signs and symptoms of primary tooth eruption: a meta-analysis · eruption of primary teeth; and (6)...

REVIEW ARTICLEPEDIATRICS Volume 137 , number 3 , March 2016 :e 20153501

Signs and Symptoms of Primary Tooth Eruption: A Meta-analysisCarla Massignan, DDS,a Mariane Cardoso, DDS, MsC, PhD,a André Luís Porporatti, DDS,b Secil Aydinoz, MD,c Graziela De Luca Canto, DDS, MsC, PhD,a,d,e Luis Andre Mendonça Mezzomo, DDS, MsC, PhD,a,d Michele Bolan, DDS, MsC, PhDa

abstractCONTEXT: Symptoms associated with the primary tooth eruption have been extensively studied

but it is still controversial.

OBJECTIVE: To assess the occurrence of local and systemic signs and symptoms during primary

tooth eruption.

DATA SOURCES: Latin American and Caribbean Health Sciences, PubMed, ProQuest, Scopus, and

Web of Science were searched. A partial gray literature search was taken by using Google

Scholar and the reference lists of the included studies were scanned.

STUDY SELECTION: Observational studies assessing the association of eruption of primary teeth

with local and systemic signs and symptoms in children aged 0 to 36 months were included.

DATA EXTRACTION: Two authors independently collected the information from the selected

articles. Information was crosschecked and confirmed for its accuracy.

RESULTS: A total of 1179 articles were identified, and after a 2-phase selection, 16 studies

were included. Overall prevalence of signs and symptoms occurring during primary tooth

eruption in children between 0 and 36 months was 70.5% (total sample = 3506). Gingival

irritation (86.81%), irritability (68.19%), and drooling (55.72%) were the most frequent

ones.

LIMITATIONS: Different general symptoms were considered among studies. Some studies

presented lack of confounding factors, no clear definition of the diagnostics methods, use of

subjective measures and long intervals between examinations.

CONCLUSIONS: There is evidence of the occurrence of signs and symptoms during primary tooth

eruption. For body temperature analyses, eruption could lead to a rise in temperature, but it

was not characterized as fever.

aDepartment of Dentistry, and dBrazilian Centre for Evidence-based Research, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil; bBauru School of Dentistry, Bauru,

São Paulo, Brazil; cGulhane Military Medical Academy, Istanbul, Turkey; and eDepartment of Dentistry, University of Alberta, Edmonton, Canada

Dr Massignan worked on study conceptualization, design, data collection, data analysis, drafted the initial manuscript, and critically reviewed manuscript; Drs

Cardoso and Porporatti worked on data analysis, and reviewed and revised the manuscript; Dr Aydinoz worked on data analysis and critically reviewed the

manuscript; Drs De Luca Canto and Mezzomo worked on study conceptualization, design, data analysis, and critically reviewed manuscript; Dr Bolan worked on study

conceptualization, design, data collection, data analysis, and critically reviewed manuscript; and all authors approved the fi nal manuscript as submitted and agree

to be accountable for all aspects of the work.

DOI: 10.1542/peds.2015-3501

Accepted for publication Nov 23, 2015

Address correspondence to Michele Bolan, DDS, PhD, Departamento de Odontologia, Universidade Federal de Santa Catarina, UFSC, Campus Universitário, CCS-ODT-

Trindade Florianópolis, Santa Catarina, Brasil 88040–900. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

To cite: Massignan C, Cardoso M, Porporatti AL, et al. Signs and Symptoms of Primary Tooth Eruption: A Meta-analysis. Pediatrics. 2016;137(3):e20153501

by guest on April 27, 2020www.aappublications.org/newsDownloaded from

MASSIGNAN et al

Tooth eruption is a physiologic

process in which teeth move

from their development position

within the alveolar bone to break

the gum toward the oral cavity.1

Nevertheless, this mechanism and

the source of the eruptive force has

not been established nor completely

understood.2

Despite being a natural process

of child development, the impacts

of primary tooth eruption on the

overall health of children are still

controversial. Recent studies have

suggested that tooth eruption

could be accompanied by different

benign symptoms, such as increased

salivation, irritability, loss of appetite

for solid foods, and rise in body

temperature.3–11

Moreover, the eruption of

primary teeth has been assumed

among parents to be associated

with behavioral and systemic

changes.12–17 The period of time

that tooth eruption occurs can be

very frustrating and stressful for

parents, especially when it happens

to their first offspring. Many parents

do not know how to identify the

signs of tooth eruption in their

children and, therefore, do not feel

confident to relieve the discomfort

of the child.18,19 Likewise, many

health professionals also believe

that there is an association between

some signs and symptoms and the

eruption of primary teeth. Surveys

with pediatricians and other child

health professionals showed that

these beliefs are common.3,20,21

The use of this diagnostic label may

lead to either parents not managing

a likely illness10 or the doctors to

ignore significant symptoms and fail

in diagnoses.22

Nevertheless, consistent evidence

on the association of tooth eruption

and general signs and symptoms

are rather low and out of date. In a

review conducted by Tighe et al23

in 2007 to identify the existence

of any pathognomonic sign and

symptom of dental eruption, a

variety of symptoms that may occur

simultaneously with the tooth

eruption was demonstrated and no

evidence suggested the existence of

any signs or symptoms that could

predict the tooth eruption.

Thus, the purpose of this systematic

review was to answer the following

focused question: “In children aged

0 up to 36 months, are there local or

systemic signs and symptoms during

the eruption of the primary teeth?”

METHODS

This systematic review was oriented

following the Preferred Reporting

Items for Systematic Reviews and

Meta-Analyses protocol.24

Protocol Registration

The systematic review protocol

was recorded at the International

Prospective Register of Systematic

Reviews25 under number CRD

42015020822.

Eligibility Criteria

Inclusion Criteria

Observational studies assessing the

occurrence of local and systemic

signs and symptoms during the

spontaneous eruption of primary

teeth in healthy children aged

between 0 and 36 months, by means

of either clinical examination or a

questionnaire directed to the parents

or health care professionals, were

included. The local and systemic

signs and symptoms evaluated were

all reported complications related

to teething described in the studies

(eg, decreased appetite, diarrhea,

drooling, fever, inflammation,

swelling, vesicles or ulceration of the

gum, irritability, rash, rhinorrhea,

sleeping disturbances, vomiting).

Exclusion Criteria

Exclusion of the studies was

performed in 2 phases. In phase 1

(titles and abstracts), the exclusion

criteria were as follows: (1) studies

conducted in children aged >36

months old; (2) reviews, letters,

conference abstracts; (3) studies in

which the sample included patients

with genetic syndromes (eg, Down

syndrome, craniofacial anomalies,

neuromuscular disorders); (4)

studies in which the sample included

malignancies, malnutrition, and

chronic diseases; (5) studies in which

the sample included nonspontaneous

eruption of primary teeth; and (6)

studies in which the eruption of

primary teeth was not the primary

outcome. Besides the 6 cited criteria,

in phase 2 (full-test) the following

exclusion criteria were added: (7)

studies in which clinical examination

was not performed by a health care

professional, and (8) articles that

evaluated the same sample.

Information Sources and Search Strategies

A systematic search was conducted

on the following electronic databases:

Latin American and Caribbean Health

Sciences (LILACS), PubMed, ProQuest

Dissertations and Theses Database,

Scopus, and Web of Science, for

titles and abstracts relevant to the

research question. The syntax has

been adapted to each database

(Supplemental Appendix 1). A partial

gray literature search was taken

using Google Scholar limited to

the first 100 most relevant articles

published in the past 5 years. The

reference lists of the included articles

were scanned to identify additional

studies of relevance. All references

were managed by reference manager

software EndNote Basic (Thomson

Reuters, New York, NY) and duplicate

hits were removed. The end search

date was May 6, 2015. No language or

date restrictions were applied.

Study Selection

The selection occurred in a 2-phase

process to minimize bias. In phase 1,

studies were independently screened

by 2 reviewers (CM, MB) based

on the titles and, if available, the

abstracts derived from the search.

Any study that clearly did not fulfill

2 by guest on April 27, 2020www.aappublications.org/newsDownloaded from

PEDIATRICS Volume 137 , number 3 , March 2016

the inclusion criteria was discarded.

In phase 2, the full text of relevant

papers was retrieved for further

analysis by the same 2 reviewers

(CM, MB) and was either included or

excluded for review on the basis of

the eligibility criteria. Disagreements

of inclusion/exclusion were handled

through discussion, and the third

reviewer (MC) was consulted to

make a final decision.

Data Collection Process

Two authors (CM, MB) independently

collected the required information

from the selected articles. After that,

all the collected information was

crosschecked and confirmed for its

accuracy. Again, any disagreement

was resolved by discussion and

mutual agreement between the

authors. The third author (MC) was

involved, when required, to make a

final decision.

Data Items

For all of the included studies, the

following structured information

was recorded: study characteristics

(authors, year of publication, country,

study design, setting), population

characteristics (sample size, age

of participants), intervention

characteristics (type of diagnostic

approach: clinical examination,

body temperature, questionnaire)

and, finally, outcome characteristics

(assessed teeth, symptoms, mean

temperature in noneruption days,

mean temperature in eruption

days, and conclusions pertaining

to the occurrence of local and

systemic signs and symptoms during

the eruption of primary teeth).

Authors were contacted for further

details when relevant information

was not reported or there was

doubt remaining about duplicate

publication.

Risk of Bias in Individual Studies

Two reviewers (CM, MB)

independently assessed the

methodological quality of the

included studies, using the “Quality

in Prognosis Studies Tool” (QUIPS).26

The QUIPS tool comprises 6 domains:

study participation, study attrition,

prognostic factors measurement,

outcome measurement, study

confounding and statistical analysis

and reporting to guide ratings of

high, moderate, or low risk of bias.

Disagreements were resolved

through consensus when possible, or

a third reviewer (MC) made the final

decision.

Summary Measures

Presence of local and systemic signs

and symptoms and differences

in body temperature during the

eruption of primary teeth were

considered the main outcomes. For

body temperature, the threshold

point was considered according to a

recent meta-analysis on accuracy of

infrared tympanic thermometry,27

between 37.4°C and 37.8°C for

tympanic temperature and 38.0°C

for rectal temperature. Any type of

related outcome measurement was

computed (categorical variables and

continuous variables).

Synthesis of Results

A meta-analysis was planned within

the studies presenting enough

data. The occurrence of signs and

symptoms of the eruption of primary

teeth was analyzed by 2 types of

meta-analysis, for fixed and random

effects following the appropriate

Cochrane Guidelines.28 Meta-

analysis was performed with the

aid of MedCalc Statistical Software

version 14.8.1 (MedCalc Software,

Ostend, Belgium). Heterogeneity

was calculated by inconsistency

indexes (I2), and a value >50% was

considered an indicator of substantial

heterogeneity between studies.29 The

significance level was set at 5%.

