The process where the primary teeth (baby teeth) first appear is called teething. Teeth that are present at birth or develop shortly thereafter are referred to as natal teeth. The first teeth usually appear some time between the ages of 3 months and 16 months. All 20 primary teeth are typically present by the time a child reaches 3 years of age. The teeth usually emerge in a set pattern and at predictable intervals of time. They tend to emerge two or four at a time.

Teething can be painless for infants but often produces some discomfort. The symptoms of teething vary widely between babies and can include irritability, drooling, chewing on things, swollen gums, disrupted sleep, changes in eating patterns and a low-grade fever. A fever above 100.4 degrees Fahrenheit (38 degrees Celsius), diarrhea, vomiting or diaper rash are not associated with teething and may signify an infection or other illness.

Teething is usually not a reason for parents or caregivers to worry or to make a special trip to a pediatrician. However, if an infant appears especially uncomfortable, a pediatrician can offer recommendations to manage the discomfort.

Teething infants need to chew. The pressure produced by chewing helps relieve the discomfort and wears down the gums in front of the tooth, making it easier for it to emerge. A clean, wet, chilled washcloth is a useful chewing aide. Teething rings, pacifiers and toys made of firm rubber are also good items for an infant to chew. Hard, unsweetened teething crackers may also be useful as well as a baby bottle filled with water. Relief of teething discomfort may come from chewing on the nipple of the bottle as well as the sucking action. Firmly rubbing the gums with a clean finger can also soothe the infant’s discomfort.

Teething is the process by which an infant’s first set of teeth erupt (emerge) through the gums. This first set may be referred to as primary teeth, deciduous teeth or baby teeth. The teeth typically emerge in a set pattern and at predictable intervals of time, although there are variations. If an infant’s teeth erupt in a pattern that is not typical, there is not necessarily anything wrong.

Tooth development begins before birth. Early teeth are present in an infant’s jaw, under the gums, at birth. As the infant ages, they continue to develop until they are ready to emerge through the gums. The age at which this occurs varies widely from infant to infant and depends largely on family history. Rarely, a tooth or two may be present at birth or erupt within the first month. However, the first teeth usually appear some time between the ages of 3 months or 4 months and 8 months to 10 months. The average age that teething begins is 6 months but a child may reach an age of 12 months to 16 months before the first teeth erupt. When a tooth is coming in, the surrounding gum may be raised, swollen and discolored (red to purple). The primary teeth are smaller than the teeth in an older child or adult’s mouth, but similar in shape and appearance. For example, an emerging incisor may look like a small, white peg. An emerging molar, on the other hand, will appear as a small, relatively flattened surface. Once the tooth emerges, any swelling or discoloration tends to fade. In some cases, an erupting tooth may cause a small amount of bleeding.

The typical pattern in which the first set of teeth erupts is as follows:

1. Lower central incisors. The two middle teeth in the front of the jaw are usually the first to emerge.
   
   
2. Upper central and lateral incisors. The four teeth in the front on the top tend to erupt a month or two after the lower central incisors.
   
   
3. Lower lateral incisors. The second pair of lower incisors, one on each side of the central incisors, generally appears about a month later.
   
   
4. First molars. The flat teeth in the back, two on top and two on bottom, tend to come after the lower lateral incisors.
   
   
5. Eyeteeth. The pointy teeth (canines) between the molars and incisors usually erupt next.
   
   
6. Second molars. The second set of flat teeth, two on top and two on bottom, usually come in last. They occur just behind the first set of molar and tend to appear at some point between the ages of 20 months and 30 months.

All 20 primary teeth are typically present by the time a child reaches 3 years of age. This set of teeth remains intact until the secondary (permanent) teeth are ready to erupt, which generally occurs somewhere around the age of 6 or 7 years.

Teething can be painless but often causes an infant some discomfort. Many infants experience typical signs and symptoms from teething but the severity of each symptom varies among infants. Signs and symptoms tend to be worst for the first few teeth, with teething becoming easier as the child ages. This may be at least partially due to the fact that some symptoms commonly associated with teething may also be due to aspects of normal infant development that occur at the same time. For example, the irritability and sleep disruption associated with teething may also be due to conditions such as separation anxiety.

Signs and symptoms associated with teething include:

• Drooling. Infants tend to produce more saliva at around the same time that they begin teething, which can cause an excessive amount of drooling. There is some controversy as to whether this is due to the teething process or merely a coincidental timing in infant development. Either way, if the saliva is allowed to remain on the skin, it can cause irritation that may lead to a rash.
  
  
• Chewing. Infants and young children generally tend to explore their environments with their mouths. This is a natural part of infant and child development. During teething, this may serve an additional benefit. It can help soothe the discomfort and wear down the gums to make the eruption of the tooth easier. Infants tend to chew on whatever they can, including their fists or finger, the finger of their parents or other people, toys, bottle nipples and edges of clothing.
  
  
• Tender, swollen gums. The gums around the area where the tooth is about to erupt may be discolored (red to purple), swollen and tender. This tends to go away after the teeth emerge, but there may be slight bleeding as the teeth erupt.
  
  
• Irritability. Teething infants can be quite irritable, cranky and fussy. They may experience bouts of fussiness, crying episodes, or long periods of mild irritability that may last for days or weeks.
  
