• Consider teething as a cause of discomfort only if other causes have been excluded (see Differential diagnosis).
• A wide variety of symptoms and signs are attributed to teething (sometimes incorrectly) and are common to a range of conditions and physiological changes (for example, salivary glands begin to function at 2–3 months of age and contribute to constant drooling).
• Limited evidence suggests that symptoms of teething tend to be mild and localized.
• Teething does not cause children to become systemically unwell.
• Symptoms associated with teething:
• Include increased biting, drooling, gum-rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite, disturbed sleep, and (possibly) mild temperature elevation (less than 38°C).
• Generally start 3–5 days before each tooth eruption.
• Check the mouth for signs of tooth eruption.
• The gums swell and are tender to palpation just before tooth eruption.

These recommendations are based on limited evidence and are in line with information provided by published narrative reviews [Peleg and Shvartzman, 1999; Ashley, 2001; Jones, 2002; McIntyre and McIntyre, 2002; Anderson, 2004; Tighe and Roe, 2007; Nield et al, 2008].

• Given that the gums swell and are tender to palpation just before tooth eruption, it is acknowledged that teething causes some discomfort to the infant.
• However, there is limited evidence from a number of studies which indicates that:
• There are no specific signs and symptoms associated with teething.
• Mild symptoms are common, and teething is not associated with severe symptoms.
• For further information, see Teething symptoms.

• Common conditions that should be excluded in infants with teething symptoms include:
• Infection — such as acute otitis media, croup, oral candidiasis, respiratory or urinary tract infections, meningitis, and primary herpetic gingivostomatitis.
• For more information, see the CKS topics on Candida - oral, Cough - acute with chest signs in children, Croup, Herpes simplex - oral, Otitis media - acute, Urinary tract infection - children.
• Gastrointestinal — such as gastroenteritis, infantile colic, and gastro-oesophageal reflux disease.
• For more information, see the CKS topics on Colic - infantile and Gastroenteritis.
• Dermatological — such as atopic eczema and nappy rash.
• For more information, see the CKS topics on Eczema - atopic and Nappy rash.