Risk of Bias Across Studies

Clinical heterogeneity (differences

in participants, interventions, and

outcomes) and methodological

heterogeneity (study design, risk of

bias) were explored.

RESULTS

Study Selection

The search identified 1318 citations

across 5 databases. After duplicates

removal, 1179 articles were screened

in phase 1. A total of 65 articles

met criteria for full-text screening.

Additionally, 100 citations from

Google Scholar were considered.

From these, 4 further studies

met the inclusion criteria. A hand

search on the reference lists was

performed for any study that might

have been inadvertently missed by

the electronic search procedures

and 6 additional references were

identified. Based on exclusion criteria

for phase 2 (full-text screening), 59

articles were excluded. Two articles

evaluated the same sample and 1 was

not found. The reasons for exclusion

are compiled in a comprehensive

list (Supplemental Appendix 2).

Therefore, 16 articles were selected

for data collection with the aim of

answering the review question.

A flowchart of the process of

identification and selection of studies

is shown in Fig 1.

Study Characteristics

Research was conducted in 8

different countries: Australia,10,30

Brazil,31–33 Colombia,34 Finland,35

India,36–38 Israel,11,39,40 Senegal,41

and United States.42,43 The sample

size ranged widely from 1640 to

116532 children. The search involved

papers published between 196935,39

and 2012.38 A summary of the study

descriptive characteristics can be

found in Table 1.

Risk of Bias Within Studies

The reported methodological

quality of the included studies

ranged between low and high risk

of bias following QUIPS26 domains.

Studies selected have shown to be

heterogeneous considering bias, 7


MASSIGNAN et al

presented high11,31,32, 36,37,41,43 risk

of bias, 4 moderate,34,38,39,42 and 5

low.10,30,33,35,40 None of them fulfill

all the methodological criteria.

Summarized assessment considering

risk of bias can be found in Table 2.

Detailed results on the use of QUIPS26

tool in selected studies can be found

in Supplemental Appendix 3.

Results of Individual Studies

There were 2 studies that

investigated exclusively local

modifications.30,36 Other studies

evaluated, besides general problems,

local disturbances that could

be involved on primary tooth

eruption.32,35,37,41 Hulland et al30

observed that 85% of 128 teeth

in 21 children presented gingival

hyperemia in the early stages

of eruption. Chakraborty et al36

reported that anterior teeth erupted

with fewer local signs than posterior.

King et al43 suggested that local signs

could be confound with oral herpetic

infection.

Shapira et al40 observed an increase

in inflammatory cytokine levels in the

gingival crevicular fluid surrounding

erupting teeth, whereas Galili et

al39 found that multiple eruptions

occurring at the same time were

associated with diseases. Bengtson et

al,31 Carpenter,42 Cunha et al,32 and

Yam et al41 observed that eruption

of primary teeth was associated

with symptoms. Kiran et al,37

Noor-Mohammed and Basha,38 and

Peretz et al34 found more symptoms

associated with the eruption of

the incisors. Tasanen35 evaluated

that mild symptoms like sucking

fingers, rubbing gums, and drooling

increased during teething, whereas

Wake et al10 reported that primary

tooth eruption was not associated

with symptoms. Jaber et al11 found

that tooth eruption in children was

associated with fever and Ramos-

Jorge et al33 found that there was a

slight rise in body temperature.

The frequency of body temperature

measurement varied between

studies. In some of them

daily registration could be

assessed,11,31,33,35,39 whereas in

others every week day,10 twice

a week,40 or monthly.42 From

the studies in which type of

thermometer and measurement

were informed, 4 studies used

rectal temperature11,35,39,42 and

2 tympanic.10,33 In studies that

presented these data, the cutoff

point to consider a child with high

temperature ranged from 37.5°C

over a period of 2 days (rectal)39

to 39°C in a single assessment (not

informed).34 A summary of body

temperature assessment can be

found in Table 3.

In relation to individual signs and

symptoms, some investigations

demonstrated that fever,11,31,32, 34,37–42 drooling,31,33–35,37 ,38,42 diarrhea,31–34,37, 38,41,42

irritability,31–33,37,40,42 loss of

appetite,31,33,35,37,42 sleeping

problems,31–33,35,37 and

rhinorrhea31–33,37,42 were associated

with primary teeth eruption. In the

opposite site, other studies exposed

that the same symptoms (fever,10,35

irritability,10 sleep disturbances,10,39

and loose stools10,39) had no

association with the eruption.

Synthesis of Results

To easily interpret the results, the

studies were clustered into overall

4

FIGURE 1Flow diagram of literature search and selection criteria. Adapted from Preferred Reporting Items for Systematic Reviews and Meta-Analyses.


PEDIATRICS Volume 137 , number 3 , March 2016 5

TABL

E 1

Su

mm

ary

of D

escr

ipti

ve C

har

acte

rist

ics

of In

clu

ded

Art

icle

s (n

= 1

6)

Stu

dy

Pop

ula

tion

Inte

rven

tion

Ou

tcom

e

Auth

or, Y

ear,

Cou

ntr

ya

Stud

y

Des

ign

Set

tin

gTo

tal n

Age,

Mea

n

or R

ange

,

mo

Clin

ical

Asse

ssm

ent

Bod

y Te

mp

erat

ure

°C (

Wh

o/H

ow)

Qu

esti

onn

aire

Asse

ssed

Tee

thS

ymp

tom

sFo

llow

-Up

Per

iod

MTN

ED/

MTE

D

(°C

)

Mai

n C

oncl

usi

on

Ben

gtso

n et

al

1988

Bra

zil31

PS

Inst

itu

tion

aliz

ed

child

ren

livi

ng

in a

sh

elte

r

365–

11C

hild

ren

wer

e

exam

ined

for

adm

issi

on t

o

the

rese

arch

.

Exam

iner

NI.

Nur

ses/

Dai

ly. T

ype

of t

herm

omet

er,

mea

sure

men

t N

I.

Nu

rses

dai

ly

regi

ster

ed

saliv

atio

n, d

iarr

hea

,

slee

pin

g tr

oub

le,

irri

tab

ility

, ru

nn

y

nos

e, r

ash

, fev

er,

dec

reas

ed a

pp

etit

e,

vom

itin

g, s

tron

g

uri

ne,

itch

ing

hea

rin

g, p

hys

ical

dif

fi cu

lty.

7288

.88%

had

saliv

atio

n,

87.5

0% d

iarr

hea

,

72.2

2% s

leep

ing

trou

ble

, 69.

44%

irri

tab

ility

,

68.0

5% r

un

ny

nos

e, 6

1.11

%

rash

, 58.

33%

feve

r, 5

0.00

%

dec

reas

ed

app

etit

e, 1

1.40

%

no

sym

pto

ms.

4 m

oN

I/N

IC

hild

ren

had

th

eir

teet

h e

rup

ted

wit

h s

ymp

tom

s.

Carp

ente

r

1978

, Uni

ted

Stat

es42

RS

Wel

l-in

fan

t cl

inic

of a

med

ical

un

iver

sity

hos

pit

al (

Sou

th

Car

olin

a)

120 re

cord

s

4–10

Med

ical

stu

den

t

and

a b

oard

-

cert

ifi ed

ped

iatr

icia

n.

Rec

ord

s u

sed

in t

he

stu

dy

ind

icat

ed

teet

h w

ere

eru

pti

ng

that

tim

e or

in

pre

viou

s vi

sit

one

mon

th

bef

ore.

Med

ical

stu

dent

and

a bo

ard-

cert

ifi ed

pedi

atri

cian

/

mon

thly

rec

tal

tem

pera

ture

s

<37

.77a

wer

e

not

reco

rded

as

feve

r.

NN

um

ber

of

teet

h N

I.

Infe

rior

pri

mar

y

cen

tral

inci

sors

.

39.1

6% h

ad 1

dis

turb

ance

an

d

22.5

0% h

ad ≥

2

dis

turb

ance

s

(fev

er, v

omit

ing,

dia

rrh

ea,

dro

olin

g,

irri

tab

ility

,

faci

al r

ash

an

d

rhin

orrh

ea)

con

curr

ent

wit

h t

eeth

ing;

17 p

atie

nts

had

feve

r.

NI

NI/

NI

Ther

e is

a

corr

elat

ion

bet

wee

n

teet

hin

g

pro

cess

an

d

the

occu

rren

ce

of s

yste

mic

dis

turb

ance

s.

Chak

rabo

rty

et a

l 199

4,

Indi

a36

PS

Ped

iatr

ic

dep

artm

ents

of d

iffe

ren

t

hos

pit

als

of

Cal

cutt

a an

d

ped

odon

tic

dep

artm

ent

Dr.

R. A

hm

ed

Den

tal C

olle

ge

201

6–12

Den

tist

/2-m

o

inte

rval

.

NA

Par

ents

wer

e as

ked

dir

ect

qu

esti

ons

on

the

app

oin

tmen

t

day

on

ext

ent

and

nat

ure

of

loca

l

dis

turb

ance

s

(in

fl am

mat

ion

of t

he

gum

,

non

spec

ifi c

oral

ulc

ers,

ch

eek

fl u

sh, c

hee

k ra

sh,

eru

pti

on c

yst)

,

wit

hin

2-m

o p

erio

d.

NI

80.0

8% s

uff

ered

from

at

leas

t 1

com

plic

atio

n

in r

elat

ion

to

ante

rior

tee

th

and

92.

53%

fro

m

pos

teri

or t

eeth

.

Infl

amm

atio

n o

f

the

gum

was

th

e

mos

t co

mm

on

com

plic

atio

n.

NI

NA

Eru

pti

on o

f

ante

rior

tee

th

was

ass

ocia

ted

wit

h f

ewer

com

plic

atio

ns

than

pos

teri

or

teet

h.


MASSIGNAN et al 6

Stu

dy

Pop

ula

tion

Inte

rven

tion

Ou

tcom

e

Auth

or, Y

ear,

Cou

ntr

ya

Stud

y

Des

ign

Set

tin

gTo

tal n

Age,

Mea

n

or R

ange

,

mo

Clin

ical

Asse

ssm

ent

Bod

y Te

mp

erat

ure

°C (

Wh

o/H

ow)

Qu

esti

onn

aire

Asse

ssed

Tee

thS

ymp

tom

sFo

llow

-Up

Per

iod

MTN

ED/

MTE

D

(°C

)

Mai

n C

oncl

usi

on

Cu

nh

a, e

t

al 2

004,

Bra

zil32

RS

Infa

nt

clin

ic o

f

Araç

atu

ba

Den

tal S

choo

l

1165

reco

rds

0–36

Exam

iner

NI/

2-m

o

inte

rval

s.

