Teething troubles?

Abstract

The relationship between the eruption of the deciduous teeth and the general health of infants has been documented for over 5,000 years. A variety of physical disturbances (anything from minor upsets to potentially fatal illnesses) have historically been attributed to teething, however a number of recent publications have alluded to a clarification of some of the disputed features of teething. It is now accepted that the localised symptoms of teething vary between individuals, however, 'teething' continues to be an inappropriate diagnosis proffered by both healthcare professionals and lay people. Severe systemic upsets are unrelated to teething and, if present, the infant should be promptly referred to a physician for an accurate diagnosis and appropriate treatment. The treatment modalities used in teething have been diverse throughout the ages, frequently depending on the tenets of the medical profession and lay people, but now principally involve pain relief. This article examines the signs and symptoms frequently attributed to teething and their possible alternative causes. The contemporary principles of the management of teething are discussed, including supportive measures, the diverse range of available topical and systemic pharmacological preparations and the 'alternative' holistic therapies.

Full text

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BRITISH DENTAL JOURNAL VOLUME 192 NO. 5 MARCH 9 2002 251
Teething troubles?
G. T. McIntyre
1
and G. M. McIntyre
2
The relationship between the eruption of the deciduous teeth and the general health of infants has been documented for
over 5,000 years. A variety of physical disturbances (anything from minor upsets to potentially fatal illnesses) have
historically been attributed to teething, however a number of recent publications have alluded to a clarification of some of
the disputed features of teething. It is now accepted that the localised symptoms of teething vary between individuals,
however, ‘teething’ continues to be an inappropriate diagnosis proffered by both healthcare professionals and lay people.
Severe systemic upsets are unrelated to teething and, if present, the infant should be promptly referred to a physician for an
accurate diagnosis and appropriate treatment. The treatment modalities used in teething have been diverse throughout the
ages, frequently depending on the tenets of the medical profession and lay people, but now principally involve pain relief.
This article examines the signs and symptoms frequently attributed to teething and their possible alternative causes. The
contemporary principles of the management of teething are discussed, including supportive measures, the diverse range of
available topical and systemic pharmacological preparations and the ‘alternative’ holistic therapies.
1
Specialist Registrar (FTTA), Department of Orthodontics,
Glasgow Dental Hospital and School, 378 Sauchiehall
Street, Glasgow G2 3 JZ;
2
Hygienist, 10 Balhousie Street,
Perth PH1 5HH
Corresponding author: Dr. Grant McIntyre, Department of
Orthodontics, Glasgow Dental Hospital and School,
378 Sauchiehall Street, Glasgow G2 3 JZ.
Email: grant@mcintyreg.freeserve.co.uk
Refereed Paper
Received 14.02.01; Accepted 20.07.01
© British Dental Journal 2002; 192: 251–255
Th
e appearance of an infant’s first tooth is
regarded by most parents as one of a series of
significant developmental landmarks, and an
‘old wives’ tale’ regards its precocious erup-
tion as a sign of great intelligence. Anecdo-
tally however, the period associated with the
eruption of the deciduous teeth in infants can
be difficult and distressing for both the child
and their respective parents. The signs and
symptoms that are assumed to be caused by
teething are outlined in Table 1. The enigma
of teething is, at least, in part historical even
though many unexplained teething myths
continue to pervade contemporary child
health. This article examines the features of
teething and the historical and contemporary
principles of the management of teething.
HISTORICAL PERSPECTIVE
The relationship between the eruption of
the deciduous teeth and the general
health of infants has been documented
for over 5,000 years. Hippocrates, Homer,
Celsus and Aristotle are known to have
associated teething with significant mor-
bidity.
1
Hippocrates regarded primary
tooth eruption as a cause of severe ill-
ness, including fever, diarrhoea and con-
vulsions. Since, a number of other condi-
tions have been identified as resulting
from teething, as diverse as photophobia,
blinking eyes, vomiting, neuralgia,
severe head cold, weight loss, toxaemia,
tonsillitis, paralysis, cholera, meningitis,
tetanus, insanity and even penile dis-
charge.
