In infants, teething is a normal physiological process in which deciduous teeth (milk teeth or baby teeth) emerge through the gums.
Most children start teething around 6 months of age (although the onset of teething may be earlier or later, usually between 4 and 12 months). A full set of milk teeth is usually present by the time the child reaches 2-3 years of age.
Teething does not cause children to become systemically unwell. Symptoms are generally mild and localized, and include increased biting, drooling, gum-rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite, disturbed sleep, and (possibly) mild temperature elevation (less than 38°C).
The differential diagnosis of teething is extensive because of the variable nature of teething symptoms. It is important to exclude other underlying conditions.
Initial management consists of reassurance and advice on self-care measures, such as gentle rubbing of the gum and allowing the child to bite on a clean and cool object.
Paracetamol or ibuprofen suspension can be considered for infants 3 months of age or older.
Treatments not recommended include choline salicylate gels, topical anaesthetics, and complementary therapies such as herbal teething powder.
This CKS topic covers the management of teething in infants.
There are separate CKS topics on Candida - oral, Colic - infantile, Cough - acute with chest signs in children, Constipation, Croup, Gastroenteritis, Herpes simplex - oral, Nappy rash, and Urinary tract infection - children.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency [MHRA, 2011]. Prescriptions have been updated to reflect the revised dosing. Issued in July 2011.
July to November 2009 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
No new evidence-based guidelines since 1 August 2009.
HTAs (Health Technology Assessments)
No new HTAs since 1 August 2009.
No new economic appraisals relevant to England since 1 August 2009.
Systematic reviews and meta-analyses
No new systematic review or meta-analysis since 1 August 2009.
No new randomized controlled trials published in the major journals since 1 August 2009.
No new national policies or guidelines since 1 August 2009.
No new safety alerts since 1 August 2009.
No changes in product availability since 1 August 2009.
To diagnose teething in infants
To give appropriate self-care advice on managing the symptoms of teething
To exclude other more serious causes of upset
In infants, teething is the process in which deciduous teeth (sometimes known as milk teeth or baby teeth) emerge through the gums [Ashley, 2001].
Teething is a normal physiological process.
Limited evidence suggests that symptoms caused by teething are mild and localized. For further information, see Diagnosis.
There is considerable variation in the timing of teething.
In general, most infants start teething around 6 months of age. However, some children start teething before the age of 4 months (1%), or after the age of 12 months (1%).
Some children are born with deciduous teeth (natal teeth: around 1 in 2000–6000 live births) or they start teething in the first 4 weeks (neonatal teeth).
A full set of milk teeth is usually through when the child reaches 2–3 years of age [Ashley, 2001]:
Deciduous lower central incisors: 5–7 months.
Deciduous upper central incisors: 6–8 months.
Deciduous upper lateral incisors: 9–11 months.
Deciduous lower lateral incisors: 10–12 months.
Deciduous canines: 16–20 months.
Deciduous first molars: 12–16 months.
Deciduous second molars: 20–30 months.
By about 6 years of age, these deciduous teeth start to fall out, to be replaced with permanent teeth.
Consider teething as a cause of discomfort only if other causes have been excluded (see Differential diagnosis).
A wide variety of symptoms and signs are attributed to teething (sometimes incorrectly) and are common to a range of conditions and physiological changes (for example, salivary glands begin to function at 2–3 months of age and contribute to constant drooling).
Limited evidence suggests that symptoms of teething tend to be mild and localized.
Teething does not cause children to become systemically unwell.
Symptoms associated with teething:
Include increased biting, drooling, gum-rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite, disturbed sleep, and (possibly) mild temperature elevation (less than 38°C).
Generally start 3–5 days before each tooth eruption.
Check the mouth for signs of tooth eruption.
The gums swell and are tender to palpation just before tooth eruption.
These recommendations are based on limited evidence and are in line with information provided by published narrative reviews [Peleg and Shvartzman, 1999; Ashley, 2001; Jones, 2002; McIntyre and McIntyre, 2002; Anderson, 2004; Tighe and Roe, 2007; Nield et al, 2008].
Given that the gums swell and are tender to palpation just before tooth eruption, it is acknowledged that teething causes some discomfort to the infant.
However, there is limited evidence from a number of studies which indicates that:
There are no specific signs and symptoms associated with teething.
Mild symptoms are common, and teething is not associated with severe symptoms.
For further information, see Teething symptoms.
