K. Kiran1, T. Swati2, B. K. Kamala3, D. Jaiswal2 which often begin to appear when children are about 6 months old, help them chew and speak. They also 1Department of Pedodontics and Preventive Dentistry, maintain the space in the jaws for permanent teeth that KLEVK Institute of Dental Sciences, Nehrunagar, Belgaum, are developing under the gums. The front four teeth Karnataka state, India usually erupt first, beginning as early as 6 months after birth. Teething has traditionally been the explanation for a 2Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Bareily, Uttar Pradesh state, India variety of symptoms and signs in the young child, both by parents and their dentists and doctors. But teething is a 3Department of Pedodontics and Preventive Dentistry normal physiological developmental stage that usually The Oxford Dental College and Hospital, Bangalore, occurs without problems. It consists of the movement of Karnataka state, India the tooth from its intraosseous position in the jaw to e-mail: [email protected] eruption in the oral cavity. It involves gingival as well as other tissues and physiological mechanisms [Massler and Shour, 1941]. Primary teeth eruption and its manifestation as local or systemic symptoms in children has been a controversial Prevalence of systemic topic among dentists and physicians as reported in literature [Correa, 1999; Noronha, 1985]. The data and local disturbances collected on local and systemic manifestations of tooth eruption on children were the result of parent’s memories in infants during and opinions; hence they are quite subjective in nature. Today it is still not clear if tooth eruption actually leads to primary teeth eruption: systemic and local disturbances. Previously many authors have coupled primary teeth a clinical study eruption with alterations such as irritability, gingival irritation, increased salivation, fever, agitated sleep, diarrhoea, and loss of appetite [Praetzel et al., 2000; ABSTRACT Bengston 1998]. Hippocrates in the 5th century B.C. Aim The purpose of this study was to find the correlations observed that during teeth eruption children had gingival between local and systemic manifestations during primary scratching, convulsions, fever and diarrhoea [Rabdill, teeth eruption and the eruption of various groups of 1965]. teeth. A study on children with erupting primary teeth Materials and methods The infants selected for the reported that 66% of them displayed systemic symptoms study purpose were between 6 months to 3 years of age during eruption [Carpenter, 1978]. These disturbances are who had at least one erupting tooth. The study group responsible for the referral of many infants to consisted of 894 infants and other 550 infants served as paedodontists and paediatricians. Parents connect these a control group. Questionnaires were distributed to all phenomena with the eruption of primary teeth. Fever, parents and the data was collected. Chi square test was diarrhoea, drooling, dermatitis, reduced appetite, performed to analyse the information obtained between constipation, restlessness, and respiratory infections are the two groups. There were 378 girls (42.2%) and 516 the general symptoms often associated with teeth boys (57.7%) in the study group. The control group eruption as reported in literature [Llyod, 1996; Mackin et consisted of 195 girls (35.4%) and 355 boys (64.5%). al., 2000]. The symptoms above can appear before Results The most common finding was gingival irritation eruption or during the eruption of the tooth; they also 821 (95.9%) and the least common symptom observed in varies among children. Pain and inflammation of the the study was running nose 234 (27.3%). The presence of eruption site, as well as irritable behaviour, are also fever –diarrhea was seen in 101 (11.7%) infants. In the described during teeth eruption. Earlier studies have control group, 92.1% of the infants did not show any reported that a rise in body temperature to 39°C has been clinical manifestations. observed during eruption of primary teeth [Jaber et al., Conclusion An association was found between primary 1992]. teeth eruption and local and systemic manifestations. In India, such correlation has not been studied, therefore Most manifestations were found during eruption of the we conducted this study to determine the occurrence of primary incisors. local and systemic disturbances in children during primary teeth eruption and to assess the correlation between Keywords: Infants; Pain; Salivation; Teething. those symptoms and the eruption of various groups of teeth.

Methodology Introduction A study was conducted at the Department of Paediatric A child’s primary teeth, sometimes called “baby teeth,” and Preventive Dentistry, Institute of Dental Sciences, and are as important as the permanent ones. Primary teeth, the Department of Paediatrics, Rohilkhand Medical