2
The bourgeois medical profes-
sion in the 16th—19th Centuries even
regarded teething as being the cause of
death in a significant number of infant
fatalities. Around one half of all infant
deaths in 18th century France were
attributed to teething, and teething
accounted for 12% of the total deaths in
children younger than 4 years old in the
Registrar General’s Report of 1842.
3
Such was the importance of teething as a
● The inaccurate historical association between teething and significant morbidity and
mortality
● The features that are currently accepted to be associated with teething
● The symptoms and signs that are unrelated to teething, which necessitate referral to a
physician
● Advice which can be given to parents about current methods of teething pain-relief,
including conventional pharmacological and ‘alternative’ holistic methods
IN BRIEF
Table 1 Signs and symptoms of teething
Pain
Inflammation of the mucous membrane overlying the tooth (possibly with
small haemorrhages)
General irritability/malaise
Disturbed sleep/wakefulness
Facial flushing (le feu des dents)/circumoral rash
Drooling/sialorhoea
Gum rubbing/biting/sucking
Bowel upset (ranging from constipation to loose stools and diarrhoea)
Loss of appetite/alteration in volume of fluid intake
Ear rubbing on the same side as the erupting tooth

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252 BRITISH DENTAL JOURNAL VOLUME 192 NO. 5 MARCH 9 2002
diagnosis, the Latin term ‘Dentio diffi-
cilis’ was coined, literally meaning diffi-
cult dentition, however, the terms patho-
logical dentition, as well as ‘teething’ per
se have all been in common use at differ-
ent historical times. Although any asso-
ciation between teething and life-threat-
ening illnesses would be ridiculed today,
the perceived link between the two was
the nervous system; the stimulation of
trigeminal nerve endings in the mucous
membrane resulted in reflex stimulation
of other cranial and spinal nerves. The
dogma of teething and ill health even
continued into the 20th century,
Schwartzman (1942),
4
calculating that
teething could affect up to 13% of chil-
dren.
Historical management of teething
The historical management of teething
could only be described as barbaric by con-
temporary standards of clinical practice.
Remedies that have been prescribed for
teething through the ages have included
blistering, bleeding, placing leeches on the
gums, and applying cautery to the back of
the head!
5
Lancing
Lancing (was introduced by the respected
surgeon Ambroise Paré in the 16th century,
and rapidly became a skilled technique; no
doctor could practice without their ele-
gantly crafted lancet in their waistcoat
pocket. The procedure was conducted in
the absence of any anaesthesia, generally
requiring two incisions crossing at 90°
overlying the ‘difficult’ tooth. Authorities
such as John Hunter are known to have
regarded the benefits of gum-lancing
highly.
6
Few doctors challenged (or would even
contemplate challenging) the rationale for
gum-lancing, such was their unquestioning
belief in its potentially life-saving effect.
Only in the late 19th century did a few scep-
tics publicly doubt both the rationale and
supposed effect of gum-lancing — that of
relieving the pressure in ischaemic mucous
membrane overlying an incipiently erupt-
ing tooth, and the resulting inexorable
reflex stimulation of other body tissues.
Surprisingly though, lancing continued
to be performed into the 20th century,
Moody (1919)
7
reporting a case where con-
vulsions and fever were present. The unfor-
tunate cherub was subjected to the gum-
lancet: only returning to normal four hours
later!
Systemic medicaments
Systemic medicaments have through the
ages been common methods of managing
teething, many containing opiates and poi-
sons such as lead acetate, mercurials and
bromide. Ironically, many of these com-
pounds are actually causative of the symp-
toms associated with teething! Antedilu-
vian topical medicaments have included
hare’s brain, animal milk, butter, a
honey/salt mixture and hen’s grease.
