TEETHING DISORDERS

PRESENTED BY
DR LEKSHMI V
SECOND YEAR POST GRADUATE STUDENT
DEPARTMENT OF PEDODONTICS
NAVODAYA DENTAL COLLEGE,RAICHUR
 CONTENTS
• INTRODUCTION
• ERUPTION SEQUENCE
• CLINICAL FEATURES OF TEETHING
• MANAGEMENT
• TEETHING PROBLEMS
• CONCLUSION
• REFERENCE
 INTRODUCTION

It is medically termed odontiasis

Teething is the physiological process by which an infant’s teeth

erupt or breakthrough the gums.
Onset of teething symptoms typically precedes the eruption of a tooth by several days

While a baby’s first tooth can present between 4 and 10 months of age, the first tooth
usually erupts at approximately 6 months of age

In most cases ,eruption of primary teeth causes no distress to the child or parents, but
sometimes process causes local irritation which may interfere with child’s sleep
 ERUPTION SEQUENCE
• General order of eruption of
primary teeth
: 6 -12 months of age

CENTRAL INCISORS

9-16 months of age

LATERAL INCISORS :

: 22-24 months of age : 16-23 months of age : 13-19 months of age

CANINE TEETH

FIRST MOLARS
 CLINICAL FEATURES OF TEETHING
• LOCAL SIGNS :
• Hyperemia or swelling of the
mucosa overlying the
erupting teeth
• Patches of erythema on the
cheeks
• Flushing may also occur in
the skin of adjacent cheek
• Increased drooling
• Restless or decreased sleeping
due to gum discomfort
• Refusal of food due to soreness of the gum region
• Fussiness that comes and goes
• Bringing hands to the mouth
• Mild rash around the mouth due to skin irritation
secondary to excessive drooling
• Rubbing the cheek or ear region as a consequence of
referred pain during the eruption of the molars
• General irritability and crying
• Loss of appetite
• Sleeplessness,restlessness
• Increased salivation and drooling
• Diarrhea SYSTEMIC
•
•
Fever
SIGNS
Meningitis
• Increased thirst
• Circumoral rash
• Cough
 MANAGEMENT OF TEETHING
• Teething rings
• Hard sugar free teething rusks
• Cucumber
• Frozen items (anything from ice cubes to
frozen banana, sliced fruit, vegetables)
• Pacifier (even frozen)
• Rub gums with clean finger,wet gauze
• Reassurance
• Analgesics/antipyretics
• Topic anesthetic agents
• Alternative holistic medicine
 NON PHARMACOLOGICAL MANAGEMENT
•Teething Rings
•Hard ,Non sweetened rusks
•Finger Pressure

TEETHING RINGS :

 Wide range of teething rings are commercially available for infants to gnaw
 Solid silicone based teething rings are superior to their liquid filled
counterparts, as the potentially harmful substances used in their
manufacture
TEETHING RING :
Temporary relief is provided by the pressure produced by chewing
the teething ring, maximal when chilled first

FINGER PRESSURE :
Clean finger or saline soaked gauze piece and increased fluid
consumption

HARD, NON SWEETENED RUSK :

It is made from flour and wheat with no sugar or sweetener
 PHARMACOLOGICAL MANAGEMENT
 TOPICAL AGENTS :
• Anesthetics and minor analgesics
• LIGNOCAINE BASED PRODUCTS :
• Lignocaine hydrochloride is a local
anesthetic that is rapidly absorbed
through mucous membrane giving
prompt relief from pain, although
temporary.
• Around 7.5 mm of gel should be placed
on a clean finger or cotton bud,and
rubbed onto the painful area.
• Although 20 minutes should elapse
between approaches,only six
applications should be used each day
,in order to prevent systemic toxicity
• SM-33 Gel : Anesthetic and analgesic
• 2% salicylic acid, 0.5% lignocaine, 0.5% tannic acid,
0.05% menthol, 0.05% thymol, 40% ethanol
• Topical use – “Apply to area every 3 hours”
• “Indicated for infant teething; abrasions and
inflammation of gums, palate, tongue”
• “Not recommended for infants less than 6mths of age”
• “Concomitant use of aspirin contraindicated in
children”
• CHOLINE SALICYLATE BASED PRODUCTS
• Salicylates Regarded as Minor analgesics
Similar to Lignocaine hydrochloride

