Signs and Symptoms Associated With Primary Tooth Eruption
Most of the children in the present study had one or more signs and symptoms during tooth eruption, in agreement with previous studies. However, the prevalences of each type of disturbance differed, possibly because of the influence of sample size, age, the method of data collection and the types of symptoms we studied. As in previous studies, we found that tooth eruption was accompanied by local disturbances such as drooling and the urge to chew on objects. However, some reported that fever, diarrhea and vomiting were the symptoms most frequently related to tooth eruption. Like others, we found no relationship between systemic symptoms and teething. Tooth eruption is a physiological process and the manifestations we studied here may be coincidental with teething rather than causal consequences. Moreover, the reporting of symptoms during tooth eruption may be influenced by healthcare factors as well as by parents' knowledge, perceptions and beliefs.
As in the present study, some earlier reports found drooling to be one of the most common teething manifestations. Increased salivation may result from irritation of the gums. Excess saliva may lead to coughing or gagging, which should not cause alarm except in children with other signs of flu. Also, drooling may cause chin rash when saliva contacts the skin around the mouth. Cleaning the child's mouth and chin is recommended to prevent the rash.
Most of the children in our study preferred biting objects to reduce gingival irritation. Pressure from the erupting teeth is relieved by counter pressure from biting. However, contamination of the objects or the child's fingers is a factor that can cause diarrhea. In this connection, swallowing excess saliva or the release of IL-1beta and IL-8 cytokines have also been suggested to contribute to looser stools during teething.
Parents believe their child's behavior changes during tooth eruption. Specifically, gum soreness and pain may lead to irritability. This reaction in association with increased levels of interleukin (IL-1beta) may cause loss of appetite and weight loss. In our study some mothers reported irritability and pain in their child; however, the reliability of their reports of pain was impossible to judge because young children cannot verbally explain their pain experiences. Therefore mothers interpreted their child's behavior and gestures to indicate pain based on, for example, facial expressions which may reflect other forms of stress or distress. Pain is also related to increased levels of inflammatory mediators such as cytokines in the gingival crevicular fluid and the stimulation of nociceptive receptors.
As in the present study, some earlier reports found mild increases (albeit within the normal range) in body temperature during tooth eruption. Our results showed low-grade increases in temperature especially on the day of eruption, but not actual fever. We found that many mothers held the misconception that teething leads to fever, whereas actual fever was found in few of the children in our study. This may reflect parents' erroneous belief in the relationship between teething and fever. Actual fever may be due to developmental changes in the child such as decreased maternal immunity and increased susceptibility to infection. In addition, the release of IL-1beta and tumor necrosis factor (TNF) alpha may be casual factors in fever and sleep disturbances. We used tympanic temperature, which provide easy, rapid and more accurate readings than axillary temperature.
Our results showed that the type of erupted tooth did not influence teething disturbances. Only canine eruption led to significantly more loss of appetite in comparison to incisors and molars. This difference may be related to the child's discomfort and pain. One study reported teething disturbances were more prominent for incisors. Additional studies are needed to evaluate the disturbances that may be associated with the eruption of different types of teeth.
The parents of low birth weight children in our study reported more teething disturbances compared to normal birth weight children. This may be due to lower "immune competence and increased vulnerability to infectious diseases" in the former subgroup. In addition, maternal anxiety in the interactions with their children may influence parents' tendency to overestimate teething disturbances in low birth weight children.
Two main methods – pharmacological and nonpharmacological – have been recommended as remedies during tooth eruption. We used nonpharmacological remedies because of the parents' attitudes towards using remedies which do not threaten their child's health. According to our results, some methods such as teething rings, cuddle therapy and rubbing the gums were more effective than others. However, none of the methods was completely effective in ameliorating all the teething problems we studied. Teething rings and rubbing the gums reduced gingival irritation and finger sucking in the present study. The pressure caused by biting teething rings or pacifiers and gingival massage may decrease pain by overwhelming the sensory receptors.
Biting or sucking cold or frozen objects including fruits, vegetables or other foods causes localized vasoconstriction and decreases inflammation; in addition, the pressure on the gums reduces pain. However, these remedies should be used only for children who are able to eat solid foods. Also, foods that are very hard should not be used, to avoid pain caused by bruising the gum. Moreover, parental supervision is needed to prevent choking on small pieces of food. In the present study pieces of ice or frozen foods were not effective, probably because the mothers found them difficult to use and they were not well accepted by the children. These problems may have influenced the time to recovery and the comparatively low level of parents' satisfaction.
Behavior therapy and cognitive management are safe methods to manage sleep disturbances and irritation in children. Our results showed that cuddle therapy was effective in controlling sleep disturbances and crying. Child crying and restlessness may be related to separation anxiety or attention seeking. Therefore parental attention and care can be effective in assuaging some symptoms. These methods focus on reducing the sensation of pain during activities such as playing with the child, which can distract the child from pain.
A potential limitation of the current study is that some mothers may not have followed our instructions correctly, or may have reported signs and symptoms inaccurately. Their reporting may be influenced by their beliefs regarding popular knowledge about teething, as exemplified by their reports of fever when their child's temperature was only very slightly increased. In addition, our limited geographic setting and limited sample size should be considered study limitations.
On the other hand, the main strength of our study was the questionnaire we developed on the basis of a comprehensive literature review. In addition, we measured body temperature during tooth eruption, recorded a variety of other symptoms during the eruption of different types of tooth, and compared our findings in normal birth weight and low birth weight children. In addition, we used nonpharmacological methods to reduce teething symptoms.
