Normal course of the illness Treatment
Similar illnesses blue mass on gums
teething vs ear infection When to seek help


Teething is a fairly easy diagnosis. Your child may experience teething pain very early in life, possibly even the first few weeks. The symptoms of teething can be and usually are seen without actually cutting a tooth. Teething pain is classically episodic pain lasting a few minutes at a time and associated with fussiness, drooling, nasal congestion, possibly mildly loose stools and a low grade fever. There are some doctors that will tell you that a child will NOT run a fever while teething. I don't think any of these doctors are pediatricians or have children. I have definitely seen fevers up to 102, but I can honestly say I have never seen a fever over 102 with teething that was not also caused by something else.

USUAL TIME OF FIRST TOOTH: The first tooth usually erupts or breaks through between 5 and 10 months, but occasionally as early as 3 months and as late as 14 months. When the first tooth erupts before 5 months, in my experience, one of the parents usually got their first tooth early and for some reason it always appears at about 3 months of age.

USUAL TIME OF THE NEXT TOOTH: The timing of tooth eruption is extremely variable and probably impossible to predict. But the order of eruption is usually fairly consistent. The lower front 2 are first followed by the upper front 4, then 1 molar on each side and top and bottom, then in-between the molars and front teeth.

TEETH AT BIRTH: There are some children that are born with teeth. These teeth usually are precursors to real teeth and are sort of a remnant of development. These early teeth when loose can sometimes come out and be swallowed or aspirated into the lungs of the child. Therefore, if your infant has one of these early teeth and it appears to be loose then call your pediatrician immediately.

HOW TO TELL WHEN YOUR CHILD ACTUALLY IS CUTTING A TOOTH: The lower front 2 teeth almost always come in first. When a tooth erupts, the gums become inflamed and feel boggy or swollen and squishy. One easy way to tell when a tooth is erupting is to compare the upper and lower front gums. If the lower gum is just as firm as the top gum, then the tooth is not erupting. If the lower gum is swollen and squishy compared to the top, then that lower front tooth is probably coming through.

There is much you can do to soothe a teething child. First, try the old time remedies. Teething rings, cold objects to bite on, etc. Just make sure the child cannot bite a piece off and choke on it. Second, try ibuprofen (Motrin, Advil). Ibuprofen is a safe anti-inflammatory medicine. Since the gums are inflamed, this medicine can relieve the inflammation and pain caused by teething quite well. Acetaminophen (Tylenol, Actinol, Tempra, etc.), on the other hand, has no anti-inflammatory effect at all. While it will help relieve the pain a little and can be used with ibuprofen, I would definitely use ibuprofen before acetaminophen. Both medicines have dosing charts on the boxes. Third, try topical teething gels (Ambisol, Oralgel, Numzit, etc.).

EAR INFECTION: Ear infection is most frequent reason to visit a pediatrician for an illness. You are about to learn something that will save you at least one visit to the pediatrician. Teething can mimic an ear infection quite closely except for a few distinct and easy to see differences. Teething gives episodic (comes and goes) pain that is mild, associated with a fever no higher than 102, is not associated with hearing loss and gives a mild runny nose. Ear infections give almost continuous and worsening pain, temperatures above 102, occasionally hearing loss and worsening cold symptoms. Ear infections are rare before 6 months of age (I have seen about 30 in 4 years). Babies below 5 to 6 months of age developmentally cannot reach for a painful ear (In other words, they can't locate the pain and then selectively reach for it, they simply cry and flail their arms and legs). There are always exceptions to the above and sometimes the differences are subtle. Please remember, 60% of ear infections go away on their own and in Europe many doctors don't treat ear infections unless their is no improvement without antibiotics for 2 to 3 days. The problem with the last sentence is that we can't tell which 60% go away on their own and Europe has seen more complications from under treating ear infections (mastoiditis). One more tidbit, most (95%)children with ear infections get their ear pain 2 to 3 days into a cold and the few (5%) that show up with ear pain alone and have an ear infection have very bad pain. The point to take away from this is that closely observing your child and simply watching a few more hours may save you a trip to the doctor.

ERUPTION CYST OR HEMATOMA: Occasionally when a tooth is erupting, it breaks through a blood vessel before it break through the skin. This will look like a blue mass about the size of a pea or peanut on the gum. This alone is nothing to worry about. When the tooth erupts through the skin, there will be a little blood come out with it. Again, this is nothing to worry about. If there is more blood than you expect (several teaspoons, >15cc) or the bleeding does not stop with pressure, then call you pediatrician or dentist immediately. If you see blue under the gum, but the whole gum or a large portion of it is covered with blue, then notify your pediatrician as soon as possible during business hours.

COLDS: A cold does not make a child very fussy, rarely has a fever more than a few hours or over 101, is not associated with loose stools and usually has a cough. Please see the colds page for more details.


Your child is bleeding and you cannot stop it with 5 minutes of firm pressure.
Your child has a tooth present from birth and it is now loose.


Your child has a blue mass on the gums.
Your child has blue gums all over.
Your child's teeth look very unusual (crooked, discolored, brown, jagged).


Your child's teeth are crooked.
Your child has a gap between the front baby teeth. (don't worry this usually won't affect the permanent teeth).

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