List of Abbreviations
WHO – World Health Organization
ED – eruption difficulties
IL-1 – interleukin-1
IL-2 – interleukin-2
IL-8 – interleukin-8
IL-1β – interleukin-1β
IL-8 – interleukin-8
ICD-10 – International Statistical Classification of Diseases and Related Health Problems, Tenth Revision
NSAIDs – non-steroidal anti-inflammatory drugs of the ATX groups: Other analgesics and antipyretics, Anti-inflammatory and antirheumatic products
PT – primary teeth eruption
TS – teething syndrome
TNF-α – tumor necrosis factor-α
Terms and Definitions
Preeclampsia is a complication of normal pregnancy that can develop after 20 weeks of gestation.
Tooth dystopia – abnormal position of one or several teeth within the dental arch.
Eruption cyst – a fluid-filled follicular sac that typically occurs during tooth eruption.
Primary tooth eruption is a physiological process consisting of the appearance of the tooth crown in the oral cavity as a result of complex multi-stage tooth development inside the jaw and its movement from the site of formation to the surface of the alveolar process.
Tooth retention – a dental condition in which a tooth germ fails to erupt fully through the bone or gingiva.
Teething syndrome, or difficult eruption of teeth (teething syndrome), is a combination of general and local symptoms that occur in infants during the emergence of primary (deciduous) teeth.
Tooth eruption disorder is a deviation from the normal process of tooth emergence in the oral cavity, which may manifest as delayed eruption timing, altered eruption sequence, absence of individual teeth, or their abnormal position following eruption [1,2].
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Tooth eruption is the process of its axial (vertical) movement from the site of formation and development inside the jaw until the crown appears in the oral cavity.
Primary tooth eruption is a natural physiological process that usually does not cause any significant changes in children's health status and is characterized by specific timing and sequence of eruption (Appendix A3.1) [1,2,3,4,5]. Some children develop a symptom complex that, according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10), is classified as teething syndrome.
Teething syndrome (TS), or difficult tooth eruption (teething syndrome), is a combination of general and local symptoms that occur in infants during the emergence of primary (deciduous) teeth.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Upon completion of crown formation, the developing tooth makes small movements combined with jaw growth. Tooth eruption (the migration process) is accompanied by the following changes:
Tooth development.
Periodontal development.
Alveolar bone remodeling.
The mechanism of tooth eruption is quite complex. By the time of tooth eruption, atrophy and resorption of the bone area covering the tooth crown occur. Similar processes take place in the gingiva. During tooth eruption, simultaneous with bone resorption in some areas, bone formation occurs in others. During root growth, bone remodeling processes also take place, resulting in a gradual deepening of the dental alveolus. Tooth eruption involves morphological changes in the teeth and surrounding tissues. There is an increase in blood supply, changes in vascular permeability, increased production of pulp and periodontal ground substance, and atrophic changes in the gingiva overlying the developing teeth [6,7].
Changes in the tissues covering the tooth include remodeling of connective tissue and epithelium. As the tooth approaches the oral mucosa, regressive changes occur in the connective tissue separating the tooth from the mucosal epithelium. This process is accelerated due to ischemia caused by the pressure of the erupting tooth on the tissue [3].
Physiological tooth eruption is characterized by three main features: specific timing, pairing, and sequence of eruption. Primary teeth begin to erupt in an infant on average at 6–7 months. The universally accepted teething schedules are those presented by Kronfeld (see Appendix A3.1).
However, the timing of tooth formation and eruption, as well as root formation and resorption, may be individual for each child [4].
An abnormal position of the tooth germ, as well as various endogenous and exogenous pathological influences on the dentofacial system, can cause abnormal positioning of the formed tooth and lead to delayed eruption [8,9].
Tooth eruption is associated with the destruction of gingival tissues. Proinflammatory cytokines play a key role in the development of various teething symptoms. According to the literature, the concentration of inflammatory cytokines (interleukins (IL) -1, -2, and -8, tumor necrosis factor α (TNF-α)) increases in the gingival fluid during primary tooth eruption, which partially explains the developing clinical manifestations. Thus, it has been established that elevated IL-1β levels in the gingival fluid are significantly more often associated with fever, gastrointestinal disturbances, sleep and appetite disorders. At the same time, it was noted that an increase in IL-8 concentration was accompanied by gastrointestinal disturbances, whereas elevated TNF-α levels were more characteristic of fever and sleep disturbances [10].
There is also evidence linking teething symptoms to mast cell activity as a source of inflammatory mediators. The number of mast cells in the pericoronal tissues of the oral cavity differs across various phases of tooth eruption (they are more numerous in the submucosal layer than in the intraosseous one). Subsequent degranulation and local release of mediators such as histamine, leukotrienes, prostaglandins, proteases, cytokines, and growth factors may be associated with teething symptoms (itching, inflammation, local redness, and sialorrhea) [7,11].
1.3 Epidemiology of the Disease or Condition
Data on the prevalence of symptoms associated with tooth eruption are heterogeneous and vary significantly depending on the research methodology. A meta-analysis by S. Massignan et al. (2016), including 16 studies on teething syndrome in children under 36 months of age from 8 countries (Australia, Brazil, Colombia, Finland, India, Israel, Senegal, USA, total sample n = 3506), showed that the incidence of signs and symptoms of primary tooth eruption in children aged 0 to 36 months reaches 70.5%. The most common manifestations are gum irritation (86.81%), irritability (68.19%), and drooling (55.72%) [12].
It must be emphasized that tooth eruption, in addition to local symptoms in the oral cavity, may be accompanied by a disturbance in the child's general condition—irritability and tearfulness, decreased appetite, body temperature up to 38℃, sleep disturbances, cough, diarrhea, which also occur in various infectious diseases [13]. Due to their non-specific nature, symptoms of certain somatic diseases may be misdiagnosed as teething syndrome (ICD-10 K00.7).
Primary teething syndrome is caused by multiple factors. Studies have shown that a particularly significant impact is exerted by maternal chronic diseases, harmful habits, pregnancy pathologies including preeclampsia, as well as health disorders in the child's first year of life [14].
Pathology of primary tooth eruption includes early, delayed, and difficult eruption. Disruption of the pairing and sequence of primary tooth eruption is also classified as eruption pathology.
Significant delay in the onset of eruption may indicate deviations in the child's physical development, metabolic disorders, or a general somatic disease. Alterations in the timing, pairing, and sequence of primary tooth eruption are observed in rickets and hypothyroidism [4].
At the same time, tooth eruption in children with various health status deviations has its own specific features. Infants with nutritional disorders, such as overweight, more frequently exhibit delayed primary tooth eruption. In children with the formerly so-called neuroarthritic constitutional type, which is based on uric acid and purine metabolism disorders accompanied by sympathicotonia manifestations—which later develop into attention deficit hyperactivity disorder and other health deviations—tooth eruption is timely but proceeds with pronounced gum pain, high fever, acetone breath, increased regurgitation up to vomiting, and hyperexcitability. In infants with atopy, tooth eruption also occurs within the established timeframes, but is more frequently accompanied by the onset of respiratory viral infections and exacerbation of food allergy and atopic dermatitis manifestations [15].
