Baby teething & associated symptoms 

Teething refers to the process during which a baby’s initial teeth emerge through the gums. Every baby experiences teething differently, but most babies will begin to grow their first tooth within the first year.

When do babies begin teething? 

Typically, teething starts around 6 months, but it can vary, with some babies starting as early as 4 months or as late as 12 months. In rare cases, some babies are even born with teeth, known as natal teeth.

Symptoms of teething 

For some babies, teeth emerge without causing much discomfort. In other cases, you may notice:

• The gums may appear sore and red where the tooth is breaking through.
• A mild fever of less than 38°C (100.4°F)
• One cheek may appear flushed
• A rash could develop on the face
• Babies may rub their ears
• Excessive drooling
• Increased chewing and gnawing on objects
• Greater fussiness than usual
• Sleep disturbances

Although some believe that teething can cause symptoms like diarrhoea, there’s no evidence to support this claim.

Is it worrisome if the baby pulls on their ear?

It is common for babies to rub their ears, tug at them, or touch the side of their head. This behaviour usually stems from either self-soothing or an attempt to ease discomfort. If a baby pulls at their ear without signs of distress, it may simply be a way to comfort themselves, especially when tired or overwhelmed. Offering a pacifier or toy might help. However, if they seem uncomfortable or cry, it could indicate ear pain from an infection, teething, or a cold, so monitoring for other symptoms and consulting a paediatrician is advisable. Additionally, ear rubbing may result from tiredness or earwax buildup, particularly if accompanied by yawning or clinginess.

Why does teething cause ear tugging in infants

It is common for babies to tug their ears while teething. As their teeth begin to emerge, pressure and pain in the gums and jaw can radiate to the nearby ear. This behaviour is particularly common when molars are coming in, as they tend to cause more pain than other teeth. To soothe themselves, babies may rub their ears or cheeks in an attempt to ease the discomfort. This phenomenon occurs because the nerves serving the gums and teeth are closely linked to those in the ears. Consequently, the pain experienced during teething can manifest as ear tugging or rubbing.

Understanding why teething pain radiates to the ears in infants

The nerve innervation connection 

Teething is a natural developmental process, but it can be an uncomfortable experience for infants due to the complex network of nerves in the face and jaw. One of the key reasons teething pain can radiate to the ears is the shared nerve pathways between the gums, teeth and ears, resulting in discomfort that can be perceived as ear pain, leading to ear tugging and discomfort in infants. The trigeminal nerve (cranial nerve V) plays a crucial role in this phenomenon, with its three major branches contributing to sensation in different parts of the face, gums, and teeth.

Nerve innervation of infant gums and teeth 

The trigeminal nerve (CN V) provides sensory innervation to the face, gums, and teeth through its three branches:

• Ophthalmic (V1): forehead, eyes, upper face
• Maxillary (V2): upper jaw, gums, teeth, nasal cavity
• Mandibular (V3): lower jaw, gums, teeth, ear

Maxillary (V2) innervation

• Superior alveolar nerves (anterior, middle, posterior) – Maxillary teeth & gums
• Greater & lesser palatine nerves – Palate & gingiva

Mandibular (V3) innervation

• Inferior alveolar nerve – Mandibular teeth
• Lingual nerve – Gingiva (tongue side)
• Buccal nerve – Buccal gingiva 

Connection between the gums, teeth, and ears

The close anatomical and neurological relationship between the jaw and the ear contributes to why teething pain can be felt in the ear. This connection is facilitated by additional cranial nerves:

1. Auriculotemporal nerve (branch of V3): Provides sensory innervation to the external ear and the temporomandibular joint (TMJ). Since it shares pathways with the mandibular nerve, pain from teething can radiate to the ear.
2. Glossopharyngeal nerve (cranial nerve IX): Innervates the middle ear via the tympanic plexus and contributes to oropharyngeal sensation, potentially linking dental discomfort to ear pain.
3. Facial nerve (cranial nerve VII): Provides some sensory input to the external ear and contributes to soft palate innervation.
4. Pressure and Inflammation: As baby teeth push through the gums, nerve endings are stimulated, sending pain signals to the ears
5. Molars Erupting: The larger molars exert more pressure on surrounding tissues, increasing discomfort that can radiate to the ears and jaw
6. Jaw and Ear Proximity: The temporomandibular joint (TMJ), located near the ear canal, can create a sensation of pressure or aching in the ear due to teething pain. Discomfort in the temporomandibular joint, due to shared trigeminal innervation, can further contribute to ear-related symptoms during teething

Did you know that teething can be mistaken for an ear infection?

Teething and ear infections are two different conditions, but their symptoms can sometimes overlap, making it difficult for parents to determine the exact cause of their baby’s discomfort. However, by carefully observing specific signs, it is possible to distinguish between the two.

Despite these symptoms, teething does not affect a baby’s hearing. The discomfort can make them fussier than usual, but they remain responsive to sounds around them.

