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A diagnosis without a disease.

Every pediatrician who is sensitive to the needs of his patients believes in the Tooth Fairy. But, do you believe in teething? Sure, we all know that somewhere between birth and their second birthday all children will have teeth erupt through their gums. But do you ever tell parents that their child's symptoms are the result of this eruption?

Many years ago, an old pediatrician told me that the only thing that teething caused was teeth. In the decades since he contributed that pearl to my necklace of inherited wisdom, I have failed to observe anything that makes me doubt his statement. However, I recently discovered that there is actually an ICD 9 code (520.7) called "teething syndrome" and worse yet, one of my colleagues has actually used it.

I vaguely remember reading where some study found a small but statistically significant association between the eruption of teeth and rhinorrhea, loose stools, and a very modest temperature elevation. But, I've never found that observation particularly helpful when I am trying to sort out what ails a fussy infant or toddler.

You have probably heard as many misattributions as I have: "'My aunt said his fever of 103 was probably his teeth," or "I thought his vomiting and blisters on his bottom were because he was teething." Nearly every day I hear about unerupted or erupting teeth being linked to some constellation of symptoms for which they are blameless. Fortunately, I can't recall a case in which a child has died because lifesaving treatment was delayed by a tragic therapeutic detour through a variety of teething remedies. But I fear that it has happened somewhere in this country.

If while relating the history of the current illness, a parent mentions that he has considered teething, I interrupt and correct the misperception. I know that ff I don't, silence is often treated as agreement.

All normal 4-month-olds begin to drool in buckets and try to mouth everything then can get their chubby little fingers around. While this oral development stage probably has some remote relationship to eventual tooth eruption, most children don't cut teeth for at least another month or so.

Of course, from time to time some children may have a cranky day or night before a tooth eruption. But in my experience, a hard wood or rubber object for the child to chew on is as effective as any medicinal intervention. The problem comes when we allow this untreatable and benign teething behavior to creep onto our list of working diagnoses.

Even a figment of thought about teething can derail our rational deductive reasoning when we are facing a diagnostic enigma. Potentially serious and treatable conditions may never make it to the radar screen when the little voice in our head says, "It's probably just teething." As difficult as it may be, the better tack is to come clean and tell the parents, "I'm not absolutely sure what's going on here, but I'm not worried about your child. I will call you tomorrow morning to check on her."

I tell the parents if they want to think about teething, it should be so low on their list of diagnoses that by the time they have ruled out the other explanations, the problem has resolved. In other words, if teething deserves an ICD 9 code it should carry a footnote warning that it should only be used retrospectively and never as a working diagnosis.


DR. WILKOFF practices general pediatrics in a multispecialty group practice in Brunswick, Maine. Write to Dr. Wilkoff at our editorial offices (pdnews@elseviencom).
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Title Annotation:Letters From Maine
Author:Wilkoff, William G.
Publication:Pediatric News
Article Type:Letter to the editor
Geographic Code:1USA
Date:Sep 1, 2008
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