Teething – is it as bad as the horror stories?

Typing teething into google yields over 20 million hits. It’s a big topic in parenting. The normal eruption of teeth seems to be fraught with bad information, legends, horror stories and urban myths. Sleep coaches need to be well informed about teething as it is often blamed for a multitude of sleep problems. Is this fair? In this article, I will try to demystify the process of teething.

What is the teething process?

Tooth development starts just a few weeks after conception, and all teeth are present within the jaw bone at birth, but most babies won’t show any signs of those undercover teeth for several months. Ultimately, as adults, we have 32 teeth, but children have 20.

There are 3 stages of tooth development:

The primary dentition stage: When the first ‘baby’ teeth erupt
Mixed dentition stage: When the child, usually after the age of 5 years, begins to lose teeth, and some permanent teeth erupt, so that there is a mixture of baby and permanent teeth
Permanent dentition stage: When the last baby tooth is lost (usually around 11-12 years) and lasts for the rest of the person’s life.

The actual mechanisms of teething are not well understood, but it is thought that hormones are responsible for skin cell death in the gum. This cellular death causes the gums to break apart and allows space for the erupting tooth below the gum-line. The words people use for teething are often unhelpful, and lead us to attribute more pain to teething than is probably the reality. We talk about ‘cutting’ teeth, for example, but the teeth do not physically slice the gums.

The cellular death that occurs in the gums does cause inflammation, which is why the gums often appear swollen or hard. Babies instinctively want to bite and chew hard objects, as this helps the dying cells to break down faster and allow the emerging tooth through.

When do teeth first appear?

Of course, there is huge variability with the eruption of teeth. Some babies get their first tooth at just a few weeks, or they are even present from birth, while other baby’s first birthday’s come and go long before the first pearly white. Teeth usually erupt in pairs, and on average, the tooth eruption process is as follows:

The 2 lower central incisors – around 6 months
The 2 upper central incisors – around 8 months
The 2 lateral upper and lower incisors – around 10 months
The first 4 molars – around 14 months
The 4 canines – around 18 months
The second 4 molars – between 2-3 years

Many people think a baby is teething at around 3 months. This is usually due to the fact that a baby will typically start to drool, and also be able to start getting their hand accurately to their mouth and chew it. Often people put these two signs together and assume that teeth are to blame. They almost never are.

The other thing that happens frequently is that the actual process of teething is often felt to be long, arduous and protracted. Unsettled behavior, fussing and unexplained sleep disturbance is often unfairly blamed on teething, when in actual fact it is more likely to be caused by something else.

What is teething blamed for?

Over the centuries, teething has been blamed for all manner of evils, from diarrhea and nappy/diaper rash, to intractable pain and even death. In fact, in 1842, records show that in nearly 5% of all infant deaths, teething was named as the cause, and it apparently caused 7% of all deaths in 1-3 year olds. Of course, nowadays, we know that infant and child mortality rates sadly used to be a lot higher, and teething just happened to coincide with a whole load of other infant and child illnesses that we are now better at treating. But it is an important part of our history.

Nowadays, it is more likely that people will blame teething for any unexplained period of fussing or sleep disturbance. The common symptoms that teething is blamed for include:

Gas and wind
Fever
Coughs, runny nose and colds
Diarrhoea
Nappy/diaper rash
Pain
Sleep problems

We will examine these one by one in a moment, but first of all, it is important to state that the actual process of dentition usually takes about 3-6 days. That’s it. This is really important, because unexplained cranky behavior, fussing, sleep disturbance and illness that is longer than this is very likely to be caused by something else.

The truth is, babies are nearly always going through one developmental stage or another. If it’s not a gross or fine motor developmental learning curve, it’s social awareness. If it’s not learning to babble, it’s learning to sit up, or crawl. If it’s not separation anxiety, it’s probably mastering some complex hand-eye coordination task! So, if a baby always seems to be cranky or fussy for a few weeks on end, it’s more likely to be caused by back-to-back developmental phases, rather than a tooth – which is usually quite a distinct, short phase of obvious fuss.

This is important to know, for many reasons, but one is: unnecessary medication. You see, if parents attribute long drawn-out phases of fussing to teething, their very reasonable assumption is that teething is a long, protracted, painful process. What parent wants their child to be in pain for days or weeks on end? But the problem is that a) pain relief won’t help if it’s a developmental phase, b) unnecessary pain relief can be harmful, and c) it leads parents to believe that their child is really suffering from teething pain which is intractable and not resolvable with simple analgesia. This serves to reinforce the belief that teething is a very painful process. It also potentially means that a child will be given pain relief at the first onset of fussy behavior – which could be around 4 months, only for the first tooth to not arrive until 8 or 9 months. That’s 5 months of unnecessary medication, and a reinforced belief that teeth take months to emerge and it is a very painful and slow process.

Gas/wind: There is no evidence that teething causes this. It is more likely to be due to something the baby ate. Don’t forget, babies are often getting teeth around the same time they are trying lots of new foods. It could just be that one of them has caused their system to react with more gas than usual.

Fever: While teething is an inflammatory process, it will not cause a significant fever. A very low grade fever of up to about 38°C (100.4°F) may be caused by teething, if there are other obvious signs as well, but a fever higher than this is almost certainly caused by an illness, such as a virus.

Coughs, runny nose and cold: There is no evidence that teething causes a viral illness such as a cold or cough. It doesn’t really make a lot of physiological sense. Teething is an inflammatory process, so it is plausible that the immune system is under more strain than usual, but even that is a stretch. What is more likely is that babies of the age to start teething are more exposed to new environments, germs and new people who are spreading coughs and colds. Approximately 10 colds per year is entirely normal for young children – which can feel almost endless during the winter months. Babies often start daycare or nursery around the time they start teething so it is likely that this is a coincidence.