Difficult primary tooth eruption is influenced by various neonatal and postnatal factors [16], including birth weight and prematurity [17,18].
In low birth weight infants, TS is most commonly accompanied by excessive drooling (92%), sleep disturbances (82.3%), and irritability (75.6%) [16].
Rational feeding in the first year of life is a crucial factor in shaping long-term human health. Nutritional disorders in early life, micronutrient and macronutrient deficiencies, including vitamin D, frequently lead to significant deviations in the physical and intellectual development of children [19,20]. Therefore, it is necessary to thoroughly analyze anamnestic data and clinical manifestations, as well as actively monitor the child's condition dynamically [21].
1.4 Features of Coding the Disease or Condition
ICD-10 Coding
K00.7 - Teething syndrome
K09.0 - Dentigerous cysts
1.5 Classification of the disease or condition
There is no universally accepted clinical classification of teething syndrome.
The clinical form can be determined according to the classification of tooth eruption diseases by T.G. Robustova (2000) [22]:
Difficult tooth eruption.
Incorrect tooth position – displacement resulting from eruption (dystopic tooth).
Incomplete eruption of a tooth through the bone tissue of the jaw or mucosa (semi-impacted tooth).
Delayed eruption of a fully formed tooth through the compact bone plate of the jaw (impacted tooth).
1.6 Clinical presentation of the disease or condition
Difficult tooth eruption in early childhood manifests as a combination of local and general symptoms, the severity of which depends on a number of perinatal factors. The duration of the eruption period for a single primary tooth is approximately 7-9 days; typically, symptoms appear 3-4 days before the emergence of the primary tooth and persist for 3-5 days after the primary tooth appears in the oral cavity [23].
General symptoms of teething syndrome include:
anxiety, irritability, sleep disturbances;
decreased appetite or refusal to eat, decreased rate of weight gain;
profuse drooling (sialorrhea);
perioral dermatitis (simple contact irritant dermatitis caused by maceration and friction);
onset of coughing against the background of teething (caused by hypersalivation and the ingress of saliva into the upper respiratory tract);
unstable stools (associated with increased salivation and enhanced intestinal motility);
low-grade fever (37.5°C–38.0°C). Febrile fever is not characteristic of this condition [3,4,12,24,25].
General symptoms of teething syndrome are nonspecific and may indicate not only teething but also other pathological conditions.
Local symptoms of teething syndrome:
swelling and hyperemia of the gingiva in the eruption area,
tenderness upon palpation of the eruption site,
drooling,
gingival bleeding.
Additionally, an increased need of the child for chewing, biting, and sucking can be noted as manifestations of teething syndrome [3,4,12,24].
Comment: most studies of large cohorts of children have not revealed a causal relationship between teething and fever or diarrhea [12,24,25]. It should be remembered that symptoms regarded as teething syndrome may be manifestations of respiratory, intestinal infections, urinary tract infections, etc. In an observational study of a group of children admitted to the hospital with suspected teething syndrome, in most cases other causes of manifestations were identified - upper respiratory tract infections (including with febrile seizures), tonsillopharyngitis, otitis media, bronchitis, diaper dermatitis, balanitis, meningitis. Thus, teething syndrome should be considered as a diagnosis of exclusion, established only after a thorough examination of the child and the exclusion of other pathological conditions [25,26].
Eruption cyst in an early childhood patient may form when root formation is incomplete. Signs may appear 1-2 weeks before the tooth emerges and are characterized by a convex, cyanotic gingival lesion containing blood, surrounded by a rim of hyperemia in the eruption area.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Diagnostics aims to identify signs of difficult eruption of primary teeth, determine the form of the clinical course of the pathological process, and assess the severity of the patient's condition, being performed to select an appropriate treatment method. Diagnostics is carried out for each tooth separately.
Criteria for establishing the diagnosis of teething syndrome:
Nosological form: Teething syndrome.
Phase: any.
Complication: uncomplicated.
ICD-10 code: K00.7
There are no universally accepted criteria for teething syndrome.
When making a diagnosis, one should take into account:
Age: patients under 20-30 months of age.
Presence of one or more local symptoms listed in section 1.6:
- swelling and hyperemia of the gingiva in the eruption area,
- tenderness upon palpation of the eruption site, drooling,
- bleeding in the area of tooth eruption,
- presence or absence of cusps or cutting edges in the area of erupting primary teeth (optional),
o Presence of one or more general symptoms of primary tooth eruption.
o Presence of the infant's need for chewing/biting/sucking.
It is recommended that patients with suspected teething syndrome presenting with general symptoms (fever, cough, diarrhea, etc.) undergo a diagnostic workup to identify another cause of the manifestations [25,26].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)
Comments: the examination is carried out according to existing clinical guidelines in accordance with the manifestations.
Important: Teething syndrome should be considered as a diagnosis of exclusion, established only after the thorough exclusion of other pathological conditions [26].
In the presence of general symptoms such as fever, cough, diarrhea, etc., regardless of the presence of local symptoms, a thorough differential diagnosis regarding respiratory and intestinal infections, as well as urinary tract infections, should be performed [25].
Nosological form: Dentigerous cysts.
Phase: any.
Complication: uncomplicated.
ICD-10 code: K09.0
Incomplete root formation in early childhood patients with primary teeth may be accompanied by the formation of an eruption cyst, which is a convex, cyanotic gingival lesion in the eruption area containing blood, with a rim of hyperemia, appearing 1-2 weeks before the tooth emerges.
These manifestations are signs of the diagnosis K09.0. Dentigerous cysts.
The cyst is formed when an erupting tooth fails to pierce the mucosa and instead traumatizes it. The gingiva, detaching from the underlying bone, forms a "blister" or "sac" that collects blood, resembling a convex hematoma in appearance. As a rule, an eruption cyst resolves on its own, but sometimes the process is accompanied by pain syndrome and inflammation [9,27].
2.1 Complaints and Anamnesis
All early childhood patients with clinical signs of teething syndrome are recommended to undergo history taking and symptom assessment for oral cavity (and dental) pathology, as well as therapeutic history taking and symptom assessment to confirm the diagnosis and prescribe necessary treatment [1,9].
Level of Evidence 5Grade of Recommendation – C (Level of Evidence – 5)
Comment: the results are entered into the patient's medical record.
Parents or legal representatives may report general symptoms such as low-grade fever, anxiety, irritability, sleep disturbance, decreased appetite, perioral dermatitis, coughing, and diarrhea. Complaints regarding local manifestations such as redness, swelling, bleeding gums, profuse salivation, and an increased need of the child for biting, chewing, and sucking are possible [3,4,15].
