OPINION personal view It’s only teething… A report of the myths and modern approaches to teething M. P. Ashley1
Paediatric dentistry is not my usual field of work. I am now based ter, come off best’. Gastrointestinal disorders and contamination of foodstuffs were more almost entirely in restorative dentistry and it is five years since I frequent in the summer. worked in the dental department of a children’s hospital. An essay In medieval times, animal substances on teething would appear to be an unusual choice of topic. With the were still being rubbed into the gums and current professional climate of ‘general professional education’ and teething infants were encouraged to chew ‘lifelong learning’ I can easily justify my time and effort studying a on hard objects such as roots. In 1429, Von Louffenberg, a German priest, summarised subject somewhat removed from my regular work. However, to be the care of a teething baby. completely honest, I have reached that age when many of my ‘Now when your baby’s teeth appear, you friends, relatives and colleagues are enjoying the sleepless nights must of these take prudent care. that accompany expanding families. Add to this the fact that I have For teething comes with grievous pain, so recently married into a family of midwives, health visitors, nurses to my word take heed again. When now the teeth are pushing and new mothers. I was not sure that I was giving the best, most up through, to rub the gums thou thus shall to date advice when asked about teething. So some reading around do. was required. If only it were that simple. I now feel equipped to give Take fat from chicken, brain from hare, a little more help than simply saying, “It’s only teething…” and these full oft on gums shall smear. If ulcers sore thereon should come, then thou shalt rub upon the gum. Historical teachings and old wives’ tales teething and the change in diet occurring at Honey and salt and oil thereto. But one Throughout history, teething has been held that age, was more likely to overcome the thing more I counsel you, responsible for a wide variety of childhood normal traumas of childhood. A salve of oil of violet, for neck and illnesses. There are references to teething dif- In 117AD, the physician Soranus of Eph- throat and gums to get. ficulties in the Homeric hymns from around esus was the first to suggest using hare’s And also bathe his head a while, with 1200BC and in the prayers of early Indian lit- brain to ease teething. This remained a water boiled with camomile.’ erature around 1000 BC. In the fourth cen- favoured remedy until the seventeenth cen- tury BC, Hippocrates wrote a short treatise, tury. There is a recorded cure from the In 1545, Thomas Phaire, an English On Dentition, ‘Teething children suffer from fourth century AD, ‘If they are in pain, smear physician, advised an ointment containing itching of the gums, fevers, convulsions and the gums with dog’s milk or hare’s brain; this oil of roses and juice of nightshade. His rec- diarrhoea, especially when they cut their eye works also if eaten. But if a tooth is coming ommended charm was, ‘The fyrst cast tooth teeth and when they are very corpulent and through with difficulty, smear Cyperas with of a colt set in silver and bone, or red coralle in costive’. (25th Aphorism, 3rd book.) butter and oil-of-lilies over the part where it lyke manner hanged about the neck, where- He also observed that the more difficult is erupting’. upon the chylde should oftentimes labour the teething period was for the child, the In the sixth century AD, Aetios of Amida his gums’. better the child would come through it recommended that hare’s brain be given in The use of coral was considered protective eventually. This may well have been a refer- the food either boiled or roast and if no hare in other ways. ‘By consent of all authors, it ence to the survival of the fittest since a child could be found, a lamb’s brain would do just resisteth the force of lightening, helpeth the strong enough to survive the pain of as well, ‘for by its nature it assists’. Aetios also chyldren of the falling evil [epilepsy] and is encouraged the practice of wearing charms very good to be made in powder and dronken and amulets to make teething easier and against all manner of bleeding of the nose or 1Specialist Registrar in Restorative Dentistry, keep death at bay. He recommended, ‘Root fundament’. Department of Restorative Dentistry, Charles Clifford of colocynth [a wild, poisonous vine] hung About the same time, Flemish physicians Dental Hospital, Wellesley Road, Sheffield S10 2SZ on the child in a gold or silver case, or bramble advised, ‘Make use, in this affliction, of the *Correspondence to above address. REFEREED PAPER root, or the tooth of a viper, especially a male canine tooth of a wolf chiefly; and that of the Received 04.08.00; Accepted 20.09.00 viper, set in gold or green jasper, suspended on she wolf has a greater reputation than that of © British Dental Journal 2001; 191: 4-8. the neck so as to hang over the stomach’. the male wolf’. This paper was placed second in The Cartwright Prize By the ninth century, physicians were Ambriose Pare (1517–1592), the French in 2000. The prize is awarded every five years by the concerned with which season was best for army surgeon, began to advocate a new Faculty of Dental Surgery. the teething child. ‘They that teethe in win- solution to the age old problem of ‘breeding
