Overview

Teething is the process by which the teeth come out from below the bones (alveolar bone) through the gum line ( oral mucosa) and into the mouth (oral cavity). It is a normal physiological process, but the teething process will be different for each baby. There are certain myths related to teething. However, recent research has debunked these, and these are now considered “old wives’ tales”¹. Even today, the exact cause of teething and how best to manage it are not fully understood. There are many mild symptoms related to teething, and fever is one of them. Research shows that mild fever may accompany teething, but high fever is always related to some other serious medical conditions.² It usually marks an important landmark in the child's overall development as it helps in (chewing) mastication, establishing oral motor behaviour and proper posture of the jaws.³ Hence, parents should be educated to debunk the myths related to teething.

Understanding teething

Teething is a natural developmental process that requires care and patience to help little ones cope with mild symptoms. That is why it is important for the parents and caregivers to understand the signs of teething and how best to manage them.

Teething occurs in an order (chronological order), and it usually varies among individuals, and it is usually based on genetics, hormonal influence, diseases, and overall health of the individual. There are 20 milk teeth (deciduous teeth). It can erupt as early as 4 - 8 months and can last up to 30-36 months²( Figure 1 and Table 1). After 6 months, a mother's protective antibodies (passive immunity) start to wean off, and the child is exposed to various pathogens, which can cause a wide variety of symptoms.⁴

Teething symptoms typically occur within an 8-day window, starting about four days before a tooth erupts, peaking on the day of eruption, and lasting for around three days afterwards. These symptoms are usually very mildincluding:

• Increased biting, gum rubbing, sucking 
• Increased irritability
• Increased drooling of saliva 
• Frequent rubbing of the ears
• Facial rash, especially around the mouth
• Swollen gums
• Loss of appetite for solid food
• Difficulty in falling asleep and night crying.
• Mild temperature elevation⁵

Teething is not associated with

• High fever more than 101F
• Rashes all over the body
• Diarrhoea, cough and cold 
• Prolonged fussiness

These should be considered alarming and should be discussed with physicians, as they can be signs and symptoms. 

Figure 1- Deciduous teeth

Table 1 shows the mean age of teething of upper and lower teeth.

Fever and teething: Examining the evidence

Recently, much research has been carried out to understand the relationship between teething and fever. A study Elbur et al conducted regarding the parental knowledge and practices on infant teething stated that most of the parents were unaware of the actual signs and symptoms. Body temperature analysis showed that there can be an increased rise in temperature, but not significant enough to cause fever. Fever can be a symptom of other serious infections.⁶ Tasanens in his study failed to get any direct relation with teething and fever. He concluded that it didn't increase infection, didn't even increase the temperature, no diarrhoea, cough, or sleep disturbances. It may cause daytime restlessness, increase finger sucking and rubbing of the gums and it can cause a reduced appetite. Most of the studies reviewed show only a slight rise in temperature related to teething.⁷

Possible mechanism behind temperature elevation

The exact mechanism between teething and the symptoms is not clearly understood. 

• It can be due to the production of inflammatory chemical mediators such as cytokines and growth factors, which cause the systemic and local effects 
• Another possibility is the reduction of maternal immunity or passive immunity to active immunity. This switch can cause an increase in infection in children. Usually, maternal immunity lasts for about 6 months²

Management and treatment strategies 

It is always believed that teething causes pain, as parents think that the teeth cut open the gums as they come out. The actual reason for pain can be due to frequent rubbing or biting on objects by the kids, or it can be due to inflammatory mediators acting surrounding the gums(crevicular area). This inflammation may also lead to a mild rise in temperature. It can be managed by pharmacological or non-pharmacological means. Use of analgesics and antipyretics can reduce the pain and temperature.²

Medicines that should be avoided

• Benzocaine is a painkiller, as it can cause methemoglobinemia
• Aspirin should never be given to children, either orally or topically, as it has been linked to Reye’s syndrome, a potentially life-threatening condition
• Teething gels are best avoided, especially if over-applied, as they can be easily swallowed and may cause harmful side effects⁸

Non-pharmacological remedies include

• Massaging the gums
• Teething ring 
• Some cooled vegetables or fruits to bite on, which should not be frozen
• Frequent breastfeeding
• Gently wiping the drooled-down saliva from the infant's mouth can reduce the risk of infections^9,10

These reduce inflammation, and cooled objects can even cause vasoconstriction and decrease pain by overwhelming the sensory receptors. Massaging has proven to be very effective in reducing the discomfort caused by teething. 

Things to be avoided

• Teething jewellery, necklace, and bracelets should be avoided
• Teething toys should be solid, and they should not have a liquid consistency inside
• Do not use hard frozen items that can damage the gums of your child
• Avoid breakable toys and plastic teething rings that may be a choking hazard
• Do not clip any teether or toy on the baby’s dress
• Homoeopathic medications are not used as it is banned by the FDA as their composition can cause harm to babies
• Avoid giving any fruits or vegetables for teething unless the baby has started solid food. Moreover, it should be done under supervision to reduce choking hazards^9,11

FAQs

What is a teething toy?

It is used to relieve the pain or the irritability caused due to teething. There is always an urge to put pressure while teething. Gnawing on these toys can relieve the urge.

How to select a teething toy?

It should be selected based mainly on safety aspects like BPA free material, it shouldn't be too hard or too soft, as it won't break easily, it should be easy to clean, it should be large enough so that it won't cause choking hazard, it should be of the material that can be cooled and used.

When should you be concerned about teething?

When there is a high grade of fever, diarrhoea, and rashes that have spread around the mouth as well as other areas, and the baby is restless or inconsolable for an extended period, then it is recommended to get a consultation.

Is teething painful for the babies?

The experience of teething can vary from baby to baby. While some may feel little to no discomfort, others may experience mild pain and irritability. This discomfort is often due to inflammatory mediators in the gums or the pressure caused by chewing on objects as the teeth begin to emerge. Both pharmacological as well as non-pharmacological methods can help soothe your baby and ease the symptoms.

Summary

Many misconceptions around teething persist, and it's important to challenge these myths with clear, evidence-based information. By understanding the true signs and symptoms of teething, parents and caregivers can better distinguish it from more serious infectious illnesses. Teething is a key developmental milestone, one that often comes before other major steps like eating solid foods and speaking. Supporting children through this stage is a shared responsibility between parents and caregivers, and it can be made smoother by using both pharmacological and non-pharmacological approaches to ease discomfort. Paediatricians and paediatric dentists play a crucial role in educating families. Many common symptoms, such as fever, are often wrongly attributed to teething and could indicate something else that needs attention. So let's bust the myths and enjoy the wonderful journey of the little ones.