Thursday, October 6, 2016

Teething/ tooth charts

Normal infants have 20 primary (baby) teeth which have started to develop in the womb.
The teeth start to erupt through the gums around 6 months of age. The baby teeth are then shed at various times throughout childhood. Below you will find a chart with the normal range of ages when most teeth start to come and go.

Occasionally I have a patient that doesn’t seem to like to follow rules, ignores the charts and does things their own way. I know of one baby who was born with teeth! Another started out with the upper canines and looked like a little vampire. As you can imagine, those parents were so happy when the rest of the teeth popped through. There is some heredity involved. If one of the parents was very early or late it is possible for the baby to follow suit. Check with grandma to see if she remembers anything special about your teething pattern!

It is rare for teeth to actually make an appearance before 4 months. Once in awhile parents will notice a smooth round white bud on a baby’s gum. This is a little benign cyst called an Epstein Pearl. It is not a tooth and it usually goes away without causing any bother.Many parents think of teething as something they are only dealing with for their young infants.  Think again. If your 6 year old is going through an extremely grumpy phase, or has a mysterious bout of mild, clear congestion that has been hanging on for a few weeks, take a feel in the back of the mouth and see if those first permanent molars are starting to pop through. By age 21, all 32 of the permanent teeth have usually erupted.


Just like the timing varies, the symptoms may also vary greatly from child to child and even from tooth to tooth. By far and away the most common first teeth are the ones in the bottom middle (and they are so cute once they come through.) Take your clean finger and run it along your baby’s gum. If the tooth is imminent  you may feel that the area of the affected gum feels soft and boggy


Let's talk about the symptoms:
Many healthcare providers and dentists dispute that there is any real relationship between teething and any of the symptoms below, but I have been at this job for a long long (long) time and I maintain that I see a connection.


Fussiness: Teething is uncomfortable. Most parents report that the babies seem fussier than usual right before a tooth pops through. Do what you can to relieve symptoms, but if your baby is inconsolable ( screaming with NO break) for more than 30 minutes and there is nothing you can do to calm them down then please call to have them checked. That would be an extreme reaction and we want to see if there is something else going on.


Drooling: Drooling starts weeks and weeks before you actually see a tooth pop through. Many kids will get a drool rash on their chins and cheeks. There are several products that I find quite useful for this. Clean of the area with Cetaphil Cleanser . (No water needed, apply with a cotton ball and wipe off.) Follow it up with aquaphor or cerave ointment (which you can use multiple times throughout the day.)


Gnawing/biting: Biting on things will feel great to the baby. Not so good to your nipples if you are nursing. If your baby starts biting you during feedings I recommend a loud “ouch!!” and immediately remove them from the breast. Most babies can be trained to stop this. Remember that you want to make the association mildly unpleasant so that they will stop the habit quickly. Biting = loud yell and loss of breast! If you are too gentle some babies will think it is quite amusing and will continue to bite at will.


Poor Sleeping: If your little one is miserable, this is not the time for sleep training. I would go in and quietly and try one of the teething remedies listed below. If you are going through a rough patch remember that parents should take shifts. Give yourselves each a few hours where you are off duty. There is no reason for both of you to be up all night. If you have the option, it is often best for the NON breastfeeding parent to go in, unless it is time for a feeding. This is a slippery slope, I would try not to feed for comfort throughout the night.


Bleeding/ bruised gums: It is not unusual to have a little bit of bleeding on the gums. Once in awhile you may also see a purple/ bluish bruise on the gums right before a tooth breaks through. This will usually resolve without any intervention although something cold will feel good on there.


Low grade temp :  Not everyone agrees that teething can cause fevers, but I see it all the time. If a fever goes higher than 100.5 I am not likely to blame it on teething. Any fever that is lasting more than three days is worth a call to the doctor's office to check in.


Loose stools: You will likely get differing opinions on whether or not teething can be the cause of loose stools and again; I will state here that I see it all the time.  Some folks speculate that swallowing all that saliva and drool might be the reason. Regardless, I do think there is a link. If you have a baby with loose stools you want to go with the bland, starchy diet and make sure they are on probiotics.


Rashes: If your child has sensitive skin and/or eczema sometimes, you might notice that the general rashiness flares up during active teething.

Congestion:  This clear runny nose and congestion can last for weeks and weeks. Sometimes it causes a post nasal drip that in turn causes a little hacky cough.  


Ear tugging: When  kids are working on some of the upper teeth they do tend to poke and play with their ears.