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teeth’: cutting the gums with a lancet. In apparently died and was laid out for intern- 1575, he described how he developed the ment. M. Lemonnier was desirous of ascer- method, from the examination of a dead ‘The fyrst cast tooth of taining the condition of the alveola. He child. ‘When we diligently sought for the a colt set in silver and accordingly made a free incision through the cause of his death, we could impute it to noth- gums but on preparing to persue further his ing else than the contumacious hardness of the bone, or red coralle in examination, he perceived the child to open gums…when we cut the gums with a knife we his eyes and give other indications of life. He found all the teeth appearing…if it had been lyke manner hanged immediately called for assistance; the shroud done when he lived, doubtless he would have was removed from the body and by careful been preserved.’ about the neck, and persevering attention, the child’s life was And later, ‘…of which kind remedy I have whereupon the chylde saved. In due time the teeth made their with prosperous and happy success made trial appearance and the child’s health was fully in some of mine own children…which is should oftentimes restored.’ much better and more safe to do as some In 1884, the Medical Society of London nurses do, who taught only by instinct of labour his gums’. held a meeting on the subject of teething. Nature, with their nails and scratching, break Edmund Owen, Surgeon to the Hospital for and tear and rent the gums’. Sick Children, stated that the lancet and the In 1668, Francois Mauriceau, a French from teething than was generally believed. leech now ‘lie together in the same dark male midwife, recommended that the pro- In his view, many of the deaths from convul- tomb’. Most colleagues at the meeting dis- cedure, ‘Be done with a lancet rather than a sions were also a result of teething. Both agreed. Many believed that childhood ail- knife, although a thin groat [a small coin] is Hunter and Hurlock tried to encourage the ments were caused by teething and had as good or better than either’. lancing of gums to prevent these deaths. anecdotal evidence to support this. It was Mauriceau challenged the effectiveness of Hunter ‘would lance a baby’s gums up to ten considered by most that failing to lance con- charms, although he believed that the silver times’. Hurlock advocated gum lancing for tributed to the high rate of infant mortality. coral stick was helpful only because its hard every childhood disease or ailment, irre- The American physician Samuel Gross smoothness soothed the child’s gums. spective of whether the tooth was evident. complained that young doctors were not ‘There are many remedies which diverse per- There do not appear to be any records of using their lancets. sons assert have a peculiar property to help the problems caused by lancing. John Hunter’s Explanations of the relationship between cutting of teeth, as rubbing them with Bitches’ view was that lancing was never attended by teething and childhood illnesses were made milk, hare’s or pig’s brains and hanging a dangerous consequences. without recognition of many diseases and viper’s tooth about the neck of the child and Marshall Hall, (1790–1857) a physician, understanding of the action of organisms suchlike trifles: but since they are founded stated that he ‘would rather lance a child’s causing infection. Most frequently, the ner- more on superstition, than any reason, I will gums 199 times unnecessarily than omit it vous system was indicated as a link between not trouble myself to enlarge on what is so use- once if necessary’ and instructed his stu- tooth eruption and systemic disease. In less’. dents to do it, before, during and after the 1887, J. W. White wrote, ‘The nervous per- Eighteenth and nineteenth century thera- teeth appeared, sometimes twice a day. turbation occasioned by the eruption of teeth pies were varied and depended on local By 1839, 5016 deaths in England and increases the susceptibility and lessens the superstition and the beliefs of the attending Wales were attributed to teething. The Eng- resistive power of the child’. physician. Doses of mercury salts, opiates, lish Registrar-General report on teething of It was believed that the difficulty experi- purgatives and emetics were recommended, 1842 discussed infant mortality: 4.8% of all enced by an erupting tooth whilst penetrat- even if the child was experiencing diarrhoea infants who died in London under the age of ing gingival tissue affected trigeminal nerve or vomiting beforehand. With modern 1, 7.3% of those between the ages of 1 and 3 endings. A ‘reflex stimulation’ of other cra- understanding of diseases it is likely that and 12% of all deaths under four years were nial and spinal nerves ensued, producing dehydration was largely responsible for directly attributed to teething. ‘functional derangements’ and diseases in many of the signs, symptoms and deaths The belief in lancing the gums was widely other organs. Lancing over an erupting associated with teething. and firmly held by both the medical profes- tooth was recommended to allow bleeding Leeches were applied to the mastoid area sion and the public. In 1850, Condie, in his and to release tissue pressure that was caus- or directly to the gums. However, leeching book Diseases of Children, reported: ing reflex stimulation of the trigeminal was not as popular as lancing. ‘A curious case is related by M. Robert, in nerve. Any sick infant could be found to John Hunter and Joseph Hurlock both his treatise on the Principal Objects of Medi- have an erupting tooth, even if the ‘tooth wrote works on teeth. In 1742, Hurlock cine, of one of the effects of difficult dentition, bud’ was deeply buried. This theory of wrote his treatise Upon Dentition. He was as of the division of the gum. A child, having reflex stimulation was reiterated as late as convinced that many more children died suffered greatly from difficult dentition, 1954.