They penetrate mucous

membrane readily and
give prompt pain relief

Their main pharmacological advantage over lignocaine based preparations is that in

addition to providing analgesia,they are also anti inflammatory and antipyretic,thus
reducing swelling
For children over 4 months old,0.5 inch (7.5mm) of gel to be massaged onto the painful
area not more often than 3 hourly, with a maximum of six applications daily
References : Tsang KLA.Teething,teething pain and teething remedies.International dentistry SA Vol 12;No 5
Nikhil Marwah.Textbook of pediatric dentistry.3rd edition
• Bonjela Teething Gel (Reckitt Benckiser)
• 87mg/g choline salicylate
• Also contains: ethanol,saccharin, cetalkonium
chloride
• Topical use – “Massage approximately 0.5cm of gel” every 3hrly and not
more than applications in any 24hrs period
• “Indicated for relief of pain and discomfort in abrasions, ulcers, irritations
of the gums, palate, cheek, tongue and lips; infant teething disorders”
• “Not recommended for infants under 4 months of age” “Preparations
containing aspirin should not be given to children under 12 years of age
during treatment”
• Curash Family Oral Pain Relieving
Gel
• 90mg/g choline salicyclate,
• 350mg/g ethanol
• Also contains: 0.38mg/g cetylpyridinium
chloride, 0.25mg/g cetalkonium chloride
• Topical use – “Apply to saliva free area
and gently rub in every 3hrs”
• “Indicated for pain relief for teething and
relief of sore gums”
• “Do not use on infants under 4 months of
age”
• “While using gel, young children should
not be given aspirin or other salicyclates”
• SYSTEMIC ANALGESICS :
• Sugar free paracetamol elixir

Systemic medicament of choice in teething

because of its action in reducing pain and pyrexia

Paracetamol dosage :
3 to 12 months 60 to 120 mg
1-5 years 120 to 250 mg
These doses are repeated at 4 to 6 hourly intervals, with a maximum of four doses in
24 hours
 ALTERNATIVE HOLISTIC MEDICINE
• Alternative nonpharmacological holistic therapies
• Acupressure,aromatherapy,massage and homeopathy have been suggested as
giving relief from the symptoms of teething
• Acupressure : requires the parent to apply pressure to certain key skin
points,providing immediate,if temporary pain relief
• Aromatherapy : uses essential oils (clove oil,tea tree oil,olive oil) often with
massage to neutralize the inflammatory mediators produced during teething
• Alternatively, chamomile oil may be placed in an aromatherapy diffuser in the
infants bedroom
• Homeopathy :Treats the whole person, not solely the illness and is
becoming a more popular method of treating the symptoms of
teething
• The main indications of these products are to soothe the child
,correct the motions,releave restlessness,fretfulness and similar
troubles incidental to the teething period..’all potentially useful
benefits during teething
 PREVENTIVE MEASURES

• Mention teething in prenatal counselling

• Educate members of the family
• Good oral and body hygeine; gums healthy and
fresh
• Gums wiped after each meal with cotton soaked
in weak antiseptic
• Adequate Vitamins,minerals,proteins
 GENERAL ADVICE

Parents should also

Adding or be advised the Teething remedies
Parents should dipping repeated application should be kept
be advised that sugar,honey or of alcohol to the well out of reach
a number of jam to feeding mucous membrane
of all children
of an infant is
outdated botttles,has ineffective as a
,because of added
practices are absolutely no topical anesthetic flavourings,childre
pain relieving and due to an n can unwittingly
potentially
effect,and is infants small body overdose
harmful weight,may lead to themselves
highly cariogenic
hypoglycemia
 CAUTION