Uh oh, many of these symptoms are the same thing we look out for if we suspect an ear infection. Even though teething may well be the cause, if I have a patient who is very fussy , feverish and is having trouble sleeping, I am likely going to want to have someone take a peek in those ears.

It is worth having an arsenal of tools at the ready for dealing with the months of teething that you have ahead of you.

Cool teething rings: make sure they are made out of a safe material. Do not tie any teething rings around your baby's neck. This could cause strangulation.

Frozen wash cloth: Wet half of a wash cloth and put it in the freezer. The baby will be able to hold the dry half and chomp happily on the frozen side.

Distraction: There is nothing as nice as a body massage and a warm bath by a calm singing parent.

Teething tablets:  there has been a recent media buzz regarding  homeopathic teething tablets.

This link shows the FDA concern and the response from Hylands

Teething gels (homeopathic):  There are several brands.  If you aren’t scared off by the news, you might want to try both the tablets and the gel and see if one works better than the other for your child.

Homeopathic drops: The ones I am familiar with are Camilia by the Boiron company. Click the Boiron link for a coupon.

Boiron was NOT impacted by the recall and their product is perfectly fine to use!


Oragel:  Oragel and other commercial teething remedies work by numbing the gums.
I keep this on the list because when used properly it is safe and can be quite effective. It is nice to be able to get relief by applying something topically and not relying so much on systemic medications like Tylenol. Before I suggest it, I usually tell parents this little anecdote:

Many years ago I had a toothache and saw that I had a tube of Oragel in my medicine cabinet. I took a pea sized glob and rubbed it on my gum. Within moments it felt like my entire mouth was numb. It is nice to know that this stuff really works, but the sensation was almost frightening. If you decide to use this on your baby I want you to put a TINY bit on your own gums first so that you can see how numb the area gets.

Currently Oragel comes with a little Q-tip applicator so that it is much easier to put really small amounts exactly where they are needed. If care is taken, I am fine when this stuff is used appropriately. As I said, it seems to give relief to some patients. I also need to mention that the ingredient Benzocaine has been linked to something called Methemoglobinemia  that can be quite serious. It is exceedingly rare. I have certainly never seen it. (If you read the fine print on any medication you won’t want to give your child anything. Try to find a balance)

Brandy/ alcohol:
Ask great grandma what she used to do for teething and she may tell you that she used to put whiskey or brandy on the baby’s gums.
Obviously giving our babies alcohol is not something that most doctors would suggest today, but I actually wouldn’t worry if you caught grandma rubbing some directly on the gums. It probably does help. Some folks also say that rubbing pure vanilla extract on the gums is an effective home remedy. That may be from the alcohol content.


Feeding bags:   (baby safe feeder, or sassy teething feeder).
If your baby has had some solid foods introduced these feeding bags are great for teething relief, Add a cold hunk of fruit or veggie (pick a food that they have been introduced to already so that you don’t need to worry about any odd reactions) and let them gnaw away happily. With the mesh bag you don’t need to worry about them breaking off a piece that could be a choking hazard. You can find these bags online pretty easily.




I have had multiple parents tell me that these beads seemed to help.


Acetaminophen (Tylenol) and Advil  (Ibuprofen) are useful but I prefer not to overuse them. Make sure you are using the proper dose.

Start with the other approaches first. If possible, I would prefer to keep these as remedies for night time use only. Tylenol and Advil are quite safe but if they are used for a long period of time they can be stressful to the liver and kidneys. If you find that you have gone more than 5 nights where you are depending on these meds to keep your child comfortable, give your doctor's office a call to see if you need to make sure that nothing else is going on.


Once your child has teeth it is especially important to keep bottles out of the crib. Milk has sugar and can cause tooth decay if a baby sleeps with a bottle in their mouth.
It is never too early to start brushing the teeth. Let's get your baby in good dental habits. It is important to use a soft toothbrush and non abrasive toothpaste. The current recommendation is to use fluoride toothpaste, just a teeny bit the size of a grain of rice.
Once they have a mouthful of teeth it makes sense to start shopping for a pediatric dentist that you can establish a relationship with. This will come in handy if you have any tooth questions or mouth injuries..

Your next task is to figure out what the going rate for the tooth fairy is!!  I can’t help you there.

Wishing you easy teething!!

To add to the mire, Here is another caution about teething tablets:

http://www.cnn.com/2016/10/12/health/hylands-teething-tablets-discontinued-fda-warning/index.html

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