Common conditions that should be excluded in infants with teething symptoms include:
Infection — such as acute otitis media, croup, oral candidiasis, respiratory or urinary tract infections, meningitis, and primary herpetic gingivostomatitis.
Gastrointestinal — such as gastroenteritis, infantile colic, and gastro-oesophageal reflux disease.
Dermatological — such as atopic eczema and nappy rash.
Scenario: Management: covers the management of teething in an infant.
Exclude other underlying conditions which could be responsible for the symptoms, especially if the child appears unwell.
Offer reassurance, that teething is normal and is not an illness. Symptoms are generally mild and self-limiting.
Give advice on self-care measures to relieve teething symptoms:
Gentle rubbing on the gum with a clean finger.
Allow the infant to bite on a clean and cool object.
Examples include a chilled teething ring or a cold wet flannel. For children who have been weaned, consider the supervised use of chilled fruit or vegetables (such as bananas or cucumber).
Avoid objects that can easily be broken into hard pieces, as these are a choking risk.
Sugar-free products are preferred as they do not promote tooth decay.
Teething biscuits and rusks are not recommended if they contain sugar.
Consider paracetamol or ibuprofen suspension for relieving the discomfort of teething symptoms in infants 3 months of age or older. Paracetamol is preferred for infants with asthma.
Oral choline salicylate gels are contraindicated because of the risk of Reye's syndrome.
Topical anaesthetics and complementary therapies (such as herbal teething powder) are not recommended.
Explain that there is no good evidence to support their use.
Advise parents to follow the manufacturer's dosage recommendations if they decide to use these products.
Advise the parent to seek medical advice if the infant becomes systemically unwell (for example with a high fever) as this indicates an underlying condition unrelated to teething.
Recommendations for excluding other underlying conditions and when to seek medical advice
Conditions other than teething should be excluded in infants who are systemically unwell or in severe distress because limited evidence indicates that teething is not associated with severe or systemic symptoms, such as high fever (see Diagnosis for further information).
Consequently, parents should be advised to seek medical advice if the infant becomes systemically unwell.
These recommendations are based on expert opinion in narrative reviews and advice from the Medicines and Healthcare products Regulatory Agency [Grundy and Shaw, 1983; Ashley, 2001; Jones, 2002; McIntyre and McIntyre, 2002; South, 2003; Anderson, 2004; Nield et al, 2008; MHRA, 2009].
There is little or no evidence about the use of any treatment (including drugs, self-care, and complementary therapies) for relieving teething symptoms.
Gentle massage to the gum or biting on objects (such as teething rings) is thought to produce relief by producing counter-pressure against the gums [Jones, 2002].
Paracetamol or ibuprofen for pain
CKS identified no studies examining the use of these analgesics for relieving the discomfort associated with teething. However, their use is widely recommended by experts [Grundy and Shaw, 1983; Ashley, 2001; Jones, 2002; Wilson and Mason, 2002; Anderson, 2004; Nield et al, 2008].
Both paracetamol (120 mg/5 mL) and ibuprofen (100 mg/5 mL) suspensions are licensed for the relief of teething symptoms in infants 3 months of age or older.
Choline salicylate gel
Although widely used in the past, the evidence to support the use of choline salicylate gel (a topical analgesic) for teething is of poor quality.
The recommendation to avoid the use of choline salicylate gel in children younger than 16 years of age is in line with recent guidance issued by the Medicines and Healthcare products Regulatory Agency and Commission on Human Medicines due to risk of Reye's syndrome in this group [MHRA, 2009]. For further information, see Evidence on the adverse effects of topical analgesics.
Bonjela® teething gel no longer contains choline salicylate. It has been reformulated with lidocaine (a local anaesthetic).
Topical anaesthetic preparations
CKS does not recommend the use of topical anaesthetic preparations (generally containing lidocaine) as:
The evidence supporting their efficacy for relieving the discomfort associated with teething is of poor quality.
Case reports provide evidence suggesting serious adverse effects (such as seizures) with excessive use of topical anaesthetic preparations.
The effectiveness of local anaesthetic teething gels has been questioned — given that the gel is rapidly removed from site of discomfort by the tongue and saliva [Ashley, 2001].
CKS does not recommended complementary therapies as there is no evidence to support their use (such as the herbal product, Ashton and Parson® teething powder).
CKS has reviewed the evidence on the symptoms associated with teething and the treatments used to relieve teething symptoms.