When taking the history, it is necessary to pay attention to the presence of concomitant pathology, allergic reactions, trauma from foreign objects or sharp edges of teeth, and medication use data.
The timing, pairing, and sequence of tooth eruption, as well as the history of general and local symptoms during the eruption of other teeth, are clarified.
It should also be clarified which remedies are/were used to relieve local and/or general adverse manifestations of difficult eruption of primary teeth.
2.2 Physical Examination
It is recommended to perform a physical examination (visual examination for oral pathology, including the maxillofacial region, palpation of oral organs, palpation for oral pathology, including the maxillofacial region, percussion for oral pathology, percussion for oral pathology, including the maxillofacial region, routine visual inspection, routine palpation, routine percussion, routine auscultation) (as part of the initial and follow-up consultation/examination by a pediatrician / general practitioner (family physician), and/or, if parents/legal representatives apply, initial and follow-up consultation/examination by a pediatric dentist / dentist), in children with clinical signs of teething to determine the presence, localization, and severity of traumatic injury to the soft tissues of the face, oral mucosa, teeth, and surrounding tissues in order to clarify the diagnosis and determine the scope of diagnostic and therapeutic interventions [9].
Level of Evidence 5Grade of Recommendation – C (Level of Evidence – 5)
Comment:
General examination involves assessing the general condition, presence of dehydration signs, the child's physical development, examination of the oral cavity, and assessment of the condition of all existing teeth, including changes in the shape and color of the crown.
Typically, the examination is performed by a pediatrician / general practitioner (family physician) and/or, if parents/legal representatives apply, by a pediatric dentist / dentist. An oral examination using additional instruments is performed by a pediatric dentist / dentist.
If signs of other diseases are detected, further diagnostics should be carried out in accordance with the discovered clinical signs (including, if the child was initially consulted by a pediatric dentist / dentist, the patient should be referred to a pediatrician / general practitioner (family physician)).
Oral examination may reveal hyperemia and edema of the gingiva at the teething site, bleeding at the teething site, and the presence of cusps and/or cutting edges in the teething area. During the oral examination, it is necessary to rule out acute inflammatory diseases of the oral mucosa and assess the oral hygiene status.
Palpation of the oral cavity may reveal tenderness at the teething site, edema, hyperthermia, and infiltration at the teething site. Palpation assesses the presence of a hematoma: density, consistency, mobility relative to surrounding tissues, fluctuation, and softening.
Palpation of lymph nodes may reveal enlargement of regional lymph nodes.
It is recommended to refer a child with clinical signs of teething syndrome to a pediatric dentist / dentist if the pediatrician / general practitioner (family physician) has doubts about the favorable course of the teething period, in complex teething cases to clarify the diagnosis and provide adequate therapy [9].
Level of Evidence 5Grade of Recommendation – C (Level of Evidence – 5)
When examining infants diagnosed with teething syndrome by a pediatric dentist / dentist, it is recommended to perform an index assessment of the severity of local clinical manifestations of difficult eruption of primary teeth in order to objectify the assessment of clinical manifestations [13].
LOU 4Level of Convincingly – C (Level of Evidence – 4)
Comments:
See Appendix G1.
In infants diagnosed with teething syndrome, it is recommended (for the pediatric dentist / dentist) to evaluate the papillary-marginal-alveolar index to determine the degree of gingival involvement [23].
Level of Recommendations – CLevel of Evidence – 4Level of Recommendations – C (Level of Evidence – 4)
Comments:
See Appendix G2.
2.3 Laboratory Diagnostics
In children with teething syndrome, including eruption cysts, laboratory diagnostic tests are not performed. Tests may be prescribed if differential diagnosis is necessary depending on the identified symptoms in accordance with the relevant clinical guidelines [25].
2.4 Instrumental Diagnostics
In children with teething syndrome, including eruption cysts, instrumental diagnostic tests are not performed. Tests may be prescribed if differential diagnosis is necessary depending on the identified symptoms in accordance with the relevant clinical guidelines [25].
2.5 Other Procedures
Not applicable.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
Treatment goals:
- elimination of local pathological manifestations of difficult eruption of primary teeth;
- elimination of general pathological manifestations associated with teething syndrome in infants [28].
General principles
Important: Teething syndrome is physiological in nature and usually resolves on its own without requiring medical intervention. During the conversation with parents/legal representatives, the expected duration of existing symptoms should be discussed, and they should be reassured that minimal interventions are sufficient.
Optionally, non-pharmacological treatment methods may be prescribed in the first place, and pharmacotherapy may also be considered (see sections 3.1, 3.2, 3.3).
The principles of treatment for children with primary teething syndrome involve simultaneously solving several tasks:
- elimination of factors causing the development of the inflammatory process of the oral mucosa;
- prevention of further spread of the inflammatory process to the surrounding oral mucosa and adjacent anatomical regions;
- improving the quality of life of patients [9].
If rhinitis therapy is necessary during teething, symptom management is carried out in accordance with the clinical guidelines "Acute Respiratory Viral Infection (ARVI) in children".
Treatment of cough associated with teething is usually not required; it resolves on its own immediately after tooth eruption.
The principles of patient management are presented in Appendix A3.2.
3.1.1. Teething syndrome in early childhood
It is recommended that parents/legal representatives of a child with teething syndrome apply cognitive behavioral therapy methods—hugging, paying attention, offering games that can distract from pain—in order to reduce teething symptoms [24].
GGR CLEL 3Grade of Recommendation – C (Level of Evidence – 3)
Comments:
Cognitive behavioral therapy is a safe and fairly effective method for relieving general symptoms of teething syndrome, including sleep and behavioral disorders in children with teething syndrome [29]. Parental attention and care can help mitigate symptoms: hug therapy has been shown to be effective in controlling sleep disorders and crying [24].
It is recommended for children with teething syndrome to selectively use non-pharmacological methods for gum massage (e.g., oral care products for children under 3 years old, teething rings, gum massage brushes) to relieve local symptoms and reduce gum discomfort [24, 28];
GGR CLEL 3Grade of Recommendation – C (Level of Evidence – 3)
Comment: there are reports of symptom relief with these interventions, but currently there is insufficient evidence of their efficacy, and cases of children biting through certain filled teethers have been described, so they should be used with caution.
Gum massage can also be performed using the index finger wrapped in a medical sterile gauze bandage for 1–2 minutes.
It is not recommended to use frozen objects in children with teething syndrome, including foods such as fruits, vegetables, or others, for biting or sucking to reduce teething symptoms [24].
GGR CLEL 3Grade of Recommendation – C (Level of Evidence – 3)
Comments:
Such an intervention carries the risk of aspiration of small food pieces, gum trauma, and hypothermia of the oral cavity.
