The trouble with teething--misdiagnosis and misuse of a topical medicament

Teething - filling in the gaps…

Dentists and dental care professionals may be faced with concerns from parents and carers regarding teething in infants and young children. Teething is a normal physiological and self-limiting process; however, the diverse signs and symptoms that have, over time, been attributed to teething, can make diagnosis challenging. Appropriate diagnosis is crucial in preventing the potentially life-threatening sequalae of dismissing symptoms as teething and delaying appropriate treatment of a systemically unwell child. Management of teething can be approached in a five-step process based on the National Institute for Health and Care Excellence clinical knowledge summary on teething. These include: 1) history-taking, clinical examination, diagnosis and referral of systemically unwell or severely distressed children for urgent medical review; 2) providing parental/carer reassurance, information and preventative advice; 3) simple, non-pharmacological management strategies; 4) pharmacological intervention; 5) safety-netting advice in case the child becomes systemically unwell, has prolonged symptoms, or is in severe distress. The purpose of this article is to bridge knowledge gaps regarding teething to enable appropriate diagnosis and encourage dissemination of preliminary information and ensure appropriate referral by frontline dental professionals.

A questionnaire-based study of Paediatric Dentists' knowledge of teething signs, symptoms and management

INTRODUCTION

Signs and symptoms attributed to erupting primary teeth are commonly known as "teething". Its existence is controversial with concern that overusing this term might mask other illnesses and some treatments may be unnecessary or harmful. Parents/carers can access over-the-counter remedies and may seek professional advice. This survey-based investigation explored gaps in knowledge, training, perceptions and experiences of UK Paediatric Dentists (PDs) regarding teething in young children.

METHOD

Cross-sectional study with a convenience sample of PDs with different training levels, accessed through the British Society for Paediatric Dentistry membership lists. A 10-item questionnaire explored participants' knowledge of teething-related issues and management. Responses are presented using descriptive statistics.

RESULTS

Of 80 responding PDs (response rate 27%), 62-74% suggested drooling, irritability, oral fixation and flushed cheeks were attributed to primary tooth eruption. Fifty-eight (72%) participants were unaware of guidelines, yet 53 (66%) felt guidance was needed.

CONCLUSION

Signs and symptoms of teething might mask underlying conditions so it should be a diagnosis of exclusion. PDs attributed similar signs and symptoms to teething, as have been reported in the literature, although some commented that they did not think teething was a condition. There was a lack of awareness over guidelines.

Choline Salicylate Analysis: Chemical Stability and Degradation Product Identification

Choline salicylate (CS) as a derivative of acetylsalicylic acid is commonly used in different drug forms. In medicine, it is applied topically to inflammation of the oral cavity mucosa and in laryngology. However, this substance in the form of an ionic liquid has not been investigated enough. There are no literature studies on stability tests constituting a stage of pre-formulation research. HPLC (Nucleosil C18, 4.6 × 150 mm, 5 μm; methanol-water-acetic acid 60:40:1, 230 nm or 270 nm) and UV (276 nm) methods for the determination of CS in 2% (g/mL) aqueous solutions were developed. Under stress conditions, CS susceptibility to hydrolytic degradation in aqueous medium, hydrochloric acid, sodium hydroxide, and hydrogen peroxide, and the effect of light on the stability of CS solutions were studied with HPLC analysis. The degradation degree of CS and the purity of the solutions were also tested. Choline salicylate has been qualified as practically stable in neutral and acid media, stable in an alkaline medium, very stable in an oxidizing environment, and photolabile in solution. The HPLC-MS/MS method was used to identify 2,3- and 2,5-dihydroxybenzoic acids as degradation products of CS under the tested conditions.

Mothers' teething beliefs and treatment practices in Mansoura, Egypt

Objectives

To reveal mothers’ beliefs about signs and symptoms associated with teething and their treatment practices.

Population and methods

A cross-sectional study done in Mansoura District on 457 mothers and their children with one or more erupted teeth. Mothers were interviewed during vaccination session at 25 chosen health facilities. Mothers were asked whether they agree or disagree about 24 signs and symptoms claimed to be associated with teething.

Results

Only 1.8% reported no symptoms at the time of teething. Majority had correct knowledge related to bite fingers/objects (70.5%) and drooling (60.0%). Inaccurate knowledge was reported as gum rubbing (42.0%), gum swelling (47.0%), diarrhea (51.0%), fever (83.2%) and weight loss (46.0%). Only 16.8% of mothers have good knowledge about teething problems. Logistic regression analysis revealed that the independent predictors of good knowledge are higher education (AOR = 3.7), urban residence (AOR = 2.5) and having a first-born child (AOR = 5.5). Only 13.4% of mothers did not give any treatment for teething problems. Antipyretics and antibiotics were the most frequently given treatments (71.3%, and 24.3%; respectively).

