Say a prayer for the safe cutting of a child's teeth: The folklore of teething.

Abstract

Throughout history, teething has been held responsible for a wide variety of childhood illnesses. References to teething pain appear as early as 3000 BC in clay tablets of the Sumerian culture. The tablets identify the goddess Ninsutu as being responsible for the care of teeth. Dental pain was ascribed to a ‘worm eating through the tooth’. Topical medication was used to treat toothaches, and Ea, the god of the nether world (the Sumerian place for the bodies of the dead to exist after death), was called upon for assistance. As in many early cultures, the Sumerians also related teething with symbols of death.1 In India, around 1000 BC, the AtharvaVeda, a sacred text of Hinduism, included a prayer for the safe cutting of a child's teeth. It compared the erupting teeth to two rampaging tigers, symbols of death in that culture. The text also included instructions on proper infant diet during teething to protect the child from illness.1 The Homeric Hymns from the ninth century BC, 33 hymns praising most of the major gods of Greek mythology, also mention the teething worm, describing it as the ‘undercutter’ or ‘woodcutter’. The Greeks believed that Demeter, the goddess of mothers and children, protected infants from the devastation of this worm.1 The Indian treaties Kashyapa Samhita, also known as Braddha Jivakiya Tantra – an important treatise on Ayurveda medicine written in ancient India by the sage Kashyap – is the first text that contains a description of various aspects of dentition.2 In the seventh century BC, the Ayurvedic scholar Vagbhata mentioned in his text, Astanga Samgrah, that during dentition the child may suffer from fever, headache, thirst, vertigo, inflammation of eyes, vomiting, respiratory troubles, diarrhoea and skin disorders.3 He mentioned that the child feels an itching sensation of the gums, so he may bite the breast during suckling, and whatever article he finds he bites with his gums to relieve itching or pain. During the dentition, some of the humours of the body (vata and kapha) are activated and produce various symptoms within a range of severity.4 In the fourth century BC, Hippocrates, who understood that teeth developed in utero, wrote a short treatise, De Dentitione, which included 32 observations on teeth, 7 of which mention teething specifically. ‘Teething children suffer from itching of the gums, fevers, convulsions and diarrhea, especially when they cut their eye teeth and when they are very corpulent and costive’ (25th Aphorism, third book).5 Hippocrates taught that teeth derive nourishment from the uterus before birth but receive nourishment from the mother's milk after birth. This is the origin of the term ‘milk teeth’. The number seven also enthralled Hippocrates. He stated that the first tooth erupted at the age of 7 months and primary dentition lasted 7 years. He believed that fat babies and constipated babies had a more difficult time with teething. He wrote that babies who had diarrhoea were less likely to have convulsions during the teething period. This idea probably arose from Hippocrates’ theory that bad humours left the body with the stools.1 In the sixth century AD, Aetios of Amida recommended hare's brain be given in the food, either boiled or roasted, to help the teething, and if a hare could not be found, a lamb's brain would do just as well. Aetios also encouraged the practice of wearing bracelets and amulets to make teething easier.1 He recommended ‘Root of colocynth [a wild, poisonous vine] hung on the child in a gold or silver case, or bramble root, or the tooth of a viper, especially a male viper, set in gold or green jasper, suspended on the neck so as to hang over the stomach’.5 Around 117 AD, another Greek physician, Soranus of Ephesus, wrote that irritation of the gums by solid food made the gums thick and prevented tooth eruption. He recommended softening the gums with olive oil ‘If they are in pain, smear the gums with dog's milk or hare's brain, this works also if eaten’. He also recommended using hare's brain to soothe the pain of teething. This mode of treatment persisted until the 17th century.1 The Greek-Roman physician Galen (129–199) recommended camphor, chloroform, mustard baths and local massage as treatments for teething. Now when your baby's teeth appear, you must of these take prudent care. For teething comes with grievous pain, so to my word take heed again. When now the teeth are pushing through, to rub the gums thou thus shall do. Take fat from chicken, brain from hare, and these full oft on gums shall smear. If ulcers sore thereon should come, then thou shalt rub upon the gum. Honey and salt and oil thereto. But one thing more I counsel you, A salve of oil of violet, for neck and throat and gums to get. And also bathe his head a while, with water boiled with camomile.5 In 1491, Bartholomaeus Metlinger published the first German paediatric text, Ein Regiment der Jungen Kinder, which attributed paralysis to teething. During subsequent centuries, teething was blamed for many illnesses, including gonorrhoea and poliomyelitis. Some older remedies for teething were violent and included blistering, bleeding,6 placing leeches on the gums and applying cautery to the back of the head.7 The French surgeon Ambroise Paré (1510–1590)8 introduced a more professional treatment: lancing babies’ gums.9 The concept that failing to lance gums contributed to infant mortality was popular during the next four centuries.10 Joseph Hurlock, who wrote a book on teething in 1472, advocated gum lancing in every disease irrespective of whether the tooth was evident.11 