8
Alternative non-pharmacological asi-
nine therapies such as dietary changes,
emetics and laxatives have all been in
favour at some time, even in the absence of
any gastrointestinal upset! Primitive peo-
ples have even been known to use a talis-
man or other phylactery in the prevention
and treatment of teething problems.
8
The decline in teething as a diagnosis and
its ensuing ‘treatment’ occurred when a num-
ber of significant diagnostic and therapeutic
medical advances were made, laboratory
medicine facilitating the accurate diagnosis
of many conditions including uncontrolled
vomiting, weight loss, septicaemia, tonsillitis,
infantile paralysis, cholera, meningitis and
tetanus, all of which were previously thought
to be caused by teething.
CONTEMPORARY PERSPECTIVE
Although many of the conditions histori-
cally thought to result from teething are
now accurately diagnosed as specific
clinical entities, the enigma of teething
continues to endure as a somewhat
wastebasket diagnosis, when no cause
can be found for a particular sign or
symptom.
The Medline (Internet Grateful Med), and
CINAHL databases were searched using the
key words: ‘infant’, ‘teething’, ‘symptoms’
and ‘signs’, to identify English language
reports of systematic reviews, cohort stud-
ies, case-control studies, case series and
secondary reviews investigating the symp-
toms and signs that are associated with
teething. Four cohort studies,
1,9–11
four sur-
veys of parents with children around the
teething age,
12–16
one case-control study,
17
and one case report
18
were identified.
In addition, two surveys of the opinions
of paediatricians regarding teething symp-
toms
19,20
have been published, whilst one
case series
21
investigated 50 children
referred to hospital that had been diag-
nosed as ‘teething’. Four secondary reviews
were also identified.
3,22–24
Bennett and
Brudno (1986)
25
in an ‘April fool’, reported
their cynical viewpoint of investigations
of teething symptoms and signs. Qualita-
tive data were abstracted from all the
reports and collated, except Bennett and
Brudno (1986).
25
Symptoms
It is now generally accepted, that the erup-
tion of the deciduous teeth is accompanied
by a number of relatively minor symptoms
(Table 1). General irritability,
1,13,24
dis-
turbed sleep,
24
gum inflammation,
12,15
drooling,
1,13,24
loss of appetite,
1,13
diar-
rhoea,
20
circumoral rash,
1,13,15,24
intra-oral
ulcers,
12,15
an increase in body tempera-
ture,
1,10,24
increased biting,
1
gum-rubbing,
1
sucking,
1
wakefulness
1
and ear-rubbing,
1
have all been identified as being temporal-
ly related to teething.
Other studies have failed to identify
daytime restlessness, diarrhoea, bronchitis,
an increase in finger sucking, gum rubbing,
drooling and a loss of appetite in teething
children,
9,13
whilst Wake et al. (2000)
11
could not confirm a strong association
between a range of teething symptoms and
tooth eruption. Although Macknin et al.
(2000)
1
identified several symptoms (see
above) to be associated with teething, con-
gestion, sleep disturbance, stool looseness,
increased stool number, decreased liquid
appetite, cough, non-facial rashes, fever
and vomiting were not significantly asso-
ciated with tooth emergence.
One survey
16
found that there is a spec-
trum of opinions held by parents regarding
the teething-associated symptoms. Whilst
only one parent in this study believed that
teething is not problematical, between
70–85% of parents reported that teething
was causally related to fever, pain, irritabili-
ty, disturbed sleep, biting, drooling and red
cheeks. Furthermore, between one-third and
one-half of these parents felt that nappy
rash, ‘sooking’, ear pulling, feeding difficul-
ties, a runny nose, loose stools, and infec-
tions were related to teething, whereas a few
parents related smelly urine, constipation,
colic and convulsions to eruptive difficulties.