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College, Bareilly, India. The sample consisted of 1,023 (95.9%), increased salivation in 809 (94.5%), irritability in infants aged 6 months to 3 years who exhibited at least 789 (92.1%), diarrhoea in 767 (89.6%), agitated sleep in one tooth in the process of eruption. Eruption was defined 452 (52.8%) infants, running nose in 234 (27.3%) infants, as visible clinical crown of the tooth, but not exceeding 3 fever in 668 (78.0%) infants, loss of appetite in 335 mm of exposure in the oral cavity. The study was (39.1%) infants. Fever and diarrhoea was reported in 107 conducted from August 2009 to July 2010. (11.7%) infants. Fever with diarrhoea and increased Out of 1,023 infants only 894 were selected for the salivation was the symptom reported less frequently, in study, the others were excluded due to lack of information 6.1% of 53 infants (Table 1). or were missing at the recall visit; 550 infants acted as Infants fever was checked by the paedodontist or control group. All children were healthy and born at term. pediatrician and later by the nurse. None of the children’s Infant’s body temperature was measured by the nurse parents reported a herpetic infection; during the course of after dental examination. this study also we did not notice any signs of infection in Parents were asked about the occurrence of local and any infants. systemic disturbances in the questionnaire-based survey. In Table 2 we can see the 38 (4.4%) infants who did not Patients were then recalled after a 3-month period for show any local or systemic manifestations during eruption evaluation and data were collected again. of primary teeth. In the control group 92.1% of infants did Analysis of the records showed the presence of the not manifest any symptom. The most commonly reported following symptoms: gingival irritations; diarrhoea; fever; manifestation was running nose in 19 subjects of the loss of appetite; irritability; increased salivation; running control group (3.4%), which can be due to seasonal nose; agitated sleep; fever with diarrhoea; fever with variation or upper respiratory tract infection. increased salivation; diarrhoea with increased salivation; Table 3 shows the clinical manifestations that were fever with diarrhoea and increased salivation. present during eruption of primary teeth according to the Data were analysed using descriptive statistics. χ2 type of teeth. Local and systemic manifestations were analysis was performed on the information obtained from more pronounced during eruption of primary incisors. the 2 groups. The level of significance was set at p <0.5. Gingival irritation and increased salivation were the most common findings. Gingival irritation and increased salivation were consistently the most common findings Results during eruption of canines and molars.

Of the 1,023 infants observed, 129 were excluded due to deficient information and lack of cooperation from Disturbance Total Percentage (%) parents. Of the 894 sample 856 (95.7%) reported some type of manifestations. The parents of the remaining 38 Gingival irritation 821 95. 9% patients did not report any symptom (4.4%) during Irritability 789 92.1% eruption of primary teeth in their children. There were 378 Loss of appetite 335 39.1% Running nose 234 27.3 % girls (42.2%) and 516 boys (57.7%) in the study group. Diarrhea 767 89.6% The control group consisted of 195 girls (35.4%) and 355 Agitated sleep 452 52.8% boys (64.5%). Fever 668 78.0% Among the 856 infants (95.7%) who manifested some Increased salivation 809 94.5% kind of symptoms, gingival irritation was observed in 821 Fever- diarrhea 107 11.7% Fever - increased salivation 89 10.3% Diarrhea- increased salivation 78 9.1% Fever- diarrhoea - increased salivation 53 6.1% Clinical signs Study group Control group TABLE 1 - Prevalence of local and systemic disturbances during Frequency Ratio Frequency Ratio primary teeth eruption. None 38 4.4 %507 92.1%* Gingival irritation 821 95. 9% 0 0 Irritability 789 92.1% 0 0 Manifestation Incisors Canines Molars Loss of appetite 335 39.1% 0 0 Gingival irritation 711 (83.0%) 356 (41.5%) 408 (47.6%) Running nose 234 27.3 % 19 3.4% Irritability 321 (37.5%) 234 (27.3%) 219 (25.5%) Diarrhea 767 89.6% 8 1.4 Loss of appetite 191 (22.3%) 108 (12.6%) 167 (19.5%) Agitated sleep 452 52.8% 3 0.5% Running nose 69 (8.0%) 45 (5.2%) 21 (2.4%) Fever 668 78.0% 12 2.1% Diarrhea 248 (28.9%) 121 (14.1%) 143 (16.7%) Increased salivation 809 94.5% 0 0 Agitated sleep 330 (38.5%) 209 (24.4%) 222 (25.9%) Fever- diarrhea 107 11.7% 0 0 Fever 254 (29.6%) 105 (12.2%) 111 (12.9%) Fever - increased salivation 89 10.3% 0 0 Increased salivation 698 (81.5%) 339 (39.6%) 377 (44.0%) Fever- diarrhea 213 (24.8%) 104 (12.1%) 161 (18.8%) Diarrhoea, increased salivation 78 9.1% 0 0 Fever - increased salivation 114 (13.3%) 89 (10.3%) 108 (12.6%) Fever, diarrhoea, incr. salivation 53 6.1% 0 0 Diarrhoea- increased salivation 203 (23.7%) 28 (3.2%) 171 (19.9%) *P <0.5, Chi- square Fever, diarrhoea, incr. salivation 91 (10.6%) 13 (1.5%) 73 (8.5%)

TABLE 2 - Distribution of the clinical manifestations in the TABLE 3 - Presence of clinical manifestations according to study and control groups. tooth type in the study group..

