-12 months of age and children have their full set of 20 teeth by the age of 3 years. The appearance of the first tooth is regarded by most parents as a significant development in their child’s life. However, teething period often causes discomfort to babies. These disturbances are short-lived but may recur several times within the teething period. 

In the 19th century, gum swelling during teething was believed to be the cause of diarrhea, vomiting, and fever in children. Diarrhea and vomiting caused dehydration which resulted in high infant deaths. By extension, people associated teething with deaths in children.

With better awareness and scientific evidence, teething is considered a physiologic process with no association with infant deaths. However, it may cause manageable, localized symptoms.

In this article, we discuss the symptoms, causes, and management of teething issues in children. 

What are the symptoms associated with teething?

Symptoms associated with teething are mainly localized and may vary between children. Here are some of the symptoms experienced by children during teething:

• Swollen gums 
• Urge to bite on hard objects
• Increased irritability
• Trouble sleeping 
• Rashes around mouth
• Drooling of saliva
• Restlessness
• Night crying
• Rubbing of gums 
• Chewing or sucking of fingers
• Loss of appetite
• Rubbing of ears or pain in the ear during the eruption of molars

Research suggests that symptoms such as fever, malaise, cough, cold, diarrhea, rashes on the body, and blisters in the mouth are not associated with teething. Despite parents’ perceptions and beliefs about these symptoms being associated with teething, there is no scientific evidence supporting this. Instead, these symptoms may be associated with other illnesses. 

What are the causes of teething-related problems?

The exact cause of teething-related issues is still unknown. Many researchers have found no direct association between teething and infection. However, several theories have been proposed. These include:

• Release of inflammatory chemicals: Research suggests that several chemicals (e.g., cytokines such as interleukins, tumor necrosis factors, and interferons) are released during tooth eruption or teething which contribute to the tissue damage and inflammation in the body. High levels of inflammation-causing chemicals in the body give rise to symptoms such as swollen gums, malaise, fever, and diarrhea. 
• Replacement of mother’s passive immunity with active immunity: Few researchers believe that teething in children coincides with the stage of development when the child’s body is trying to establish its active immunity and replace the declining passive immunity received from the mother. This phase impacts the overall health of the child and may result in ENT (Ear nose and throat) or gastrointestinal infections. In addition, other signs and symptoms such as fever, irritability, restlessness, and eating difficulties could be due to herpes virus infections (primary herpetic gingivostomatitis) common in children between 2-5 years of age. Some kids may also cry during the night or wake up frequently. This could be due to attention-seeking or separation anxiety. 

What are the different stages of teething in babies?

Here are the 5 stages of teething in babies:

Stage 1: 0-6 months

• In this stage, a complete set of 20 teeth are present within the jaw bone, below the gums. 
• These teeth are known as “milk teeth” as babies are mostly dependent on their mother’s milk or formula.

Stage 2: 6-8 months

• In this stage, upper and lower front teeth (incisors) begin to appear in the mouth.
• Teething pain may be experienced for a few months until teeth completely erupt in the mouth.
• Babies may develop the urge to place objects into their mouths to relieve the teething pain. The use of teething rings, cold objects, cucumbers, or carrots may be helpful in relieving pain and discomfort.
• Excess drooling of saliva may be seen which may cause rashes around babies’ chins.

Stage 3: 10-14 months

• In this stage, molar teeth (back teeth) begin to appear in the mouth through the gums. 
• Discomfort or pain during teething may increase.
• Symptoms such as irritability, excess drooling, loss of appetite, disturbed sleep, and urge to chew or bite on objects are more often seen.
• Over-the-counter pain medications are recommended in case of severe pain.

Stage 4: 16-22 months

• In this stage, canine teeth (third teeth from the midline) begin to appear in the oral cavity.

Stage 5: 23-33 months 

• This stage is considered the most painful stage of teething for many children.
• During this time, molars which are the largest set of teeth, erupt in the mouth
• Giving babies a piece of hard, small vegetable to bite or chew may be effective. 

How to manage problems related to teething?