Over past decades, there has been a perception among parents and healthcare professionals that teething can cause severe systemic symptoms (such as high fever) [Honig, 1975; Swann, 1979; Coreil et al, 1995; Wake et al, 1999; Wake and Hesketh, 2002; Sarrell et al, 2005]. However, there is increasing recognition that the symptoms of teething are mild [Illingworth, 1969; Anonymous, 1970; Anonymous, 1975; Swann, 1979; Ingram, 1981; King, 1994a; Peleg and Shvartzman, 1999; DenBesten, 2000; Ashley, 2001; McIntyre and McIntyre, 2002; Wilson and Mason, 2002; Anderson, 2004; Tighe and Roe, 2007; Nield et al, 2008].
Although the overall quality of evidence is poor, it is more supportive for an association between teething and localized symptoms than systemic symptoms [Wake et al, 2000]. No one symptom is diagnostic of teething.
The inappropriate use of teething as a diagnosis was highlighted in a prospective study. It involved 50 children (3–30 months of age) admitted to a Scottish hospital (in 1 year) with symptoms that were attributed to teething by their parents or GP [Swann, 1979].
An organic cause for the symptoms was identified in 48 children (such as upper respiratory tract infection, febrile convulsion, bronchitis, eczema) with one child diagnosed with meningitis. No known cause was found in two children. The investigators warned against using 'teething' as a diagnosis except for the 'most trivial symptoms'.
Although numerous symptoms have been attributed to teething, there have been few direct studies examining the relationship between teething and systemic symptoms. Five studies were identified by CKS. Four studies found teething resulted in mild symptoms (such as daytime restlessness, finger sucking or rubbing of the gum, drooling, and appetite loss) and possibly a mild fever. The fifth study had a number of methodological weaknesses which make it difficult to interpret the findings.
A Finnish prospective study examined 192 tooth eruptions in 126 infants (4–30 months of age) and 107 controls (totalling 1538 examinations). Teething did not increase the following outcomes: the incidence of infection, temperature, erythrocyte sedimentation rate, white cell count, diarrhoea, cough, sleep disturbance, or rubbing of the ear or cheek [Tasanen, 1968]. The only outcomes that increased with teething were daytime restlessness, amount of finger sucking or rubbing of the gum, drooling, and appetite loss.
In a small study based in a clinic in Israel, the mothers (who were blinded to the study objective) of 46 infants were asked to record daily rectal temperature as well as evidence of tooth eruption and other systemic diseases or symptoms [Jaber et al, 1992]. Although a statistical increase in mean daily temperature was found between the day of tooth eruption (37.6°C, 95% CI 37.33 to 37.86) and the period 4–19 days before eruption (36.9–37.1°C, 95% CI not reported, p < 0.025), the mean difference was approximately 0.5°C, indicating a mild fever. No difference was found for otitis media, diarrhoea, and cough. No convulsions were reported.
In a well-conducted US prospective cohort study undertaken in a paediatric clinic, data were collected by the parents of 125 infants (3–5.6 months of age) over an 8-month period — including twice-daily monitoring of temperature (by ear) and a daily log of 18 symptoms (including systemic illnesses). The study only found mild symptoms associated with teething, based on data from 19,422 child-days and 475 tooth eruptions [Macknin et al, 2000]. No teething child had a fever of 40°C or a life-threatening illness.
The only symptoms that were statistically associated with teething (over an 8-day period; defined as 4 days before tooth emergence to 3 days after) were increased biting, drooling, gum-rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite for solid foods, and mild temperature elevation.
Although many symptoms were associated with teething, none occurred in more than 35% of teething infants. In addition, no symptoms occurred 20% more often in teething than in non-teething infants.
Of the 2067 days children had a temperature higher than 37.8°C, only 64 days were associated with tooth emergence. Only 1 day (of 50 days) was associated with tooth emergence where the temperature was higher than 39.4°C. Only one of 369 tooth eruptions occurred when the child's temperature was higher than 39.4°C. Temperatures higher than 38.3°C (but not more than 38.9°C) showed a significant association (p < 0.01) with tooth emergence.
In another prospective cohort study based in three Australian city child care centres, 21 children (6–24 months of age) were followed for 7 months. Overall, 2067 days of data were collected, covering 236 tooth-days (defined as any of the 5 days leading up to and including the day of tooth eruption) and 895 non-tooth-days [Wake et al, 2000]. The mean age of the children was 14.4 (+/– 4.9) months; this is older than in other studies.
The study found no relationship between tooth eruption and fever (adjusted for age). Mean temperatures were almost identical for tooth-days and non-tooth-days for each children.