Ear infection symptoms and causes

Unlike teething, ear infections are caused by bacterial or viral infections that lead to inflammation and fluid buildup in the ear. They are often triggered by colds, allergies, or sinus infections that cause congestion and trap fluid in the ear canal.

Unlike teething discomfort, ear infections typically worsen over time rather than coming in waves. Some key signs of an ear infection include:

• Persistent and worsening ear pain, which may cause the baby to cry more frequently
• Ear pulling or rubbing, similar to teething, but accompanied by increased fussiness
• Hearing difficulties, such as muffled or dulled hearing due to fluid buildup
• Fever above 38°C, which is higher than what is seen with teething
• Fluid or pus-like drainage from the ear, indicating an infection
• Cold symptoms, such as nasal congestion or coughing, often appear before the infection
• Loss of balance or coordination, especially in younger babies
• Difficulty sleeping, as ear infections cause increased pressure when lying down

Unlike teething, an ear infection can significantly impact a baby’s hearing if left untreated. If a baby appears less responsive to sounds or is constantly pulling on their ear while showing signs of illness, it is important to consult a paediatrician.

By paying close attention to the symptoms and their progression, parents can better assess whether their baby is teething or suffering from an ear infection. If there is any uncertainty, especially if the baby has a high fever, ear drainage, or appears to have hearing difficulties, seeking medical advice is always the safest approach.

Can teething lead to ear infections?

Although teething doesn't directly cause ear infections, it can indirectly contribute. Excessive drooling during teething can cause moisture to accumulate in the ear canal, creating an environment where bacteria may thrive. If a baby is experiencing significant discomfort from teething, it's important to watch for signs of an ear infection, such as fussiness, ear rubbing, or fluid draining from the ear.

To help with ear tugging caused by teething, the following methods can help manage teething pain: Safe and effective approaches 

Teething is a natural but often uncomfortable process for infants. While parents seek relief for their baby’s sore gums, choosing safe and effective methods is essential.

Non-pharmacological approaches 

Several natural remedies can help soothe teething discomfort:

• Cooling Techniques: Chilled teething rings, cold wet towels, and cold fruits or vegetables (such as cucumber, carrot, or apple) can provide relief;  applying a cold compress to the gums may also help
• Rubbing Methods: Gingival massage using firm finger pressure, chewing on teething rusks, dry toast, or pacifiers can ease discomfort
• Chilled Fruit in a Feeder: For babies who have started solids, chilled or frozen fruit can be both soothing and a tasty treat; a mesh or silicone feeder offers a safe way for babies to chew without choking risks
• Cold Washcloth: If a feeder is unavailable, a damp washcloth placed in the freezer can provide relief while also keeping the baby hydrated
• Teething Toys: choose  solid, non-gel-filled teething toys, as gel-filled ones may break and expose harmful substances; opt  for freezer-safe toys and ensure they are cleaned regularly
• Gum Massage: Using a clean finger or a silicone fingertip massager, gently massage the baby’s gums in a circular motion to ease soreness
• Comfort and Cuddles: When other remedies don’t seem to work, a comforting hug can help reassure and soothe a fussy baby

Pharmacological treatments and safety concerns 

Medications can provide relief, but they should be used with caution and only under pediatric guidance:

• Common pain relievers include paracetamol, ibuprofen, choline salicylates, lignocaine, and benzocaine. Many parents turn to paracetamol or ibuprofen to ease discomfort
• Some mistakenly resort to antibiotics like amoxicillin and metronidazole, especially when symptoms like diarrhoea appear. However, unnecessary antibiotic use can lead to superinfection and antibiotic resistance, potentially worsening a child’s health
• The FDA warns against benzocaine and lidocaine-based topical medicines, as they can cause serious risks like methemoglobinemia and even death. Similarly, homoeopathic teething tablets and amber teething necklaces pose choking and strangulation hazards

When to consider medication 

If a baby is extremely fussy or in significant discomfort, consult a paediatrician before using any over-the-counter pain relief medication. A doctor can recommend the safest and most appropriate option to ease pain without harming the baby’s developing teeth and gums.

Summary: teething and ear pulling in infants

Teething usually begins around 6 months and can cause symptoms like sore gums, drooling, sleep disturbances, and ear pulling. Ear tugging is common during teething due to shared nerve pathways between the gums and ears, particularly via the trigeminal nerve. This referred pain, especially during molar eruption, can make babies rub or pull at their ears.

While ear pulling can be a self-soothing behaviour, it may also signal discomfort or ear infections. Unlike teething, ear infections are caused by bacteria or viruses and often include persistent pain, fever over 38°C, hearing issues, and fluid drainage. Teething doesn’t directly cause ear infections, but excessive drooling may increase moisture, potentially creating an environment for bacteria.

To relieve teething-related discomfort, safe methods include cold teething toys, gum massages, and chilled fruits. Medications like paracetamol or ibuprofen should only be used under pediatric guidance, and topical numbing agents or homoeopathic remedies are not recommended due to safety risks. Always consult a doctor if symptoms worsen or if infection is suspected.