Teething

1. DEEPTHI P. R. PUSHPAGIRI COLLEGE OF DENTAL SCIENCES TEETHING

2. CONTENTS INTRODUCTION DEFINITION CLINICAL FEATURES MANAGEMENT STUDY REPORTS ASSOCIATION WITH HERPES SIMPLEX INFECTION CONCLUSION BIBLIOGRAPHY

3. INTRODUCTION Teething - ‘eruption of primary teeth’. Abnormal or difficult eruption Eruption of primary teeth - fifth or sixth month. Eagerly awaited and important MILESTONE No distress Sometimes local irritation- minor or severe enough to interfere with the child’s sleep Relatively large molars Diseases – 6 to 26 months –19 th century  teething

4. Teething is the physiologic process of the eruption of primary teeth through the gums.

5. CLINICAL FEATURES LOCAL SIGNS Hyperemia or swelling of the mucosa overlying the erupting teeth Patches of erythema on the cheeks Flushing of the skin of the adjacent cheek Hand and fingers always put in the mouth

6. CLINICAL FEATURES SYSTEMIC SIGNS General irritability and crying Increased salivation and drooling Loss of appetite Insanity Sleeplessness and restlessness Meningitis Increased thirst Circumoral rash Cough

7. ASSOCIATED PROBLEMS SYSTEMIC Fever Convulsions Diarrhea Vomiting Bronchitis Cholera Tetanus Infantile paralysis

8. ASSOCIATED PROBLEMS LOCAL Eruption hematoma Eruption sequestrum Ectopic eruption Transmigration Transposition

9. POSSIBLE EXPLANATION FOR THE SYMPTOMS Eruption- local inflammatory process Irritability- child puts whatever object found into mouth- relief Unclean objects- infection and inflammation in the already inflamed gums If not relieved- restless, wakeful, fretful, fearful and refuses nourishment

10. POSSIBLE EXPLANATION FOR THE SYMPTOMS Alimentary canal active-diarrhea, nausea, vomiting, convulsions Association with diarrhea, fever, convulsions- coincidental Mouthing of contaminated toys or teethers used to rub the gums

11. MANAGEMENT PREVENTIVE MEASURES Mention teething in prenatal counselling - the first postnatal oral issue confronted Educate members of the family Good oral and body hygiene; gums healthy and fresh Gums wiped after each meal with cotton soaked in weak antiseptic- 1:100 KMnO4 Adequate vitamins, minerals, proteins

12. LOCAL MANAGEMENT Gentle massage - clean finger or saline soaked gauze piece & increased fluid consumption TEETHING OBJECTS Satisfy the natural desire of the infant to chew on hard objects Stimulates the gumpads for the smooth and painless eruption

13. LOCAL MANAGEMENT Teething foods -Hard non sweetened firm rusks -Toasted bread -Biscuit preparations - Hard fruits and vegetables apple,guava,carrot

14. LOCAL MANAGEMENT Teething toys Specifically manufactured teething rings, keys, blowers, rattles Relief from soreness by the pressure Liquid containing ones – avoided Caution against cheap toys with lead

15. LOCAL MANAGEMENT Pacifiers releasing preventive agents- sodium fluoride, xylitol Teething necklaces Clove oil, licorice sticks, vanilla extract Frozen items

16. LOCAL MANAGEMENT Topical Medicaments - glycerin -lignocaine hydrchloride ( tds / qid ) Caution : Rapid systemic absorption- toxic doses if misused -benzyl alcohol -mild purgatives (phenolphthalein, castor oil, calomel, milk of magnesia)

17. INGREDIENTS IN PREPARATIONS NAME LOCAL ANALGESIC ANTISEPTIC ANALGESIC/ ANTI-INFLAMMATORY AGENT Bonjela none 0.01% cetalkonium chloride 4.6% glycerin 8.7% choline salicylate 0.05% menthol Dentinox 0.3% lignocaine hydrochloride 0.1% cetylpyridinium chloride 0.3% polyethoxdodecane 3% alcohol 0.06% menthol 0.08% myrrh tincture Pyralvex none 5% anthraquinone glycosides 1% salicylic acid Teejel none 0.01% cetalkonium chloride 8.7% choline salicylate

18. SYSTEMIC TREATMENT Only if local treatment has been ineffective ANALGESICS Sugar free Paracetamol preparations(5ml=120mg) Dosage: upto 1year- 5ml at bedtime 1-5 years - 10ml at bedtime Soluble acetyl salicylic acid tablets Chamomilla - homeopathic medicine