In a survey of US paediatricians, Honig
(1975)
19
found that only 5 of 64 paediatri-
cians believed that irritability, eating prob-
lems, wakefulness and rashes were not
consequent to teething, and 18 paediatri-
cians thought that fevers of up to 39
º
C
could be caused by teething. Moreover, a
British Medical Journal editorial in 1975,
26
stated that fever, diarrhoea, rashes, fits, and
bronchitis should not be attributed to
teething. Paediatricians that diagnose these
symptoms and signs as teething were
delaying the diagnosis and treatment of
pyogenic meningitis, bronchopneumonia,
gastroenteritis, urinary tract infections and
other serious disorders.
Despite this information, Swann
(1979)
21
examined the records of 50 chil-
dren admitted to hospital with symptoms
attributed to teething by either parents or
doctors. In 48 of these children, organic
causes other than teething, including con-
ditions as diverse as upper respiratory tract
infections, febrile convulsions, bronchitis,
eczema and meningitis were identified.
Considerable variability exists in the
presence or absence of teething-associat-
ed symptoms, up to 75% of infants may
experience at least one local disturbance

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BRITISH DENTAL JOURNAL VOLUME 192 NO. 5 MARCH 9 2002 253
on eruption of the anterior deciduous den-
tition, the corresponding figure being
100% for the posterior teeth.
12
Carpenter
(1978)
14
found that in 120 subjects, dur-
ing the eruption of the mandibular decid-
uous central incisor teeth, only 39%
exhibited one of several symptoms (fever,
vomiting, diarrhoea, drooling, irritability,
facial rashes or rhinorrhoea), and of the
six children that were followed-up for 6
months or greater; the symptoms disap-
peared on either the day of, or the day
after eruption of the tooth.
Does teething cause sytemic upset?
The argument usually levelled against
teething as the cause of systemic upset is
that infancy, and especially the timing of
eruption of the deciduous incisors (6–12
months), coincides with the diminution of
the circulating maternal humoral immunity
conferred via the placenta, and the estab-
lishment of the child’s own humoral immu-
nity: most children of this age being rela-
tively susceptible to a myriad of relatively
minor infections.
Furthermore, the study reported by King
et al. (1992)
17
explored the possibility that
certain teething symptoms (fever, irritabili-
ty and eating disturbance) result from an
undiagnosed primary herpetic infection,
finding that 9 out of 20 infants reported to
be ‘teething’ by one of their parents pro-
duced an oral swab positive for herpes sim-
plex virus (HSV). Seven had an elevated
temperature, demonstrated signs of an
intraoral infection, and had general symp-
toms indicative of primary herpetic gin-
givostomatitis. Interestingly, none of the 11
HSV negative subjects demonstrated signs
of an oral herpetic infection, although five
had elevated temperatures.
An undiagnosed concurrent primary
herpetic infection could be responsible for
the symptoms of fever, irritability and
appetite loss, and that the formation of a gin-
gival crevice around a newly erupting tooth
could act as a portal of entry for herpes
viruses.
3
This ‘portal of entry’ theory cannot
explain the occurrence of these symptoms in
advance of that tooth’s emergence into the
oral cavity.
The symptoms of elevated temperature
and facial rash could be explainable by
infection with the Human Herpes Virus 6
(HHV-6) agent, which is ubiquitous among
infants of teething age.
3
Despite the fact that there is disagree-
ment as to which of the signs and symp-
toms in Table 1 are actually causally relat-
ed to teething
1
and that several of these
features can be explained by alternative
non-teething aetiologies, many parents
will testify that their children are teething.
This is because of the transient nature and
close temporal relationship of the features
of teething to the pre-, peri-, and post-
eruptive period of individual teeth; Mack-
nin et al. (2000)
1
finding that teething was
associated with an 8 day window: 4 days
before, the day of, and 3 days after emer-
gence of the tooth. There is, however, con-
siderable variability between and within
individuals as to the presence and severity
of any symptoms and signs of teething,
and that the symptomatology cannot pre-
dict the emergence of tooth.