Infants with severe systemic upset should be promptly

referred to physician for an accurate diagnosis and
appropriate treatment …
 TEETHING PROBLEMS
• ERUPTION HAEMATOMA
(ERUPTION CYST)

• Bluish purple,elevated area of tissue,commonly

called eruption hematoma,occasionally develops
few weeks before the eruption of primary or
permanent tooth

• It is a soft tissue analogue of the dentigerous cyst,

but recognized as a separate clinical entity
• Dentigerous cyst develops around the crown of an unerupted
tooth lying in the bone,the eruption cyst occurs when tooth is
impeded in its eruption within the soft tissues overlying the bone
• The blood filled cyst is most frequently seen in the primary 2nd
molar or the 1st permanent molar regions
• It is developmental soft tissue cyst of odontogenic origin
• Lesion appears as a circumscribed, fluctuant,often
translucent swelling of alveolar ridge over the site of the
erupting tooth
• When the circumcoronal cystic cavity contains blood,
the swelling appears purple or deep blue; hence the
term “Eruption Haematoma”
Differential Diagnosis : Hemangioma, Neonatal alveolar
lymphangioma, Pyogenic Granuloma, Amalgam Tattoo

On radiographic examination, it is difficult to distinguish the

cystic space of eruption cyst because both the cyst and tooth are
directly in the soft tissue of the alveolar crest and no bone
involvement is seen
 MANAGEMENT

The cyst roof may be removed

to allow the tooth to erupt
although most of them burst
spontaneosly

Surgical
excision
 ERUPTION SEQUESTRUM

• The eruption sequestrum is seen occasionally in children at the time of the

eruption of the first permanent molar
• An eruption sequestrum is composed of cementum like material formed
within the dental follicle
• They have little or no clinical significance,as they usually sequestrate
spontaneously
• Eruption Sequestrum ,is an anomaly associated with erupting teeth in
children,was first described by Starkey and Shafer
• Regardless of its origin,hard tissue fragment is generally
overlying the central fossa of the associated tooth
embedded and contoured within the soft tissue.
• As the tooth erupts and the cusps emerge the fragment
sequestrates
• In case where eruption sequestrum is causing local
irrritation and as surfaced through the mucosa it may easily
be removed
 ETIOLOGY

• As the molar teeth erupt through the bone ,they will occasionally
separate a small osseous fragment from the surrounding
contagious bone
• In most cases ,this fragment probably undergoes total resorption
prior to eruption
• If the bony spicule is larger or eruption is fast, complete resorption
cannot occur and the eruption sequestrum is observed
 CLINICAL FEATURES

• Eruption Sequestrum is a tiny, irregular spicule of bone overlying

the crown of an erupting permanent molar, found just prior to or
immediately following the emergence of the tips of cusps
through the oral mucosa
• The spicule directly overlies the central occlusal fossa but is
contained within the soft tissue
• As the tooth continues to erupt and the cusp emerge, the
fragment of bone completely sequestrates through the mucosa
and is lost
• For a few days,the fragment of bone may be seen, lying on the
crest of ridge in a tiny depression from which it may be easily
removed
 RADIOGRAPHIC FEATURES

A radiopaque fragment of
sequestrating bone can be seen
overlying an impacted third molar

• It is possible to recognize eruption sequestrum radiographically

even before teeth begins to erupt in the oral cavity or before the
bony spicule perforates the mucosa
• It appears as a tiny ,irregular opacity overlying the central occlusal
fossa but seperated from the tooth itself
 CLINICAL SIGNIFICANCE AND TREATMENT

