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Child health Oral health

Teething

Last revised in October 2024

Teething is a normal physiological process in which deciduous teeth (milk teeth or baby teeth) emerge through the gums.

Teething: Summary

  • Teething is the normal physiological process of deciduous teeth emerging through the gums, causing usually mild and localized symptoms.
    • During teething, teeth move from their developmental position within the alveolar bone to break the gum in the oral cavity.
    • Most infants start teething around 6 months of age. However, some children start teething before the age of 4 months (1%) or after the age of 12 months (1%).
    • A full set of deciduous teeth has usually emerged by 2–3 years of age.
    • By about 6 years of age, these deciduous teeth start to fall out, to be replaced with permanent teeth.
  • Teething should be suspected as a cause of symptoms in an infant or young child up to the age of 3 years if alternative causes have been excluded and there are:
    • Clinical features, which generally start 3–5 days before each tooth eruption, such as pain, increased biting and chewing, drooling, gum-rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite, disturbed sleep, and in some cases, mild pyrexia.
    • Signs of gum swelling, redness, and tenderness on palpation just before tooth eruption.
  • Management of an infant or child with suspected teething should include advice on:
    • Sources of information and support.
    • Self-care measures to relieve teething symptoms, such as gentle rubbing of the gum with a clean finger, allowing the infant to bite on a clean and cool object, cuddling and reassuring the child, and wiping away excess saliva regularly to reduce the risk of facial rash.
    • Considering the use of over-the-counter paracetamol and/or ibuprofen to provide symptom relief in infants three months of age or older, if self-care measures have not helped.
    • Oral lidocaine-containing products for infant teething are only available under the supervision of a pharmacist and should be avoided where possible due to possible risk of harm. 
    • There is no good-quality evidence to support the use of homeopathic teething tablets, gels, or herbal medicines.
    • Seeking urgent medical review if the infant or child becomes systemically unwell, is severely distressed, or has prolonged symptoms.

Have I got the right topic?

From birth to 36 months.

This CKS topic covers the management of teething in infants and young children up to 3 years of age.

There are separate CKS topics on Candida - oral, Colic - infantile, Cough - acute with chest signs in children, Constipation in children, Croup, Feverish children - risk assessment and management, Gastroenteritis, GORD in children, Herpes simplex - oral, Nappy rash, Sepsis, and Urinary tract infection - children.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

October 2024 — reviewed. A literature search was conducted in October 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The information on lidocaine-containing teething products has been updated to reflect the latest recommendations and manufacturers' information. No other significant changes to the recommendations have been made.

Previous changes

June 2020 — minor update. Over-the-counter analgesics updated to reflect revised SPC that Bonjela® is not suitable for children under 5 months.

October 2019 — reviewed. A literature search was conducted in September 2019 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The topic has undergone minor restructuring. The recommendations on the assessment and management of a teething child have been amended in line with current evidence. The information in the Supporting Evidence section has been incorporated into the relevant Basis for recommendation nodes in the Management section.

May 2014 — reviewed. A literature search was conducted in July 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made.

July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency (MHRA). Prescriptions have been updated to reflect the revised dosing. 

July to November 2009 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 October 2024.

HTAs (Health Technology Assessments)

No new HTAs since 1 October 2024.

Economic appraisals

No new economic appraisals relevant to England since 1 October 2024.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 October 2024.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 October 2024.

New policies

No new national policies or guidelines since 1 October 2024.

New safety alerts

No new safety alerts since 1 October 2024.

Changes in product availability

No changes in product availability since 1 October 2024.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of teething in infants.
  • Give appropriate self-care advice to parents on managing symptoms.
  • Exclude more serious causes of discomfort and non-specific symptoms in children.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Teething is the normal physiological process of deciduous teeth (sometimes known as 'milk teeth', 'baby teeth' or 'primary teeth') emerging through the gums, causing (usually) mild and localized symptoms.
    • During teething, teeth move from their developmental position within the alveolar bone to break the gum toward the oral cavity.

[Ashley, 2001; Nield, 2008; Hatibovic-Kofman, 2013; Massignan, 2016]

At what age does teething occur?

Teething usually occurs between 4 and 36 months of age, but there is considerable variation in the specific timing.