1
Pain
Pain is reported as a common feature of
teething by parents. It is known that the
tooth does not actively contribute to erup-
tion and that the dental follicle is a rich
source of eicosanoids, cytokines and
growth factors,
27
which could result in a
localised inflammatory response, leading
to pain. Anecdotally, lay people state that
the symptoms of the teething process, in
the absence of any visible imminent teeth
are caused by ‘the tooth coming through
the bone’. There is no evidence to support
this proposal, and indeed, it is far more
plausible that the aetiology of the teething
symptoms in this situation are caused by
one of the many childhood illnesses.
MANAGEMENT OF TEETHING
The majority of investigations of ‘teething’
have sought to confirm the presence or
absence of associated features. Compara-
Table 2 Management of teething
Teething rings (chilled)
Hard sugar-free teething rusks/bread-sticks/oven-hardened bread
Cucumber (peeled)
Frozen items (anything from ice cubes to frozen bagels, frozen banana, sliced fruit,
pretzels, vegetables!)
Pacifier (even frozen)
Rub gums with clean finger, cool spoon, wet gauze
Reassurance
Analgesic/antipyretics (see Table 3)
Topical anaesthetic agents (see Table 3)
Alternative holistic medicine
Table 3 Teething medicaments
Local anaesthetics Dentinox Teething Gel® (DDD, Watford), Calgel® (Warner Wellcome, Eastleigh) Lignocaine hydrochloride 0.33%, cetylpyridinium chloride 0.1%
Rinstead Teething Gel® (Schering-Plough, Welwyn Garden City) Lignocaine hydrochloride 0.5%, cetylpyridinium chloride 0.1%
Woodward’s Teething Gel® (LRC, London) Lignocaine 0.5%, cetylpyridinium chloride 0.025%, ethanol 30%
Anbesol Teething Gel® (Whitehall laboratories Ltd, Maidenhead) Lignocaine hydrochloride 0.9%, chlorocresol 0.1%, cetylpyridinium
chloride 0.02%
Minor analgesics Choline Salicylate Dental Gel BP, Choline salicylate 8.7%, cetalkonium chloride 0.01%
Bonjela® (Reckitt & Colman Ltd, Kingston upon Hull),
Teejel® (Seton healthcare, Oldham)
Paracetamol Paracetamol Oral Suspension Paracetamol 120mg/5ml
based preparations Infadrops® (Goldshield Pharmaceuticals Ltd, Croydon) Paracetamol 100mg/1ml
Calpol Infant (sugar-free available)® (Glaxo Wellcome, Middlesex) Paracetamol 120mg/5ml
Disprol infant suspension® (Reckitt & Colman, Kingston upon Hull) Paracetamol 120mg/5ml
Panadol Baby and Infant Suspension® Paracetamol 120mg/5ml
(Smithkline Beecham plc, Welwyn Garden City)
Medinol Under 6® (SSL International plc, Knutsford) Paracetamol 120mg/5ml
Medised® (Martindale Pharmaceuticals Ltd, Romford) Paracetamol 120mg, promethazine 1.5mg/5ml
Fennings Children’s Cooling Powders® (Anglian Pharma, Hitchin) Paracetamol 50mg per 200mg dosage
Panaleve Junior® (Pinewood Healthcare, Dublin) Paracetamol 120mg/5ml
Boots Infant Pain Relief® (The Boots Co plc, Nottingham) Paracetamol 120mg/5ml, ethanol 4.8% v/v
Placidex Syrup® (E. C. De Witt & Co Ltd, Runcorn) Paracetamol 120mg/5ml

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254 BRITISH DENTAL JOURNAL VOLUME 192 NO. 5 MARCH 9 2002
tively little research has investigated the
management of teething, in particular the
treatment of teething pain (advice regularly
sought by frustrated parents). The current
methods of the management of teething are
presented in Table 2. Table 3 details the pro-
prietary names and constituents of teething
medicaments. Infants with severe systemic
upset should be promptly referred to a
physician for an accurate diagnosis and
appropriate treatment.
