NICE CKS—teething

This summary has been developed for use by community pharmacists under our Guidelines for Pharmacy title and therefore only covers the information relevant to this setting. Please refer to the full guideline for the complete set of recommendations.

At what age does teething occur?

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%)
• In around 1 in 2000–6000 live births, children are born with deciduous teeth (so-called ‘natal teeth’), or they start teething in the first 4 weeks of life (‘neonatal teeth’)
• Generalized delay in tooth eruption has been noted in hypopituitarism, hypothyroidism, infantile rickets, and Down’s Syndrome
• A full set of milk teeth has usually emerged through the gums when the child reaches 2–3 years of age

When should I suspect a child is teething?

• Consider teething as a cause of symptoms in an infant or young child up to the age of 3 years, only after other possible causes have been excluded
  • ask the parent/carer about signs and symptoms associated with teething, which generally start 3–5 days before each tooth eruption
    • clinical features may include pain, increased biting and chewing, drooling, gum-rubbing, sucking, irritability, wakefulness, ear rubbing, facial rash, decreased appetite, disturbed sleep, and in some cases mild pyrexia (temperature less than 38°C)
    • be aware that symptoms associated with teething tend to decrease with age, and no specific symptom or sign is diagnostic for teething
  • examine the child for signs of tooth eruption
    • just before tooth eruption, the gums may swell, appear red, and become tender on palpation
    • there may be associated facial flushing

What else might it be?

Conditions that may cause symptoms or signs similar to those associated with teething include:

• Physiological drooling—salivary glands begin to function at 2–3 months of age and contribute to constant drooling
• Eruption cyst—swelling of the soft tissue covering one tooth, which is usually not tender and resolves by itself. The swelling can last for 1 or 2 months
• Eruption haematoma—this is most frequently seen in the primary second molar or the first permanent molar region, and may also occur following the eruption of primary molars when canines are erupting. It causes red inflammation from the region of the laterals to the molars and can be painful, particularly if the four canines are erupting simultaneously
• Infection—such as acute otitis media, croup, oral candidiasis, respiratory or urinary tract infections, and primary herpetic gingivostomatitis
• Gastrointestinal—such as gastroenteritis, infantile colic, gastro-oesophageal reflux disease (GORD), and constipation
• Skin—such as atopic eczema and nappy rash

Management of teething from birth to 36 months

If an infant or young child presents with suspected teething

• Exclude any alternative conditions which may cause similar symptoms, especially if the child is systemically unwell or severely distressed
• If an alternative diagnosis is unlikely, offer parents/carers advice on sources of information and support:
  • reassure that teething is a normal process and not an illness, and symptoms are generally mild and self-limiting
  • as soon as teeth erupt in the mouth brush them twice daily, to reduce the risk of secondary gingivitis due to plaque accumulation
  • encourage parents/carers to take their child to the dentist before the first tooth erupts, at about six months of age
  • the NHS information leaflets Baby teething symptoms and Tips for helping your teething baby may be helpful
  • the patient information leaflet Teething available on the www.patient.info website may be helpful
• Give advice on self-care measures to relieve teething symptoms, such as:
  • gentle rubbing of the gum with a clean finger
  • allowing the infant to bite on a clean and cool object, such as a chilled teething ring or a cold wet flannel
    • for children who have been weaned, the supervised use of chilled fruit or vegetables (such as banana or cucumber) can be considered
    • objects that can easily be broken into hard pieces should be avoided because of the risk of choking
    • sugar-free products are preferred as they do not promote tooth decay
  • cuddling and reassuring the child
  • wiping away excess saliva regularly to reduce the risk of facial rash
• Consider the use of over-the-counter paracetamol and/or ibuprofen to provide symptom relief in infants three months of age or older, if self-care measures have not helped
• Give advice on the use and availability of other over-the-counter treatments
  • advise that topical oral lidocaine-containing products for infant teething (such as Bonjela^® and Dentinox^® teething gels) are only available under the supervision of a pharmacist
  • do not recommend the use of topical oral salicylate gels for children under 16 years of age (such as Teejel^®) as these are contraindicated in this age-group
  • do not recommend the use of homeopathic teething tablets or gels or herbal medicines (such as teething powders). If parents/carers choose to use these products, advise them to follow the manufacturers’ dosage instructions and to avoid any unlicensed products
• Give safety-netting advice to parents/carers to seek urgent medical review if the infant or child becomes systemically unwell, is severely distressed, or has prolonged symptoms