  • Most infants start teething around 6 months of age. However, some children start teething before the age of 4 months (1%) or after the age of 12 months (1%).
  • Around 1 in 2000–6000 live births, children are born with deciduous teeth (so-called 'natal teeth'), or they start teething in the first 4 weeks of life ('neonatal teeth').
  • Generalized delay in tooth eruption has been noted in hypopituitarism, hypothyroidism, hypoparathyroidism, growth hormone deficiency, sickle cell anaemia, Down's Syndrome and a number of rare syndromic disorders including hypophosphatemic rickets. Hyperthyroidism may accelerate tooth eruption.
  • Timing of tooth eruption varies significantly with geography and ethnicity, with the literature suggesting that it occurs earlier in Europe and later in South America.
  • Usually, central incisors erupt first, followed by lateral incisors, first molars, canines, and finally, second molars.
  • A full set of deciduous teeth has usually emerged by the time a child reaches 2–3 years of age. 
  • By about 6 years of age, these deciduous teeth start to fall out, to be replaced with permanent teeth.

[Ashley, 2001; Muthu, 2024; Papadopoulou, 2024]

Diagnosis of teething

When should I suspect a child is teething?

  • Consider teething as a cause of symptoms in an infant or young child up to the age of 3 years, only after other possible causes have been excluded.
    • Ask the parent/carer about signs and symptoms associated with teething, which generally starts 3–5 days before each tooth eruption.
      • Clinical features may include pain, increased biting and chewing, drooling, gum-rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite, disturbed sleep, and in some cases mild temperature elevation (temperature less than 38°C).
      • Be aware that symptoms associated with teething tend to decrease with age, and no specific symptom or sign is diagnostic for teething.
    • Examine the child for signs of tooth eruption.
      • Just before tooth eruption, the gums may swell, appear red, and become tender on palpation.
      • There may be associated facial flushing.

Basis for recommendation

The information on when to suspect a child is teething is based on a meta-analysis of signs and symptoms during teething [Massignan, 2016], a meta-analysis of the association between teething and fever [Nemezio, 2017], a cross-sectional survey of teething symptoms [Wake, 2002], a prospective longitudinal study of symptoms and signs of teething [Ramos-Jorges, 2011], a non-randomized clinical trial of teething symptoms [Memarpour, 2015], a prospective cohort study of teething symptoms [Macknin, 2000], and expert opinion in review articles on teething, Teething - filling in the gaps [Mamdani, 2024], It's only teething... A report of the myths and modern approaches to teething [Ashley, 2001], Teething troubles? [McIntyre, 2002], The trouble with teething - misdiagnosis and misuse of a topical management [Wilson, 2002], Does a teething child need serious illness excluding? [Tighe, 2007], and Managing discomfort caused by teething [Hatibovic-Kofman, 2013].

Excluding other possible causes of signs and symptoms

  • The recommendation to exclude other causes of symptoms and signs before making a working diagnosis of teething is based on a prospective cohort study of teething symptoms [Macknin, 2000] and expert opinion in review articles [Wilson, 2002; Tighe, 2007; Hatibovic-Kofman, 2013; Mamdani, 2024].
    • A diagnosis of teething should only be made once other systemic or local causes have been excluded [Wilson, 2002; Mamdani, 2024].
    • A review of prospective studies found that no specific symptoms or clusters of symptoms can reliably predict the emergence of a tooth or differentiate teething symptoms from symptoms of early serious infection, and concluded that teething is a diagnosis of exclusion [Tighe, 2007]. CKS considers this to be particularly important in infants who are systemically unwell or in severe distress.
    • This is supported by the findings of a prospective cohort study that found no symptom cluster could reliably predict the imminent emergence of a tooth [Macknin, 2000].
  • A Scottish perspective study highlights the potential inappropriateness of teething as a diagnosis [Swann, 1979]:
    • Fifty children (aged 3 to 30 months) were admitted to hospital over one year with symptoms that were attributed to teething by their parents or GP. An organic cause for the symptoms (such as upper respiratory tract infection, febrile convulsion, bronchitis, and eczema) was identified in 48 children, which included one child diagnosed with meningitis. No known cause was found in the remaining two children.