Par

ents

wer

e as

ked

rega

rdin

g th

e

occu

rren

ce o

f

feve

r, t

ype

of

ther

mom

eter

,

mea

sure

men

t N

I.

Par

ents

wer

e as

ked

rega

rdin

g th

e

occu

rren

ce o

f

dis

turb

ance

s

du

rin

g er

up

tion

.

Gin

giva

l irr

itat

ion

,

run

ny

nos

e,

dia

rrh

ea, f

ever

,

gen

eral

agi

tati

on,

incr

ease

d

saliv

atio

n, a

gita

ted

slee

p w

ere

anal

yzed

.

889b

95%

of

the

reco

rds

rep

orte

d

som

e ty

pe

of

man

ifes

tati

on,

85%

gin

giva

l

irri

tati

on, 7

4%

agit

atio

n, 7

0%

incr

ease

d

saliv

atio

n,

46%

fev

er,

39%

agi

tate

d

slee

p, 3

5%

dia

rrh

ea, 2

6%

run

ny

nos

e. T

he

mos

t fr

equ

ent

teet

h in

volv

ed

wer

e th

e lo

wer

cen

tral

inci

sors

52%

, max

illar

y

cen

tral

inci

sors

20%

.

Rec

ord

s fr

om

Jan

199

6

to D

ec

2001

wer

e

anal

yzed

.

NI/

NI

Ch

ildre

n s

how

ed

som

e ty

pe

of

dis

turb

ance

du

rin

g er

up

tion

of t

eeth

.

Gal

ili e

t al

1969

,

Isra

el39

PS

Inst

itu

tion

aliz

ed

child

ren

resi

den

ts

of a

Wiz

o

Bab

y H

ome,

Jeru

sale

m

435–

23 M

ean

11.0

7 (±

0.8)

Auth

or/W

eekl

y.

Eru

pti

on w

as

regi

ster

ed if

any

por

tion

of

the

occl

usa

l

surf

ace

had

pen

etra

ted

the

gin

giva

.

Nu

rses

/Dai

ly/R

ecta

l

tem

per

atu

re o

f

at le

ast

37.5

°C

over

a p

erio

d

of 2

d w

as

des

ign

ated

as

feve

r.

Nu

rses

dai

ly

regi

ster

ed s

tool

,

con

sist

ence

an

d

nu

mb

er, v

omit

ing,

sick

nes

s, d

rool

ing

and

res

tles

snes

s.

They

ref

erre

d

the

child

to

the

resi

den

t

ped

iatr

icia

n in

case

of

any

sign

of

dis

turb

ance

.

93Th

e d

iffe

ren

ce

bet

wee

n

eru

pti

ons

in p

erio

ds

wit

h f

ever

of

un

know

n o

rigi

n

and

th

ose

in

per

iod

of

hea

lth

is s

ign

ifi ca

nt.

The

asso

ciat

ion

bet

wee

n

eru

pti

on a

nd

feve

r w

ith

out

app

aren

t ca

use

is s

ign

ifi ca

nt.

Mu

ltip

le

eru

pti

ons

asso

ciat

ed w

ith

feve

r an

d il

lnes

s

was

sig

nifi

can

t.

4 m

oN

I/ N

ITh

ere

was

no

asso

ciat

ion

betw

een

toot

h

erup

tion

and

syst

emic

dist

urba

nces

.

Erup

tion

and

feve

r w

itho

ut

reco

gniz

able

caus

e w

as

asso

ciat

ed.

Mul

tipl

e

erup

tion

and

dise

ase

(res

pira

tory

and

alim

enta

ry)

was

asso

ciat

ed.

TABL

E 1

Con

tin

ued



Stu

dy

Pop

ula

tion

Inte

rven

tion

Ou

tcom

e

Auth

or, Y

ear,

Cou

ntr

ya

Stud

y

Des

ign

Set

tin

gTo

tal n

Age,

Mea

n

or R

ange

,

mo

Clin

ical

Asse

ssm

ent

Bod

y Te

mp

erat

ure

°C (

Wh

o/H

ow)

Qu

esti

onn

aire

Asse

ssed

Tee

thS

ymp

tom

sFo

llow

-Up

Per

iod

MTN

ED/

MTE

D

(°C

)

Mai

n C

oncl

usi

on

Hul

land

et

al 2

000,

Aust

ralia

30

PS

3 d

ay c

are

cen

ters

216–

24 M

ean

14.4

(±

4.9)

Den

tal h

ygie

nis

t

exam

ined

(tac

tile

an

d

visu

al)

the

alve

olar

rid

ges

to

iden

tify

red

nes

s or

swel

ling

and

stag

e of

too

th

eru

pti

on/e

very

wee

kday

, mid

-

mor

nin

g,

NA

NA

128

On

ly 1

6

obse

rvat

ion

s

of s

wel

ling.

Red

nes

s

occu

rred

in 8

5%

of t

eeth

in t

he

earl

y st

ages

of

eru

pti

on.

7 m

oN

A/ N

AD

uri

ng

eru

pti

on

mos

t of

tee

th

show

ed s

ign

s

of g

ingi

val

red

den

ing

(hyp

erem

ia)

and

sof

t ti

ssu

e

swel

ling

is

un

com

mon

.

Jab

er e

t

al 1

992,

Isra

el11

PS

Auth

or’s

pri

vate

clin

ic t

o

con

fi rm

too

th

eru

pti

on

466–

18m

othe

rs

exam

ined

gum

s da

ily.

Prof

essi

onal

confi

rm

atio

n of

toot

h er

upti

on.

Mot

her

s/D

aily

/

Rec

tal

Mot

her

s, d

aily

not

ed

if t

her

e w

as

any

dia

rrh

ea,

con

vuls

ion

s,

bro

nch

ial

sym

pto

ms,

or

any

oth

er d

isea

ses;

med

icat

ion

s

and

med

ical

exam

inat

ion

s. A

ll

dat

a re

fer

to t

he

pre

viou

s 20

d.

Num

ber

of t

eeth

NI.

Onl

y da

ta

colle

cted

up t

o th

e

erup

tion

of t

he

fi rst

too

th

(inc

isor

s)

wer

e

anal

yzed

.

Sin

ce t

he

day

th

at

toot

h e

rup

tion

was

reg

iste

red

was

ref

erre

d t

o

day

0, a

nd

all

dat

a re

fer

to

the

pre

viou

s 20

d, t

he

resu

lts

of c

omp

aris

on

of d

ays

0 to

9

and

10

to 1

9

show

ed 4

7 vs

67 d

of

otit

is

med

ia, 8

5 vs

72

d o

f d

iarr

hea

,

and

52

vs 5

8

d w

ith

cou

gh;

no

con

vuls

ion

s

occu

rred

.

NI

MTN

ED M

DT

36.9

an

d

37.1

fro

m

day

19

to

day

4. T

hre

e

day

s b

efor

e

the

toot

h

eru

pti

on

occu

rred

the

MD

T

incr

ease

d

to 3

7.14

(0.6

6) o

n

day

3, 3

7.2

(0.6

8) o

n

day

2, 3

7.4

(0.7

6) o

n

day

1.

Infa

nts

cu

t th

eir

teet

h w

ith

feve

r.

MTE

D 3

7.6

(0.8

5) o

n

the

day

the

toot

h

eru

pte

d

(95%

CI

37.3

3–

37.8

6).

TABL

E 1

Con

tin

ued


MASSIGNAN et al 8

Stu

dy

Pop

ula

tion

Inte

rven

tion

Ou

tcom

e

Auth

or, Y

ear,

Cou

ntr

ya

Stud

y

Des

ign

Set

tin

gTo

tal n

Age,

Mea

n

or R

ange

,

mo

Clin

ical

Asse

ssm

ent

Bod

y Te

mp

erat

ure

°C (

Wh

o/H

ow)

Qu

esti

onn

aire

Asse

ssed

Tee

thS

ymp

tom

sFo

llow

-Up

Per

iod

MTN

ED/

MTE

D

(°C

)

Mai

n C

oncl

usi

on

Kin

g et

al 1

999,

Un

ited

Sta

tes43

CS

SG

pat

ien

t at

a

den

tal s

choo

l

ped

iatr

ic

den

tist

ry c

linic

,

a co

mm

un

ity

hos

pit

al, a

nd

the

pri

vate

offi

ces

of

a p

edia

tric

den

tist

an

d a

ped

iatr

icia

n;

CG

sel

ecte

d b

y

age-

mat

chin

g

to S

G, a

t lo

cal

chu

rch

’s in

fan

t

care

fac

ility

40 T

otal

20 S

G

dist

ress

from

toot

h

erup

tion

20 C

G

no

dist

ress

7–30

Res

pons

ible

pers

onne

l

at e

ach

loca

tion

mad

e

exam

inat

ion

and

vira

l

sam

plin

g

prot

ocol

for

HVS

, for

SG

and

one

of t

he

auth

ors

for

CG s

ubje

cts.

Sam

ples

for

vira

l cul

ture

wer

e ob

tain

ed

from

sub

ject

’s

ging

iva

in b

oth

grou

ps.

Exam

iner

NI/

Type

of t

herm

omet

er,

mea

sure

men

t

and

freq

uenc

y

NI.

Whe

n

tem

pera

ture

s

wer

e ob

tain

ed

by o

ther

tha

n th

e

oral

met

hod

(ski

n

tape

, rec

tal)

, the

y

wer

e ad

just

ed

to o

ral v

alue

s

for

com

pari

son

purp

oses

.

N, o

nly

th

at

info

rmat

ion

obta

ined

on

eac

h

sub

ject

was

reco

rded

on

a

pre

par

ed f

orm

and

incl

ud

ed

nam

e, a

ge, g

end

er,

tem

per

atu

re, a

nd

oral

fi n

din

gs.

NI

SG P

osit

ive

cult

ures

for

HVS

in 9

infa

nts,

the

y

pres

ente

d

infl

amm

atio

n,

swel

ling,

ves

icle

s,

ulce

rati

on)

limit

ed t

o ar

ea

adja

cent

/ be

yond

to e

rupt

ing

toot

h

(tee

th).

CG

all

nega

tive

for

HVS

and

norm

al o

ral

fi ndi

ngs

NA,

Sin

gle

clin

ical

asse

ssm

ent

MTN

ED N

ACh

ildre

n ha

d

elev

ated

tem

pera

ture

that

cou

ld n

ot

be e

xpla

ined

by

othe

r di

seas

es

duri

ng t

eeth

ing

peri

od.

