This site is intended for health professionals only

Teething pain in babies

In infants, teething is the process in which deciduous teeth (sometimes known as milk teeth or baby teeth) emerge through gums.1 This is a normal physiological process.

There is considerable variation in the time of teething. In general, most infants start teething at six months. However, some children start teething before the age of four months (1%), or after 12 months (1%). Some children are born with deciduous teeth (natal teeth; around one in 2000-6000 live births), or they start teething in the first four weeks (neonatal teeth).

A full set of milk teeth are usually through when the child reaches two to three years of age.1

By six years of age, these deciduous teeth start to fall out, to be replaced with permanent teeth.2,3
Signs and symptoms
A wide variety of signs and symptoms are attributed to teething, sometimes incorrectly. For centuries people believed the teething process caused many childhood illnesses, and even death.4 Although numerous symptoms have been attributed to teething, there have been few direct studies examining the relationship between teething and systematic symptoms. Limited evidence suggests that symptoms of teething tend to be mild and localised.
It is important for health professionals to be aware that teething does not cause children to become systemically unwell, such as with a high fever.
Symptoms usually associated with teething include:

- Increased biting and gnawing.5
- Excessive dribbling.6,7
- Gum inflammation and rubbing.8,9
- Sucking.5
- Irritability.6,7
- Wakefulness.5
- Ear rubbing.5
- Facial rash.5,8
- Decreased appetite.6
- Loose stools.10
- Disturbed sleep.7
- Possible mild temperature elevation (less than 38*C).11

These symptoms generally start three to five days before each tooth eruption.
On checking the baby's mouth for signs of tooth eruption the gums will appear swollen and tender to palpation just before the tooth erupts.

Management of teething
The management of a teething baby can be split into two categories: self-care (non-medical solutions), and medical measures, such as over-the-counter medicines.

In the first instance parents will need to be reassured that teething is normal and is not an illness. Symptoms are generally mild and self-limiting.

Next best practice is to advise parents regarding self-care measures to relieve teething symptoms such as:
- Gentle rubbing on the gum with a clean finger.
- Allowing the baby to bite and chew on a clean and cool object. Examples include:
> Chilled teething ring.
> Cold wet flannel. Suggest putting a clean wet dishcloth or towel in the refrigerator and let it get cold. By letting the baby gnaw on the cloth this will help ease inflamed gums and will feel good in the baby's mouth.
> Place a spoon in the fridge for a few hours and then let the baby have it. The cold metal against the gums will bring comfort.
> For children who have been weaned, consider the supervised use of chilled fruit or vegetables, such as a full-sized washed and peeled carrot placed in the fridge for an hour before letting the baby chew on it. Bananas and cucumber are also good choices.
> Avoid fruit that can be easily broken into hard pieces, such as apples, as these could present a choking risk.
> Teething biscuits and rusks are not recommended if they contain sugar, which causes tooth decay. Sugar-free products are preferred.

Many babies may present with a sore face or chin due to excessive saliva production, which often causes a facial rash. Parents should be encouraged to try and remove any dribble with a soft cloth, and a soap that gently cleanses without drying while also moisturising and protecting the skin. These soaps tend to be used regularly for children who have very dry skin. If the skin is very sore, the parents can be advised to use a very thin layer of barrier cream to protect the skin after cleaning.

Along with trying to distract a teething baby through play, self-care management can be extremely successful during the daytime, but less appropriate at night when parents often report teething to be most problematic. This is when parents will require advice regarding medication.

Parents should be advised to consider giving paediatric sugar-free paracetamol or ibuprofen suspension for relieving the discomfort of teething symptoms in infants three months of age or older. Paracetamol is preferred for infants with asthma.

In 2009 the Medicines and Healthcare products Regulatory Agency (MHRA) issued precautionary advice for the use of topical oral pain relief gels containing salicylates.12 These oral gels are now contra-indicated for all children under 16 years old because of the risk of Reye's syndrome. The main products concerned are gels generally used for adults.

Infant teething gels do not contain salicylates so are safe to use and can be recommended. They appear to be effective topical treatments to provide pain relief. They typically contain two ingredients, one of which is lignocaine, a local anesthetic that relieves pain sensations by temporarily blocking the pathway of pain signals along the nerves.