Symptoms and signs associated with teething

  • Expert opinion in a review article notes there is variation of opinion in the literature on the significance and association of symptoms with teething [McIntyre, 2002].
  • This view is supported by a non-randomized clinical trial of teething symptoms, which suggests this may reflect differences in sample size, age, the method of data collection, and the types of symptoms studied. It highlights that reported symptoms may be coincidental rather than causally associated with teething [Memarpour, 2015].
    • The trial of teething symptoms (n = 270 children under 3 years of age) found the most frequent teething symptoms were drooling, sleep disturbance, and irritability (the latter was presumed to be secondary to gum pain). Low-grade increases in body temperature were observed on the day of tooth eruption only, but these remained within the normal temperature range. There was no significant correlation between perceived fever as reported by mothers and temperature readings obtained by the study investigators, and the study concluded there was no association between tooth eruption and systemic symptoms such as fever and diarrhoea.
  • A large international meta-analysis of 16 observational studies (n = 3506) of local and systemic signs and symptoms during teething in children aged 0–3 years found that gum irritation, irritability, and drooling were most commonly reported [Massignan, 2016].
    • There was significant heterogeneity between the studies, and methodological limitations included different definitions of tooth eruption, use of subjective measures (parental observations of symptoms), and long intervals between examinations.
  • A small prospective, longitudinal study undertaken in Brazil of symptoms and signs of teething the day before and after tooth eruption (n = 47 healthy infants) found that irritability, increased salivation, runny nose, loss of appetite, diarrhoea, rash, and sleep disturbance were associated with primary tooth eruption, and concluded that severe systemic signs such as markedly raised temperature were not associated with teething [Ramos-Jorges, 2011].
    • The authors noted that some of the symptoms, such as irritability, loss of appetite, and increased salivation, were subjective.
  • An Australian questionnaire-based cross-sectional survey of the health beliefs of child health professionals and parents on teething symptoms noted that symptoms are typically infrequent and mild [Wake, 2002].
    • The number of different symptoms attributable to teething differed across professional groups.
  • A large US prospective, cohort study of parentally-reported symptoms associated with teething (n = 125 healthy infants) found that increased biting, drooling, gum-rubbing, irritability, sucking, wakefulness, ear-rubbing, facial rash, decreased appetite, and mild temperature elevation were significantly associated with teething [Macknin, 2000].
    • Symptoms were only significantly more frequent in the four days before a tooth emergence, the day of the emergence, and three days after it.
    • No symptom occurred in more than 35% of teething infants during each teething period, and no symptom occurred 20% more often in the teething period than in the non-teething period.
    • The authors noted that the study may have been subject to biased parental reporting of symptoms.
  • A meta-analysis of six studies found no association between primary tooth eruption and fever in the overall analysis, however a sub-group analysis using only rectal temperature measurements found an association [Nemezio, 2017].
    • Heterogeneity among the meta-analysis studies in the methods of temperature measurement and study design was, however, noted.
  • The information that symptoms associated with teething tend to decrease with age is based on a meta-analysis of signs and symptoms during teething [Massignan, 2016].
  • The recommendation to examine the mouth and gums to look for signs of tooth eruption is based on expert opinion in review articles [Ashley, 2001; Tighe, 2007] and is also pragmatic, based on what CKS considers to be good clinical practice.

What else might it be?

Conditions that may cause symptoms or signs similar to those associated with teething include:

  • Physiological drooling — salivary glands begin to function at 2–3 months of age and contribute to constant drooling.
  • Eruption cyst — swelling of the soft tissue covering one tooth, which is usually not tender and resolves by itself. The swelling can last for 1 or 2 months.
  • Eruption hematoma — this is most frequently seen in the primary second molar or the first permanent molar region, and may also occur following the eruption of primary molars when canines are erupting. It causes red inflammation from the region of the laterals to the molars and can be painful, particularly if the four canines are erupting simultaneously.
  • Infection — such as acute otitis media, croup, oral candidiasis, respiratory or urinary tract infections, and primary herpetic gingivostomatitis. See the CKS topics on Candida - oral, Cough - acute with chest signs in children, Croup, Herpes simplex - oral, Otitis media - acute, and Urinary tract infection - children for more information.
  • Gastrointestinal — such as gastroenteritis, infantile colic, gastro-oesophageal reflux disease (GORD), and constipation. See the CKS topics on Colic - infantile, Gastroenteritis, GORD in children, and Constipation in children for more information.
  • Skin — such as atopic eczema and nappy rash. See the CKS topics on Eczema - atopic and Nappy rash for more information.