Non-pharmacological management
A wide range of teething rings are com-
mercially available for infants to ‘gnaw’
however, parents should be advised to
check the packaging carefully for any
potentially harmful substances used in
their manufacture. Solid silicone-based
teething rings are superior to their liquid
filled counterparts, as the potentially
irritant contents may leak, if damaged,
and furthermore, usually, they cannot be
sterilised. Temporary pain relief is pro-
vided by the pressure produced by chew-
ing the teething ring, maximal when
chilled first.
Teething rings should be attached to
the infants clothing, and not tied around
the neck, as strangulation could result.
Hard, non-sweetened rusks such as Bick-
iepegs, made from flour and wheatgerm
with no sugar or sweetener can also be
attached onto the infant’s clothing.
Many infants achieve pain relief when
chewing breadsticks and oven-hardened
bread, whilst other parents recommend
frozen breads (for example bagels). A vari-
ety of fresh and frozen fruit and vegetables
have been used by teething infants, any-
thing from peeled cucumber to frozen
bananas!
Although many parents have strong
views about providing infants with a
pacifier at any time, many teething chil-
dren are comforted by a pacifier, and will
chew the teat to provide temporary pain
relief. Several of the methods described
above involve the application of pressure
to the painful area of mucous membrane,
and mild pressure can also be applied
with a clean finger (possibly with wet
gauze) or a cold spoon. Excessive saliva-
tion commonly runs onto the infant’s
skin, and should be wiped away regularly
otherwise, a rash (which may be consid-
ered pathognomic of teething) may
develop.
Reassurance can often be one of the
most effective methods of calming a dis-
tressed teething child.
Pharmacological management
Most parents prefer to avoid using pharma-
cological preparations during teething,
however, a wide range of effective topical
and systemic preparations are available
when local measures fail to provide relief.
Topical agents
This group of medicaments includes local
anaesthetics (lignocaine-based prepara-
tions) and minor analgesics (choline salicy-
late based preparations). Parents should be
advised to wash their hands thoroughly
before applying topical agents directly to
the painful area of mucous membrane.
Some of their reported relief may be due to
the pressure of application.
Lignocaine-based products
Lignocaine hydrochloride is a local anaes-
thetic that is rapidly absorbed through
mucous membrane giving prompt relief
from pain, although temporary. Anbesol
Teething Gel® (Whitehall laboratories Ltd,
Maidenhead), Dentinox Teething Gel®
(DDD, Watford), Calgel® (Warner Wellcome,
Eastleigh), Rinstead® Teething Gel® (Scher-
ing-Plough, Welwyn Garden City) and
Woodward’s Teething Gel® (LRC, London)
are the proprietary over-the-counter (OTC)
products available. Although Anbesol® is
marketed as a teething gel, it is primarily
marketed as an adult remedy (for denture
irritation), and the concentration of ligno-
caine is almost three times that of Dentinox
Teething Gel® (see Table 3), even though
the instructions for teething babies are
similar on both packets.
Dentinox Teething Gel®, Calgel® and
Rinstead Teething Gel® are specifically
formulated for teething infants, the dosage
of lignocaine being reduced in accordance
with the much smaller body size of infants.
Around 7.5 mm of gel should be placed on
a clean finger or cotton bud, and rubbed
onto the painful area. Although 20 min-
utes should elapse between approaches,
only six applications should be used each
day, in order to prevent systemic toxicity.
Woodward’s Teething Gel® is available
OTC, however it surprisingly consists of
some 30% ethanol (alcohols are not rec-
ommended for infants, and specifically the
application directly to mucous membrane
should be avoided).
It should be remembered that products
containing lignocaine should be avoided if
any sensitivity is suspected.
