What is the Healthy Teething Process in Babies?

What Teething Is and When It Starts

Teething is the eruption of the primary teeth, also called milk or baby teeth, through the gum. A complete primary dentition has 20 teeth, and in most children all of them are in place by around the age of three. The tooth buds are already formed inside the jaw at birth; what parents see in the first years is those teeth moving up through the bone and the gum until they meet the teeth of the opposite jaw.

The first tooth to appear is usually a lower central incisor, one of the two small front teeth in the lower jaw. The age at which that happens varies much more than the often-quoted six months suggests. A systematic review and meta-analysis of 42 studies covering 42,109 children found the mandibular central incisor erupting at 6 months in North America and at 13.5 months in Asia (PubMed 38128337). Eruption was earliest in the European population, followed by North America, Africa, Oceania and Asia, and latest in the South American population.

This spread has a practical meaning. A baby whose first tooth arrives several months after six months is, in many populations, within the normal range, and a comparison with a cousin or a neighbour's child says little on its own. The same review found that the role of sex, jaw and socio-economic status in eruption timing was insignificant, although teeth on the left side tended to erupt slightly earlier than those on the right (PubMed 38128337).

Healthy teething is therefore defined less by a date on the calendar and more by a pattern. Teeth appear in a broadly fixed order, each tooth comes through over days to a few weeks, and the child continues to feed, grow and develop normally while it happens. When that pattern holds, a later or earlier start is usually a variation.

The Order in Which Primary Teeth Appear

Primary teeth come through in a broadly predictable sequence, even though the ages attached to each step vary between children and between populations. The lower central incisors usually appear first, followed by the upper central incisors. The lateral incisors, the teeth on either side of the front pair, come next in both jaws. The first primary molars then appear towards the back of the mouth, followed by the canines, which fill the gap between the incisors and the first molars. The second primary molars are the last to arrive and complete the set of 20.

The timing of the last step varies as much as the first. In the same meta-analysis, the mandibular second molar erupted at 20.1 months in Europe and at 29 months in South America (PubMed 38128337). A child who is still waiting for the back molars after the second birthday is therefore not unusual.

Each tooth takes time to come through. The period from the moment the gum over a tooth begins to swell until the crown is fully visible usually ranges from a few days to a few weeks, and several teeth can be moving at the same time. This is why a baby may seem uncomfortable for a stretch of days, settle, and then go through another difficult spell as the next teeth approach the surface.

Gaps between the front teeth are common and often useful, since the permanent teeth that follow are larger. Small differences in timing between the left and right sides are also common. What deserves attention is a clear break from the sequence, such as a tooth erupting far out of order or in the wrong position, which a dentist can assess at an early visit.

Signs During Eruption

Most babies show some signs while teeth are coming through, but not all of them do. A meta-analysis of 16 observational studies including 3,506 children aged 0 to 36 months found an overall prevalence of signs and symptoms during primary tooth eruption of 70.5% (PubMed 26908659). Roughly three in ten children in those studies went through eruption without recorded symptoms.

The most frequent signs were local. Gingival irritation at 86.81%, irritability at 68.19% and drooling at 55.72% were the most frequent ones (PubMed 26908659). In daily life this looks like red or swollen gums over the erupting tooth, a baby who puts hands and toys into the mouth constantly and bites or rubs the gums, more drooling than usual, and a baby who is more unsettled.

Other changes parents often notice are disturbed sleep, a smaller appetite for a few days, rubbing of the cheek or pulling at the ear on the same side as the erupting tooth, and a stronger urge to suck or, in some babies, a refusal to feed because sucking presses on sore gums. These are usually short-lived and follow the eruption of individual teeth.

The studies behind these figures have limitations. The authors noted that some studies did not account for confounding factors, lacked a clear definition of diagnostic methods, relied on subjective measures or had long intervals between examinations (PubMed 26908659). The overall picture is still clear: teething causes local discomfort in most children, and the signs centre on the gum and the mouth. Symptoms that affect the whole body, such as a high temperature, repeated vomiting or a baby who is listless and difficult to wake, point to another cause.