Basis for recommendation

This information is based on a Scottish prospective study of the inappropriate use of teething as a diagnosis [Swann, 1979] and expert opinion in review articles on teething, Teething - filling in the gaps [Mamdani, 2024], It's only teething... A report of the myths and modern approaches to teething [Ashley, 2001], Teething troubles? [McIntyre, 2002], Does a teething child need serious illness excluding? [Tighe, 2007], and Managing discomfort caused by teething [Hatibovic-Kofman, 2013].

Management

Scenario: Management of teething

From birth to 36 months.

How should I manage a child with teething symptoms?

If an infant or young child presents with suspected teething:

  • Exclude any alternative conditions which may cause similar symptoms, especially if the child is systemically unwell or severely distressed. See the CKS topics on Feverish children - risk assessment and management and Sepsis for more information on performing a clinical risk assessment in children.
  • If an alternative diagnosis is unlikely, offer parents/carers advice on sources of information and support:
    • Reassure that teething is a normal process and not an illness, and symptoms are generally mild and self-limiting.
    • As soon as teeth erupt in the mouth, advise they should be brushed twice daily (one time being last thing before bedtime) with a fluoride-containing toothpaste, to reduce the risk of secondary gingivitis due to plaque accumulation. The NHS website has information on Looking after your baby's teeth..
    • Encourage parents/carers to take their child to the dentist when the first tooth erupts or at the latest, by their first birthday.
    • The NHS information leaflets Baby teething symptoms and Tips for helping your teething baby may be helpful.
  • Give advice on self-care measures to relieve teething symptoms, such as:
    • Gentle rubbing of the gum with a clean finger.
    • Allowing the infant to bite on a clean and cool object, such as a chilled teething ring or a cold wet flannel.
      • For children who have been weaned, the supervised use of chilled fruit or vegetables (such as banana or cucumber) can be considered.
      • Objects that can easily be broken into hard pieces should be avoided because of the risk of choking.
      • Sugar-free products are preferred as they do not promote tooth decay.
    • Cuddling and reassuring the child.
    • Wiping away excess saliva regularly to reduce the risk of facial rash.
  • Consider the use of over-the-counter sugar-free paracetamol and/or ibuprofen in licensed doses for weight and age to provide symptom relief if self-care measures have not helped.
  • Give advice on the use and availability of other over-the-counter treatments.
    • Advise that topical oral lidocaine-containing products for infant teething (such as Anbesol®, Calgel® and Dentinox® teething gels) are only available under the supervision of a pharmacist and are not licensed for children under the age of 5 months. Bonjela Junior Gel®  is not licensed for teething. Advise that lidocaine-containing gels should be avoided if possible due to potential risk of harm, and should only be used where non-pharmacological measures and simple analgesics have not been helpful and there is significant distress. Advise that where these products are used, the pharmacist's advice should be followed strictly and the recommended dose or frequency of use not exceeded.
    • Do not recommend the use of homeopathic teething tablets or gels or herbal medicines (such as teething powders). If parents/carers choose to use these products, advise them to follow the manufacturer's dosage instructions and to avoid any unlicensed products.
  • Give safety-netting advice to parents/carers to seek urgent medical review if the infant or child becomes systemically unwell, is severely distressed, or has prolonged symptoms.

Basis for recommendation

These recommendations are based on the Medicines and Healthcare products Regulatory Agency (MHRA) drug safety update Oral lidocaine-containing products for infant teething: only to be available under the supervision of a pharmacist [MHRA, 2018a] and accompanying guidance for pharmacists [MHRA, 2018b], the MHRA drug safety update Oral salicylate gels: not for use in those younger than age 16 years [MHRA, 2014], the MHRA press release Parents advised not to use unlicensed homeopathic teething products in infants and children [MHRA, 2016]; the multi-agency guidance on the UK government website Delivering better oral health: an evidence-based toolkit for prevention [GOV.UK, 2021], the NHS England Starting Well Core: 0 - 2s dental access and prevention framework [NHSE, 2019], advice to parents on managing teething from the American Academy of Pediatrics (AAP) [AAP, 2024], a prospective longitudinal study of symptoms and signs of teething [Ramos-Jorges, 2011], a non-randomized clinical trial of non-pharmacological treatments for teething symptoms [Memarpour, 2015], a prospective cohort study of teething symptoms [Macknin, 2000], and expert opinion in review articles on teething Teething - filling in the gaps [Mamdani, 2024], It's only teething... A report of the myths and modern approaches to teething [Ashley, 2001], Teething troubles? [McIntyre, 2002], The trouble with teething - misdiagnosis and misuse of a topical management [Wilson, 2002], Does a teething child need serious illness excluding? [Tighe, 2007], and Managing discomfort caused by teething [Hatibovic-Kofman, 2013].