• Occasionally a child may complaint of a slight soreness in the area,

• probably produced
Occasionally a childby
maythecomplaint
compression of aof soft soreness
slight tissue over
in the spicule
area,
during eating
probably and just
produced prior
by the to its breaking
compression through
of soft tissuethe mucosa,or
over by
the spicule
the movement
during of the
eating and justspicule
prior toinits
thebreaking
soft tissue cyst during
through mastication
the mucosa,or by
and following eruption
the movement through
of the spicule thesoft
in the mucosa
tissue cyst during mastication
• No
andtreatment
following is
eruption through
necessary as thethe mucosaresolves by itself
condition
• No treatment is necessary as the condition resolves by itself
 ECTOPIC ERUPTION

Before permanent
When the eruption
teeth erupt into the
path is incorrect
oral cavity and are
,the tooth will erupt
visible ,they move
in the mouth in an
through the bone
incorrect position or
along their path of
may not erupt at all
eruption

When this
occurs,this
undesirable
eruption is called
“ectopic
eruption’
 ETIOLOGY

• Inadequate space in the jaws for the teeth

• The eruption is deflected due to the crowding and the tooth
erupts “ectopically”(in the incorrect position)or not at all

Ectopically erupting tooth If an ectopic does erupt,it

may erupt against the root of will of course ,erupt in an If the ectopic tooth
an adjacent tooth with incorrect position because erupts it will erupt
enough pressure to cause root by definition ,it has had an toward the palate or
resorption and the ultimate incorrect path or direction of
loss of adjacent tooth
out against the cheek
eruption
 MANAGEMENT

 If the tooth has inadequate space ,adequate space should be

made as soon as possible ,preferably without removing
permanent teeth
 After adequate space is achieved ,the ectopic tooth eruption
should be closely observed
 An ectopic tooth may not erupt through the gum at all and may
require orthodontics, as well as surgery ,to bring it into
functional position
• Interceptive treatment benefits the ectopic
teeth by the following
 Fewer extraction of permanent teeth are
necessary
 Less orthodontic treatment needed once the
tooth erupts
 Fewer side effects :
A. Resorption of the roots of adjacent permanent teeth
B. Periodontal problems if the ectopic tooth is allowed to
erupt in toward the palate or out toward the cheek
C. Better self esteem than if the ectopic tooth erupts out of
alignment and creates negative peer pressure
D. Interceptive treatment will usually greatly improve the
eruption of the ectopic tooth but final orthodontic
alignment is normally required to obtain an ideal result
 NATAL AND NEONATAL TEETH

NEONATAL TEETH

• Eruption of teeth at or immediately after birth is a relatively rare phenomenon

• These have been defined by Massler and Savara.These teeth are known as
“natal” teeth if present at birth and “neonatal “ teeth if they erupt during the
first thirty days of life
• Prematurely erupted primary teeth present at birth have also been described
in the literature as “congenital teeth”,fetal teeth,or dentition praecox
• Neonatal teeth often present with :

 Hypoplastic enamel
 Underdeveloped roots with resultant mobility

• However such teeth also should be further classified according

their degree of maturity
• A mature natal or neonatal tooth Exhibits normal
development Has a relatively good prognosis
• While the term Immature natal and neonatal tooth
Defective development and poor prognosis for retention
 PREVALENCE

• The reported prevalence of natal and neonatal

teeth has varied considerably from one in
every 11.25 to 30 000 births
• Natal teeth are encountered more often than
neonatal teeth in an approximate ratio of 3:1
• More predlictions in females
TEETH AFFECTED
• The teeth most often affected are lower
primary central incisors
 ETIOLOGY

• Over the years there have been many postulations regarding the
cause of premature eruption including hypovitaminosis, hormonal
stimulation,trauma ,febrile states and syphilis,but a cause and
effect relationship has not yet been established
• The current concept suggest that natal and neonatal teeth are
attributed to a superficial position of the developing tooth
germ,which predisposes the tooth to erupt early

Natal and Neonatal teeth are also found to be associated with

multisystem syndromes and developmental abnormalities providing
the evidence of genetic contribution
 CLINICAL APPEARANCE