250 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • VOL. 12/4-2011 SYSTEMIC AND LOCAL DISTURBANCES DURING PRIMARY TEETH ERUPTION

Discussion glands, which occurs during this age rather than tooth eruption, as well as inability of the child to swallow saliva In the literature information on tooth eruption and its [Correa, 1999; Kruska, 1946]. As reported in previous complications is contradictory and subjective [Neaderland, studies, increased salivation can also be due to the fact 1952; Radbill, 1965; Seward, 1969, 1971 and 1972; that teething disturbs the oral cavity, producing irritation Tanner, 1964]. Literature reviews show that many authors and redness of the gums. believe that tooth eruption is a physiological procedure Irritability was exhibited by 789 (92.1%) infants. Tooth and it does not cause any distress. To a certain extent local eruption is supposed to cause an anxiety crisis, perceived and systemic disturbances occur parallel to the eruptive in almost in all infants as a mood change, provoking the process [Bloom, 1939; Schwartzman, 1942; Kruska, 1946; constant need to be held in the caregiver’s arm, with fear Kahtalian, 1980; McDonald and Avery, 1995]. On the reactions triggered by inoffensive stimuli [Giglio, 1983]. contrary many authors have reported that tooth eruption Many authors have also suggested that irritability might be causes fever, diarrhoea, loss of appetite, sleep disturbance due to sleep alterations, with baby presenting insomnia or [Bengston, 1988; Noronha, 1985; Bennet and Spencer, agitated sleep during primary tooth eruption. 1986; Rocha et al., 1988; Abujamra et al., 1994], Fever was reported in 668 (78.0%) of the sample. Galili increased salivation, dehydration, cutaneous eruption and et al. [1969] and Carpenter et al, [1978] reported that gastrointestinal disturbances [Inada, 1999]. multiple tooth eruption may establish a stress condition, In a controlled study, Tasanen [1968] described daytime during which the resistance against infections is reduced restlessness, increased finger sucking, gum rubbing, and incidence of infectious diseases is increased. Research drooling and loss of appetite during teething. Honig works [Bennet and Spencer, 1986] suggested that fever [1977] analysed the opinions of 6 paediatricians practicing during primary tooth eruption is caused by a human in the Philadelphia area and found that 18 considered that teething virus (HT virus), which remains in latent phase in teething caused fever, 12 that it had altered bowel habits, the alveolar crest and is stimulated during eruptive 10 that it caused skin rashes and only 5 that no signs or movements, initiating fever as well as local signs and symptoms were attributable to teething. In contradiction, symptoms, such as gingival inflammation, hemorrhage a longitudinal study by Tasanen of 126 infants in an and pain. institution demonstrated conclusively that the eruption of Diarrhoea is associated with tooth eruption and it is tooth bore no relation whatsoever to the incidence of mainly due to the contamination of the baby’s fingers or infections, diarrohea, bronchitis, fever, rashes, convulsions, objects that are inserted into the mouth [Foster and sleeplessness at night, or ear rubbing. It was however Hamilton, 1969; Rocha et al., 1988; Kruska, 1946]. In the associated with some restlessness during the day and present study diarrhoea was present in 767 (89.6%) of the increase of salivation, thumb sucking, and gum rubbing, infants. and, sometimes, refusal of food [Tasanen, 1968]. The least frequently reported disturbance was running Illingworth [1969] in his study reported that evening and nose in 234 (27.3%) infants, in agreement with previous nocturnal cry of baby aged 5 to 12 months was not due studies [Praetzel et al., 2000; Cunha et al., 2004]. to teething but to bad habit: the babies had discovered As mentioned, dental and paediatric literature projects that as they cried at night, they were picked up, played different views in regard to teething and its with, and given a thoroughly enjoyable time. manifestations. It is difficult to separate objective sign and Several authors believe that undiagnosed primary symptoms related to primary teeth eruption from changes herpetic stomatitis could be the major reason for the in child behavior based solely on the parent’s subjective systemic symptoms, while others did not find a view, owing to the extended period of time of teething. relationship between herpetic stomatitis infection and teething [Illingworth, 1969]. Limitations of the study In the present study, local and systemic symptoms were The present study was limited by the population, which observed in 856 (95.7%) of infants aged between 6 did not represent all type of population. The study should months to 3 years. The most common manifestation was be done for a longer period of time to find appropriate gingival irritation 821 (95.9%).This is in agreement with relationships between eruption of primary teeth and local previous studies [Barlow et al., 2009; Cunha et al., 2004] and systemic manifestations. in which the authors found that gingival irritation was the most common disturbance. A possible reason for gingival Recomendations irritation was given by Pierce et al. [1986], who stated that Currently various treatments are available for the relief immunoglobulins are present in the tissue of erupting of the discomfort or pain related with eruption of teeth. tooth. These immunoglobulins interact with matrix Many of them have their origins in past centuries. proteins which can lead to stimulation of mast cells which, Rubbing substances on the gums and chewing on hard in turn, cause irritation. This reaction vary in children due objects are still very common practices. Chewing on clean, to differences in their immunological reaction. A previous hard, cool objects will give relief from soreness. Chilled study by Peretz et al. showed that drooling was the most teething rings and rattles, cold wet flannels, chilled hard common symptom, while Galili et al. [1969] and vegetables such as carrots and celery and an ice cube tied Carpenter et al. [1978] found out that a high percentage in a cloth are all recommended and probably entirely safe. of children had fever. Teething biscuits and rusks are not suitable as they can Increased salivation 809 (94.5%) was the second most promote tooth decay. common finding. This can be due to maturation of salivary Lignocaine-containing products have proven to be

EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • VOL. 12/4-2011 251 KIRAN K., SWATI D. AND KAMALA B.K. effective topical agent in reliveing pain and gum irritation. disturbances: relevance in a clinic for infants. J Dent Child However, many authors advise that these gels alone are 2004;71(1):24-26. largely insufficient to treat the symptom, as they are Foster TD, Hamilton MC. Occlusion of the primary dentition - Study of rapidly washed away by saliva. children at 21/2to 3 years of age. Br Dent J 1969;126:7-79. A sugar-free elixir of paracetamol is the basis for some Galili G, Rosenzweig KA, Klein H. Euption of primary teeth and general commercially available products. It is effective particularly pathologic conditions. J Dent Child 1969;36:51-55. due to its analgesic and antipyretic effects. Steward Giglio EMO. Significado psicologico dos dentes. Rev Odont Metodista recommended the following approach to the treatment of 1983;4:37-40. teething [1972]. Honing PJ. Teething - Are today's pediatricians using yesterday's notions? J • First, give the child teething objects to bite. Cold Pediatrics 1977;87(3):415. objects bring greatest relief, so teething rings can be Illingworth RS. Teething. Dev Med Child Neurol 1969;11:376-7. kept in the fridge. All teething rings should be safe and Inada DY. Sinais e Sintomas Relacionados com a Eropcao dos Dentes easy to clean. Carbohydrate-containing foods should Deciduos. Londrina. Puerto Rico: Associacao Odontologica do Norte do be avoided. Parana; 1999. vol. 28. • If pain is troublesome, use the appropriate dose of a Jaber L, Cohen IJ, Mor A. Fever associated with teething. Arch Dis Child paracetamol elixir, preferably sugar-free. This may be 1992;67:223-224. given regularly, every 4–6 hours. Kahtalian IY. Doenca Periodontal na Infancia. In: Lascada NJ, Moussali NH • If additional analgesia is required, lignocaine-based eds. Periodontia Clinica - Especialidades Afins. Sao Paulo: Artes Medicas; teething gels could be used. 1980. p.595. Kruska HJ. Teething and its significance. J Dent Child 1946;13:110-2. Llyold S. Teething in babies: Separating fact from fiction. Prof Care mother Conclusion child 1996;6:55-156. Mackin ML, Piedmonte M, Jacobs J, Skibinski C. Symptoms associated with To summarize the teething procedure, Neaderland infant teething - A prospective study. Pediatrics 2000;105:747-752. [1952] described the three most common concepts. Masler M, Shour I. Studies sin tooth development: theories of eruption. Am • Teething is a pathological process with a cause-effect J Orthod 1941;27:522-576. relationship between dental eruption and the McDonald RE, Avery DR. Erupcao dos Dentes: Fatores Locais, Sistermicos a occurrence of clinical symptoms; Aoncgenitos que Influenciam o Processo. In: McDonald RE, Avery DR. • Teething is a physiological process in which systemic Odontopediatria. 6th ed. 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