Choline salicyate-based products
Salicylates are regarded as minor anal-
gesics and are similar to lignocaine
hydrochloride in that they penetrate
mucous membrane readily and give
prompt pain relief. Their main pharmaco-
logical advantage over lignocaine-based
preparations is that in addition to provid-
ing analgesia, they are also anti-inflamma-
tory and antipyretic, thus reducing
swelling.
Choline salicylate is a non-irritating
compound. Choline Salicylate Dental Gel
BP, Bonjela® (Reckitt & Colman Ltd,
Kingston upon Hull) and Teejel® (Seton
healthcare, Oldham) consist of 8.7%
choline salicylate with cetalkonium chlo-
ride 0.01%, a quaternary ammonium com-
pound.
The Dental Practitioners’ Formulary
(2000–2002)
28
[DPF] recommends for
children over 4 months old, 0.5 inch
(7.5 mm) of gel to be massaged onto the
painful area not more often than 3 hourly,
with a maximum of six applications daily,
however the DPF
28
suggests its benefit in
teething may merely be caused by the
pressure of application.
Choline salicylate is related to aspirin,
each tube containing 870 mg of choline
salicylate, equivalent to 600 mg of
aspirin, and according to the manufactur-
er’s recommendation of one application
every 3 hours, one third of one tube could
be utilised in 24 hours, equalling 200 mg
of aspirin.
The link between aspirin and Reyes
syndrome is not relevant for non-aspirin
salicylates.
28
Although the Reyes syn-
drome problems are specific to the use of
aspirin after viral infections, many paedi-
atricians and pharmacists now advocate
the avoidance of choline salicylate prepa-
rations in teething.
29
Frequent application of choline salicy-
late preparations to the oral mucosa may
result in a chemical burn.
SYSTEMIC ANALGESICS
A sugar-free paracetamol elixir is the sys-
temic medicament of choice in teething
because of its action in reducing pain and
pyrexia (where present). Paracetamol is
thought to act by inhibiting prostaglandin
production. Surprisingly, primary-care
prescriptions of non-proprietary paraceta-
mol have to specifically request a sugar-
free preparation. Paracetamol elixir is
available either on prescription, or in a
number of OTC preparations. The DPF
28
recommended paracetamol dosage is:
3–12 months = 60–120 mg
1–5 years = 120–250 mg
(It should be noted, that the BNF
30
recom-
mends the prescription of paracetamol for
infants under 3 months of age on a doctor’s
advice only). These doses are repeated at 4–6
hourly intervals, with a maximum of four
doses in 24 hours. A graduated syringe should
be used for doses under 5 ml, and a calibrated
spoon for doses over 5 ml.
Most OTC preparations contain the same
dose of paracetamol (120 mg/5 ml), however
Infadrops® (Goldshield Pharmaceuticals Ltd,
Croydon) contain 100 mg/1 ml. Medised®
(Martindale Pharmaceuticals Ltd, Romford)
also contains promethazine (an antihista-

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BRITISH DENTAL JOURNAL VOLUME 192 NO. 5 MARCH 9 2002 255
mine), which may make the infant drowsy.
Fennings Children’s Cooling Powders®
(Anglian Pharma, Hitchin) contain a much
lower dosage of paracetamol than would
appear from the 200 mg ‘dosage’, which
could be confusing for parents.
Underdoses of paracetamol for
teething children are ineffective, whilst
overdosing may lead to severe hepatocel-
lular necrosis and renal tubular necrosis
(DPF).
28
Certain medical conditions (eg
HIV-positive and malnourishment) and
enzyme-inducing drugs (eg carbe-
mazepine) mean that infants may devel-
op toxicity at significantly lower plasma
paracetamol concentrations and this
should be borne in mind when recom-
mending or prescribing paracetamol.
Ibuprofen suspension can be given to
children over one year, but is not recom-
mended for teething.
‘Alternative’ holistic medicine
Alternative non-pharmacological holistic
therapies (acupressure, aromatherapy,
massage and homeopathy) have been sug-
gested as giving relief from the symptoms
of teething.