Here are some of the ways to manage problems during teething in children. These include:

General management:

• Solid silicone-based teething rings can be used to curb the urge to bite on hard objects. Chewing these rings (especially the chilled ones) also provides temporary relief from pain. Choose a solid teething ring over liquid-filled counterparts, as they are leakproof. 
• A hard, non-sweetened teething rusk, bread sticks, oven-hardened bread, bagels, peeled cucumber or carrot, and other sliced fruit (e.g., frozen banana) can be used in addition to teething rings. Biting on chilled objects may provide relief from soreness and fasten the process of teeth eruption.
• Sometimes, many teething children may feel comfortable with the use of a pacifier. Even chewing the teat provides temporary pain relief. 
• A clean finger, wet gauze, or a cold spoon can be used to rub painful areas on the gums.
• Excess drooling saliva should be wiped away regularly to avoid the development of a rash on the skin around the mouth. 
• Comforting and reassurance of children are important to calm the distressed child. 

Specific Management:

• Teething gel: The application of medicated, anesthetic gels (e.g., lignocaine-based preparations or choline-salicylate-based preparations) is recommended to provide relief from pain in the gum areas. During application, 7.5mm of gel can be placed on a clean finger or cotton bud and rubbed on the painful areas. These gels are recommended only in children over 4months and should not be applied more than 6 times a day to avoid toxicity.
• Oral medications: In children with severe pain, fever, or discomfort, sugar-free paracetamol preparations may be recommended by the doctor to reduce the fever and pain. 
• Alternative therapy: The use of alternative therapies such as acupressure, aromatherapy, massage, and homeopathy are also recommended to overcome the symptoms of teething. It is also believed that teething children can be comforted by a full body massage. Many over-the-counter homeopathic medications contain chamomile which helps treat children with diarrhea and irritability.

What precautions should be taken while treating teething-related problems?

Here are some of the things that parents should be aware of while managing teething issues:

• Avoid the use of plastic teethers present with disononyl phthalate which is considered a carcinogenic chemical. Several animal studies have demonstrated toxicities and fetal demise with the use of this chemical. 
• The use of teething bagels, frozen food, or vegetables should be avoided in children who haven’t started the intake of solid foods. 
• Avoid the use of topical anesthetic gels containing “Benzocaine” in children younger than 2 years. Benzocaine may cause rare but a serious complication called methemoglobinemia. In this disorder, the oxygen-carrying capacity of blood vessels is greatly reduced. 
• Use only sugar-free objects and medications prescribed during teething. 
• Avoid adding teething medicine or any remedies into the child’s food or feeding bottles as it is difficult to control the dosage ingested. Also, ingredients in the medication can interact with foods and may have after-effects. 
• Avoid the use of homeopathic medications. This is recommended by FDA as lab testings have found the presence of the toxic substance in some of the homeopathic tablets given for teething.

Frequently asked questions:

What problems can teething cause?

During the teething period i.e., between 6 months to 3 years of age, a child may experience common problems such as pain and swelling in the gums, increased biting and sucking of fingers, drooling of saliva, rashes around the mouth, increased irritability, appetite loss, and trouble while sleeping. 

When should I be concerned about teething?

If the child develops symptoms such as high fever, diarrhea, severe rashes around the mouth, or cries a lot due to discomfort and remains inconsolable then you should contact your pediatrician. 

What stage of teething hurts the most?

The emergence of molar teeth in stage 5 at the age of 22-23 months is considered to be the most painful stage of teething. This could be due to the large size of molars.

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References:

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• Markman L. Teething: facts and fiction. Pediatr Rev. 2009 Aug;30(8):e59-64. 
• King DL. Teething revisited. Pediatric Dentistry. 1994 May 1;16(3):179-82.
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• Tsang AK. Teething, teething pain and teething remedies. International Dentistry South Africa. 2010 Sep 1;12(5):48-61.
• Eisenstadt M, Malkiel S, Pollak U. It’s Alright, Ma (I’m only Teething...) dispelling the Myth from the Teeth. Acad J Ped Neonatol. 2017;3(4):1-4.
• https://edition.cnn.com/2016/02/19/health/baby-teething-no-fever/index.html
• https://www.mouthhealthy.org/en/az-topics/t/teething
• https://www.fda.gov/consumers/consumer-updates/safely-soothing-teething-pain-and-sensory-needs-babies-and-older-children

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