It is recommended for infants with teething syndrome to relieve adverse oral symptoms (edema, hyperemia, gingival bleeding) in case a decision is made to use drugs from the following groups: "Anti-infectives and antiseptics for local oral treatment" (ATX group - A01AB), "Other drugs for local oral treatment" (ATX group - A01AD) (dental gels containing antiseptics, anesthetics, plant extracts), lidocaine in combination with other drugs (ATX group - N01BB52), strictly follow the instructions (especially age restrictions), and monitor the child's clinical manifestations [4, 28].
GCP CLoE 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) – C (Level of Evidence – 5)
Comment: today, agents used to alleviate teething-related symptoms generally have a favorable effect, but there is no conclusive evidence of their efficacy. Additional larger-scale studies are needed to draw final conclusions [28, 30, 31].
In addition, various dental gels containing lidocaine as an analgesic (lidocaine in combination with other drugs [ATC group: N01BB52]) are unsafe for children due to the high risk of serious adverse effects: respiratory arrest, methemoglobinemia, seizures, and other conditions, including fatal outcomes [28, 31, 32]. This is because, firstly, these drugs are difficult to dose accurately, and secondly, some medications are more toxic to infants and young children due to the immaturity of their liver and kidneys [39].
Some dental gels contain ethanol. Studies, primarily concerning alcohol content in breast milk, show that infants exposed to alcohol sleep less, cry more frequently, and exhibit impaired motor development. Behavioral consequences and potential risks associated with its use indicate that the administration of ethanol-containing products should be avoided in children [31].
The use of drugs from the ATC group A01AD, for example, choline salicylate + cetalkonium chloride dental gel, especially when used concomitantly with acetylsalicylic acid** (tablets) or other NSAIDs—such as in convalescents of viral infections or susceptible children—may trigger Reye's syndrome [34].
Rare, serious, and potentially fatal adverse effects have been reported in association with the use of benzocaine-containing dental gels and liquids applied to a child's gums or oral cavity [24, 37].
There are reports of potential cytotoxic and antifungal effects in in vitro studies of lidocaine in combination with other drugs from the ATC group N01BB52 (lidocaine-containing dental gels) [38].
If a decision is made to use such products after conducting a benefit-risk assessment, caution should be exercised, instructions must be strictly followed, and the child's clinical manifestations should be closely monitored.
It is recommended to selectively administer pain-relief medications (paracetamol** or ibuprofen**) to children with teething syndrome in accordance with the instructions for use, taking into account age restrictions and dosage forms [35, 36].
Level of Recommendations – CLevel of Evidence – 4Level of Recommendations – C (Level of Evidence – 4)
Comment:
These drugs should not be prescribed routinely; when making a decision, the necessity of this intervention should be assessed, and they should be prescribed only if the expected benefit outweighs potential adverse reactions.
The pediatrician should also ensure that conditions mimicking teething syndrome have been ruled out.
3.2 Surgical Treatment
It is recommended that in the case of eruption cyst formation (when spontaneous drainage of the cyst contents does not occur), the contents of the cyst be evacuated and local adverse manifestations of delayed or difficult eruption of primary teeth be managed (A16.01.004 - Surgical debridement of a wound or infected tissue) by a pediatric dentist / dentist / maxillofacial/dental surgeon for therapeutic purposes [42, 43].
Level of Recommendations – CLevel of Evidence – 4Level of Recommendations – C (Level of Evidence – 4)
Comments: the cyst must be opened with a scalpel and complete evacuation of its contents achieved, followed by antiseptic treatment of the difficult eruption area of the primary tooth using chlorhexidine** (A01AB03). Recommendations regarding oral hygiene and dietary intake must be provided [42, 43].
3.3 Other Treatment
Complementary and alternative medicine methods involve a combination of various therapeutic approaches that are not fully based on conventional medical principles. These methods do not replace the primary treatment listed above and may be used optionally, following an assessment and discussion of potential benefits.
Selective administration of a preparation containing *Chamomilla vulgaris*, *Phytolacca decandra*, and *Rheum officinale* may be considered for children with teething syndrome to relieve general and local symptoms [23, 28, 40, 41].
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not required.
5. Prevention and Dispensary Observation
5.1. Prevention
Specific prophylaxis for teething syndrome or eruption cysts is not required.
For difficult eruption of primary teeth, dynamic monitoring of both the eruption area and the child's developing body as a whole is indicated for the timely detection and treatment of complications associated with delayed dental development and to create conditions for the normal development of the child's dentofacial system.
Individual utensils and personal hygiene items should be designated and used exclusively for the child.
Thorough dental sanitation and the elimination of all foci of chronic infection in the body help reduce recurrences. To prevent the spread of infection in childcare facilities, premises, household items, and toys are disinfected using antiseptics and disinfectants, alongside quartz sterilization and room ventilation.
5.1. Observation
It is recommended that children with teething syndrome experiencing difficult tooth eruption undergo dynamic monitoring through consultations with a pediatric dentist. Data obtained during the examination must be recorded in the patient's medical documentation to rule out the development of dentofacial anomalies [9].
GCP CLoE 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) – C (Level of Evidence – 5)
Comments: a favorable outcome following difficult eruption of a primary tooth is characterized by the following signs: absence of pathological symptoms in the area of the erupting primary tooth and preservation of a normal oral mucosa state.
Follow-up visits are scheduled individually, on average 6–9 days after the end of the active treatment period, and subsequently every 5–6 months if necessary.
6. Organization of Medical Care
When necessary, medical care may be provided to children with teething syndrome or eruption cysts in any settings and forms stipulated by legislation. Primary health care is the most common.
Care for patients with teething syndrome is provided by pediatricians, general practitioners (family physicians), and pediatric dentists/dentists. Physician assistants (feldschers) and nursing staff (patronage nurses) may also participate in the provision of care.
In isolated cases of difficult tooth eruption accompanied by the formation of an eruption cyst, patients are indicated for an appointment (examination, consultation) with a pediatric dentist/dentist or dental surgeon in specialized dental medical organizations, or in pediatric dentistry departments and offices of multidisciplinary healthcare facilities (preferably in a specially equipped room).
7. Additional Information
7.1 Complications
Teething syndrome typically proceeds without complications. In the event of an eruption cyst formation or signs of ectopic/improper tooth eruption (dystopia or abnormal tooth position), the patient should be referred for an appointment (examination, consultation) with a pediatric dentist/dentist.