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There remained a widespread fear of whereas one per cent have not had their first the role of teething in infant illness and tooth erupt by the age of twelve months. mortality. In 1894 Dr M. Thrasher, writing A rough rule of thumb Parents should be reassured that many in Dental Cosmos, stated his belief that, ‘So is that the age in months delay in tooth eruption in an other- deadly has teething become, that one third of wise normally developing child is of no con- the Human family die before the twenty months minus six cern. A rough rule of thumb is that the age deciduous teeth have fully appeared’. in months minus six gives the average num- Soon after this, in 1896, Dr S. W. Foster, gives the average ber of teeth, up to age 2 years. Environmen- also in Dental Cosmos, explained, ‘The number of teeth, up to tal factors such as climate or illness have not teething child becomes wakeful, restless and been found to have a significant effect on fretful, refuses nourishment; the alimentary age 2 years. the rate of dental development; nor is a gen- canal becomes more active, diarrhoea follows der relationship evident. Premature infants and if relief is not given, relaxation of the vital get their first teeth at a later chronological forces follows and we have nausea, vomiting, With increasing understanding of medi- age, but at the same post-conceptual age as convulsions, paralysis and not infrequently, cine and diseases came a gradual but recog- full-term infants. death’. nisable change in the belief and practice of Generalized delay in eruption has been He stated that more deaths occur in the the dental profession. In 1910, 1600 deaths noted in hypopituitarism, hypothyroidism, teething period than in any similar period in England and Wales were attributed to infantile rickets, Down’s Syndrome, clei- during the human lifespan and inferred that teething, compared with 5016 in 1839. docranial dysostosis, osteopetrosis, Gar- teething may be the leading cause of death dener’s syndrome and achondroplastic in the population. The process of teething dwarfism. Over the centuries, an extensive folklore Normally a deciduous tooth begins its Sometimes children are born with teeth had built up around teething. The condition upward movement about the time of crown (natal teeth) or they erupt in the first month even acquired a Latin name, Dentitio Diffi- completion. Until the tooth emerges of life (neonatal teeth). The reported inci- cilis. However, not everyone agreed with the through the gingivae, its crown is covered by dence of natal teeth is between 1 in 2000 live belief of the majority. In 1771, George Arm- the reduced enamel epithelium. Gradually births and 1 in 6000 live births. Some cases strong, a paediatrician, wrote, ‘Teething in the connective tissue between the enamel of natal teeth have been associated with cleft the manner as was observed in convulsions is epithelium and the oral epithelium disap- lip and palate cases, Pierre–Robin syndrome said to carry off a much greater number of pears, with the two layers of epithelium fus- and other syndromes with a head and neck children than it actually does, for almost all ing together over the advancing cusp or involvement. children that die whilst they are about teeth incisal edge. This area of fused epithelium Most natal and neonatal teeth are are said to die of teething’. breaks down to allow the tooth to emerge mandibular incisors and are usually part of At the time that Drs Thrasher and Foster into the mouth. The eruptive force is the normal deciduous dentition and not were writing in Dental Cosmos, Dr W. C. believed to come from the growth of pulp supernumery teeth. Frequently there is a Barrett addressed the First District Dental tissue at the end of the developing root. family history of natal or neonatal teeth. Society of New York. His paper was called Deciduous tooth eruption is sometimes These teeth may appear normal or may The Slaughter of the Innocents and attacked preceded by an eruption cyst of the overly- appear as simple shell like structures, with the hypocrisy of his colleagues. ing gum or by a smooth bluish swelling due little or no root. Root growth progresses ‘“The child is teething”, is the vague expla- to haematoma formation. They occur most normally and the tooth gradually becomes nation given to many an anxious mother by commonly over deciduous molars but are firmer (usually within four weeks), but the practitioners who are either incompetent to also seen occasionally over deciduous enamel is always hypomineralized and form a complete diagnosis, or too indolent incisors. Some eruption cysts originate tends to break away. Natal and neonatal and careless to seek for the hidden springs of from remnants of the reduced enamel teeth should be retained if possible, as they disease… “Only teething”. To how many epithelium and are true dentigerous cysts, are part of the normal dentition. They promising young existences in which were located in the soft tissue rather than bone. should only be extracted if they cause centered the hopes, the ambitions, the heart Others are simply an accumulation of blood trauma to the infant, to the mother’s nipple affections of a family circle, have these words or fluid from the connective tissue between or if there is a danger of them being swal- sounded the knell. “Only teething”, and the the two layers of epithelium. lowed or inhaled. fond parents looked with but little alarm Variations in the normal sequence of upon the symptoms of the gravest character.’ Timing of tooth eruption eruption may occur with dental infections, It is easy to imagine that he was not only a The timing of tooth eruption varies widely. additional teeth in the path of eruption, dentist with views ahead of his time, but a One per cent of infants acquire their first insufficient space in the arch and ectopic theatrical orator also. tooth before the age of four months, development of teeth.
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Behavioural changes ation who will naturally suck or chew their Throughout the early stages of an infant’s Average deciduous teething dates fingers. life, their behaviour changes. Parents More recently, the possibility of the signs understandably become concerned by lower central incisors 5–7 months and symptoms related to teething being due some of these changes and wonder how to upper central incisors 6–8 months to viral infection has been proposed and stop the problem. Between the ages of four upper lateral incisors 9–11 months investigated. King studied 20 infants pre- months and three years, parents attribute a lower central incisors 10–12 months senting with a parental diagnosis of teething variety of their child’s behaviour to canines 16–20 months difficulty, compared with 20 infants with no teething. The use of a simple diagnosis of first molars 12–16 months distress acting as a control.6 Almost half of teething helps to reduce their anxiety. Par- second molars 20–30 months the studied group had oral swabs positive ents often find that attributing problems for herpes simplex virus (HSV). None of the associated with changes in sleeping and eat- control group had positive oral swabs. King ing patterns to teething is reasonable and tions and disturbances of behaviour.2 He concluded that oral HSV infection should effective. showed that tooth eruption bore no relation be included in the differential diagnosis of Opinions about the local and systemic at all to infection, diarrhoea, fever, rash, infants presenting with teething difficulties. disturbances in the teething infant vary. convulsions, sleep disturbance, cough or ear The few remaining signs and symptoms Much of the information gathered about rubbing. Teething was associated with day- left to teething, eg fever, irritability and eat- teething is based on subjective parental time restlessness, loss of appetite, hand ing difficulties, are quite consistent with pri- opinion that is influenced by the desire to sucking, drooling and some appetite loss. mary herpetic gingivostomatitis. explain behavioral changes with an anxiety- Illingworth suggested that in 6–12- reducing diagnosis. It is also difficult to sep- month-old infants, much of the evening Treatment arate the signs and symptoms of teething and nighttime crying that is attributed to Various treatments are now advocated for from the normal psychological and physio- teething may be due to bad habit formation the relief of the discomfort or pain associ- logical changes, such as drooling and wake- and mismanagement.3 Infants of this age ated with teething. Many of these have their fulness. have discovered that if they cry at night, they origins in methods used for centuries. Rub- Teething is almost certainly a little will be picked up, taken downstairs, played bing substances into the gums and chewing uncomfortable for the child. The gums swell with and given a thoroughly enjoyable time on hard objects are still extremely common, and are tender to palpation just prior to In a 1975 study of 64 primary care paedia- although the use of animal brains is no tooth eruption. Children will chew their fin- tricians in Philadelphia, Honig found that longer recommended! The action of gum gers and can drool excessively. Other obser- only five believed that teething was not lancing is now confined to history, although vations are lip and object biting, irritability, responsible for symptoms such as irritabil- surgical removal of eruption cysts overlying restlessness and night crying. These obser- ity, eating problems, wakefulness and a deciduous tooth may still be carried out vations parallel those reported by authori- rashes.4 Eighteen felt that teething could be when indicated.1 ties in veterinary medicine. Dogs have responsible for temperatures up to 39.4°C. Chewing on clean, hard, cool objects will increased salivation, loss