The other ingredient acts as a mild antiseptic that kills a variety of bacteria and fungi that might infect sore or broken skin in the mouth. Each dose can be applied after every three hours. Only six applications should be used each day.

Complimentary therapies, such as herbal teething powders, are not generally recommended, as there is no good evidence to support their use. If parents do decide to use them then they should be advised to follow the manufacturers dosage recommendations.

The role of the health visitor
There is no shortage of advice on every aspect of parenting, including teething. Parents will have often been told of terrible teething experiences and may have already mistakenly diagnosed their own child's symptoms as teething.
A major role of the health visitor is to listen carefully to what the parent is actually telling them to establish whether the issues they are describing are the symptoms of teething, or an underlying condition. This may not sound difficult, but in the surroundings of a busy clinic it can be easy to overlook another condition, where the parents may need to seek further medical advice.

Parents will often associate systemic conditions like diarrhoea, vomiting and fever (any temperature above 38*C) with teething. The teething time frame roughly coincides with when young children experience most of their infections, especially viral infections, which are the most likely cause of fevers in this age group.

Therefore before considering giving advice on how to manage teething symptoms, it is important to exclude other common conditions such as otitis media or respiratory and urinary tract infections.

Although there appears to be limited evidence to suggest that a baby tends to have loose stools while teething, many parents will report this to be so. If this is the case you will also need to ensure that the child is not suffering from gastroenteritis. If a nappy rash is reported then a fungal infection will need to be excluded before giving appropriate advice on how to deal with what many health visitors call a 'teething bottom.'

Once any other underlying conditions have been excluded, especially if the child is unwell, the health visitor should reassure the parent that teething is normal and not an illness, and give appropriate advice on the management of teething as described.

Teething should be considered as a normal physiological process. It is acknowledged that it is associated with the appearance of symptoms, most of which are minor and relate to discomfort rather than physical illness, but a substantial minority still ascribe potentially serious symptoms to teething.13
It is recommended that a diagnosis should not be made before excluding other more serious causes of upset, as there is the possibility that the parent may have overlooked an illness, which could need medical attention and appropriate treatment.

Once teething has been established as the cause, the parent should be reassured that teething is normal and advised on appropriate management including self-care measures and over-the-counter paediatric pain relief for babies over three months.

1. Ashley MP. It's only teething: a report of the myths and modern approaches to teething. British Dental Journal 2001;191(1):4-8.
2. Anderson JE. Nothing but the tooth: dispelling myths about teething. Contemporary Pediatrics 2004;21(7):75.
3.  Nield LS, Stenger JP, Kamat D. Common pediatric dental dilemmas. Clinical Pediatrics 2008;47(2):99-105.
4. Museum of the Royal Pharmaceutical Society, 2008. Available at:
5. Macknin ML, Piedmonte M, Jacobs J, Skibinski C. Symptoms associated with infant teething: A prospective study. Paediatrics 2000;105:747-52.
6. Steward MH. General disturbances attributed to eruption of the human primary dentition. J Dent Child 1972;39:178-83.
7. Holt R, Roberts G, Scully C. ABC of oral health. Oral health and disease. British Medical Journal 2000;320:1652-5.
8. Steward MH. Local disturbances attributed to eruption of the human primary dentition. British Dental Journal 1971;130:72-7.
9. Chakraborty A, Sarkar S, Dutta BB. Localised disturbances with primary teeth eruption. Journal of Indian Paediatric Preventative Dentistry 1994;12:25-8.
10. Coreil J, Price L, Barkey N. Recognition and management of teething diarrhoea among Florida peadiatricians. Clinical Paediatrics 1995;34:591-6.
11. Jaber L, Cohen IJ, Mor A. Fever associated with teething. Archives of Diseases in Childhood 1992;67:233-4.
12. MHRA. Oral salicylate gels: not for use in those younger than age 16 years. Drug safety update 2009;2(11):4-5.
13.  Sarrell EM, Horev Z, Cohen Z, Cohen HA. Parents' and medical personnel's beliefs about infant feeding. Patient Education and Counselling 2005;57(1):122-55.