MTE

D S

G 7

from

9 po

sitiv

e

for

HVS

had

tem

pera

ture

>37

.77a f

rom

11 n

egat

ive

5 pr

esen

ted

elev

ated

tem

pera

ture

CG a

ll

nega

tive

for

HVS

nor

mal

tem

pera

ture

.

Kira

n e

t al

2011

, In

dia

37

PS

Dep

artm

ent

of

Ped

iatr

ic a

nd

Pre

ven

tive

Den

tist

ry,

Inst

itu

te

of D

enta

l

Sci

ence

s, a

nd

the

Dep

artm

ent

of P

edia

tric

s,

Roh

ilkh

and

Med

ical

Col

lege

894

6–36

Exam

iner

NI/

3-m

onth

inte

rval

s.

Eru

pti

on w

as

defi

ned

as

visi

ble

clin

ical

crow

n o

f th

e

toot

h, b

ut

not

exce

edin

g

3 m

m o

f

exp

osu

re in

the

oral

cav

ity.

Nu

rse/

Afte

r d

enta

l

exam

inat

ion

.

Typ

e of

ther

mom

eter

,

mea

sure

men

t N

I.

Pare

nts

wer

e

aske

d ab

out

the

occu

rren

ce o

f

loca

l and

sys

tem

ic

dist

urba

nces

.

Anal

ysis

of t

he

reco

rds

show

ed

the

pres

ence

of t

he

follo

win

g sy

mpt

oms:

ging

ival

irri

tati

ons;

diar

rhea

; fev

er;

loss

of a

ppet

ite;

irri

tabi

lity;

incr

ease

d

saliv

atio

n; r

unni

ng

nose

; agi

tate

d sl

eep;

feve

r w

ith

diar

rhea

;

feve

r w

ith

incr

ease

d

saliv

atio

n; d

iarr

hea

wit

h in

crea

sed

saliv

atio

n; fe

ver

wit

h di

arrh

ea a

nd

incr

ease

d sa

livat

ion.

Nu

mb

er o

f

teet

h N

I.

Inci

sors

,

can

ines

, an

d

mol

ars.

95.7

% r

epor

ted

som

e ty

pe o

f

man

ifest

atio

ns,

ging

ival

irri

tatio

n

was

obs

erve

d in

95.9

%, i

rrita

bilit

y

in 9

2.1%

, fev

er

in 7

8.0%

. In

the

cont

rol g

roup

92.1

% o

f inf

ants

did

not m

anife

st

any

sym

ptom

.

11 m

oN

I/N

ILo

cal a

nd s

yste

mic

man

ifest

atio

ns

wer

e m

ore

pron

ounc

ed

duri

ng e

rupt

ion

of p

rim

ary

inci

sors

.

Ther

e w

as

asso

ciat

ion

bet

wee

n

pri

mar

y to

oth

eru

pti

on a

nd

inci

den

ce o

f

sign

s an

d

sym

pto

ms.

TABL

E 1

Con

tin

ued



Stu

dy

Pop

ula

tion

Inte

rven

tion

Ou

tcom

e

Auth

or, Y

ear,

Cou

ntr

ya

Stud

y

Des

ign

Set

tin

gTo

tal n

Age,

Mea

n

or R

ange

,

mo

Clin

ical

Asse

ssm

ent

Bod

y Te

mp

erat

ure

°C (

Wh

o/H

ow)

Qu

esti

onn

aire

Asse

ssed

Tee

thS

ymp

tom

sFo

llow

-Up

Per

iod

MTN

ED/

MTE

D

(°C

)

Mai

n C

oncl

usi

on

Noo

r- Moh

amm

ed

and

Bas

ha

2012

, In

dia

38

CS

Ch

ild h

ealt

h

inst

itu

te a

nd

rese

arch

cen

ter

1100

4–36

On

e of

th

e

auth

ors.

Eru

pti

on w

as

det

erm

ined

if t

he

clin

ical

crow

n o

f th

e

toot

h w

as

visi

ble

, bu

t

not

exc

eed

ing

3-m

m

exp

osu

re

abov

e th

e

gin

giva

.

Mot

her

s co

mp

lete

a

shor

t an

d s

imp

le

qu

esti

onn

aire

in

a ye

s/n

o m

ann

er

incl

ud

ing

feve

r.

Pare

nts

com

plet

ed a

ques

tion

nair

e in

a ye

s/no

man

ner

abou

t 3

obje

ctiv

e

man

ifes

tati

ons

note

d du

ring

the

erup

tion

of

the

prim

ary

teet

h

incl

udin

g dr

oolin

g,

diar

rhea

, fev

er, a

nd

the

com

bina

tion

of

thes

e sy

mpt

oms.

Nu

mb

er o

f

teet

h N

I.

The

mos

t fr

eque

nt

clin

ical

man

ifes

tati

ons

wer

e fe

ver

(16%

), d

rool

ing

(12%

), d

iarr

hea

(8%

), f

ever

-

droo

ling

(15%

),

feve

r-di

arrh

ea

(8%

), d

rool

ing-

diar

rhea

(6%

), a

nd t

he

com

bina

tion

of

feve

r-dr

oolin

g-

diar

rhea

(3%

).

NA,

Sin

gle

clin

ical

asse

ssm

ent

NI

Ther

e w

as

asso

ciat

ion

betw

een

gene

ral

obje

ctiv

e si

gns

(dro

olin

g,

feve

r, an

d

diar

rhea

) an

d

the

erup

tion

of p

rim

ary

teet

h. M

ost

sign

s ap

pear

ed

duri

ng t

he

erup

tion

of

the

prim

ary

inci

sors

.

Typ

e of

ther

mom

eter

,

mea

sure

men

t N

I.

Inci

sors

,

can

ines

, an

d

mol

ars.

Freq

uen

cy N

A.

Per

etz

et

al 2

003,

Col

omb

ia34

CS

Pu

blic

ch

ild c

ente

r58

54–

36D

enti

st/S

ingl

e

asse

ssm

ent.

Nu

rse/

Freq

uen

cy

NA/

Typ

e of

ther

mom

eter

,

mea

sure

men

t

NI.

Feve

r w

as

reco

rded

wh

en

exce

eded

39°

C.

Par

ents

acc

omp

anyi

ng

the

child

com

ple

ted

a q

ues

tion

nai

re.

Info

rmat

ion

was

rel

ayed

in a

yes/

no

man

ner

abou

t 3

obje

ctiv

e

man

ifes

tati

ons

not

ed d

uri

ng

the

eru

pti

on o

f th

e

pri

mar

y te

eth

,

incl

ud

ing

dro

olin

g,

dia

rrh

ea, f

ever

, an

d

the

com

bin

atio

n o

f

thes

e sy

mp

tom

s.

The

den

tist

an

d t

he

nu

rse

con

fi rm

ed

dro

olin

g an

d f

ever

du

rin

g th

e cl

inic

al

chec

kup

.

Nu

mb

er o

f

teet

h N

I.

Inci

sors

,

can

ines

, an

d

mol

ars.

CG 9

3% o

f th

e

child

ren

did

not

pres

ent

any

clin

ical

man

ifes

tati

on.

In t

he S

G, o

nly

39%

. The

mos

t

freq

uent

clin

ical

man

ifes

tati

ons

wer

e dr

oolin

g

(15%

), d

iarr

hea

(13%

), a

nd

droo

ling-

diar

rhea

(8%

),

feve

r an

d fe

ver-

diar

rhea

(8%

).

NA,

Sin

gle

clin

ical

asse

ssm

ent

NI

An a

ssoc

iati

on

has

bee

n

show

n b

etw

een

gen

eral

obje

ctiv

e si

gns

(dro

olin

g, f

ever

,

dia

rrh

ea)

and

the

eru

pti

on o

f

pri

mar

y te

eth

wit

h d

rool

ing

bei

ng

the

mos

t

pre

vale

nt

sign

.

145

SG

Eru

pti

on w

as

det

erm

ined

if t

he

clin

ical

crow

n o

f th

e

toot

h w

as

visi

ble

, bu

t n

ot

exce

edin

g 3

mm

exp

osu

re

abov

e th

e

gin

giva

.

Mos

t si

gns

app

eare

d

du

rin

g th

e

eru

pti

on o

f

the

pri

mar

y

inci

sors

.

340

CG

TABL

E 1

Con

tin

ued


MASSIGNAN et al 10

Stu

dy

Pop

ula

tion

Inte

rven

tion

Ou

tcom

e

Auth

or, Y

ear,

Cou

ntr

ya

Stud

y

Des

ign

Set

tin

gTo

tal n

Age,

Mea

n

or R

ange

,

mo

Clin

ical

Asse

ssm

ent

Bod

y Te

mp

erat

ure

°C (

Wh

o/H

ow)

Qu

esti

onn

aire

Asse

ssed

Tee

thS

ymp

tom

sFo

llow

-Up

Per

iod

MTN

ED/

MTE

D

(°C

)

Mai

n C

oncl

usi

on

Ram

os-J

orge

et a

l 201

1,

Bra

zil33

PS

/RS

Res

iden

ces

of t

he

infa

nts

475–

1511

val

idat

ed

trai

ned

den

tist

s/

dai

ly.

11 v

alid

ated

tra

ined

den

tist

s/D

aily

.

Mot

hers

wer

e

inte

rvie

wed

to

inve

stig

ate

the

occu

rren

ce o

f sig

ns

and

sym

ptom

s

such

as

incr

ease

d

saliv

atio

n, r

ash,

runn

y no

se,

diar

rhea

, los

s of

appe

tite

, col

d,

irri

tabi

lity,

feve

r,

smel

ly u

rine

,

cons

tipa

tion

,

vom

itin

g, c

olic

,

and

seiz

ure,

in t

he

prev

ious

24

h an

d 1

wee

k af

ter

the

end

of d

ata

colle

ctio

n,

the

mot

hers

answ

ered

the

sam

e

ques

tion

nair

e.

231

(inc

isor

s).

Mea

n

num

ber

of

teet

h pe

r

infa

nt w

as

near

ly 5

(ran

ge=

2–8)

.

The

asso

ciat

ions

betw

een

sign

s

and

sym

ptom

s

repo

rted

by

mot

hers

and

toot

h er

upti

on

wer

e st

atis

tica

lly

sign

ifi ca

nt.