When reports from child care staff and parents were compared, the only variable independently associated with tooth eruption was parent reports of looser stools on tooth-days (but this was not the case from staff reports) (odds ratio 1.86, 95% CI 1.26 to 2.73). No differences in other symptoms were found.
In a retrospective case-controlled study of 585 healthy children attending a Colombian infant clinic over a 4-month period, 145 teething children (4–36 months of age, with at least one erupting tooth) were compared with the other 440 children (the control group) [Peretz et al, 2003]. Symptom assessment was based on parent feedback/recall at the time of examination.
Although the study reported more children with at least one erupting tooth (46%) had a fever (temperature greater than 39°C as measured by a nurse) and/or diarrhoea (severity unknown) compared with controls (11%), this study had a number of important limitations. For example, it is unclear how the control group was defined and whether teething occurred in this group or whether both groups were matched. In addition, data for 19.5% of the control group were missing and no information was provided as to whether other conditions (such as infections) were considered for the differences in symptoms reported.
CKS identified two other retrospective studies. Although a higher incidence of symptoms was reported, these results should be interpreted with caution, given that the observed symptoms might not be related to teething (as other potential causes, such as infections, were not excluded).
In a US retrospective study reviewing the records of 120 teething children (4–10 months of age) in a hospital 'well-baby' clinic, 39% of children exhibited one systemic disturbance while 22% reported more than one systemic disturbance (fever, rhinorrhoea, facial rash, vomiting, irritability, drooling, and diarrhoea) [Carpenter, 1978]. However, 38% children exhibited no symptoms.
Although fever (defined as a rectal temperature higher than 37.8°C) was reported in 23 children (19%), 12 of these children only had a temperature of 37.8°C, indicating a mild fever. Five children had a temperature of 38–39.3°C. No information was given for five children.
In a retrospective case series involving a review of 1104 records from a Brazilian dental baby clinic, gingival irritation (85%) was the most commonly-reported symptom by parents of children (0–3 years of age) with primary tooth eruption [Cunha et al, 2004]. This was followed by agitation (74%), increased salivation (70%), fever (unspecified, 46%), agitated sleep (39%), diarrhoea (35%), and runny nose (26%).
There is poor quality evidence to indicate that choline salicylate gel is effective for relieving the symptoms of teething in infants. However, in the UK, it is no longer recommended for children younger than 16 years of age.
For information on adverse effects, see Adverse effects.
CKS identified one small US double-blind study of poor methodological quality (with 86 participants), which compared a proprietary choline salicylate gel (Teejel®, strength and duration of treatment unspecified) with an unspecified placebo in infants (4–15 months of age) with 'objective signs of distress' (such as fussiness, drooling, and crying) [Palmer, 1962].
More parents in the choline salicylate gel group reported improvement for the combined outcome of restlessness and anorexia than the placebo group (76% compared with 22.5%, respectively). Response time to effect was also faster.
However, this study had a number of methodological weaknesses. For example, it is uncertain from the inclusion criteria whether these infants were teething or not. In addition, no information was given on how the participants were recruited or randomized, or how symptoms were objectively assessed.
Systemic and localized adverse effects have been reported with inappropriate use of choline salicylate 8.7% gel. This product is no longer recommended for teething by the Medicines and Healthcare products Regulatory Agency (MHRA) and Commission on Human Medicines (CHM) following a case report of salicylate toxicity.
The MHRA and CHM recommendation is in response to a case report (from Belfast) in which a 20-month-old boy presented with a 1-day history of severe vomiting, lethargy, and photophobia following excessive use of choline salicylate 8.7% gel (one 15 g tube over 24 hours, equivalent to 930 mg aspirin) [Oman et al, 2008]. A diagnosis of suspected Reye's syndrome was made by the authors of the case report after exclusion of metabolic disorders and because the systemic salicylate concentration was just above the therapeutic range.
However, a review by the MHRA and CHM concluded that a diagnosis of salicylate toxicity was more likely, given the high dose of salicylate and that the diagnostic criteria for Reye's syndrome were not fully met [MHRA, 2009].
In line with advice for aspirin, they recommended that topical oral salicylate preparations should be contraindicated in children younger than 16 years of age, because:
Although the threshold salicylate concentration to precipitate Reye's syndrome is unknown, there is a theoretical risk that the excessive use of choline salicylate gels could increase the risk of Reye's syndrome.
There are alternative treatment options to alleviate the pain associated with infant teething, orthodontic braces, and mouth ulcers.