of appetite and Dentists are equally reluctant to discard give relief from soreness and there seems to irritability when their teeth erupt. Monkeys the teething diagnosis. Most dentists do not be a limitless number of items recom- become irritable and hyperactive and routinely treat children of this age and their mended for this purpose. Chilled teething exhibit increased biting activity. Other signs opinions often reflect dental folklore. Most rings and rattles, cold wet flannels, chilled commonly attributed to teething such as parents (and grandmothers!) believe in the hard vegetables such as carrots and celery diarrhoea, cough, ear rubbing, rashes, fever distress of teething. and an icecube tied in a cloth are all recom- and convulsions, have not been found to Teething complaints are confined almost mended and probably entirely safe. have any relationship to teething. These exclusively to the eruption of the deciduous Teething biscuits and rusks are not suitable signs are much more likely to have another dentition. Other than impacted third as they can promote tooth decay. cause. molars, the eruption of permanent teeth is In 1998, Government Safety Regulators in Seward studied the association of 18 dis- free from the symptoms frequently ascribed the United States asked manufacturers to turbances with the eruption of the decidu- to the eruption of the deciduous teeth. In stop using a chemical known to be a car- ous teeth in 224 normal children.1 1990, Wray commented that the current cinogen in baby rattles and teething toys. Irritability, night crying, drooling, poor understanding was that teething coincides The chemical, disononyl phthalate, is used appetite, circumoral rash and inflammation with the stage of development when active as a softening agent. The child is likely to of the gums were common findings. immunity is struggling to take over from the ingest small amounts of the chemical as it Tasanen studied teething infants in North waning passive immunity of the mother.5 leeches out of the product. Although there Finland, with daily recording of tempera- This often results in ENT or gastrointestinal have been no reported cases of phthalate- ture, appearance of gums, presence of infec- infection in a child with an obvious oral fix- related cancer in infants using teething
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products, manufacturers worldwide have • First, give the child teething objects to heavily on their reputation amongst their ceased using these chemicals in their prod- bite. Cold objects bring greatest relief, so peers and patients. Maybe things have not ucts. teething rings can be kept in the fridge. changed so much after all. Will our col- The use of chilled topical preparations in All teething rings should be safe and easy leagues of the future be smirking at our mis- gel form remains popular. Lignocaine-con- to clean. Carbohydrate containing foods guided ways? taining products have been shown to be should be avoided. more effective than similar, control prepara- •If pain is troublesome, use the appropri- The author acknowledges the support and assistance tions without lignocaine. However, many ate dose of a paracetamol elixir, prefer- of Mr Keith Ashley in the preparation of this paper. authorities advise that these gels are largely ably sugar-free. This may be given insufficient to treat the condition when used regularly, every 4–6 hours. 1Seward M H. The treatment of teething in alone, due to the rapid washing away from •If additional analgesia is required, ligno- infants. Br Dent J 1972; 132: 33-36. the site of discomfort. caine-based teething gels should be used. 2Tasanen A. The eruption of teeth in children. A sugar-free elixir of paracetamol is the Ann Pediatr Fenn 1968; 14:1-41. 3Illingworth R S. Teething. Dev Med & Child basis for some commercially available prod- Conclusion Neur 169; 11: 376-7. ucts. It is effective particularly due to its The beliefs and superstitions associated 4Honig P J. Teething – are today’s pediatricians analgesic and antipyretic effects. The use of with teething throughout history appear using yesterday’s notions? J Pediatr 1975; 87: 415. aspirin in either topical or systemic form is amusing and it may cause concern that the 5Wray D. The torment of teething. Br Dent J contraindicated in children and teenagers profession was so willing to go along with 1990; 169: 7. due to the association with the brain and practices so incorrect. Yet it is sobering to 7King D L. Herpetic gingivostomatitis and liver disorder, Reye’s syndrome. appreciate that our historic colleagues were teething difficulties in infants. Pediatr Dent 1992; 14: 82-85. Steward recommended this approach to acting on their existing knowledge and their 8Steward M. Infant care – teething troubles. the treatment of teething.7 professional and personal standing relied Community Outlook 1988; May: 27-28.
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