Diarrhea: It is highly improbable that teething causes diarrhea. Lots of parents anecdotally report that their baby has a ‘vinegar’ smelling nappy around the time of teething, but true diarrhea (very loose, runny, watery, foul-smelling stool) is not likely to be caused by teething. It is far more likely that the baby has touched something or been exposed to a bug that has upset their tummy. Don’t forget, around the time babies start teething, they are also crawling around, putting everything in their mouth, touching the dog’s rear end, putting other children’s chewed toys in their mouths – you get the picture!

Nappy/diaper rash: Again, this is a common young childhood complaint. While lots of parents report some nappy rash around the time of teething, it is just as likely to be caused by something their little one ate that has caused a particularly offensive stool. If the baby has had a ‘vinegar poo’ then it is possible that the skin may be more irritated than usual, but a significant nappy/diaper rash should not just be attributed to teething, in case it is a fungal or bacterial rash that needs medical attention.

So what can teething cause?

So, now you know what teething probably doesn’t cause, you’ll most likely want to know what it does cause. Here we go:

Pain: Ok, now we get to the crux of it! Teething causes the gums to break down, inflammation and swelling. This can be painful, no denying it. Nobody wants their little one to be in pain. Actually, some babies don’t seem to be bothered by teething at all. And others will really let you know about it. In fact, both my own two children were completely different. One shouted and screeched for 3 days, the other just woke up and there it was – we knew nothing about its impending arrival. It is not uncommon for parents to experience a totally different reaction from different children. I can only put this down to differences in pain perception, different inflammatory responses, and different anatomy. I’ll come back to what you can do to relieve teething pain later on.

Sleep problems: Right, now we’re talking! Do teeth cause sleep issues? Well, probably, if they cause pain. See above! Some children genuinely seem to wake up with a new tooth that nobody knew was imminent. Other babies and children will give you advance warning. Teething can cause a variety of problems with sleep. Common symptoms include:

More frequent breastfeeding (the action of breastfeeding soothes the pressure in the jaw and mouth)
Drooling
Chewing on lots of hard objects – including knuckles, wooden toys, feet, utensils and any other hard object they can lay their hands on!
Reluctance to eat
Pulling at their ears
Bright red cheeks

These symptoms are actually quite specific, and focused around the jaw and mouth itself. It should be fairly obvious when a child is teething – it will be 3-5 days of gnawing and chewing, and possible fussing.

So, does this affect sleep? Well, it may do. It is important to note that teething does not always seem to cause a baby any trouble. But other babies seem to have trouble with teething for a few possible reasons:

There are fewer distractions in the nighttime. In the day, a baby may be more easily pacified with a toy, a change of scene, or a cuddle. At night, it is dark, quiet, and there is less stimulation. As distraction is a well-known form of pain relief, it makes total sense that nights would be worse than days.
Babies usually lie down to sleep. In the daytime, when they are upright, there is less blood flow to the head. Lying down may increase the pressure in the head. This is also true of any sinus-related pain – it is always better once you are standing upright, due to gravity.
Overtired babies release more cortisol to cope with fatigue. If babies are struggling with sleep anyway, they may have higher circulating cortisol, which increases the pain response, and also slows down would healing, suppresses the immune system, and leads to more anxiety and stress. So the link between tiredness, poor sleep and teething may be closely related, though more complex than it might first appear.

Is there anything we can do about teething?

Many parents want to know what to do about teething. Any pharmaceutical shelf will have a wide array of gels, powders, and granules to rub on the gums to ease teething pain. Some good general advice is that if a parent is not sure if their baby is unwell, or teething, they should get them seen by a doctor.

For example: a baby with a fever, who is reluctant to feed, and pulling their ears may have an ear infection, rather than about to get a new tooth. Rubbing teething gel on their gums will do nothing to address the underlying condition.

If a parent is certain that this is new behaviour, specific to teething, then they could certainly try a teething gel or homeopathic remedy. But I would urge sleep coaches and parents alike to not use these for more than a few days. If the baby is still upset after this, it is more likely to be something else.

There are many parents who feel more comfortable trying non-pharmacological remedies. Some simple ones include:

Putting a clean flannel/washcloth in a plastic bag and freezing it. Let it thaw a little before giving it to the baby – frozen flannels can stick painfully to lips!
Offer cold, hard, watery foods to chew – such as cucumber, melon and frozen banana (again – thaw a little first)
Make a ‘momsickle’ or ‘booby lolly’ – use expressed breast milk (or formula) to make a milk popsickle that the baby can suck
Some people want to try Baltic amber teething necklaces or bracelets. The theory is that the amber is warmed against the skin and slowly releases pain relieving and anti-inflammatory properties to ease teething pain.

There is no evidence to back this up. The problems with this strategy are th

It feeds into the idea that teething is a long drawn out process
They pose a choking risk
They are a strangulation hazard
Try teething chew toys that are specifically designed for teething babies. Some can be chilled first
Consider naps in a baby carrier to have the baby upright
Try to prioritise sleep as much as possible, using any means necessary – it will prevent overtiredness which can make the experience of teething more painful
Promote a stress-free environment. Since stress can cause inflammation, try to optimize a calming atmosphere. This is also good for bonding and is more conducive to sleep!

To round up:

So, despite millions of hits on Google, thousands of blog posts on how to help with teething, hopefully it’s a little clearer that teething is both simpler, and more complex than you might think! Here’s a summary:

Teeth are present from birth, and usually begin to emerge around 6 months
Teething is often blamed for many other problems. It is important to rule out illness, tiredness and developmental stages before you assume that teeth are to blame
Try to avoid prolonged use of pain relieving gels and medications
Try to keep the atmosphere calm and relaxed, and minimize stress and overtiredness – these things will make teething worse.