7.2 Outcomes and Prognosis
Teething syndrome usually resolves spontaneously within 2 to 8 days.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance evaluation |
|---|---|---|
1 | A physical examination was performed (visual inspection for oral pathology, including the craniomaxillofacial region; palpation of oral cavity structures; palpation for oral pathology, including the craniomaxillofacial region; percussion for oral pathology; percussion for oral pathology, including the craniomaxillofacial region; routine visual inspection; routine palpation; routine percussion; routine auscultation) (within the framework of initial and follow-up appointments/examinations/consultations by a pediatrician/general practitioner [family physician] and/or, in the case of a visit by parents/legal representatives, initial and follow-up appointments/examinations/consultations by a pediatric dentist/dentist) in children with clinical signs of tooth eruption | Yes/no |
3 | Evacuation of cyst contents and management of adverse local manifestations of difficult primary tooth eruption (A16.01.004 - Surgical debridement of a wound or infected tissue) were performed by a pediatric dentist / dentist / dental surgeon upon the formation of an eruption cyst (in cases where spontaneous drainage of the cyst contents does not occur) | Yes/no |
References
Show references
McKinney R, Olmo H. Developmental Disturbances of the Teeth, Anomalies of Number. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK573071/.
Roulias P, Kalantzis N, Doukaki D, Pachiou A, Karamesinis K, Damanakis G, Gizani S, Tsolakis AI. Teeth Eruption Disorders: A Critical Review. Children (Basel). 2022 May 24;9(6):771. doi: 10.3390/children9060771. PMID: 35740708; PMCID: PMC9222051.
Detskaya stomatologiya: uchebnik / pod red. Yanushevicha O.O., Kiselnikovoy L.P., Topolnitskogo O.Z. - Moscow: GEOTAR-Media, 2020. - 744 p. - ISBN 978-5-9704-5318-6.
Drobotko L.N., Zueva T.E., Kiselnikova L.P. Sindrom prorezivaniya zubov: kogda i kak lechit. Farmateka. 2019;26(10):77–81. DOI: https://dx.doi.org/10.18565/pharmateca.2019.10.77-81.
Klinicheskie rekomendatsii «Sindrom prorezivaniya vremennykh zubov». Stomatologicheskaya Assotsiatsiya Rossii, 2024 – 34 p.
Marks SC Jr, Schroeder HE. Tooth eruption: theories and facts. Anat Rec. 1996 Jun;245(2):374-93. doi: 10.1002/(SICI)1097-0185(199606)245:2<374::AID-AR18>3.0.CO;2-M. PMID: 8769674.
Soloviev V.A. Morfologicheskoe i gistoradiograficheskoe izuchenie prorezivaniya zubov. Stomatologiya. 1980;59(1):9–11.
Tarasenko S.V. Khirurgicheskaya stomatologiya: uchebnik / pod red. S.V. Tarasenko // Moscow: GEOTAR-Media. – 2020
Detskaya terapevticheskaya stomatologiya. Natsional'noe rukovodstvo / pod red. V.K. Leont'eva, L.P. Kisel'nikovoy. – 3-e izd., pererab. i dop. – M. GEOTAR-Media, 2025. – 960 s. – (Seriya «Natsional'nye rukovodstva»). DOI:10.33029/9704-8915-4-DTS-2025-1-960. ISBN: 978-5-9704-8915-4
Shapira J., Berenstein-Ajzman G., Engelhard D. et al. Cytokine levels in gingival crevicular fluid of erupting primary teeth correlated with systemic disturbances accompanying teething // Pediatr Dent. 2003. Vol. 25. P. 441–448.
Franzolin S.O.B., Pardini M.I.M.C., Francischone L.A., Deff une E., Consolaro A. (2019) Explanation for the signs and symptoms of tooth eruption: mast cells. Dental Press J. Orthod., no 24 (2), pp. 20–31.
Massignan C., Cardoso M., Porporatti A.L. et al. Signs and symptoms of primarytooth eruption: a meta-analysis // Pediatrics. 2016. Vol. 137(3). e20153501.
Tsarev V.N., Kiselnikova L.P., Podporin M.S., Balafendieva F.M. Sravnitelnaya otsenka vliyaniya lekarstvennykh form mestnogo i sistemnogo primeneniya na oralnyy mikrobiotsenoz pri zatrudnennom prorezivanii zubov. — Klinicheskaya stomatologiya. — 2022; 25 (4): 44—49. DOI: 10.37988/1811-153X_2022_4_44.
Cunha R.F., Pugliesi D.M., Garcia L.D., et al. Systemic and local teething disturbances: prevalence in a clinic for infants. J Dent Child. 2004; 71: 24–26.
Macknin M.L., Piedmonte M., Jacobs J., Skibinski C. Symptoms associated with infant teething: a prospective study. Pediatrics. 2000; 104: 747–752.
Balafendieva F.M., Kiselnikova L.P. Analysis of certain factors influencing primary tooth eruption. Problemy stomatologii. 2023; 1: 00. © Balafendieva F.M., et al., 2023 DOI: 10.18481/2077-7566-2023-19-1-00.
Devraj IM, Nandlal B, Narayanappa D, Deshmukh S, Dhull KS. Effect of Neonatal Factors on the Eruption of Primary Teeth in Children: A Longitudinal Prospective Cohort Study. Int J Clin Pediatr Dent. 2023 Mar-Apr;16(2):321-326. doi: 10.5005/jp-journals-10005-2518. PMID: 37519964; PMCID: PMC10373756.
Zaidi I, Thayath MN, Singh S, Sinha A. Preterm Birth: A Primary Etiological Factor for Delayed Oral Growth and Development. Int J Clin Pediatr Dent. 2015 Sep-Dec;8(3):215-9. doi: 10.5005/jp-journals-10005-1316. Epub 2015 Sep 11. PMID: 26628856; PMCID: PMC4647043.
Borovik T.E., Ladodo K.S., Yatsyk G.V., et al. Scientific and practical program "Optimization of infant feeding in the Russian Federation" // Pediatriya. – 2008. – No4. – P. 75-79.
Sahin M, Toptanci IR. Evaluation of serum levels in children with delayed eruption. BMC Oral Health. 2024 Nov 21;24(1):1418. doi: 10.1186/s12903-024-05210-9. PMID: 39574100; PMCID: PMC11580453.
Zaplatnikov A.L., Kasyanova A.N., Maykova I.D. Teething syndrome in infants: a new look at an old problem // RMJ. 2018; 5 (II): 68-71.
Robustova Tatyana Grigorievna. Surgical dentistry: textbook for students of dental faculties of medical universities / [Robustova T.G. et al.] ; edited by T. G. Robustova. - 3rd ed., revised and expanded. - Moscow: Meditsina, 2003. - 503, [1] p. : il. ; 27 cm. - (Educational literature for students of dental faculties of medical universities).
Kiselnikova L.P., Tsarev V.N., Podporin M.S., Balafendieva F.M. Clinical and microbiological efficacy of treatment for difficult primary tooth eruption. Pediatriya im. G.N. Speranskogo. 2023; 102 (4): 8–15.
Memarpour M, Soltanimehr E, Eskandarian T. Signs and symptoms associated with primary tooth eruption: a clinical trial of nonpharmacological remedies. BMC Oral Health. 2015 Jul 28;15:88. doi: 10.1186/s12903-015-0070-2. PMID: 26215351; PMCID: PMC4517507.