8 m

oM

TNED

Tym

pan

ic

36.3

9 (0

.26)

Ther

e ar

e

asso

ciat

ions

betw

een

teet

hing

and

slee

p

dist

urba

nce,

incr

ease

d

saliv

atio

n, r

ash,

runn

y no

se,

diar

rhea

, los

s

of a

ppet

ite,

irri

tabi

lity,

and

a sl

ight

ris

e in

tem

pera

ture

.

Feve

r w

as m

ore

freq

uent

ly

repo

rted

in

the

RS.

Non

inst

itutio

naliz

edM

ean

8.9

(± 2

.7)

The

day

of

eru

pti

on w

as

defi

ned

as

the

fi rs

t d

ay

on w

hic

h t

he

inci

sor

edge

emer

ged

in

the

oral

cav

ity

wit

hou

t b

ein

g

com

ple

tely

cove

red

by

gin

giva

l

tiss

ue.

Infr

ared

au

ricu

lar

ther

mom

eter

and

a d

igit

al

axill

ary

ther

mom

eter

.

The

mos

t co

mm

on

sym

ptom

s on

days

of e

rupt

ion

wer

e ir

rita

bilit

y,

incr

ease

d

saliv

atio

n, r

unny

nose

, and

loss

of

appe

tite

. Fev

er

was

rep

orte

d %

tim

es m

ore

ofte

n

in t

he R

S.

Axill

ary

35.9

8

(0.3

6)

MTE

D

Tym

pan

ic

36.5

1 (0

.20)

Axill

ary

35.9

9

(0.4

6)

TABL

E 1

Con

tin

ued



Stu

dy

Pop

ula

tion

Inte

rven

tion

Ou

tcom

e

Auth

or, Y

ear,

Cou

ntr

ya

Stud

y

Des

ign

Set

tin

gTo

tal n

Age,

Mea

n

or R

ange

,

mo

Clin

ical

Asse

ssm

ent

Bod

y Te

mp

erat

ure

°C (

Wh

o/H

ow)

Qu

esti

onn

aire

Asse

ssed

Tee

thS

ymp

tom

sFo

llow

-Up

Per

iod

MTN

ED/

MTE

D

(°C

)

Mai

n C

oncl

usi

on

Sh

apir

a et

al 2

003,

Isra

el40

PS

Day

car

e ce

nte

r16

5–14

Ped

iatr

ic d

enti

st/

Twic

e w

eekl

y.

Eru

pti

on o

f

the

teet

h w

as

refe

rred

to

the

act

of

teet

h b

reak

ing

out

the

gum

.

Info

rmat

ion

pro

vid

ed

by

par

ents

/

care

give

rs.

Twic

e w

eekl

y.

The

child

ren

’s s

ign

s

and

sym

pto

ms

for

each

day

wer

e

reco

rded

by

the

exam

inin

g d

enti

st

on t

he

bas

is o

f

the

info

rmat

ion

pro

vid

ed b

y

par

ents

as

wel

l as

care

give

rs a

t th

e

day

car

e ce

nte

r.

The

follo

win

g si

gns

and

sym

pto

ms

wer

e re

cord

ed:

feve

r; v

omit

ing;

gast

roin

test

inal

dis

turb

ance

s;

dro

olin

g; b

ehav

iora

l

pro

ble

ms;

sle

ep

dis

turb

ance

s;

cou

ghin

g; a

pp

etit

e

dis

turb

ance

s; a

nd

bit

ing;

su

ckin

g.

50 t

eeth

(an

teri

or),

eval

uat

ed

and

sam

ple

s

from

21

of

them

for

the

test

an

d

the

con

trol

grou

p (

fl u

id

from

th

e

sulc

us)

.

Du

rin

g th

e

teet

hin

g p

erio

d,

beh

avio

ral

pro

ble

ms

wer

e

obse

rved

in 5

0%

of t

he

infa

nts

,

com

par

ed w

ith

16%

in t

he

con

trol

per

iod

(P <

.01)

; fev

er

was

ob

serv

ed

in 2

4% o

f th

e

infa

nts

du

rin

g

toot

h e

rup

tion

and

in 8

% o

f th

e

infa

nts

du

rin

g

the

con

trol

per

iod

(P

= .0

4);

and

cou

ghin

g

was

ob

serv

ed

in 1

2% d

uri

ng

toot

h e

rup

tion

com

par

ed

wit

h 2

% (

P

= .0

6) o

f th

e

infa

nts

du

rin

g

the

con

trol

per

iod

. In

teet

hin

g p

erio

d

vom

itin

g (2

%),

dro

olin

g (1

2%),

and

ap

pet

ite

dis

turb

ance

s

(12%

), b

ut

wer

e

abse

nce

du

rin

g

the

con

trol

per

iod

.

5 m

oM

TNED

Du

rin

g

the

con

trol

per

iod

,

8% o

f th

e

child

ren

exh

ibit

ed

low

/

mod

erat

e

feve

r, n

o

epis

odes

of h

igh

feve

r w

ere

fou

nd

.

Teet

hin

g w

as

asso

ciat

ed

wit

h f

ever

,

beh

avio

ral

pro

ble

ms,

cou

ghin

g, a

nd

the

cyto

kin

e

tum

or n

ecro

sis

fact

or-α

leve

ls.

Flu

id f

rom

th

e

sulc

us

was

colle

cted

on

the

day

of

eru

pti

on o

r

on 1

of

the

follo

win

g 3

d,

and

was

aga

in

colle

cted

for

the

con

trol

grou

p f

rom

the

sam

e

toot

h 1

mo

late

r.

Typ

e of

ther

mom

eter

,

mea

sure

men

t N

I.

MD

T N

I

A ch

ild w

ith

a

tem

per

atu

re

<37

.5°C

was

clas

sifi

ed

as h

avin

g

“no

feve

r.”

A

tem

per

atu

re o

f

37.6

°C t

o 38

.5°C

was

reg

ard

ed a

s

low

/mod

erat

e

feve

r, a

nd

a

tem

per

atu

re

>38

.5°C

was

clas

sifi

ed a

s

hig

h f

ever

.

MTE

D In

th

e

teet

hin

g

per

iod

,

14%

of

the

child

ren

exh

ibit

ed

low

/

mod

erat

e

feve

r

and

10%

exh

ibit

ed

hig

h f

ever

MD

T N

I

TABL

E 1

Con

tin

ued


MASSIGNAN et al 12

Stu

dy

Pop

ula

tion

Inte

rven

tion

Ou

tcom

e

Auth

or, Y

ear,

Cou

ntr

ya

Stud

y

Des

ign

Set

tin

gTo

tal n

Age,

Mea

n

or R

ange

,

mo

Clin

ical

Asse

ssm

ent

Bod

y Te

mp

erat

ure

°C (

Wh

o/H

ow)

Qu

esti

onn

aire

Asse

ssed

Tee

thS

ymp

tom

sFo

llow

-Up

Per

iod

MTN

ED/

MTE

D

(°C

)

Mai

n C

oncl

usi

on

Tasa

nen

, 196

9,

Fin

lan

d35

PS

/CS

Nu

rser

y, d

ay-

nu

rser

y,

wel

fare

cen

ter

SG

: PS

:

42 n

urs

ery

GI

43 d

ay-n

urs

ery

GII

41 w

elfa

re

cen

ter

GIII

CG

: CS

:

107

the

sam

e

loca

ls

126

SG

107

CG

+50

new

born

and

50 te

ethi

ng

child

ren

for

eval

uatio

n

of th

e gu

m

colo

r

+17

mu

cosa

l

spec

imen

s

0–30

1 in

vest

igat

or w

ith

both

med

ical

and

dent

al

qual

ifi ca

tions

,

daily

, gro

ups

I /II

and

sum

mon

ed

whe

n er

uptio

n

occu

rred

,

grou

p III

.

Erup

tion:

fi rs

t

time

the

edge

of in

ciso

r/

cusp

of m

olar

emer

ges

thro

ugh

ging

iva

and

is

palp

able

with

the

fi nge

rnai

l.

Coin

cide

ntal

infe

ctio

n: if

feve

r or

oth

er

sign

of i

nfec

tion

was

not

ed 1

wk

befo

re o

r 5

d

afte

r er

uptio

n,

child

was

pla

ce

in th

e in

fect

ed

grou

p. B

lood

inve

stig

atio

n:

sedi

men

tatio

n

rate

per

hou

r

and

tota

l whi

te

bloo

d ce

ll

coun

t. Lo

cal

inve

stig

atio

ns:

cond

ition

of

Sam

e in

vest

igat

or:

rect

al

tem

pera

ture

,

twic

e da

ily

(mor

ning

/

afte

rnoo

n),

1-m

inut

e

ther

mom

eter

°C.

a

Beh

avio

r di

stur

banc

es:

nurs

ing

staf

f/

mot

hers

. Sym

ptom

s:

slee

p, d

ayti

me

rest

less

ness

,

rubb

ing

the

chee

k

and

ear,

rubb

ing

gum

and

suc

king

the

fi nge

r, dr

oolin

g,

appe

tite

and

loos

e

stoo

ls.

Qu

esti

onn

aire

mat

ern

al o

pin

ion

:

200

mot

her

,

100

>40

y o

ld.

Sym

pto

ms:

fev

er,

slee

p d

istu

rban

ces,

rest

less

nes

s

du

rin

g th

e d

ay,

gum

ru

bb

ing

and

fi n

ger

suck

ing,

chee

k an

d e

ar

rub

bin

g, a

pp

etit

e,

dro

olin

g, d

iarr

hea

,

con

vuls

ion

.

192

(in

cisi

ve,

can

ine,

mol

ar).

Infe

ctio

n d

uri

ng

eru

pti

on: 2

6%

SG

, 15%

CG

.

Tem

per

atu

re:

NoI

was

in

aver

age

of

0.1°

C lo

wer

in

pre

- an

d p

ost-

eru

pti

ve p

has

e.

Sed

imen

tati

on

rate

: du

rin

g an

d

afte

r er

up

tion

not

sig

nifi

can

t.

Wh

ite

blo

od c

ells

du

rin

g er

up

tion

:

sign

ifi ca

nt

only

for

lym

ph

ocyt

e

rati

o in

SG

com

par

ed C

G.

Dis

turb

ance

s

in b

ehav

ior:

stat

isti

cal

dif

fere

nce

on

ly

for

rest

less

nes

s

and

dro

olin

g in

SG

an

d a

pp

etit

e

show

ed li

ttle

dec

reas

e

for

SG

. Loc

al

obse

rvat

ion

:

Aver

age

per

iod

of 1

3.3

d

MTP

E

NoI

37.

0

I 37.

2

MTE

D

NoI

36.

9

I 37.

3

MTP

NoI

37.

0

I 37.