Discussion
Most of the children in the present study had one or more signs and symptoms during tooth eruption, in agreement with previous studies. However, the prevalences of each type of disturbance differed, possibly because of the influence of sample size, age, the method of data collection and the types of symptoms we studied. As in previous studies, we found that tooth eruption was accompanied by local disturbances such as drooling and the urge to chew on objects. However, some reported that fever, diarrhea and vomiting were the symptoms most frequently related to tooth eruption. Like others, we found no relationship between systemic symptoms and teething. Tooth eruption is a physiological process and the manifestations we studied here may be coincidental with teething rather than causal consequences. Moreover, the reporting of symptoms during tooth eruption may be influenced by healthcare factors as well as by parents' knowledge, perceptions and beliefs.
As in the present study, some earlier reports found drooling to be one of the most common teething manifestations. Increased salivation may result from irritation of the gums. Excess saliva may lead to coughing or gagging, which should not cause alarm except in children with other signs of flu. Also, drooling may cause chin rash when saliva contacts the skin around the mouth. Cleaning the child's mouth and chin is recommended to prevent the rash.
Most of the children in our study preferred biting objects to reduce gingival irritation. Pressure from the erupting teeth is relieved by counter pressure from biting. However, contamination of the objects or the child's fingers is a factor that can cause diarrhea. In this connection, swallowing excess saliva or the release of IL-1beta and IL-8 cytokines have also been suggested to contribute to looser stools during teething.
Parents believe their child's behavior changes during tooth eruption. Specifically, gum soreness and pain may lead to irritability. This reaction in association with increased levels of interleukin (IL-1beta) may cause loss of appetite and weight loss. In our study some mothers reported irritability and pain in their child; however, the reliability of their reports of pain was impossible to judge because young children cannot verbally explain their pain experiences. Therefore mothers interpreted their child's behavior and gestures to indicate pain based on, for example, facial expressions which may reflect other forms of stress or distress. Pain is also related to increased levels of inflammatory mediators such as cytokines in the gingival crevicular fluid and the stimulation of nociceptive receptors.
As in the present study, some earlier reports found mild increases (albeit within the normal range) in body temperature during tooth eruption. Our results showed low-grade increases in temperature especially on the day of eruption, but not actual fever. We found that many mothers held the misconception that teething leads to fever, whereas actual fever was found in few of the children in our study. This may reflect parents' erroneous belief in the relationship between teething and fever. Actual fever may be due to developmental changes in the child such as decreased maternal immunity and increased susceptibility to infection. In addition, the release of IL-1beta and tumor necrosis factor (TNF) alpha may be casual factors in fever and sleep disturbances. We used tympanic temperature, which provide easy, rapid and more accurate readings than axillary temperature.
Our results showed that the type of erupted tooth did not influence teething disturbances. Only canine eruption led to significantly more loss of appetite in comparison to incisors and molars. This difference may be related to the child's discomfort and pain. One study reported teething disturbances were more prominent for incisors. Additional studies are needed to evaluate the disturbances that may be associated with the eruption of different types of teeth.
The parents of low birth weight children in our study reported more teething disturbances compared to normal birth weight children. This may be due to lower "immune competence and increased vulnerability to infectious diseases" in the former subgroup. In addition, maternal anxiety in the interactions with their children may influence parents' tendency to overestimate teething disturbances in low birth weight children.
Two main methods – pharmacological and nonpharmacological – have been recommended as remedies during tooth eruption. We used nonpharmacological remedies because of the parents' attitudes towards using remedies which do not threaten their child's health. According to our results, some methods such as teething rings, cuddle therapy and rubbing the gums were more effective than others. However, none of the methods was completely effective in ameliorating all the teething problems we studied. Teething rings and rubbing the gums reduced gingival irritation and finger sucking in the present study. The pressure caused by biting teething rings or pacifiers and gingival massage may decrease pain by overwhelming the sensory receptors.
Biting or sucking cold or frozen objects including fruits, vegetables or other foods causes localized vasoconstriction and decreases inflammation; in addition, the pressure on the gums reduces pain. However, these remedies should be used only for children who are able to eat solid foods. Also, foods that are very hard should not be used, to avoid pain caused by bruising the gum. Moreover, parental supervision is needed to prevent choking on small pieces of food. In the present study pieces of ice or frozen foods were not effective, probably because the mothers found them difficult to use and they were not well accepted by the children. These problems may have influenced the time to recovery and the comparatively low level of parents' satisfaction.
Behavior therapy and cognitive management are safe methods to manage sleep disturbances and irritation in children. Our results showed that cuddle therapy was effective in controlling sleep disturbances and crying. Child crying and restlessness may be related to separation anxiety or attention seeking. Therefore parental attention and care can be effective in assuaging some symptoms. These methods focus on reducing the sensation of pain during activities such as playing with the child, which can distract the child from pain.
A potential limitation of the current study is that some mothers may not have followed our instructions correctly, or may have reported signs and symptoms inaccurately. Their reporting may be influenced by their beliefs regarding popular knowledge about teething, as exemplified by their reports of fever when their child's temperature was only very slightly increased. In addition, our limited geographic setting and limited sample size should be considered study limitations.
On the other hand, the main strength of our study was the questionnaire we developed on the basis of a comprehensive literature review. In addition, we measured body temperature during tooth eruption, recorded a variety of other symptoms during the eruption of different types of tooth, and compared our findings in normal birth weight and low birth weight children. In addition, we used nonpharmacological methods to reduce teething symptoms.