A Nemezio M, Mh De Oliveira K, C Romualdo P, M Queiroz A, Wg Paula-E-Silva F, Ab Silva R, C Küchler E. Association between Fever and Primary Tooth Eruption: A Systematic Review and Meta-analysis. Int J Clin Pediatr Dent. 2017 Jul-Sep;10(3):293-298. doi: 10.5005/jp-journals-10005-1453. Epub 2017 Feb 27. PMID: 29104392; PMCID: PMC5661046.
Tighe M, Roe MF. Does a teething child need serious illness excluding? Arch Dis Child. 2007 Mar;92(3):266-8. doi: 10.1136/adc.2006.110114. PMID: 17337688; PMCID: PMC2083427.
Alline J de Oliveira, Maria LG Silveira, Danilo A Duarte, Michele B Diniz Eruption Cyst in the Neonate. Int J Clin Pediatr Dent. 2018 Jan-Feb; 11(1): 58–60. Published online 2017 Feb 1. doi: 10.5005/jp-journals-10005-1485 PMCID: PMC5968165
Canto FMT, Costa Neto OC, Loureiro JM, Marañón-Vásquez GA, Ferreira DMTP, Maia LC, Pithon MM. Efficacy of treatments used to relieve signs and symptoms associated with teething: a systematic review. Braz Oral Res. 2022 May 2;36:e066. doi: 10.1590/1807-3107bor-2022.vol36.0066. PMID: 36507753.
Meer Z, Meer A. Teething trouble and its management in children. Int J Dent Clin. 2011;3:75–77.
Abdulsatar F, Miller MR, Taheri S. Use of Unsafe Teething Remedies: A Survey. J Can Dent Assoc. 2022 Aug;88:m7. PMID: 36322634.
Monaghan, N. Teething products may be harmful to health. Br Dent J 227, 485–487 (2019). https://doi.org/10.1038/s41415-019-0715-7
Teoh L, Moses GM. Are teething gels safe or even necessary for our children? A review of the safety, efficacy and use of topical lidocaine teething gels. J Paediatr Child Health. 2020 Apr;56(4):502-505. doi: 10.1111/jpc.14769. Epub 2020 Jan 3. PMID: 31898380.
National Institute for Health and Care Excellence. Teething clinical knowledge summary. 2014. Available at https://cks.nice.org.uk/teething (accessed August 2019).
Tsang AKL. Teething, teething pain and teething remedies. Int. Dent (Aus Ed). 2010; 5 (4): 14–28.
Bedard P, Winsor GL, Garlock ES, Azad MB, Becker AB, Mandhane PJ, Moraes TJ, Sears MR, Turvey SE, Subbarao P, Brinkman FSL, Kozyrskyj AL. From Prescription Drugs to Natural Health Products: Medication Use in Canadian Infants. Children (Basel). 2022 Sep 27;9(10):1475. doi: 10.3390/children9101475. PMID: 36291411; PMCID: PMC9600175/
Thompson K, Huntington MK. Methods of Symptomatic Relief of Teething in Infants and Young Children Recommended by South Dakota Physicians. S D Med. 2019 Nov;72(11):509-512. PMID: 31985901.
Aşık A, Bayır E, Acar S, Sağlam C, Çoğulu D, Uzel A. Cytotoxic and antifungal effects of different teething oral gels: an in-vitro study. Head Face Med. 2025 Jul 5;21(1):47. doi: 10.1186/s13005-025-00524-7. PMID: 40615859; PMCID: PMC12228206
Kearns GL, Abdel-Rahman SM, Alander SW, Blowey DL, Leeder JS, Kauffman RE. Developmental pharmacology—drug disposition, action, and therapy in infants and children. N Engl J Med. 2003 Sep;349(12):1157-67.https://doi.org/10.1056/NEJMra035092/
Tsarev V.N., Kiselnikova L.P., Podporin M.S., Balafendieva F.M. Comparative evaluation of the effect of local and systemic dosage forms on oral microbiocenosis during difficult tooth eruption. — Klinicheskaya stomatologiya. — 2022; 25 (4): 44—49.
Kiselnikova L.P., Tsarev V.N., Balafendieva F.M., Podporin M.S., Borodina P.K. Possibilities of normalizing oral microbiota in children in the treatment of difficult primary tooth eruption. Stomatologiya detskogo vozrasta i profilaktika. 2023;23(4):320-328.
Bilodeau EA, Hunter KD. Odontogenic and Developmental Oral Lesions in Pediatric Patients. Head Neck Pathol. 2021 Mar;15(1):71-84. doi: 10.1007/s12105-020-01284-3. Epub 2021 Mar 15. PMID: 33723756; PMCID: PMC8010029
Sen-Tunc E, Acikel H, Sonmez IS, Bayrak S, Tuloglu N. Eruption cysts: a series of 66 cases with clinical features. Med Oral Patol Oral Cir Bucal. 2017;22(2):e228–ee32. doi: 10.4317/medoral.21499.
Appendix A1. Working Group Composition
Balafendieva Fatima Muradovna – Assistant, Department of Pediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health.
Baranov Alexander Alexandrovich – Academician of the Russian Academy of Sciences, Professor, MD; Honorary President of the Union of Pediatricians of Russia, Advisor to the Head of the Research Institute of Pediatrics and Child Health of the Clinical Research Center No. 2 of the Petrovsky National Research Center of Surgery, Professor at the Department of Pediatric Padiatrics and Pediatric Rheumatology, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Chief freelance pediatric specialist of the Russian Ministry of Health.
Belyaeva Irina Anatolyevna – MD, Head of the Department of Preconceptional, Antenatal, and Neonatal Medicine, Research Institute of Pediatrics and Child Health of the Clinical Research Center No. 2 of the Petrovsky National Research Center of Surgery, Professor at the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Member of the Union of Pediatricians of Russia, Honorary Professor of the Russian Association of Perinatal Medicine Specialists.
Bombardirova Elena Petrovna – MD, Professor, Chief Researcher of the Department of Preconceptional, Antenatal, and Neonatal Medicine, Neonatologist, Research Institute of Pediatrics and Child Health of the Clinical Research Center No. 2 of the Petrovsky National Research Center of Surgery, Member of the Union of Pediatricians of Russia.
Vasilieva Nataliya Yuryevna – Candidate of Medical Sciences, Associate Professor, Department of Pediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health.
Vishneva Elena Alexandrovna – MD, Professor of the Russian Academy of Sciences, Deputy Head of the Research Institute of Pediatrics and Child Health of the Clinical Research Center No. 2 of the Petrovsky National Research Center of Surgery, Professor at the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Member of the Union of Pediatricians of Russia.
Golovach Ekaterina Alekseevna – Assistant, Department of Faculty Pediatrics with a Course of Childhood Diseases, Faculty of Medicine, Siberian State Medical University of the Russian Ministry of Health.