3

Erup

tion

did

not

infl

uenc

e

the

body

tem

pera

ture

or in

crea

se

the

poss

ibili

ty

of in

fect

ion.

Suck

ing

fi nge

r,

rubb

ing

gum

,

droo

ling,

dayt

ime

rest

less

ness

,

loss

of a

ppet

ite

incr

ease

d

duri

ng t

eeth

ing.

Ther

e w

as n

o

chan

ge in

the

colo

r of

muc

osa

in o

ne-t

hird

of

the

erup

ting

teet

h. T

here

wer

e so

me

loca

l

com

plic

atio

ns

duri

ng t

eeth

ing.

Mot

her

attr

ibut

ed s

ome

dise

ase

to

teet

hing

.

TABL

E 1

Con

tin

ued



Stu

dy

Pop

ula

tion

Inte

rven

tion

Ou

tcom

e

Auth

or, Y

ear,

Cou

ntr

ya

Stud

y

Des

ign

Set

tin

gTo

tal n

Age,

Mea

n

or R

ange

,

mo

Clin

ical

Asse

ssm

ent

Bod

y Te

mp

erat

ure

°C (

Wh

o/H

ow)

Qu

esti

onn

aire

Asse

ssed

Tee

thS

ymp

tom

sFo

llow

-Up

Per

iod

MTN

ED/

MTE

D

(°C

)

Mai

n C

oncl

usi

on

the

muc

osa:

norm

al, s

light

redn

ess

and

deep

red

.

Sens

itivi

ty o

f

ging

iva:

fi ng

er

palp

atio

n,

mod

erat

e

pres

sure

.

Sens

itivi

ty

of to

oth

to

pres

sure

:

with

spe

cial

equi

pmen

t 800

g. H

isto

logi

c

inve

stig

atio

n:

gum

at t

he

erup

tion

site

.

gum

col

or

chan

ge: i

n

40%

was

dee

p

red

. Ch

ange

s

in m

uco

sa: 2

8

in 1

26 c

ases

show

ed s

ligh

t

hem

orrh

ages

,

mod

erat

e

per

icor

onor

ite,

fi st

ula

s,

swel

ling,

or

eru

pti

on c

yst.

No

dif

fere

nce

cou

ld b

e fo

un

d

in r

elat

ion

to t

he

oth

er

fi n

din

gs. P

ain

was

not

fou

nd

in

pre

ssu

re t

o th

e

gin

giva

or

to t

he

eru

pti

ng

teet

h.

No

inve

stig

atio

n

was

mad

e

con

cern

ing

corr

elat

ion

bet

wee

n c

linic

al

and

his

tolo

gic

fi n

din

gs. A

t le

ast

20%

of

mot

her

s

bel

ieve

d t

hei

r

child

ren

cou

ld

pre

sen

t so

me

of

the

inve

stig

ated

sym

pto

ms.

TABL

E 1

Con

tin

ued


MASSIGNAN et al 14

Stu

dy

Pop

ula

tion

Inte

rven

tion

Ou

tcom

e

Auth

or, Y

ear,

Cou

ntr

ya

Stud

y

Des

ign

Set

tin

gTo

tal n

Age,

Mea

n

or R

ange

,

mo

Clin

ical

Asse

ssm

ent

Bod

y Te

mp

erat

ure

°C (

Wh

o/H

ow)

Qu

esti

onn

aire

Asse

ssed

Tee

thS

ymp

tom

sFo

llow

-Up

Per

iod

MTN

ED/

MTE

D

(°C

)

Mai

n C

oncl

usi

on

Wak

e et

al

2000

,

Aust

ralia

10

PS

/RS

3 ch

ild c

are

cen

ters

216

– 2

4D

enta

l th

erap

ist

exam

ined

for

toot

h e

rup

tion

ever

y w

eekd

ay

(mid

mor

nin

g).

An e

rup

tion

day

was

defi

ned

as

the

fi rs

t d

ay

that

th

e ed

ge

of a

n in

ciso

r

or c

usp

of

a

mol

ar c

row

n

cou

ld b

e

seen

or

felt

emer

gin

g

thro

ugh

th

e

gum

.

Den

tal t

hera

pist

Ever

y w

eekd

ay

(mid

mor

ning

)/

Infr

ared

tym

pani

c

ther

mom

eter

Two

qu

esti

onn

aire

s:

to s

taff

(af

tern

oon

)

and

par

ents

(mor

nin

g) in

qu

ired

abou

t th

e ch

ild’s

moo

d, w

elln

ess/

illn

ess,

dro

olin

g/

dri

bb

ling,

sle

ep,

stoo

ls, w

et d

iap

ers,

and

ras

hes

/

fl u

shin

g ov

er t

he

pre

ced

ing

24 h

wer

e an

swer

ed

ever

y w

eekd

ay.

At t

he

end

of

the

stu

dy,

par

ents

com

ple

ted

a

qu

esti

onn

aire

abou

t th

eir

bel

iefs

and

exp

erie

nce

s

rela

ted

to

teet

hin

g.

90 (

inci

sive

,

can

ine,

mol

ar).

Anal

ysis

did

not

ind

icat

e a

rela

tion

ship

bet

wee

n t

ooth

eru

pti

on a

nd

feve

r. A

ll p

aren

ts

retr

osp

ecti

vely

rep

orte

d t

hat

thei

r ow

n c

hild

had

su

ffer

ed

teet

hin

g

sym

pto

ms.

7 m

oM

TNED

36.

18To

oth

eru

pti

on is

not

ass

ocia

ted

wit

h f

ever

,

moo

d

dis

turb

ance

,

illn

ess,

sle

ep

dis

turb

ance

,

dro

olin

g,

dia

rrh

ea,

stro

ng

uri

ne,

red

ch

eeks

,

or r

ash

es/

fl u

shin

g on

th

e

face

or

bod

y.

Mea

n 1

4.4

(± 4

.9)

MTE

D 3

6.21

Yam

et

al 2

002,

Sen

egal

41

PS

Ch

ild h

ealt

h

inst

itu

te C

entr

e

de

Pro

tect

ion

Mat

ern

elle

et In

fan

tile

in

Dak

ar-M

édin

a

499

5–30

Med

ical

ser

vice

Mon

thly

.

Info

rmat

ion

pro

vid

ed b

y

par

ents

.

NI

Nu

mb

er o

f

teet

h N

I.

Inci

sors

,

can

ines

, an

d

mol

ars.

Loca

l ob

serv

atio

n:

7 h

emat

oma

of e

rup

tion

, 5

wid

esp

read

gin

givi

tis,

297

loca

l gin

givi

tis.

At le

ast

60%

of t

he

child

ren

had

≥1

of t

he

sym

pto

ms:

hyp

erth

erm

ia,

vom

itin

g,

dia

rrh

ea

and

ap

pet

ite

pro

ble

ms.

NI

NI/

NI

Ch

ildre

n c

ut

thei

r

teet

h w

ith

loca

l

and

sys

tem

ic

dis

turb

ance

s.M

oth

ers

shou

ld

bri

ng

the

child

ren

if

ther

e w

ere

any

sign

s or

sym

pto

ms

in

this

per

iod

.

Typ

e of

ther

mom

eter

,

mea

sure

men

t N

I

HS

V, h

erp

es s

imp

lex

viru

s; I,

infe

cted

; MD

T, m

ean

dai

ly t

emp

erat

ure

; MTE

D, m

ean

tem

per

atu

re in

eru

pti

on d

ays;

MTN

ED, m

ean

tem

per

atu

re in

non

eru

pti

on d

ays;

MTP

E, m

ean

tem

per

atu

re b

efor

e er

up

tion

; MTP

; mea

n t

emp

erat

ure

aft

er e

rup

tion

; NA,

not

ap

plic

able

; NI,

not

info

rmed

; N, n

o; N

oI, n

onin

fect

ed; P

S, p

rosp

ecti

ve s

tud

y; R

S, r

etro

spec

tive

stu

dy;

SG

, stu

dy

grou

p.

a D

ata

wer

e m

odifi

ed b

y au

thor

s (°

F to

°C

).b D

ata

calc

ula

ted

by

auth

ors.

TABL

E 1

Con

tin

ued



prevalence of signs and symptoms

(Fig 2) and separately prevalence

for each individual sign or symptom

(Fig 3). A total of 10 studies were

included in the meta-analysis. Eight

studies had data enough to conduct

15

TABL

E 2

Ris

k of

Bia

s S

um

mar

ized

Ass

essm

ent

(QU

IPS

26)

Bia

ses

Ben

gtso

n

et a

l

1988

31

Car

pen

ter

1978

42

Ch

akra

bor

ty

et a

l 199

436

Cu

nh

a

et a

l

2004

32

Gal

ili

et a

l

1969

39

Hu

llan

d

et a

l

2000

30

Jab

er e

t

al 1

99211

Kin

g et

al

1999

43

Kira

n e

t

al 2

01137

Noo

r-

Moh

amm

ed

and

Bas

ha

2012

38

Per

etz

et a

l

2003

34

Ram

os-

Jorg

e et

al 2

01133

Sh

apir

a

et a

l

2003

40

Tasa

nen

1969

35

Wak

e et

al 2

00010

Yam

et

al

2002

41

Stu

dy

par

tici

pat

ion

Hig

hM

odLo

wLo

wM

odLo

wM

odLo

wLo

wLo

wLo

wLo

wLo

wLo

wLo

wH

igh

Stu

dy

attr

itio

nH

igh

XM

odX

Hig

hH

igh

Hig

hX

Low

Low

Hig

hM

odH

igh

Mod

Mod

Hig

h

PF

mea

sure

men

tH

igh

Mod

Hig

hH

igh

Hig

hM

odH

igh

Hig

hH

igh

Hig

hLo

wLo

wM

odLo

wLo

wH

igh

Ou

tcom

e

Mea

sure

men

t

Hig

hLo

wH

igh

Hig

hLo

wLo

wH

igh

Hig

hH

igh

Hig

hM

odLo

wLo

wLo

wLo

wH

igh

stu

dy

con

fou

nd

ing

Hig

hLo

wH

igh

Hig

hLo

wLo

wH

igh

Hig

hH

igh

Hig

hH

igh

Low

Low

Low

Low

Hig

h

Sta

tist

ical

an

alys

is

and

pre

sen

tati

on

Hig

hH

igh

Low

Hig

hLo

wLo

wH

igh

Hig

hH

igh

Low

Low

Low

Low

Low

Low

Hig

h

Ove

rall

Hig

hM

odH

igh

Hig

hM

odLo

wH

igh

Hig

hH

igh

Mod

Mod

Low

Low

Low

Low

Hig

h

Rat

ings

: Hig

h, m

oder

ate,

an

d lo

w in

dic

ates

hig

h, m

oder

ate,

an

d lo

w r

isk

of b

ias,

res

pec

tive

ly. P

F, p

rogn

osti

c fa

ctor

.

