Mrs. Ibersen brings her 4½-month-old baby boy, Daniel, to your office. Daniel has a fever of 39°C. for the past 3 days and some diarrhea. His mother noticed a lower central incisor breaking through his gum.

Does teething cause any symptoms? If so, which ones? How should ‘teething’ be treated? What does the evidence show?

A bit of history

Historically, teething, like circumcision, has become surrounded with mythology. Many different symptoms and a multitude of remedies have been proposed. Here’s a brief sampling beginning with Hippocrates. Teething children suffer from itching of the gums, fever, convulsions, diarrhoea, especially when they cut their eye teeth, and when they are very corpulent. J.W.Holtman in his manual for mothers (1845) stated: Beside the general febrile symptoms attendant upon the teething of children, many other troublesome and sometimes fatal complaints follow. Mrs. Nathaniel Hawthorne’s chronic illness was attributed to teething difficulties in infancy; miraculously, her symptoms resolved when she married Nathaniel Hawthorne at age 31 and was taken out of the hands of her physicians! The Registrar General of England reported 5,016 deaths due to teething in 1839.

A recent survey sent to health professionals in Victoria State, Australia, indicated that most thought that teething caused a variety of symptoms — irritability, dribbling, biting objects, sleep difficulties, inflamed gums, red cheeks, feeding problems, pulling ears, loose stools, cold symptoms and smelly urine.

Many remedies for teething have been prescribed, including lancing the gum at the site of eruption, applying capon’s grease mixed with nutmeg and honey to the gums (Nicholas Culpeper, 1616-1654), topical anesthetics, opium, paracetomol, antihistamines, applying whiskey to the gums, phenobarbital, rubbing or applying ice to the gums, teething rings and others. More recent OTC remedies include benzocaine topical anesthetic (Orajel) applied to the gums — not recommended because of the risk of methemoglobinemia in young infants. A recent review of folk remedies for teething (Smitherman) pointed out the dangers of several of them i.e. asafetida sold as a tincture or spice in health food stores (methemoglobinemia); whiskey (ethanol poisoning and hypoglycemia).

Recent evidence

Two prospective cohort studies have been published. The Australian study (Wake) prospectively followed a cohort of 21 children, between 6 months and 2 years of age, in 3 different daycare centres. Parents and staff completed a questionnaire asking about the child’s mood, well or ill appearance, drooling, rashes and diarrhea over the preceding 24 hours. A dental therapist daily assessed each child’s temperature and determined if any tooth had erupted. Contrary to the parents’ beliefs that teething caused a variety of symptoms — mood changes, unwell appearance, sleep disturbances, drooling, diarrhea, strong urine, red cheeks or rashes — the trial did not find any significant associations.

The second study (Macknin) recruited 125 infants (age 3-5.6 months) from the staff of the Cleveland Clinic Foundation. Patients recorded their infant’s temperature twice daily and kept a log of 18 symptoms. They checked daily whether a new tooth had erupted. The teething period was defined as 8 days beginning 4 days before eruption and extending 3 days afterwards. During the study period, 475 teeth erupted in 89 children. These authors did find associations of biting, drooling, gum rubbing, irritability, sucking, sleep disturbance and ear rubbing during the teething period. A connection between a slight fever on the day of eruption or one day before was observed. The temperature associated with tooth eruption was never greater than 38.3°C. Temperatures over 38.8°C showed no connection with tooth eruption. There was no association of teething with cough, rash other than facial, or diarrhea.

“Teething produces nothing but teeth”

Our answer for Mrs. Ibersen is her son’s fever and diarrhea cannot be attributed to teething. Physicians must discover the cause of the fever. Mistakes will be made if a child’s high fever and lethargy or other symptoms are attributed to teething — this is the reason for the 5,016 deaths attributed to teething in 1839 England! If a child is uncomfortable during teething, a cold teething ring to chew on and a dose of acetaminophen is all that’s required.