Gutnik Andrey Alexandrovich – Assistant, Department of Pediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health.
Zueva Tatyana Evgenyevna – Candidate of Medical Sciences, Associate Professor, Department of Pediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health.
Kiselnikova Larisa Petrovna – Doctor of Medical Sciences, Professor, Head of the Department of Pediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health.
Margieva Tea Valikovna – PhD, Chief Specialist of the Methodological Center for Accreditation of Specialists, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Nephrologist, Member of the Union of Pediatricians of Russia.
Namazova-Baranova Leyla Seymurovna – Academician of the Russian Academy of Sciences, Professor, MD, President of the Union of Pediatricians of Russia; Past-President of EPA/UNEPSA; Head of the Research Institute of Pediatrics and Child Health of the Clinical Research Center No. 2 of the Petrovsky National Research Center of Surgery, Head of the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Chief freelance pediatric specialist for preventive medicine of the Russian Ministry of Health.
Platonova Maria Mikhailovna – PhD, Researcher, Research Institute of Pediatrics and Child Health of the Clinical Research Center No. 2 of the Petrovsky National Research Center of Surgery, Pulmonologist, Member of the Union of Pediatricians of Russia.
Selimzyanova Liliya Robertovna – PhD, Head of the Department of Standardization and Study of Evidence-Based Medicine Foundations, Research Institute of Pediatrics and Child Health of the Clinical Research Center No. 2 of the Petrovsky National Research Center of Surgery, Associate Professor, Department of Pediatrics and Pediatric Rheumatology, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Associate Professor, Department of Faculty Pediatrics, Institute of Motherhood and Childhood, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Member of the Union of Pediatricians of Russia.
Strakhova Svetlana Yuryevna – Candidate of Medical Sciences, Associate Professor, Department of Pediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health.
Turti Tatyana Vladimirovna – MD, Chief Researcher, Department of Preconceptional, Antenatal, and Neonatal Medicine, Research Institute of Pediatrics and Child Health of the Clinical Research Center No. 2 of the Petrovsky National Research Center of Surgery, Professor at the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Member of the Union of Pediatricians of Russia.
Fedorova Olga Sergeevna – MD, Professor, Vice-Rector for Research and Postgraduate Training, Head of the Department of Faculty Pediatrics with a Course of Childhood Diseases, Faculty of Medicine, Siberian State Medical University of the Russian Ministry of Health, Chief freelance pediatric specialist of the Russian Ministry of Health in the Siberian Federal District.
Fedotova Marina Mikhailovna – PhD, Associate Professor, Department of Faculty Pediatrics with a Course of Childhood Diseases, Faculty of Medicine, Siberian State Medical University of the Russian Ministry of Health.
The authors declare no financial support or conflicts of interest that need to be disclosed.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Pediatricians;
General practitioners (family physicians);
Medical students;
Residents;
Pediatric dentist / dentist;
Oral and maxillofacial surgeon.
1. Scale for evaluating levels of evidentiary validity (LEV) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1. | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2. | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3. | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4. | Non-comparative studies, case report |
5. | Only justification of mechanism of action or expert opinion is available |
2. Scale for assessing levels of evidence reliability (LER) for prevention, treatment, and medical rehabilitation methods, including those based on the use of natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)
LoE | Definition |
|---|---|
1. | Systematic review of randomized controlled trials with meta-analysis |
2. | Individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3. | Non-randomized comparative studies, including cohort studies |
4. | Non-comparative studies, case report or case series, case-control study |
5. | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
3. Scale for assessing levels of recommendation persuasiveness (LRP) for methods of prevention, diagnostics, treatment, and medical rehabilitation, including those based on the use of natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitation interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Care delivery pathways:
Order of the Ministry of Health and Social Development of the Russian Federation No. 366n dated April 16, 2012, "On approval of the Procedure for providing pediatric care".
Order of the Ministry of Health and Social Development of the Russian Federation No. 521n dated May 5, 2012, "On approval of the Procedure for providing medical care to children with infectious diseases".
Criteria for assessing the quality of medical care: Order of the Ministry of Health of the Russian Federation No. 203n dated May 10, 2017, "On approval of criteria for assessing the quality of medical care".
Other documents used in the preparation of the clinical guidelines:
Order of the Ministry of Health and Social Development of the Russian Federation No. 541n dated July 23, 2010, "On approval of the Unified Qualifications Directory of Positions of Managers, Specialists, and Employees, section 'Qualifications characteristics of employee positions in the healthcare sector'".
Federal Law No. 489-FZ dated December 25, 2018, "On amendments to Article 40 of the Federal Law 'On compulsory medical insurance in the Russian Federation' and the Federal Law 'The fundamentals of protecting the health of citizens in the Russian Federation' regarding clinical guidelines".
Order of the Russian Ministry of Health No. 103n dated February 28, 2019, "On approval of the procedure and timelines for the development of clinical guidelines, their revision, the standard template of clinical guidelines, and requirements for their structure, composition, and scientific validity of the information included in the clinical guidelines."
Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017, "On Approval of the Nomenclature of Medical Services."
Order of the Russian Ministry of Health No. 1094n dated November 24, 2021, "On Approval of the Procedure for Prescribing Medicinal Products, Forms of Prescription Forms for Medicinal Products, the Procedure for Issuing These Forms, Their Accounting and Storage, Forms of Prescription Forms Containing Designations for Narcotic Drugs or Psychotropic Substances, the Procedure for Their Manufacture, Distribution, Registration, Accounting and Storage, as Well as the Rules for Issuing Prescription Forms, Including in the Form of Electronic Documents".
State Register of Medicines: https://grls.rosminzdrav.ru.
Appendix A3.1 Timing of tooth development and eruption
The timing of tooth formation, eruption, as well as root formation and resorption is individual for each child, leading to variations in the data presented by different authors. The universally accepted tooth eruption schedule is the one proposed by Kronfeld in 1955 [3].
Table. Timing of tooth development and eruption (according to Kronfeld)
Teeth | Start of mineralization | End of enamel formation | Tooth eruption | End of root formation | Start of root resorption |
|---|---|---|---|---|---|
I | from 4 months i/u | by 4 months p/n | 6-8 months | 1.5-2 years | from 4 years |
II | from 4.5 months i/u | by 5 months p/n | 8-10 months | 1.5-2 years | from 5 years |
III | from 5 months i/u | by 9 months p/n | 16-20 months | 4-5 years | from 8 years |
IV | from 5 months i/u | by 6 months p/n | 12-16 months | 2.5-3.5 years | from 6 years |
V | from 6 months i/u | by 10-12 months p/n | 20-30 months | 3-4 years | from age 7 |
i/u – intrauterine developmental period; p/n – postnatal.
Appendix A3.2. Principles of patient management with teething syndrome
Principles of patient management with teething syndrome
1. Teething syndrome in infants and young children
Nosological form: teething syndrome.