• Natal and Neonatal teeth may resemble normal primary teeth;

but ,in many instances ,they are poorly developed, small, conical,
yellowish, with white hypoplastic enamel and dentin and with
poor or total failure of development of roots
• The appearance of each natal
tooth can be classified in one
of the following categories by
Hebling (1997)
• Category 1 : A shell like crown
structure loosely attached to
the alveolus by a rim of oral
mucosa; no root
• Category 2 : A solid crown
loosely attached to the alveolus
by oral mucosa;little or no root
• Category 3 : The incisal edge
of the crown just erupted
through the oral mucosa
• Category 4: A mucosal
swelling with the tooth
unerupted but palpable
 HISTOLOGY

• Histological investigations

Most of the crowns of natal and neonatal teeth are covered with

Hypoplastic
enamel with Absence of Lack of Irregular Ample and
varying root cementum dentin vascularized
degrees of formation formation formation pulp
severity
 STUDY REPORT

• A retrospective study of neonates who visited the Department

of Pedodontics and Preventive Dentistry, College of Dental
Sciences, Davangere, India, between 2003 and 2006 was
carried out.
• It was a study of clinical data, such as the age and gender of
the patients, the history and chief complaints of mothers, the
clinical appearance and location of natal/neonatal teeth, and
associated complications and treatments
• RESULTS
• Among 15 patients, 17 teeth (6 natal, 11 neonatal)
were diagnosed in 15 patients who were 8 days to one
month old . There was no significant gender preference
(8 male, 7 female).
• A significant single occurrence of natal/neonatal teeth
was observed .
• There was a significant preference for the mandibular
incisor position.
• In the mandible, a majority (16/17) of natal/neonatal
teeth involved the central incisor position; in one
patient, a tooth in the maxillary incisor area was
visible..
• Clinical histories were checked for symptoms, and in all cases, there was a
difficulty in feeding or refusal to suckle milk due to pain.
• The reasons for making a first visit to a dentist were the appearance of the
tooth and its mobility, presence of sublingual ulceration, refusal to suckle,
and possible aspiration of the tooth because of mobility.
• A natal tooth associated with cleft lip and palate was observed in one
patient.
• Clinically, three patients exhibited enamel hypoplasia of the natal/neonatal
tooth, one patient showed gingival hyperplasia , and three patients
displayed sublingual ulceration .
• The natal/neonatal teeth in all patients exhibited hyper mobility.
• A radiographic examination of all patients confirmed that these teeth were
supernumerary.
• Extraction was performed in all 15 cases under topical anesthesia, since all
were hyper mobile and mothers of all patients were willing to have these
teeth removed.
• Eleven of extracted teeth exhibited rudimentary roots, and six teeth showed
no roots
• Conclusions:
• The occurrence of a natal/neonatal tooth is a
rare phenomenon. When it occurs, the teeth
have a variety of clinical characteristics and
lead to different complications.
• Knowledge of the management of these
structures is essential for the overall well
being of a child.
 MANAGEMENT
• A radiograph should be made to determine the amount of root
development and the relationship of prematurely erupted tooth
to its adjacent teeth
 King and Lee recommended :

• Chlorhexidine gluconate gel :

Inflamed gingival tissue around teeth should be controlled by

applying chlorhexidine gluconate gel 3 times a day
Adv :
Selective grinding of tooth as in some cases sharp incisal edge of
the tooth may cause laceration of the lingual surface of the tongue
Most prematurely erupted teeth are hyper mobile because of the
limited root development

Some teeth may be mobile to the extent that there is danger of

aspiration,in which case the removal of the tooth is indicated

If extraction of tooth is indicated,after the tooth is removed ,careful

curettage of the socket is indicated in an attempt to remove any
odontogenic cellular remnants that may otherwise be left in the
extraction site
Earlier it was recommended to delay surgical procedures on
newborns until after 10th postpartum day to inability of clotting but
nowadays it is no longer considered because of prophylactic
administration of vitamin K as a standard procedure in most hospitals
• If breastfeeding is painful for mother initially, the use of a breast
pump and bottling the milk are recommended
 COMPLICATIONS