Conclusions

The majorities of mothers had low knowledge about teething problems and gave unnecessary treatments.

Parental knowledge and practices on infant teething, Taif, Saudi Arabia

Background

Parents’ false beliefs about signs and symptoms associated with teething have been documented in many studies around the world. This study was conducted to assess parental knowledge on infant teething process and to investigate parents’ practices used to alleviate teething disturbances.

Methods

A cross-sectional survey was conducted among parents of children of 6 months–5 years old in Taif, Saudi Arabia during April 2013. Convenience method of sampling was adopted and the data was collected by mean of a structured-questionnaire. Data was processed by SPPS. Logistic regression analysis was performed. P value <0.05 was considered statistically significant.

Results

Overall, of 493 participants were included in the final analysis with mean age 35 years. Females constituted more than two-third. All the parents attributed one or more of the listed signs and symptoms to teething process. Desire to bite, fever, gum irritation, increased salivation and diarrhea were the most reported signs and symptoms of teething by 459 (93.1 %), 429 (87 %), 415 (84.2 %), 414 (84 %) and 409 (83 %) of the parents respectively. The only predictor of ascribing fever as a sign of infant teething was female gender (P = 0.001). However, female gender (P < 0.001), residence (P = 0.039) and educational level (P = 0.006) were found to be significantly associated with ascribing diarrhea as one of the teething symptoms. Only 91 (18.5 %) of the parents responded correctly to all questions designed to assess their knowledge on teething process.

Conclusions

Wide gaps in parents’ knowledge and practices related infant teething was identified. Educational interventions are needed to upgrade parents’ knowledge and improve their practices regarding infant teething process.

Signs and symptoms associated with primary tooth eruption: a clinical trial of nonpharmacological remedies

Background

To evaluate disturbances in primary tooth eruption and their management with nonpharmacological remedies.

Methods

In this nonrandomized clinical trial, 270 children aged between 8 and 36 months were selected and divided into 5 groups with 54 children initially enrolled in each group. The children were seen during an 8-day period during tooth eruption. At each appointment data were recorded from oral examination, tympanic temperature measurement and a questionnaire. The five methods used as remedies to reduce teething symptoms were: 1) cuddle therapy, 2) ice, 3) rubbing the gums, 4) teething rings and 5) food for chewing. Teething symptoms, the type of erupted tooth, symptoms of recovery and the mother’s satisfaction with treatment were evaluated.

Results

Two hundred and fifty four children (mean age 16 ± 7.2 months) completed the study. The most frequent teething symptoms were drooling (92 %), sleep disturbances (82.3 %) and irritability (75.6 %). These symptoms were more pronounced in low birth weight children (p > 0.05). Canine eruption led to more loss of appetite than incisor (p = 0.033) or molars eruption (p = 0.014). Low grade increases in body temperature were observed only on the day of eruption (36.70 ± 0.39 °C), when body temperature was significantly different compared to the day before and the day after eruption (both p < 0.001). There was no significant correlation between fever as reported by mothers and temperature readings obtained by the investigators. The most favorable results for time to recovery and the mother’s satisfaction were seen when teething rings were used, followed by cuddle therapy and rubbing the gums.

Conclusions

There was no association between teething and symptoms such as fever or diarrhea. Low birth weight children may have more teething symptoms. Teething rings, cuddle therapy and rubbing the gums were the most effective methods to reduce symptoms.

Trial registration

Iranian Registry of Clinical Trials: code IRCT201211127402N3

Are one or two dangerous? Methyl salicylate exposure in toddlers

Serious toxicity can result from exposure to small amounts of methyl salicylate. Methyl salicylate is widely available as a component in many over-the-counter brands of creams, ointments, lotions, liniments and medicated oils intended for topical application to relieve musculoskeletal aches and pains. Among the most potent forms of methyl salicylate is oil of wintergreen (98% methyl salicylate). Other products with varying concentrations of methyl salicylate are ubiquitous throughout many parts of the world, including a number of products marketed as Asian herbal remedies. The toxic potential of all of these formulations is often underestimated by health care providers and the general public. A comprehensive review of the existing medical literature on methyl salicylate poisoning was performed, and data compiled over the past two decades by the American Association of Poison Control Centers (AAPCC) was examined. Methyl salicylate continues to be a relatively common source of pediatric exposures. Persistent reports of life-threatening and fatal toxicity were found. In children less than 6 years of age, a teaspoon (5 mL) or less of oil of wintergreen has been implicated in several well-documented deaths. More needs to be done to educate both health care providers and the general public regarding the dangers of these widely available formulations.