Excluding alternative conditions
  • The recommendation to exclude other causes of teething symptoms and signs before making a working diagnosis of teething is based on a prospective cohort study of teething symptoms [Macknin, 2000] and expert opinion in review articles [Wilson, 2002; Tighe, 2007; Hatibovic-Kofman, 2013; Mamdani, 2024].
    • A diagnosis of teething should only be made once other systemic or local causes have been excluded [Wilson, 2002; Mamdani, 2024].
    • A review of prospective studies found that no specific symptoms or clusters of symptoms can reliably predict the emergence of a tooth or differentiate teething symptoms from symptoms of early serious infection, and concluded that teething is a diagnosis of exclusion [Tighe, 2007]. CKS considers this to be particularly important in infants who are systemically unwell or in severe distress.
    • This is supported by the findings of a prospective cohort study that no symptom cluster could reliably predict the imminent emergence of a tooth [Macknin, 2000].
Giving advice on sources of information and support
  • The information that teething symptoms are generally mild and self-limiting is based on a prospective cohort study of teething symptoms [Macknin, 2000] and expert opinion in a review article [Tighe, 2007].
  • The recommendation to brush the erupting tooth area twice daily is based on the multi-agency guidance on the UK government website Delivering better oral health: an evidence-based toolkit for prevention [GOV.UK, 2021] and expert opinion in a review article [Hatibovic-Kofman, 2013].
  • The recommendation to encourage parents/carers to take their child to the dentist when the first tooth erupts or by their first birthday is based the multi-agency guidance on the UK government website Delivering better oral health: an evidence-based toolkit for prevention [GOV.UK, 2021] and the NHS England Starting Well Core: 0 - 2s dental access and prevention framework [NHSE, 2019]. The latter document notes a 2017 campaign led by the British Society of Paediatric Dentistry which called for children's first dental checks to be carried out before their first birthday.
Giving advice on self-care measures

A non-randomized clinical trial of non-pharmacological treatments for teething symptoms (n = 270 children aged 8–36 months) examined the impact of cuddle therapy, ice, rubbing the gums, teething rings, and food for chewing [Memarpour, 2015].

