Signs and Symptoms Associated With Primary Tooth Eruption: A Clinical Trial of Nonpharmacological Remedies

Mahtab Memarpour; Elham Soltanimehr; Taherh Eskandarian


BMC Oral Health. 2015;15(88) 

In This Article


The research protocol was approved by the Human Ethics Review Committee of the Faculty of Dentistry, Shiraz University of Medical Sciences. For this 5-month, nonrandomized clinical trial, which started in June 2013, 270 noninstitutionalized children (i.e., receiving care at home) were enrolled at three local public health care centers in Shiraz.

Inclusion criteria: The children were between 8 and 36 months of age. All had at least one erupted primary tooth (no natal or neonatal teeth), and the parents were familiar with teething symptoms. The children also had at least one primary tooth in the process of eruption.[22]

Exclusion criteria: The exclusion criteria included history of medical treatment for any systemic disease that might influence the signs and symptoms of teething, current drug treatment, congenital physical or mental disability, oral or dental anomalies or disabilities, and lack of parental consent to participate in the research.

Data Recording

All parents were interviewed and informed about the aims of the study and the methods to be used, and all provided their informed consent in writing. One trained dentist (E.S.) was responsible for data collection from three sources: 1) interview with the parents and information recorded on a questionnaire completed by the researcher at each appointment, 2) tympanic temperature taken by the dentist, and 3) clinical examination by the dentist.

To ensure that all data were recorded correctly, first the dentist was given instructions by a senior author (M.M.) on how to perform the oral examination, interview the mothers and record teething symptoms in 25 children (pilot test). The dentist was also taught how to record body temperature with a tympanic thermometer. In the pilot test with a group of 25 mothers, all questionnaire items were clearly understood by all participants.

Teething Signs and Symptoms

At the first appointment the child's mother was asked about new erupting teeth if signs of tooth eruption had appeared, and data were recorded for each child with the help of a questionnaire designed on the basis of a comprehensive literature review. The first part of the questionnaire recorded demographic information about the child including age, gender, normal or low birth weight (<2500 g), general health status and dental history. Information was also noted about the mother's level of education, employment and age. The questionnaire contained 27 items about local and systemic teething disturbances attributable to eruption. Four dentists specialized in pediatric dentistry evaluated the questionnaire, which was revised as necessary based on their comments. The children were allocated into five equal groups to receive a different nonpharmacological treatment as a teething remedy. The parents were asked to attend regular follow-up appointments with their child during 8 days.

Oral Examination

An initial oral examination was done before the tooth erupted; then the children were selected. During the 8-day window for tooth eruption,[8] all data were collected during the 4 days before eruption, on the day of eruption and 3 days after eruption. The mothers were asked to come to the health clinic as soon as they observed the initial signs of tooth eruption. Then they were interviewed to record the occurrence symptoms during the previous 24 hours and the daily data record sheet was completed, including nonpharmacological treatments used as teething remedies. For oral examination the gingiva surfaces were cleaned by wiping with a cotton roll. Intraoral examination was done with a head light and palpation of the alveolar ridge with the index finger to palpate the incisal edge or tip of the tooth cusp. The day of tooth eruption was considered the day when the crown edge of the tooth had visibly emerged in the oral cavity and was no longer than 3 mm.[22] The type of erupting tooth (incisor, canine or molar) was also recorded. Body temperature was measured with a tympanic thermometer (MT 50, Microlife, Basel, Switzerland) at every appointment.

Experimental Groups

Five different methods were compared as teething remedies, with 54 children initially enrolled in each group.

  1. Cuddle therapy based on child behavior therapy. This included extra attention, care and reassurance by parents. The participating mothers were advised to hug or cuddle the child when the child felt distressed or manifested discomfort because of teething symptoms. Activities to distract the child such as reading, singing or playing were also used.[7,23]

  2. Pieces of ice wrapped in a towel or other soft cloth were placed on the gums and mucous membrane overlying the erupting teeth for 1–2 min, and this was repeated as necessary when the child manifested teething symptoms.[3]

  3. Rubbing the child's gums: Mothers were instructed to apply a light massage with their clean fingertips or a very soft finger toothbrush for 1–2 min.[3,7]

  4. Teething rings: A solid plastic teething ring (Panberiz, Bushehr, Iran) was given to mothers, who were asked to give the ring to the child to chew or bite on. The teething ring we used did not cause cavities or choking, and had advantages over liquid-filled rings.[3,7]

  5. Food for chewing: The children in this group were selected among those who had started to eat solid foods. The mothers were instructed to give the child small pieces of a frozen fruit or vegetable such as banana, apple or cucumber to bite or chew under the mothers' supervision to prevent swallowing chunks of food material.[3,7]

The next appointment was scheduled for each child after initial signs of tooth eruption were observed by the mothers and the researcher. All children were examined daily (between 9:00 and 12:00 AM) and the data were recorded for teething symptoms, body temperature,[4] and recovery following use of the remedy. We defined a variable for recovery from different symptoms on the day of eruption and after eruption, and compared the results to the period before eruption. For example, if the child had a symptom during the 4 days before eruption and the symptom disappeared in subsequent follow-up appointments, the child was considered to have recovered from the symptom. If the symptom did not disappear or if it became worse, it was recorded as no recovery. Children who had no symptoms during the study period were excluded from the analysis of recovery. On the last day, all mothers were asked to rate their satisfaction with the remedy on a 4-point Likert scale from 1 (completely effective) to 4 (completely ineffective).

If the mothers did not follow the instructions or used other methods or medical treatment as remedies for teething problems, the child was excluded from the analysis. If systemic symptoms such as fever (temperature higher than 38 °C),[24] nausea, diarrhea or seizures were observed, the child was referred to a pediatrician.[4] The primary outcomes were clinical manifestations of tooth eruption, fever and recovery after the intervention. The mothers' satisfaction was considered as a secondary outcome.

Statistical Analysis

All data are reported here as frequencies (percentages) and mean ± standard deviation. Demographic variables were compared between groups with one-way analysis of variance (ANOVA) and chi-squared tests. The associations between different teething symptoms and birth weight categories (normal vs. low birth weight) were determined with the chi-squared test. Trends in body temperature during the study period were determined with repeated measures ANOVA (p < 0.05). The agreement between body temperature reported by mothers and recorded by the dentist was measured as the kappa coefficient. Chi-squared tests and Fisher's exact test were used to evaluate recovery during the days of eruption and after eruption in comparison to before eruption. All analyses were done with SPSS v.16 software.