TABLE 3 Summarized Body Temperature Assessment

Measurement MTNED MTDE Study Reference Association

Rectal42 NI NI 37.7°C Yes

Rectal39 NI NI 37.5°C Yes

Rectal11 36.9–37.1°C 37.6°C NI Yes

Rectal35 37.0°C 36.9°C 37.5°C No

Tympanic33 36.39°C 36.51°C NI Yes (slight rise)

Tympanic10 36.18°C 36.21°C NI No

It was not possible to calculate the weighted average because data were insuffi cient. MTED, Mean temperature in eruption

days; MTNED, Mean temperature in noneruption days.

FIGURE 2Forest plot for all signs and symptoms that occurred during the eruption of primary teeth. Sample = 3506.

FIGURE 3Pooled prevalence for each individual sign or symptom that occurred during the eruption of primary teeth.


MASSIGNAN et al

meta-analysis11,32,34,37, 38,40, 42,43

of general prevalence of signs and

symptoms. Another 2 studies were

included in the meta-analysis of

individual signs or symptoms.33,35

Because of the heterogeneity

between the studies, a random model

was chosen.44 All the information

about the meta-analysis of individual

studies is described in Fig 2 and

Supplemental Appendix 4. The

results from this meta-analysis

revealed that the overall prevalence

of signs and symptoms associated

with primary tooth eruption in

children between 0 and 36 months

was 70.5% (total sample = 3506;

Fig 2), where gingival irritation,

irritability, and drooling were the

most frequent ones with 86.81%,

68.19%, and 55.72%, respectively.

Additional information regarding

the meta-analysis can be found in

Supplemental Appendices 4 and 5.

Risk of Bias Across Studies

The studies were heterogeneous

and had different designs. Analysis

revealed that the weakness in

methods was not considered an

important confounder capable

of masking possible signs and

symptoms related to other diseases

that could occur simultaneously with

primary tooth eruption.

DISCUSSION

This systematic review investigated

the available evidence about primary

tooth eruption and local and systemic

signs and symptoms. Currently,

the American Academy of Pediatric

Dentistry guidelines have indications

that eruption of primary teeth leads

to local discomfort, irritation, and

drooling.45

Parents follow the development of

children and witness any change

in behavior, mood, or health. Thus,

they can be helpful in assisting in

the detection of related problems.46

Although cooperative, parents

retrospectively reported symptoms

associated with primary tooth

eruption were memory biased. In a

retrospective study about parents’

beliefs related to primary tooth

eruption, the mean number of

symptoms reported per child was

11, whereas in the study sample the

mean number was 8.10 Similarly,

fever was reported 5 times more

often in the retrospective than

children experienced fever during

teething period in the prospective

study.33 Limitations of these studies

are represented by the subjectivity

of the parents’ observations. In

this context, a study that had the

collaboration of parents who daily

measured children’s temperature,

checked for tooth eruption, and kept

a daily log of symptoms, despite

presented adequate methods, was

excluded based on the criteria for this

systematic review because children

did not receive health professional

examination during the follow-up.

There was a significant association

to tooth emergence: biting, drooling,

gum rubbing, irritability, sucking,

sleep awakenings, ear rubbing, rash

on face, decreased appetite for solids,

and slight temperature elevation.6

Regarding the local signs, the most

frequent was inflammation of

the gum36 or gingival reddening

(hyperemia),30 mostly in posterior

teeth. The timing of eruption of the

primary teeth (6 months onward)

coincides with the age when infants

start to explore the environment. In

this phase, the introduction of the

hands and objects into the mouth

is normal; this, in turn, can bring

harmful microorganisms and cause

infection.47 Even sucking behavior,

nutritive and nonnutritive, may lead

to bruising or may traumatize the

gums causing inflammation.48

Regarding the most frequent general

symptoms during primary tooth

eruption, irritability and drooling

were the most observed followed

by decreased appetite, sleeping

problems, rhinorrhea, fever, diarrhea,

rash, and vomiting. Eruption was

associated with fever,40 did not

influence the body temperature,35

or leads to a slight rise in body

temperature.33 In contrast, symptoms

that were not related to primary

tooth eruption in the selected studies

were in this sequence: sickness,10,35,39

sleeping disturbances,10,39 loose

stools,10,39 drooling,10,39 vomiting,39

and fever.10,35 Three of most robust

studies in this systematic review

showed that sucking fingers, gum

rubbing, daytime restlessness, loss

of appetite,35 sleep disturbance,

increased salivation, rash,

rhinorrhea, diarrhea, irritability,33

and coughing40 increased during

teething.

Another robust study,10 which

accompanied 90 erupting teeth from

21 children every weekday, reported

that fever, mood disturbance, illness,

sleeping disturbance, drooling,

diarrhea, strong urine, red checks, or

rashes did not have association with

primary tooth eruption.

The stage of eruption considered

to represent the day of eruption

for the studies differed from the

first day the edge of an incisor or

a cusp of a molar could be seen or

felt emerging through the gum,10,33

palpable with the fingernail35;

clinical crown of the tooth visible

but not exceeding 3 mm of exposure

above the gingiva34,37,38 to any

portion of the occlusal surface

penetrated the gingiva.39 Besides

that, the frequency of clinical

examination varied from single in

cross-sectional (CS) studies to daily

assessment in some prospective

investigations. This is important

information, as Hulland et al30

found that the mean duration

of primary tooth eruption from

imminent eruption to completion

of the emergence phase was in an

average rate of 0.7 mm per month.

Those studies that evaluated

the eruption as the tooth crown

visible through gingiva but not

exceeding 3 mm or those in which

clinical examinations occurred in



monthly intervals may have lost

or overestimated some signs or

symptoms.

It seems that symptoms associated

with primary tooth eruption decrease

with age. Most manifestations were

observed during the eruption of

primary incisors32,34,37,38 or were

studied only in incisors.11,33,40 Also

there was a significant difference

between the mean age at which

eruptions were accompanied by

disturbances (11.8 months) and

the average age (14.8 months) at

which teeth erupted without general

disturbances. On the other hand,

there seems to be an association

between multiple eruption with

fever and respiratory and alimentary

illnesses that could be due to the

stress that led to the low resistance of

the body against infections.39

Accurate determination of body

temperature is essential to diagnose

fever.49 A recent systematic review

investigating the accuracy of infrared

tympanic thermometry used in

the diagnosis of fever in children,

disclosed that the accuracy of this

kind of thermometer is high, using

rectal measurement as the “gold

standard.” Besides, as temperature

measured by tympanic thermometry

was always 0.6°C to 0.2°C less than

rectal temperature, the threshold

of fever diagnosed by tympanic

thermometry can be decreased.

Therefore, if 38.0°C is the fever

diagnosed by rectal temperature,

the threshold of infrared tympanic

thermometry should be 37.4°C to

37.8°C.27 Under these circumstances,

in this systematic review, in 1 study

using rectal temperature, mothers

on a daily basis verified temperature

and the threshold point was not

informed. Fever was associated

with teething and the mean daily

temperature in days of noneruption

was between 36.90°C and 37.10°C,

and on the eruption day 37.60°C.11

Two studies with moderate risk

of bias used rectal temperatures

>37.77°C (100°F)42 and >37.50°C39;

these authors stated that fever was

associated with tooth eruption,

but mean daily temperature was

not informed. Analyzing the 3

most robust studies, 1 used rectal

temperature and detected that

eruption did not interfere in body

temperature with mean daily

temperature in noninfected children

(37.0°C in noneruption days and

36.9°C in eruption days) in twice-

daily examinations.35 The others

used tympanic measurements. One

study discovered a slight rise from

36.39°C in noneruption days to

36.51°C in eruption days in a daily

check by dentists,33 whereas the

other stated that children do not have

fever during the teething period,

with 36.18°C in noneruption days

and 36.21°C in eruption days every

weekday by the dental therapist.10

LIMITATIONS

Some methodological limitations of

this review should be considered.

Different general symptoms were

considered among studies and not all

studies related confounding factors,

such as other disease that might have

occurred with tooth eruption, or

several symptoms happening at the

same time. All of these may obscure

the actual findings.

Most studies failed to expose a clear

definition of the diagnostic methods.

Examinations were performed in

long intervals that could compromise

adequate data collection. Besides,

some symptoms did not use objective

measures, but parents’ observation,

such as irritability and loss of

appetite. In addition, some symptoms

need more specific examination,

such as diarrhea that may be caused

by infection and, without a virology

study the diagnostic is not conclusive.

Most of the selected studies

demonstrated a high risk of bias,

especially in relation to study design.

Articles with lower risk of bias had

small samples: 21 to 126 children

evaluated. The biggest samples were

found in studies with high risk of

bias, although a random effect for

meta-analysis was used, this might

have affected the results.

CONCLUSIONS

Based on the current limited

evidence, there are signs and

symptoms during primary tooth

eruption. Gingival irritation,

irritability, and drooling were

the most common. For body

temperature analyses, it was

possible to evaluate that eruption

of primary teeth is associated with

a rise in temperature, but it was not

characterized as fever.

17

ABBREVIATIONS

CG: control group

CI: confidence interval

CS: cross-sectional

LILACS: Latin American and

Caribbean Health

Sciences

QUIPS: Quality in Prognosis

Studies Tool

Copyright © 2016 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.

FUNDING SOURCE: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.


MASSIGNAN et al

REFERENCES

1. Cahill DR, Marks SC Jr. Tooth eruption:

evidence for the central role of

the dental follicle. J Oral Pathol.

1980;9(4):189–200

2. Proffi t WR, Frazier-Bowers SA.

Mechanism and control of tooth

eruption: overview and clinical

implications. Orthod Craniofac Res.

2009;12(2):59–66

3. Honig PJ. Teething—are today’s

pediatricians using yesterday’s

notions? J Pediatr. 1975;87(3):415–417

4. Gibbons HL, Hebdon CK. Teething as

a cause of death. A historical review.

West J Med. 1991;155(6):658–659

5. Dally A. The lancet and the gum-lancet:

400 years of teething babies. Lancet.

1996;348(9043):1710–1711

6. Macknin ML, Piedmonte M, Jacobs

J, Skibinski C. Symptoms associated

with infant teething: a prospective

study. Pediatrics. 2000;105(4 pt

1):747–752

7. McIntyre GT, McIntyre GM.

Teething troubles? Br Dent J.