Fever, Illness and What Teething Does Not Explain

A mild rise in temperature can accompany teething, but a true fever is a different matter. In the meta-analysis of eruption symptoms, eruption could lead to a rise in body temperature, but that rise was not characterised as fever (PubMed 26908659). A baby with a high temperature during the teething months therefore needs to be assessed for another illness, and attributing the fever to teeth can delay that assessment.

The same caution applies to diarrhoea, a rash beyond the chin area where drool collects, persistent vomiting, breathing difficulty or unusual drowsiness. Babies in the teething age range also meet many common infections for the first time, and the two often happen together by coincidence. When a symptom would worry a parent in a baby who was not teething, it deserves the same attention in a baby who is.

Some findings in the mouth are also unrelated to teeth. A white coating on the tongue or inside the cheeks that looks like cottage cheese and does not wipe off easily points to oral thrush, a yeast infection which the NHS describes as common in babies. Thrush needs its own treatment and does not clear as a tooth comes through. Blisters on the gums or lips, bleeding from the gums without an erupting tooth nearby, or a swelling that persists after the tooth has appeared are also reasons for an examination.

Antibiotics have no role in normal teething. Teething is a developmental process, and giving antibiotics without a diagnosed bacterial illness exposes the baby to side effects without benefit. The same applies to medicines left over from an older sibling or from a previous illness.

Soothing Sore Gums Safely

The measures that help during teething are aimed at the gum itself, where the discomfort is. Cold and gentle counter-pressure are the two mechanisms that work. A chilled teether, cooled in the refrigerator and not frozen hard, gives the baby something firm and cool to bite on. Gently massaging the gum with a clean finger or the back of a cooled spoon can ease the pressure. If the baby uses a pacifier, a cooled pacifier works on the same principle.

For babies who have started solid food, firm pieces of vegetable or fruit can be offered to chew under close supervision, since small pieces can break off and cause choking. Soft, cool foods such as yogurt, banana or well-cooked vegetables are often easier to accept on days when the gums are sore. Keeping the chin and neck dry and applying a gentle barrier cream helps prevent the rash that constant drooling can cause.

Some things are better avoided. Painkillers or numbing gels made for adults are not used without advice from a doctor or pharmacist, and teething gels in general are used only on medical recommendation. Very cold items such as ice, and very hot foods, can injure the gum. Teething rings and toys need to be cleaned regularly, and anything tied around the baby's neck, such as necklaces or cords, carries a risk of strangulation or choking.

Comfort matters as much as any product. A calm bedtime routine, a gum massage before sleep, a warm bath and a safe, comfortable sleep environment help a baby through the restless nights that teething can bring. Distraction with play and extra cuddles during the day eases irritability while each tooth completes its eruption.

Cleaning New Teeth, Diet and the First Dental Visit

Cleaning starts as soon as the first tooth breaks through. In the first months a clean, damp cloth or a finger brush wiped over the tooth and gum after feeds removes milk and food residue. From around the age of one, a small soft toothbrush with toothpaste replaces the cloth, and brushing twice a day becomes part of the routine. Parents brush for the child; young children do not yet have the control to clean their own teeth.

Diet protects the new teeth. Sugary and sticky foods and sweetened drinks are kept to a minimum. Falling asleep with a bottle of milk or juice is stopped as the teeth come in, because liquid pooled around newly erupted teeth during sleep is the classic mechanism of early childhood decay. A balanced diet that includes calcium-rich foods such as milk and dairy products, with vitamin D as advised by the child's doctor, supports healthy development of the teeth and bones.

The first dental visit takes place after the first tooth appears, and by the first birthday at the latest. The visit is a check-up. The dentist checks whether eruption and jaw development are on track, looks for early signs of decay, and discusses feeding, cleaning and fluoride. Early visits also make later appointments more familiar and less stressful for the child.

Late teething is common and usually normal, as the wide variation in eruption timing shows. If no tooth has appeared well past the first birthday, or the sequence seems unusual, an examination can check for rarer causes such as genetic factors, nutritional deficiencies or general health problems. The questions a parent can bring to that visit are simple: when the first tooth appeared, which teeth have come through since, how the baby is feeding and sleeping, and how the teeth are being cleaned each day.