Lancing the gums became common practice. John Hunter (1728–1793) would lance a baby's gums ‘up to 10 times’.12 J. Marion Sims (1813–1883) treated his first patient, a baby who was 18 months old: ‘As soon as I saw some swelling of the gums, I at once took out my lancet and cut the gums down to the teeth’.13 The physician Marshall Hall (1790–1857) wrote that he would rather lance a child's gums 199 times unnecessarily than omit it once if necessary,14 and he instructed his students to do it before, during and after the teeth appeared, sometimes twice a day.15 Eventually, the practice of lancing gums started to decline. By 1896, some observers were ‘even going so far as to say that the growth of teeth causes no more symptoms than the growth of hair’.16 In New York, in 1898, the pioneer paediatrician, Abraham Jacobi, pronounced that ‘Lancing the gums has lost most of its charms’.17 Nevertheless, as late as 1938, one dentistry textbook18 advised that the dental surgeon should be consulted ‘with a view to lancing the gums’ and gave instructions on how to perform the operation. The bourgeois medical profession in the 16–19th centuries regarded teething as being the cause of a significant number of infant fatalities.19 Approximately one-half of all infant deaths in 18th century France were attributed to teething.20 By 1839, 5016 deaths in England and Wales were attributed to teething.5 The 1842 English Registrar-General report on teething discussed infant mortality: 4.8% of all infants who died in London under the age of 1 year, 7.3% of those between the ages of 1 and 3 and 12% of all deaths under 4 years were directly attributed to teething.5 Early Utah pioneer records list teething as a relatively common cause of childhood death. In the period 1847–1881, a total of 521 deaths were attributed to teething.21 However, not everyone agreed with the common belief that teething led to childhood mortality, seizures, diarrhoea, fever or other serious conditions. This concept was criticised as early as the 17th century by Francois Ranchin.22 In 1797, Johann Wichmann claimed that the diagnosis of teething was being used to hide the physician's ignorance. A French physician, Billard, described works that catalogued difficulties with teething as ‘an extended chapter of absurdities’.1 In 1771, the paediatrician George Armstrong wrote, ‘Teething in the manner, as was observed in convulsions, is said to carry off a much greater number of children than it actually does, for almost all children that die whilst they are about teeth are said to die of teething’.5 Over the centuries, an extensive folklore built up around teething. The condition even acquired a Latin name, Dentitio Difficilis.5 In contrast, in 1975, the BMJ published that there can be no excuse for attributing fever, fits, diarrhoea, bronchitis or rashes to teething.23 The Teething Virus,24 a humorous publication, amusingly criticised the attribution of symptoms to teething, considering it a medical issue. Parents were encouraged to check for teething at the first sign of fever and to quickly begin their prophylactic Valium if the baby's Leech test (probably meaning a parental bleeding finger rescued from the baby's suck) for tooth eruption is positive. It was also recommended that paediatricians approach their 2 am calls as a time to educate parents about the positive aspects of teething. This advice would minimise the hoarding of left-over amoxicillin (instead of Jack Daniel's) until such a time when a vaccine is developed to rid mankind of this pesky little virus.24 Several studies have been published in the past decade trying to identify what symptoms parents and medical personnel still believe can be attributed to tooth eruption. In a survey of 200 Finnish mothers in the 1960s, 90% believed teething causes gum rubbing and finger sucking; 77% that it causes drooling; and 50% that it leads to fever, sleep disturbance and daytime restlessness.22 In an Australian study of parents of 92 infants in the 1990s, the majority believed that teething causes fever, pain, irritability, sleep disturbance, biting, drooling and red cheeks; some considered diaper rash, ear pulling, feeding problems, runny nose, loose stools and infections as caused by teething; and a few reported smelly urine, constipation, colic or convulsions. Only one parent believed that teething causes no problems.25 In a survey of Turkish parents, over 85% reported five or more symptoms caused by teething; the most common were increase in biting, irritability and fever.26 Several studies regarding beliefs about teething in Africa have been published. In 1991, a study of the knowledge and beliefs about teething of rural Nigerian Yoruba communities showed that nearly 60% of the respondents believed that teething may be accompanied by various medical problems, including fever, diarrhoea and conjunctivitis.27 A cross-sectional survey conducted among 542 nurses in Ibadan, a city in southwestern Nigeria, showed that the majority believed that loss of appetite, crying, increased salivation, irritability, fever and diarrhoea are signs of teething. The older and more experienced nurses and males tend to attribute more symptoms to teething.28 Another Nigerian study on the beliefs of Community Health Officers about teething found that 60% of the respondents believed that children have systemic problems during teething periods, mainly fever and diarrhoea.29 An Israeli survey of parents’ and medical personnel's beliefs about infant teething included 45 paediatricians, 108 nurses and 309 parents; 76% of the responders, mostly parents and nurses and less so physicians, believed that teeth eruption in infants is frequently