2002;192(5):251–255

8. Romero-Maroto M, Sáez-Gómez JM.

Eruption of primary dentition—a grave

health problem according to Spanish

doctors of the XVI-XVIII centuries. J

Dent Res. 2009;88(9):777–780

9. Owais AI, Zawaideh F, Bataineh O.

Challenging parents’ myths regarding

their children’s teething. Int J Dent

Hyg. 2010;8(1):28–34

10. Wake M, Hesketh K, Lucas J.

Teething and tooth eruption in

infants: a cohort study. Pediatrics.

2000;106(6):1374–1379

11. Jaber L, Cohen IJ, Mor A. Fever

associated with teething. Arch Dis

Child. 1992;67(2):233–234

12. Castiglia PT. Teething. J Pediatr Health

Care. 1992;6(3):153–154

13. Wake M, Hesketh K, Allen M. Parent

beliefs about infant teething: a survey

of Australian parents. J Paediatr Child

Health. 1999;35(5):446–449

14. Baykan Z, Sahin F, Beyazova U,

Ozçakar B, Baykan A. Experience of

Turkish parents about their infants’

teething. Child Care Health Dev.

2004;30(4):331–336

15. Sarrell EM, Horev Z, Cohen Z, Cohen

HA. Parents’ and medical personnel’s

beliefs about infant teething. Patient

Educ Couns. 2005;57(1):122–125

16. Feldens CA, Faraco IM, Ottoni AB,

Feldens EG, Vítolo MR. Teething

symptoms in the fi rst year of life and

associated factors: a cohort study. J

Clin Pediatr Dent. 2010;34(3):201–206

17. Kakatkar G, Nagarajappa R, Bhat N,

Prasad V, Sharda A, Asawa K. Parental

beliefs about children’s teething in

Udaipur, India: a preliminary study.

Braz Oral Res. 2012;26(2):151–157

18. Plutzer K, Keirse MJNC. Teething:

a problem for children, parents

and their doctors. Med Today.

2011;12(12):44–48

19. Kozuch M, Peacock E, D’Auria JP. Infant

teething information on the world wide

web: taking a byte out of the search. J

Pediatr Health Care. 2015;29(1):38–45

20. Wake M, Hesketh K. Teething

symptoms: cross sectional

survey of fi ve groups of child

health professionals. BMJ.

2002;325(7368):814–814

21. Faraco Junior IM, Del Duca FF.

Rosa FMd, Poletto VC. Pediatricians

knowledge and management

regarding tooth eruption. Rev Paul

Pediatr. 2008;26(3):258–264

22. Swann IL. Teething complications, a

persisting misconception. Postgrad

Med J. 1979;55(639):24–25

23. Tighe M, Roe MF. Does a teething child

need serious illness excluding? Arch

Dis Child. 2007;92(3):266–268

24. Moher D, Liberati A, Tetzlaff J, Altman

DG; PRISMA Group. Preferred reporting

items for systematic reviews and

meta-analyses: the PRISMA statement.

Int J Surg. 2010;8(5):336–341

25. PROSPERO. University of York.

Available at: www. crd. york. ac. uk/

PROSPERO/ display_ record. asp? ID=

CRD42015020822. Accessed August 28,

2015

26. Hayden JA, van der Windt DA,

Cartwright JL, Côté P, Bombardier

C. Assessing bias in studies of

prognostic factors. Ann Intern Med.

2013;158(4):280–286

27. Zhen C, Xia Z, Ya Jun Z, et al. Accuracy

of infrared tympanic thermometry

used in the diagnosis of fever in

children: a systematic review and

meta-analysis. Clin Pediatr (Phila).

2015;54(2):114–126

28. Macaskill P, Gatsonis C, Deeks JJ,

Harbord RM, Takwoingi Y. Analysing

and presenting results. In: Deeks JJ,

Bossuyt PM, Gatsonis C, eds. Cochrane

Handbook for Systematic Reviews of

Diagnostic Test Accuracy Version 5.1.0.

Oxford, United Kingdom: The Cochrane

Collaboration; 2010: Chapter 10

29. Higgins JPT, Green S, eds. Cochrane

handbook for systematic reviews

of interventions version 5.1.0

[updated March 2011]. The Cochrane

Collaboration, 2011. Available at: www.

cochrane- handbook. org. Accessed

August 28, 2015

30. Hulland SA, Lucas JO, Wake MA,

Hesketh KD. Eruption of the primary

dentition in human infants: a

prospective descriptive study. Pediatr

Dent. 2000;22(5):415–421

31. Bengtson NG, Bengtson AL, Piccinini DP.

Eruption of deciduous teeth. General

symptoms [in Portuguese]. RGO.

1988;36(6):401–405

32. Cunha RF, Pugliesi DM, Garcia LD,

Murata SS. Systemic and local

teething disturbances: prevalence in

a clinic for infants. J Dent Child (Chic).

2004;71(1):24–26

33. Ramos-Jorge J, Pordeus IA, Ramos-

Jorge ML, Paiva SM. Prospective

longitudinal study of signs and

symptoms associated with

primary tooth eruption. Pediatrics.

2011;128(3):471–476

34. Peretz B, Ram D, Hermida L, Otero

MMM. Systemic manifestations during

eruption of primary teeth in infants. J

Dent Child (Chic). 2003;70(2):170–173

35. Tasanen A. Eruption of the teeth

in children [in Finnish]. Suom

Hammaslaak Toim. 1969;65(4):217–230

36. Chakraborty A, Sarkar S, Dutta BB.

Localised disturbances associated


PEDIATRICS Volume 135 , number 2 , February 2015 19

with primary teeth eruption.

J Indian Soc Pedod Prev Dent.

1994;12(1):25–28

37. Kiran K, Swati T, Kamala BK, Jaiswal

D. Prevalence of systemic and local

disturbances in infants during primary

teeth eruption: a clinical study. Eur J

Paediatr Dent. 2011;12(4):249–252

38. Noor-Mohammed R, Basha S. Teething

disturbances; prevalence of objective

manifestations in children under age 4

months to 36 months. Med Oral Patol

Oral Cir Bucal. 2012;17(3):e491–e494

39. Galili G, Rosenzweig KA, Klein H.

Eruption of primary teeth and general

pathologic conditions. ASDC J Dent

Child. 1969;36(1):51–54

40. Shapira J, Berenstein-Ajzman G,

Engelhard D, Cahan S, Kalickman I,

Barak V. Cytokine levels in gingival

crevicular fl uid of erupting primary

teeth correlated with systemic

disturbances accompanying teething.

Pediatr Dent. 2003;25(5):441–448

41. Yam AA, Cisse D, Diop F, et al.

The health of the child during

eruption of the deciduous teeth

[in French]. Odontostomatol Trop.

2002;25(98):12–14

42. Carpenter JV. The relationship between

teething and systemic disturbances.

ASDC J Dent Child. 1978;45(5):381–384

43. King DL, Steinhauer W, García-Godoy F,

Elkins CJ. Herpetic gingivostomatitis

and teething diffi culty in infants.

Pediatr Dent. 1992;14(2):82–85

44. Deeks J, Higgins JPT, Altman DG.

Analysing data and undertaking meta-

analyses. In: Deeks J, Higgins JPT,

Altman DG, eds. Cochrane Handbook

for Systemic Reviews of Interventions.,

Chapter 9. West Sussex, England: The

Cochrane Collaboration; 2008

45. American Academy of Pediatric

Dentistry. Guideline on infant oral

health care. Reference Manual.

2014;36(6). Available at: www. aapd. org/

policies. Accessed August 10, 2015

46. Squires J, Bricker D, Heo K, Twombly

E. Identification of social-emotional

problems in young children using

a parent-completed screening

measure. Early Child Res Q.

2001;16(4):405–419

47. Agbaje MO, Ayankogbe OO, Wright

KO, Adeniyi AA. The perception of

caregivers attending a Nigerian

teaching hospital on teething. Nig Q J

Hosp Med. 2012;22(2):94–98

48. Coldebella CR, Azevedo ER, Oliveira

ALBMd, Domaneschi C, Zuanon ÂCC.

General and local manifestations

during tooth eruption. J Health Sci Inst.

2008;26(4):450–453

49. Hooker EA, Smith SW, Miles T, King

L. Subjective assessment of fever

by parents: comparison with

measurement by noncontact

tympanic thermometer and

calibrated rectal glass mercury

thermometer. Ann Emerg Med.

1996;28(3):313–317


DOI: 10.1542/peds.2015-3501 originally published online February 18, 2016; 2016;137;Pediatrics

De Luca Canto, Luis Andre Mendonça Mezzomo and Michele BolanCarla Massignan, Mariane Cardoso, André Luís Porporatti, Secil Aydinoz, Graziela

Signs and Symptoms of Primary Tooth Eruption: A Meta-analysis

ServicesUpdated Information &

http://pediatrics.aappublications.org/content/137/3/e20153501including high resolution figures, can be found at:

Referenceshttp://pediatrics.aappublications.org/content/137/3/e20153501#BIBLThis article cites 44 articles, 7 of which you can access for free at:

Subspecialty Collections

ubhttp://www.aappublications.org/cgi/collection/dentistry:oral_health_sDentistry/Oral Healthfollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:


http://http://pediatrics.aappublications.org/content/137/3/e20153501

http://pediatrics.aappublications.org/content/137/3/e20153501#BIBL

http://www.aappublications.org/cgi/collection/dentistry:oral_health_sub

http://www.aappublications.org/cgi/collection/dentistry:oral_health_sub

http://www.aappublications.org/site/misc/Permissions.xhtml

http://www.aappublications.org/site/misc/reprints.xhtml

DOI: 10.1542/peds.2015-3501 originally published online February 18, 2016; 2016;137;Pediatrics

De Luca Canto, Luis Andre Mendonça Mezzomo and Michele BolanCarla Massignan, Mariane Cardoso, André Luís Porporatti, Secil Aydinoz, Graziela

Signs and Symptoms of Primary Tooth Eruption: A Meta-analysis

http://pediatrics.aappublications.org/content/137/3/e20153501located on the World Wide Web at:

The online version of this article, along with updated information and services, is

http://pediatrics.aappublications.org/content/suppl/2016/02/16/peds.2015-3501.DCSupplementalData Supplement at:

1073-0397. ISSN:60007. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. Print

the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it


http://pediatrics.aappublications.org/content/137/3/e20153501

http://pediatrics.aappublications.org/content/suppl/2016/02/16/peds.2015-3501.DCSupplemental

signs and symptoms of primary tooth eruption: a meta-analysis · eruption of primary teeth; and (6)...

Documents