Recommendations for excluding other underlying conditions and when to seek medical advice

• Conditions other than teething should be excluded in infants who are systemically unwell or in severe distress because limited evidence indicates that teething is not associated with severe or systemic symptoms, such as high fever (see Diagnosis for further information).
• Consequently, parents should be advised to seek medical advice if the infant becomes systemically unwell.

Self-care measures

• These recommendations are based on expert opinion in narrative reviews and advice from the Medicines and Healthcare products Regulatory Agency [Grundy and Shaw, 1983; Ashley, 2001; Jones, 2002; McIntyre and McIntyre, 2002; South, 2003; Anderson, 2004; Nield et al, 2008; MHRA, 2009].
• There is little or no evidence about the use of any treatment (including drugs, self-care, and complementary therapies) for relieving teething symptoms.
• Given that teething is a normal physiological and self-limiting process, simple self-care measures are recommended as the risk of harms to the infant is minimal [Jones, 2002; Wilson and Mason, 2002].
• Gentle massage to the gum or biting on objects (such as teething rings) is thought to produce relief by producing counter-pressure against the gums [Jones, 2002].
• Cold objects are preferred for biting on, as the cold can help to ease symptoms by producing an anaesthetic effect on the gum [Jones, 2002; Anderson, 2004].

Paracetamol or ibuprofen for pain

• CKS identified no studies examining the use of these analgesics for relieving the discomfort associated with teething. However, their use is widely recommended by experts [Grundy and Shaw, 1983; Ashley, 2001; Jones, 2002; Wilson and Mason, 2002; Anderson, 2004; Nield et al, 2008].
• Both paracetamol (120 mg/5 mL) and ibuprofen (100 mg/5 mL) suspensions are licensed for the relief of teething symptoms in infants 3 months of age or older.

Choline salicylate gel

• Although widely used in the past, the evidence to support the use of choline salicylate gel (a topical analgesic) for teething is of poor quality.
• The recommendation to avoid the use of choline salicylate gel in children younger than 16 years of age is in line with recent guidance issued by the Medicines and Healthcare products Regulatory Agency and Commission on Human Medicines due to risk of Reye's syndrome in this group [MHRA, 2009]. For further information, see Evidence on the adverse effects of topical analgesics.
• Bonjela^® teething gel no longer contains choline salicylate. It has been reformulated with lidocaine (a local anaesthetic).

Topical anaesthetic preparations

• CKS does not recommend the use of topical anaesthetic preparations (generally containing lidocaine) as:
• The evidence supporting their efficacy for relieving the discomfort associated with teething is of poor quality.
• Case reports provide evidence suggesting serious adverse effects (such as seizures) with excessive use of topical anaesthetic preparations.
• Their use is discouraged by some experts [Ashley, 2001; Anderson, 2004].
• The effectiveness of local anaesthetic teething gels has been questioned — given that the gel is rapidly removed from site of discomfort by the tongue and saliva [Ashley, 2001].

Complementary therapies

• CKS does not recommended complementary therapies as there is no evidence to support their use (such as the herbal product, Ashton and Parson^® teething powder).