• Traumatic ulceration on the ventral

surface of the tongue, frenulum or lip is
the most commonly associated
complication of natal teeth
• Ulceration of the sublingual area in
infants was first described in 1857 by
Cardarelli
• In 1881 and 1890 ,Riga and Fede
described this lesion histologically and it
has subsequently been known as “Riga
fede disease”
• Although a more appropriate ,descriptive
term is “Neonatal sublingual traumatic
ulceration”
 NONERUPTION OF TEETH

• Noneruption of teeth beyond their common eruption schedule

• Adv :
Minor incision to facilitate their eruption if they are not
associated with impactions or pathologies
 CASE REPORT
• Teething induced fever in a 9-month old child: a case report
• Case
• A 9-month old baby girl presented to Al-Jumaa Heath Centre, Mwanza,
Tanzania, with a history of high grade fever, loss of appetite, restless and
diarrhoea (passing loose stools 7 times per day) for one day.
• The child was febrile (axillary temperature, 38.2oC) and weighed 9.5 kg. The
child did not have any tooth and there was no other remarkable finding on
physical examination.
• Upon investigations, no malaria parasites were observed under microscopic
examination and malaria antigen (rapid diagnostic) test was negative.
• Urinalysis showed yellow urine. Neither cysts nor trophozoids were seen in
stool analysis.
• Despite of negative malaria tests, the child was covered on artemether and
lumefantrine (1 tablet start, then second tablet after 8 hours followed by 1
tablet twice daily for next 2 days), paracetamol 125 mg thrice daily and oral
rehydration solutions
• On the third day, the child continued to have episodes of high fever and
diarrhoea.
• The child was returned to hospital where blood and urine were collected
for further investigations
• Full blood picture as well as blood and urine culture were performed.
After blood and urine collection, the patient was prescribed
Metronidazole 125mg thrice daily for 5 days
• No bacteria growth was observed in either blood or urine culture. Despite
of these negative laboratory findings, the patient continued to have fever
and diarrhoea and the mother hesitated to give her medication
(metronidazole).
• On the fourth day, the mother noticed a pair of lower central incisor teeth
erupted and on the fifth day, the child had neither fever nor diarrhoea.
• A month later, the child experienced similar symptoms
for 3 days before eruption of the upper central incisor
teeth.
• This time, the child was given paracetamol syrup only,
and symptoms subsided after teeth eruption.
• Although viral infections were not ruled out when the
child had fevers which were followed by teeth
eruption, the two coincidences of teeth eruptions
preceded by fever suggests a likelihood that teething
is associated with fever.
• Discussion
• While a number of paediatricians and other scholars
consider systemic signs such as fever during teeth
eruption to be merely coincident with period of teething
,the current case suggests that teething induces fever.
• The timing of fever and other symptom presented with,
and their disappearance relative to first teeth eruption
and lack of evidence of other causes of the fever
strongly suggest that fever and other systemic
disturbances in the present case were due to teething.
• Conclusion
• This case study demonstrated that teething is associated with
fever.
• This case also shows that teething induced fever can cause
unnecessary use of anti-malarial drugs and antibiotics.
• Indiscriminate use of anti-malarial drugs and antibiotics is likely
to be practiced among children aging 6–20 months with
teething fever.
• Though not all children are affected by teething induced fever,
we appeal for the health care workers to consider teething as
one of cause of fever among children at this age group.
 CONCLUSION
Educating parents, caregivers and the general public will help to
correct the false beliefs attributed to teething and foster
prompt health-seeking behavior. This role of health education
falls on health professionals and educators. The content of
health education given to mothers during antenatal clinic as
well as well baby clinic visits should include evidence-based
information on infant teething. Mothers should also be
informed about appropriate measures to take when mild
symptoms are noticed as well as recognition of danger signs
and symptoms of common childhood illnesses, which would
necessitate presentation at a health facility.
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