Acupressure requires the parent to apply
pressure to certain key skin points, provid-
ing immediate, if temporary pain relief.
Aromatherapy uses essential oils (for exam-
ple diluted clove oil, tea tree oil or even
olive oil), often with massage to neutralise
the inflammatory mediators produced dur-
ing teething. Alternatively, chamomile oil
(recommended for teething) may be placed
(out of reach) in an aromatherapy diffuser
in the infant’s bedroom.
Teething children can be comforted
and stimulated by a full body massage,
however this is not recommended for
young infants.
Homeopathy uses the following three
principles. Minute doses of a substance
that causes a particular condition in a
healthy person are curative in the ill indi-
vidual. Serial dilution increases the cura-
tive power and avoids unwanted side-
effects. Homeopathy treats the whole
person, not solely the illness and is
becoming a more popular method of
treating the symptoms of teething.
The active ingredient in Ashton and
Parsons Infant Powders® (SSL Interna-
tional PLC, Knutsford) is matricaria tinc-
ture (4 mg), a carminative related to
chamomile. The main indications of this
product are to ‘soothe the child, correct
the motions, relieve restlessness, fretful-
ness and similar troubles incidental to
the teething period…’ all potentially use-
ful benefits during teething, although
chamomile and its relations are not
reported to have any pain relieving qual-
ities. Teetha® (Nelson Bach USA Ltd,
Wilmington, MA, USA) and Boots Home-
opathic Teething Granules® (The Boots
Co plc, Nottingham) contain 6c potency
of Chamomilla, one sachet should be
poured into the infant’s mouth every 2
hours, up to a maximum of six doses in
24 hours.
Practices that are not recommended
Parents should be advised that a number
of outdated practices are potentially
harmful. Adding sugar, honey or jam to
feeding bottles, or dipping a pacifier in
honey or jam has absolutely no pain
relieving effect, and is highly cariogenic.
Similarly, giving a teething infant a feed-
ing bottle in bed should be discouraged.
Parents should also be advised the repeat-
ed application of alcohol to the mucous
membrane of an infant is ineffective as a
topical anaesthetic and due to an infant’s
small body weight, may lead to hypogly-
caemia.
General advice regarding medication
Only sugar-free objects and medication
should be prescribed during teething. The
potential exists for parents to unwittingly
overdose their child when dispensing
medicaments, with phrases like ‘…and
one spoonful extra for the cot’, and the
dangers of paracetamol overdose should
never be ignored. Paynter and Alexander
(1979)
31
reported the case of an infant
overdosed with a salicylate-containing
teething gel, where a well-meaning
mother had liberally applied the gel onto
the gums of her apparently teething child.
It transpired that in 48 hours, she had
used three complete tubes, some 2,610 mg
of choline salicylate!
Teething remedies should be kept well
out of reach of all children, as even
‘childproof’ containers can be opened by
small children, and because of added
flavourings, children can unwittingly
overdose themselves. Medicines, includ-
ing teething remedies, should never be
added to food or feeding bottles, as par-
ents (or carers) cannot accurately control
the dosage ingested. In addition, the
active ingredient of the medication may
adversely interact with foodstuffs and
the possibility exists for other children to
share potentially harmful medication in
this way.
CONCLUSIONS
• The diagnosis of teething, although his-
torically having been applied to almost
any condition whatsoever, is now
reserved for a specific collection of vari-
able signs and symptoms.
• Severe systemic upsets are unrelated to
teething and, if present, the infant should
be promptly referred to a physician for
an accurate diagnosis and appropriate
treatment.
• The currently accepted methods of pain
relief for teething infants have pro-
gressed considerably since the days of
leeching and gum-lancing.
• A number of supportive measures as well
as topical and systemic pharmacological
preparations, in addition to alternative
holistic therapies can be used to relieve
the pain of teething.
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