ICD-10 code: K00.7
1.1. Diagnostic procedures:
1.1.1. Collection of complaints and anamnesis (pediatrician / general practitioner (family physician) and/or pediatric dentist / dentist).
1.1.2. Physical examination (pediatrician / general practitioner (family physician) and/or pediatric dentist / dentist).
1.1.3. Instrumental oral cavity examination (performed when necessary by a pediatric dentist / dentist).
1.1.4. Regardless of the severity of difficult primary tooth eruption, a set of diagnostic measures is carried out, including basic and additional diagnostic methods to rule out acute respiratory infections and other pathologies presenting with similar symptoms.
1.2. Treatment
1.2.1. Gum massage with a special brush (gum massage can also be performed with a finger wrapped in a sterile bandage) (instructed by a pediatrician / general practitioner (family physician) and/or pediatric dentist / dentist; performed by parents/legal representatives, nursing staff).
1.2.2. Use of chilled teething rings or teethers (instructed by a pediatrician / general practitioner (family physician) and/or pediatric dentist / dentist; performed by parents/legal representatives, nursing staff).
1.2.3. Pharmacotherapy (see section 2) (prescribed by a pediatrician / general practitioner (family physician) and/or pediatric dentist / dentist; administered by parents/legal representatives, nursing staff).
1.3. Dynamic follow-up
1.3.1. In case of difficult primary tooth eruption, mandatory dynamic follow-up is required both for the area of primary tooth eruption and for the child's developing organism as a whole. It is optimal to consult a doctor 8 days after the end of the active treatment period, and subsequently as needed.
2. Cysts formed during tooth formation (in infants and young children)
Nosological form: eruption cyst.
ICD-10 code: K09.0
2.1 Diagnostic procedures:
2.1.1. Collection of complaints and anamnesis.
2.1.2. External examination of the maxillofacial region.
2.1.3. Instrumental oral cavity examination.
2.2. Treatment
When an eruption cyst forms (in cases where spontaneous drainage of the cyst contents does not occur), it is recommended to consult a dentist for evacuation of the cyst contents and relief of undesirable local manifestations of difficult primary tooth eruption [9].
2.2.1. Dissection of the cyst wall to evacuate its contents. This procedure is performed on an outpatient basis:
– using topical anesthetics in the form of an application;
– antiseptic treatment of the oral mucosa in the area of the eruption cyst;
– incision of the cyst membrane;
– removal of pathological fluid from the cyst cavity;
– treatment of the cyst cavity with a drug from the group "Antimicrobials and antiseptics for local treatment of oral diseases" (antiseptic solution);
– application of a cotton swab moistened with a drug from the group "Antimicrobials and antiseptics for local treatment of oral diseases" (antiseptic solution) [8,22].
2.3. Recommendations
1.3.1. After surgical intervention, infants and young children should be put to the mother's breast (if breastfed) or fed with formula, thereby alleviating undesirable local symptoms in children. Complementary foods are not recommended to be introduced in the first 2–3 hours after surgery.
1.3.2. Antiseptic wound care must be performed using a cotton swab moistened with a drug from the group "Antimicrobials and antiseptics for local treatment of oral diseases" (antiseptic solution) for several days after the surgical intervention.
1.3.3. During the first 7–10 days, a soft-bristled toothbrush must be used and a sparing diet must be followed.
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Primary tooth eruption is a natural process that usually does not cause serious health problems in children. Between the 6th month and the 2nd year of life, 20 primary teeth erupt. However, some children may experience certain symptoms known as teething syndrome.
Teething syndrome (TS) is a set of symptoms that may appear in infants during the period when their primary (milk) teeth begin to grow.
Signs of TS may appear 4 days before eruption and generally resolve spontaneously within 3 days after tooth emergence. The most common manifestations of TS are swelling and redness of the gums at the site of tooth eruption, excessive drooling, the child's urge to put a fist in the mouth, and to bite or chew on everything. Excessive salivation may even cause coughing due to saliva entering the upper respiratory tract, and loose stools due to increased intestinal motility and skin irritation and redness on the face. Restlessness, crankiness, sleep problems, decreased appetite, and even food refusal may also be noted. Fever is generally not characteristic of TS, but a temperature up to 38°C may occasionally occur. A temperature above 38°C requires a visit (examination, consultation) with a pediatrician to rule out infectious diseases.
A consultation with a pediatrician and/or dentist should also be prompted by: lack of improvement in the child's condition, ineffectiveness of ongoing measures or their complications, or doubts about the benign nature of the condition.
Examinations: in most cases, additional examinations are not required for a child with TS.
Treatment: TS is a benign condition that usually resolves on its own and requires no treatment.
First of all, cognitive-behavioral psychotherapy methods should be applied – hugging the child, paying attention to them, and offering games that can distract them from pain.
To reduce gum discomfort, it is recommended to massage the gums with a special brush with a flexible head and a round limiter, similar to a pacifier.
Teething rings or teethers can be used to relieve symptoms.
Treatment of cough associated with teething is usually not required; it resolves on its own immediately after tooth eruption.
Complications: tooth eruption is in the vast majority of cases uncomplicated. If examination reveals signs of abnormal tooth eruption, a dentist should be consulted to rule out dental pathology.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Appendix G1. Index assessment of the severity of local clinical manifestations of difficult primary tooth eruption
Title in Russian: Index assessment of the severity of local clinical manifestations of difficult primary tooth eruption.
Original title (if applicable): none.
Source (official developer website, publication with validation): Tsarev V.N., Kiselnikova L.P., Podporin M.S., Balafendieva F.M. Comparative evaluation of the effect of local and systemic dosage forms on the oral microbiocenosis during difficult tooth eruption. — Clinical Dentistry. — 2022; 25 (4): 44–49. DOI: 10.37988/1811-153X_2022_4_44; Massignan C., Cardoso M., Porporatti A.L. et al. Signs and symptoms of primary tooth eruption: a meta-analysis // Pediatrics. 2016. Vol. 137(3). e20153501
Type (underline):
- rating scale
- score
- questionnaire
- other (specify):_____________________________________________________
Purpose: assessment of the severity of local clinical manifestations of difficult primary tooth eruption
Content (template):
Purpose: assessment of the severity of local clinical manifestations of difficult primary tooth eruption
Content (template):
When evaluating the papillary-marginal-alveolar (PMA) index, the following criteria are used:
1 point – inflammation of the gingival papilla (P),
2 points – inflammation of the marginal gingival margin (M),
3 points – inflammation of the alveolar part of the gingiva (A).
Calculation formula: PMA = sum of points / n * 3 (in %), where n is the number of teeth.
Key (interpretation): Interpretation of the obtained values:
o < 30% – mild gum involvement,
o 31–60% – moderate degree,
o 61% and more – severe degree.
Notes: none.