What are the recommended steps for an otherwise healthy infant experiencing delayed teething?

Delayed Teething in Infants

Primary Recommendation

For an otherwise healthy infant with delayed teething beyond 12-13 months, schedule a dental evaluation and ensure the infant is receiving appropriate fluoride supplementation based on water fluoride levels, while reassuring parents that normal tooth eruption can vary from 6-13 months without indicating underlying pathology. 1, 2

Understanding Normal Teething Timeline

• Primary teeth typically begin erupting at 6-8 months of age, starting with lower central incisors, and continue until approximately 24-30 months when all primary teeth have emerged 1
• Most infants grow their first tooth at some point during their first year, with normal variation in timing 3
• The average age for teething onset is 6 months, but this represents a population average rather than an absolute threshold 2

Initial Assessment Steps

Evaluate for systemic conditions if delayed teething is accompanied by:

• Poor weight gain, hypotonia, or ineffective sucking (consider Prader-Willi syndrome with immediate molecular DNA testing) 4
• Developmental delays or neurodevelopmental concerns requiring formal assessment 4
• Feeding difficulties requiring evaluation by feeding specialists 4

For isolated delayed teething without systemic symptoms:

• Confirm the infant is otherwise healthy with normal growth parameters (weight, length, head circumference plotted on appropriate growth curves) 4
• Document family history of delayed tooth eruption 1
• Perform oral examination to assess gum health and rule out gingival abnormalities 1

Mandatory Dental Referral

The American Academy of Pediatric Dentistry recommends the first dental examination occur within 6 months of first tooth eruption but no later than 12 months of age, regardless of whether teeth have erupted. 5, 1

• This early dental visit allows for risk assessment and anticipatory guidance even before tooth emergence 5
• Delaying dental evaluation until 3 years of age can result in extensive carious lesions that could have been prevented with earlier intervention 5
• Early dental intervention provides opportunity for parental education on oral hygiene, fluoride use, and feeding practices 5

Fluoride Management During Delayed Eruption

Fluoride supplementation should be prescribed only after testing confirms suboptimal fluoride concentration in drinking water (<0.3 ppm). 5, 1

• Systemic fluoride is incorporated into dentin and enamel of unerupted teeth, making them more resistant to acid demineralization when they eventually emerge 5
• Fluoride also works topically through saliva secretion, accumulating in plaque to decrease microbial acid production 5
• Enamel formation in primary dentition is complete by 11 months of age, making early fluoride exposure critical 5
• Excessive fluoride causes fluorosis, so supplementation must be carefully dosed based on water testing 5

Preventive Oral Health Education

Begin oral hygiene practices before tooth eruption:

• Wipe gums with clean cloth after feeding to establish bacterial control before teeth emerge 1
• Once teeth erupt, implement twice-daily brushing with rice grain-sized fluoridated toothpaste (1,000-1,100 ppm fluoride) 1, 6
• Mothers are the primary transmitters of cariogenic bacteria (Streptococcus mutans), making maternal oral health crucial 1

Dietary counseling to prevent future caries:

• Discontinue bottle use by 12-24 months to prevent prolonged exposure to fermentable carbohydrates 1
• Avoid allowing children to sleep with bottles containing anything other than water 1
• Limit free-sugars intake to less than 10% of total energy intake, ideally less than 5% 1
• Restrict total eating occasions to four or fewer per day to reduce cariogenic effects 1

Critical Pitfalls to Avoid

• Do not dismiss delayed teething as benign without evaluating for systemic conditions, particularly if accompanied by poor weight gain, hypotonia, or developmental delays 4
• Do not delay dental referral beyond 12 months of age, even if no teeth have erupted, as this misses the critical window for preventive education 5
• Do not prescribe fluoride supplementation without first testing water fluoride levels, as excessive fluoride causes fluorosis 5
• Do not assume delayed teething indicates future dental problems, as normal variation exists and isolated delayed eruption in otherwise healthy infants typically resolves without intervention 2, 3

Parental Reassurance

• Teething is a normal physiological and self-limiting process with significant individual variation 7, 3
• When teeth do emerge, mild symptoms (increased biting, drooling, gum-rubbing, irritability) occur in less than 35% of teething infants and only during an 8-day window around eruption 8
• No life-threatening illnesses are caused by teething itself; fever above 102°F or systemic symptoms require evaluation for other causes 8