Bonjela® teething gel no longer contains choline salicylate. It has been reformulated with lidocaine (a local anaesthetic).
CKS identified one other similar case report in the UK, involving a 21-month-old boy who was admitted in a semi-conscious state after being treated with three 10 g tubes of choline salicylate 8.7% gel over 48 hours (serum salicylate level was 380 mg/L) [Paynter and Alexander, 1979].
A case report of localized adverse effect (yellow-white lesions) has also been reported with inappropriate use of choline salicylate 8.7% gel [Wilson and Mason, 2002].
Although concerns about Reye's syndrome have previously been highlighted [Sarll and Duxbury, 1986], CKS found no case reports of this adverse effect connected with choline salicylate gel.
There is poor quality evidence to indicate that topical anaesthetics are effective for relieving the symptoms of teething in infants.
For information on adverse effects, see Adverse effects.
CKS identified one double-blind trial (performed over a 1-year period), comparing a topical anaesthetic solution (containing 0.3% lidocaine and 0.3% benzyl alcohol) with placebo [Seward, 1969]. A total of 215 infants (5–31 months of age) were recruited and assessed to be commencing tooth eruption and experiencing discomfort or pain during teeth eruption. No information was given regarding how treatment was randomly assigned or if the two groups were matched.
Based on response time to treatment, more mothers in the topical anaesthetic group reported treatment to be excellent (relief within 2 minutes) and moderate (relief within 5 minutes) than with placebo (p = 0.0006). Tooth eruption was reported to be visible in 40% of infants.
However, it is difficult to interpret these findings as it is not possible to determine the type and magnitude of relief reported. Given the results were based on feedback forms from parents, it is unclear if the results were biased by parents returning multiple forms (since 144 of 178 mothers returned more than one form).
No other trials investigating the use of topical anaesthetic gels for relieving teething were found.
Case reports provide evidence that topical anaesthetics can cause severe systemic adverse effects when used inappropriately in infants.
Adverse effects have been reported with oral use of topical anaesthetics in children younger than 2 years of age.
Seizure has been documented in three case reports with excessive use of lidocaine 2% solution. This included a 1-year-old girl (treated for herpetic gingivostomatitis), a 5-month-old boy (lidocaine used for teething) [Hess and Walson, 1988], and an 11-month-old boy (lidocaine also for teething) [Mofenson et al, 1983].
Severe methaemoglobinaemia was documented in a case report of a 15-month-old girl (with a complex medical history) who received small amounts of benzocaine 7.5% oral gel for teething [Bong et al, 2009].
A US literature review highlighted the dangers of local and topical anaesthetics in children [Curtis et al, 2009]:
It reported that, in 2003, there were 8576 exposures to local/topical anaesthetics reported to the American Association of Poison Control Centers; 67% of these cases involved children younger than 6 years of age.
A review of the American Association of Poison Control Centers' annual reports found seven deaths from topical anaesthetics, all in children younger than 6 years of age, during the period 1983–2003.
CKS found no randomized controlled trials examining the use of simple analgesics (such as paracetamol and ibuprofen) for symptomatic relief of teething in infants. However, their use is widely recommended by experts [Grundy and Shaw, 1983; Ashley, 2001; Jones, 2002; Wilson and Mason, 2002; Anderson, 2004].
Despite their widespread availability, CKS found no randomized controlled trials (RCTs) examining the use of complementary therapies (including herbal or homeopathic remedies) for relieving the symptoms of teething in infants (such as the herbal product, Ashton and Parson® teething powder).
Two reviews of homeopathic treatment for teething were identified [King, 1994b; Jordan, 2005]. Both failed to identify any evidence from RCTs specifically examining the use of homeopathic remedies for teething.
CKS found no randomized controlled trials examining the use of non-drug treatment (such as teething rings) for symptomatic relief of teething in infants.
Scope of search
A literature search was conducted for guidelines, systematic reviews, randomized controlled trials and background reviews on the primary care management of teething (up to 2 years).
Dates unrestricted — August 2009
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
tooth eruption/, teething.tw
|/||indicates a MeSH subject heading with all subheadings selected|
|.tw||indicates a search for a term in the title or abstract|
|exp||indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree|
|$||indicates that the search term was truncated (e.g. wart$ searches for wart and warts)|
Sources of guidelines
Medline (with guideline filter)
Sources of systematic reviews and meta-analyses
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NHS Economic Evaluations
Health Technology Assessments
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
Sources of national policy
Health Management Information Consortium (HMIC)
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