Teething

Overview of teething

There are several milestones in the growing years of a child. These include- crawling, walking, the growth of teeth and the development of speech. Among all these milestones, teething seems to be the most unpleasant and painful experience for a child. It is an indicator of the development of a child’s first set of teeth. Medically, teething is not a disease. But there are numerous complications related to this condition that a child has to cope with. It usually starts at the age of 4 months and can extend up to 8 months. Teething marks a very important stage in the dental development of a child. Parents should take care so that no oral or dental disease develops during this period.

What is teething?

Teething or “difficult dentition” or “dentition difficilis” is the natural phenomenon of the eruption of the first few teeth in the earliest stage of a child’s development. It starts with the appearance of upper and lower incisors. Normally, the process starts at the age of 4 months and is almost complete at the age of 8 months. The process is fully complete within the age of 30-36 months, with the eruption of the second primary molars. Usually, the two front teeth present in the bottom are the first ones to erupt. Around 4-8 weeks later, the four front teeth present in the upper gum appear. Within 3 years of age, almost all children have their 20 primary teeth formed. 

How does teething occur?

The phenomenon of teething involves two main processes- bone formation and bone resorption. An eruption pathway is generated on opposite sides of the dental follicle. The common tooth germs from within the dental follicle at this stage. A reduced enamel epithelium forms over the dental follicles. The enamel epithelium and the oral epithelium merge at the cusp of the erupting tooth. In the next stage, the upper layer (of fused epithelium) degrades. The development of the periodontal ligament, pulp, and roots of the teeth occurs in the next stage. Finally, the tooth crown emerges and the process of growth of teeth is complete.

What are the factors regulating teething?

There are numerous factors that regulate the mechanism of teeth development. Some of these factors may accelerate the process, while some may delay it. The commonly studied factors are listed below-

• Genes: A particular variety of gene called C-FOS is responsible for “protein-coding” in the early years of a child’s development. Mutations or abnormal activities of this gene can adversely impact the process of teeth development.
• Hormones: Some important hormones that are regulators of the teething mechanism are- Thyroid hormones, Parathyroid hormones and Pituitary Growth Hormones. These hormones also regulate the functioning of the salivary glands which become overactive during teeth development.
• Growth factors: Certain growth factors such as Transforming Growth Factors β1 (TGF- β1), Colony Stimulating Factor-1 (CSF-1), Epidermal Growth Factor (EGF) are directly related to “teething”. Infants feeding on breast milk for a long period of time usually have a healthy and timely teething. On the other hand, malnourished children usually exhibit an extremely delayed teething with numerous complications.
• Cytokines: A few harmful chemicals are released into the child’s body during the “teething period” that lead to the complications associated with teething. These chemicals are called cytokines. A few examples of these types of chemicals are- Interleukin 1α (IL-1α), Interleukin 1β (IL-1β), Tumour Necrotising Factor α (TNF- α) and Interleukin 10.
• Proteins: A few proteins are closely related to “teething”. These are- Immunoglobulin-A (IgA), Parathyroid Hormone related Peptide (PTHrP) and Monocyte Chemotactic Protein-1 (MCP-1). Defects in protein-coding can lead to complications in the teething period. 

What are the common signs and symptoms?

Teething is accompanied by two main types of symptoms- localized and systemic. The localized symptoms include- irritation and swelling of gums, rubbing of gums and constant thumb-sucking. The systemic manifestations include- excessive drooling, poor appetite, restlessness, constant crying, fever, and irritability. The symptoms are discussed in details below-

• Drooling: In a few infants, excessive drooling occurs within the age of 3-4 months. This occurs due to the generation of excess saliva in the mouth.
• Biting: A baby in its teething period tends to bite and nibble at every solid object around it. This helps relieve the pressure of emerging teeth under the gums.
• Rubbing: A teething baby is often found to rub its cheeks and pull its ears frequently. This happens due to pain in the gums radiating to the cheeks and ears. This symptom is more prominent when the back molars start erupting.
• Coughing: A baby is found to cough constantly during the teething period. This occurs due to the accumulation of excess saliva in the mouth.
• Irritation: Irritation and inflammation of gums occur during the teething process. This is also accompanied by soreness and redness of gums when the molars erupt.
• Rashes: Red patches and tiny reddish dots may appear on the chin and around the mouth. This is often a result of excessive salivation and constant drooling that irritates the sensitive skin of the child.
• Flu-like symptoms: A child may be found to have a low-grade fever and an extremely runny nose, with constant itching during the teething period. A proper diagnosis should be carried out to check whether the symptoms are associated with teething or any other infection.
• Disturbed sleep: Interrupted sleep occurs especially at night, due to increasing pain caused by the developing molars.
• Bowel incontinence: Some children show Diarrhoea-like symptoms during teething. This is caused by the swallowing of excess saliva that increases the liquidity of the stool.
• General malaise: The child may exhibit restlessness, irritability and constant crying. 

What are the necessary diagnostic tests?

Dental caries may develop at an advanced stage when the child has already grown a few teeth. Dental probe and dental radiograph are recommended by the dentists in such cases.

Treatment and management

There are no treatments for teething. However, the sore gums of the baby can be managed by the following methods:

• Hard foods– Giving the baby chilled solid foodstuffs to bite on (such as a peeled cucumber or carrot) can ease the irritation.
• Teething toys– Hygienic and cold teething toys can be given to the baby to ease the sore gums. A cold washcloth, a cold spoon etc. can also help to relieve the discomfort. Use of fluid-filled teething rings should be avoided. The teething toy should be safe for the baby.
• Gum massage– Massaging with a mild pressure can help in relieving the discomfort. A clean finger or a moistened gauze pad can be used to massage the baby’s gums.
• Over-the-counter remedy- In cases where the baby becomes cranky and irritable, over-the-counter medications such as ibuprofen or acetaminophen can be given.

As teething is a natural phenomenon occurring while the teeth erupt in the mouth, there are no methods to prevent it.

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