associated with irritability, fever and loose stools or diarrhoea.30 A cross-sectional study of nurses, pharmacists, general practitioners, dentists and paediatricians from Australia regarding teething symptoms beliefs found that the mean number of symptoms ascribed to teething per group was 2.8 in the paediatricians, 4.4 in the dentists, 6.5 in the general practitioners, 8.4 in the pharmacists and 9.8 in the nurses; 32% of the pharmacists and 19% of the dentists reported that teething may cause fever (>38°C), compared with 8% of the general practitioners, 7% of the nurses and only 2% of the paediatricians. Only 9% of the paediatricians, but 30–50% of each of the other groups, believed that teething predisposes to infections, most commonly colds and ear infections. In every group, most of those who believed that teething causes symptoms ascribed irritability, dribbling or drooling, biting objects, sleep problems, inflamed gums and red cheeks to teething. Only a few from any group ascribed eczema, other rashes, colic, convulsions or constipation to teething. Only nurses commonly ascribed diaper rash, feeding problems, pulling ears, loose stools, cold symptoms and smelly urine to teething. Professionals in all groups believed that parents experience as much (or more) distress as their infants during teething.31 A survey in Iowa, USA, evaluated the differences in the beliefs of paediatricians, paediatric dentists and parents regarding symptoms caused by teething in infants. The majority of individuals in each group believed that teething in infants can cause swollen gums, drooling, irritability, inflamed gums, restlessness, sleeplessness and fever. The largest difference between the groups was related to the association between teething and diarrhoea. The majority of parents and paediatric dentists believed that diarrhoea is associated with teething, compared to less than 10% of paediatricians.32 A mail survey of 215 paediatricians practicing in Florida also investigated beliefs related to teething and diarrhoea. The author cited 18 studies from America, Asia, Africa and Australia that expressed a near-universal folk belief that teething is related to diarrhoea; 35% of respondents believed in a real association between diarrhoea and tooth eruption. A comparison of paediatricians who do not believe in teething diarrhoea and physicians who believed in teething diarrhoea found the latter to be more recent graduates of medical school, general paediatric practitioners, females who see more patients per week and practice in metropolitan areas. Proposed explanations for the association between dentition and diarrhoea include changes in eating habits, increased salivation and stress.33 A study from Jordan was designed, in part, to investigate parents’ beliefs about teething signs and symptoms and their practices used to relieve teething manifestations; 1500 randomly picked parents answered a questionnaire that required data on their beliefs regarding their infants’ teething signs and their management during this period. The researchers found that most of the parents incorrectly attributed fever, diarrhoea and sleep disturbances to teething, while more than half believed that systemic symptoms are not related to the process. More than half of the parents allowed their children to bite on chilled objects, and most of them used systemic analgesics and rubbed the gums with topical analgesics to relieve the symptoms associated with teething.34 A recent Brazilian study aimed to compare mothers’ actual observations of symptoms associated with the eruption of primary incisors in their infants with their own recollections of the same period after eruption. The researchers concluded that mothers reported similar manifestations of sleep disturbance, diarrhoea, loss of appetite and irritability in the prospective and retrospective studies. Reports of increased salivation and a runny nose were more frequent in the prospective study, whereas fever was reported five times more often in the retrospective study.35 The cultural imprint of medical practice entwined within the evolution of medicine. The anthropological aspects are fascinating and can be fully visualised only in the mirror of their era. A judgmental approach should be taken when addressing mystic rituals in the name of medicine. Throughout history, teething has been held responsible for a wide variety of childhood illnesses. Over the centuries, an extensive folklore has built up around teething. The wind of change was empowered in the early 1970s, when publications in major medical journals were seeking to dispel the notion of teething as a source of serious systemic illness. In 1975, Illingworth proclaimed that ‘Teething produces nothing but teeth’.36 While several studies have been published in the past decade trying to identify the symptoms parents and medical personnel still believe can be attributed to tooth eruption, other studies have been published trying to identify the actual signs and symptoms that can be attributed to tooth eruption. Ramos-Jorge et al.37 evaluated 47 healthy Brazilian infants aged 5–15 months and showed that body temperature rises on the day of the eruption within a normal range and could not have been defined as ‘fever’. On the other hand, irritability, increased salivation, runny nose and loss of appetite were statistically significantly associated with teething. A recent review published by Massignan et al.38 included 16 studies that met the inclusion criteria. They found that the 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. Fever, sepsis and death were not found to be associated with teething as oppose to previous beliefs…