  
• Disrupted sleep. The discomfort of teething may cause an infant to wake up more often at night. In addition, they may have more difficulty falling asleep and taking naps during the day.
  
  
• Problems eating. Teething infants may refuse certain foods or may be reluctant to nurse.
  
  
• Low-grade fever. Occasionally, a mild fever that remains below 100.4 degrees Fahrenheit (38 degrees Celsius), as measured by a rectal thermometer, may accompany teething.

Teething is usually not a reason for parents to worry or to make a special trip to a physician’s office. All scheduled well-child visits still need to be continued. Any normal concerns about an infant’s teething may be discussed at these visits. However, if an infant appears especially uncomfortable, a pediatrician or other healthcare professional can suggest ways to manage the discomfort.

If no teeth have emerged by the age of 1 year, a visit to a pediatrician may be necessary to evaluate the possible cause of the delay. The pediatrician will typically ask questions about the infant’s family history, such as at what ages the mother and father first began teething. This is usually no cause for concern. It is not rare for teething to begin later than the average age and can start as late as 12 months to 16 months.

Though some infants have few or no symptoms while teething, the process can make other babies quite uncomfortable. It is important to try to soothe the infant and make him or her more comfortable. However, it is typically recommended that parents and caretakers avoid disrupting established routines as much as possible. For example, changing bedtime may lead to problems with sleeping and napping. These routines are important for a developing infant or child’s sense of order and predictability.

Infants drool quite a bit, particularly when teething. It is important to keep the skin dry to prevent skin irritation and rashes. Gently wiping away the saliva can help, as well as keeping a small bib on the infant during the day. When an infant is sleeping, a clean cloth diaper under the head can be used to absorb the saliva. This can also prevent the need to frequently change the infant’s bed sheets due to drooling.

Teething infants are frequently found to be chewing on a number of things – from their fists to toys. The pressure caused by chewing helps relieve the discomfort and wears down the gums in front of the tooth, making it easier for it to emerge. There are many products available specifically for chewing during the teething process. It is important to use only items that are too big to swallow or ones that cannot break into smaller pieces. They should never be tied around the neck because of the risk of strangling the child. They should also never be dipped in sweet liquids, as this can cause tooth decay.

A clean, wet, chilled washcloth is a useful chewing aid. A cloth can be chilled by placing it in the freezer for a short time (about 30 minutes) or putting it in the refrigerator. In fact, cold is good for most chewing items, but these items should not be frozen. The extreme cold can cause even more pain and the cold, hard surface can bruise the gums.

Teething rings, pacifiers and toys made of firm rubber are good items for an infant to chew on. Hard, unsweetened teething crackers may also be useful. Caution must be taken with liquid- or gel-filled teething rings and toys. These items may break, particularly when the infant has a tooth or two for leverage.

A bottle of water helps many infants. Relief of teething discomfort may come from chewing on the nipple of the bottle as well as the sucking action. Bottles of formula, milk or juice should not be used for this purpose, as prolonged exposure to these sugary liquids can cause tooth decay (baby bottle tooth decay).

Firmly rubbing the gums with a clean finger can soothe the infant’s discomfort. A moistened gauze pad or damp washcloth can also be used to massage the gums. Although it may be a common practice, rubbing liquor on a baby’s gums is not safe and can cause harm.

If chewing on things and gum massage do not seem to help, an infant dose of acetaminophen or ibuprofen (pain relief medications) may be useful. However, a pediatrician should always be consulted before giving an infant any medications. Aspirin should never be given to a child due to its association with Reye syndrome.

Some physicians may advise against topical pain relievers such as teething gels. They are frequently not effective because they can be washed away by drool before they begin to work. When they do work, they do not last long and they cannot be used frequently. In some situations, they can even be dangerous because of its contents (i.e., anesthetic preparations, alcohol). These gels can numb the entire inside of the mouth, including the back of the throat. This can make if difficult for the infant to swallow or can interrupt the gag reflex (which helps protect the airway). Furthermore, some infants are allergic to the ingredients in these gels.

Oral hygiene should begin before the teeth erupt. Use a clean cloth or gauze pad to wipe an infant’s gums and teeth (when present) after every meal. A soft infant (multi-tufted) toothbrush may also be used, but it is generally recommended to avoid toothpaste until the child is old enough to spit it out – usually around age 3. Plain water is all that is needed for infants.

The American Dental Association (ADA) recommends that babies see a dentist by age 1, when six to eight teeth are in place. This will enable the dentist to spot any potential problems and advise parents about preventive care.

Preparing questions in advance can help parents have more meaningful discussions with their physicians or healthcare professionals regarding their child’s health. The following questions related to teething may be helpful:

1. When can I expect my infant to begin teething?
   
   
2. How will I recognize when a tooth is coming in?
   
   
3. How long is it likely to take for all of my infant’s primary teeth to come in?
   
   
4. Is late teething related to any developmental delays?
   
   
5. Can teething cause my baby to have a fever?
   
   
6. What symptoms are not normal for a teething infant?
   
   
7. What medications are safe to give my child during teething?
   
   
8. What do you recommend for chewing during teething?
   
   
9. Will all my children have the same teething development?
   
   
10. Can I continue to nurse if my child is teething?
    
    
11. Now that my infant has teeth, what can I do to keep them healthy?
    
    
12. How soon should I begin taking my child to the dentist?