19. SYSTEMIC TREATMENT HYPNOTICS & SEDATIVES To restore normal sleep rhythm after a succession of sleepless nights Combined with analgesics

20. SYSTEMIC TREATMENT Chloral Elixir Paediatric BPC (5ml=200mg of chloral hydrate) Dosage: Upto 1year- 2.5ml bd 1-5 years- 2.5-5ml tds Dichloralphenazone Elixir BPC ( Welldorm Elixir ) (5ml= 225mg dichloralphenazone ) Dosage: Upto 1 year- 2.5-5ml hs 1-5 years- 5-10ml hs

21. CAUTION If symptoms persist for more than 24 hours, physician should be consulted to rule out URTI and other diseases of infancy

22. SELECTION OF TREATMENT COMPLAINT TREATMENT Irritation at the site of tooth eruption Topical application Daytime irritability and fretfulness Topical application & systemic analgesics Disturbed sleep Topical application, systemic analgesics &hypnotic

23. SURGICAL TREATMENT Pain relief from an eruption cyst or hematoma TECHNIQUE: Two semilunar incisions are made over the crown of the tooth which meet at their extremities The intervening portion of the tissue which lies over the occlusal portion of the unerupted tooth , is then removed with a pair of tissue forceps

24. STUDY REPORTS King & Dally reported 5016 deaths in England & Wales – teething (1839) Illingworth – failed to produce evidence of teething causing fever, convulsions, bronchitis or diarrhea Supported by Tasanen’s study observing 192 eruptions in 126 infants & 107 controls, which concluded that teething does not increase the incidence of infection does not cause any rise in temperature, ESR, WBC count does not cause diarrhea, cough, sleep disturbance or rubbing of the ear or cheek

25. STUDY REPORTS It does cause : Day time restlessness Increase in finger sucking Increase in drooling Loss of appetite Change in the colour of the mucosa in the area of the erupting tooth: No change in 1/3 rd of the children Slight change in another 1/3 rd Pronounced change with small haemorrhages in 1/3 rd

26. STUDY REPORTS Study on 46 healthy infants - Jaber , Cohn & Mor a small increase in body temperature - 43% -the day of emergence of their first tooth Macknin et al confirmed these results Leung reported- serious systemic disturbances were overlooked by ascribing symptoms to teething Swann identified an organic cause of illness in 48 patients out of 50 hospitalised due to symptoms- teething

27. ASSOCIATION WITH HERPES SIMPLEX INFECTION Few scientific data to implicate teething as the etiology of fever, diarrhea Children with teething symptoms- culture positive for HSV Type1 On examination : Generalized erythematous gingiva Several ulcerated areas in the mucosa Coated white tongue Several partially erupted teeth

28. ASSOCIATION WITH HERPES SIMPLEX INFECTION Diagnosis Subjective symptoms Prodrome of itchiness or mild tingling sensation before the development of the lesions Mild flulike symptoms Objective symptoms 2-4 mm diameter size vesicles Rupture & crust over in 36-48 hours Heals in 7 days

29. ASSOCIATION WITH HERPES SIMPLEX INFECTION Investigations Viral titre peak in 48 hours - then falls Tzanck preparation of the vesicles- multinucleated giant cells ( Tzanck cells) & inclusion bodies ( Lipschutz bodies)

30. ASSOCIATION WITH HERPES SIMPLEX INFECTION Therapy Keep the lesions well lubricated with an emollient to promote healing Isolate the patient from persons at risk for primary herpes infection Prophylactic oral acyclovir reduce the frequency

31. CONCLUSION Since the time of Hippocrates (460-377BC) it has been observed that teething infants often suffer from several systemic conditions including fever, diarrhea, convulsions. This discussion concludes with the note that, from the review of the available literature on teething there is no conclusive evidence to attribute teething as the sole factor leading to the conditions associated with it. This is an area that requires still lot of investigation for explanation.

32. BIBLIOGRAPHY Dentistry for the Child and Adolescent- McDonald, Avery, Dean(8 th edition) Pediatric Dentistry- Infancy through Adolescence- Pinkham(3 rd edition) A manual of paediatric dentistry- R.J.Andlaw & W.P.Rock (4 th edition) Textbook of Pedodontics - Shobha Tandon (2 nd edition) Textbook of Pediatric Dentistry- S.G.Damle (3 rd edition) Principles & Practice of Pedodontics - Arathi Rao (2 nd edition) Jablonki’s Dictionary of Dentistry www.infantteethingtoys.com

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