    • The most favourable results for time to recovery and parental satisfaction were seen with teething ring use, followed by cuddle therapy and rubbing the gums.
    • Cuddle therapy was effective in controlling sleep disturbances and crying.
    • It is theorized that biting pressure may decrease pain by overwhelming the sensory receptors [Memarpour, 2015; Mamdani, 2024]
  • The recommendation to offer a clean, cool object to bite on such as a teething toy or cloth is also based on expert opinion in review articles [Ashley, 2001; McIntyre, 2002; Wilson, 2002; Hatibovic-Kofman, 2013].
    • Pressure from the erupting teeth is relieved by counter pressure from biting, and chilled objects may provide greater pain relief [McIntyre, 2002; Wilson, 2002].
    • Chewing on clean, hard, cool objects that are easy-to-clean will give pain relief. Teething biscuits and rusks are not suitable as they can promote tooth decay [Ashley, 2001].
    • Objects must be non-toxic, sugar-free, and not easily broken into small pieces, which could constitute an airway risk [Wilson, 2002].
    • Guidance from the American Academy of Pediatric Dentistry (AAPD), Guideline on perinatal and infant oral health care advises that treatment includes the use of chilled teething rings and oral analgesia [AAPD, 2021].
    • Advice for parents from the NHS in England and the American Academy of Pediatrics in the USA states that teething rings should be chilled, as frozen teething rings may cause damage [NHS, 2022; AAP, 2024].
  • The recommendation to wipe away excess saliva regularly to avoid facial rash is based on a non-randomized clinical trial of teething symptoms [Memarpour, 2015] and expert opinion in a review article [McIntyre, 2002].
Giving advice on the use of over-the-counter analgesia
  • The recommendation to consider over-the-counter analgesia to manage pain and/or fever symptoms is based on a guideline from the American Academy of Pediatric Dentistry (AAPD), Guideline on perinatal and infant oral health care [AAPD, 2021], the quick reference guide for pharmacists from the MHRA, Oral lidocaine-containing products for teething in children [MHRA, 2018b], and expert opinion in review articles [Ashley, 2001; Wilson, 2002; Hatibovic-Kofman, 2013; Mamdani, 2024].
Giving advice on other over-the-counter treatments
  • The advice that topical oral lidocaine-containing products (anaesthetics) are only available under the supervision of a pharmacist is based on the MHRA drug safety update and associated guidance, which highlights these products should only be considered when simple self-care measures have not provided symptom relief, following an in-depth review of their benefits and risks [MHRA, 2018a; MHRA, 2018b]
    •  The MHRA identified a number of case reports of medication errors which, although not usually responsible for harm or adverse effects, highlighted the need for clear information about the safe dosing and administration of these products for parents and carers.
    • The SPCs for Anbesol®, Calgel® and Dentinox® teething gels have been updated to advise that they are not licensed for use in children under the age of 5 months [EMC, 2021a]  [EMC, 2021b; EMC, 2023a]. The SPC for Bonjela® Junior Gel no longer includes teething in the indications for use [EMC, 2023b].
    • The American Academy of Pediatric Dentistry (AAPD) and the American Academy of Pediatrics (AAP) recommend that these products should be avoided due to the potential risk of toxicity [AAPD, 2021; AAP, 2024].
  • The use of topical oral salicylate gels for teething is not included in the recommendations as these products are contraindicated in children less than 16 years of age following the MHRA drug safety update on oral salicylate gels, which followed the publication of a case report of suspected Reye's syndrome due to chronic and excessive topical use of choline salicylate teething gel in a 20-month old child [MHRA, 2014].
    • The MHRA concluded that the case report was more likely to represent features of salicylate toxicity, however, there is a theoretical risk of Reye's syndrome (unexplained non-inflammatory encephalopathy and usually hepatic involvement) with excessive use of these products.
  • The advice not to recommend homoeopathic teething tablets or gels or herbal medicines is based on the fact CKS found no good-quality evidence to support their use. This is supported by the advice given to parents by the American Academy of Pediatrics (AAP) [AAP, 2024], and the expert opinion of previous external reviewers of this CKS topic.
    • The advice to avoid any unlicensed homeopathic preparations is based on the MHRA press release, which states that these products may cause serious adverse effects such as seizures, difficulty breathing, lethargy, excessive sleepiness, muscle weakness, skin flushing, constipation, difficulty urinating, or agitation [MHRA, 2016].
Giving safety-netting advice

Supporting evidence

This CKS topic is largely based on drug safety updates from the Medicines and Healthcare products Regulatory Agency (MHRA): Oral lidocaine-containing products for infant teething: only to be available under the supervision of a pharmacist [MHRA, 2018a] and accompanying guidance for pharmacists [MHRA, 2018b], Oral salicylate gels: not for use in those younger than age 16 years [MHRA, 2014], Parents advised not to use unlicensed homeopathic teething products in infants and children [MHRA, 2016]; the multi-agency guidance on the UK government website Delivering better oral health: an evidence-based toolkit for prevention [GOV.UK, 2021], the NHS England Starting Well Core: 0 - 2s dental access and prevention framework [NHSE, 2019], advice to parents on managing teething from the American Academy of Pediatrics (AAP) [AAP, 2024], together with various studies of the symptoms and signs of teething, and expert opinion in review articles on teething. The rationale for the individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on primary care management of teething (up to 36 months).

Search dates

September 2019 - September 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 11th September 2019). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S4    S1 OR S2 OR S3 
S3    AB tooth eruption* OR TI tooth eruption* 
S2    AB teething OR TI teething 
S1    (MH "Tooth Eruption")     

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

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