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Review
Oral Biology

A review of the eruption of primary teeth

C H Chu1*, C Y Yeung1

Abstract us to the focus of our management for the future. This

Introduction paper gives a general overview of eruption of deciduous
Eruption of deciduous teeth remains a rather sophisticated teeth and explores on some implications of the process.
process. This paper gives a general overview of the process
and explores on its implications. Overview of Eruption
Overview Eruption and emergence of teeth
Eruption of deciduous teeth may be divided into pre- Eruption of teeth may be defined as the natural
eruptive tooth movement, eruptive tooth movement and physiological process by which a tooth moves from its site
post-occlusal tooth movement. Emergence of deciduous of development to its final functional position in the oral
teeth is usually accompanied by teething symptoms. cavity.3 Emergence of teeth may be defined as the initial
Mechanisms for eruption are still not entirely apparent. appearance of any part of the tooth crown penetrating

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
Proposed mechanisms included root elongation, through the gingiva into the oral cavity.1,4 Therefore,
hydrostatic pressure, periodontal ligament traction, bone ‘eruption’ and 'emergence' of teeth denote slightly
remodeling and genetic pre-programming / cellular- different things. With 'eruption', the developing tooth
molecular determinants. moves in the axial direction from its original location
Discussion and Conclusion inside the jaw bone to its functional position in the oral
Understanding of the eruption of deciduous teeth made cavity.1,5 Eruption of deciduous teeth appears to go
possible age estimation for children, shed light on through a rather standard sequence of happenings. The
management of teething issues and likely point towards a process of eruption commences way before the emergence
treatment philosophy of minimal intervention with definite of the concerning tooth.1 And, the process of eruption

All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
building blocks of close observation and monitoring. continues until the erupting tooth is in functional position,
normally.1,4
Introduction
‘Deciduous teeth’ from the Latin word meaning ’to fall off’. The eruption process
This is because they will be shed like leaves of the Deciduous teeth develops within the developing jaws are

Competing interests: None declared. Conflict of interests: None declared.

deciduous tree and be replaced by the adult permanent too small to accommodate them initially and they are
dentition. Other terms such as ‘milk teeth’, ‘baby teeth’, crowded within the jaws. To that end, each deciduous
even ‘temporary dentition’ describe the nature of the tooth germ started off rather small. The tooth germ grows
deciduous dentition, namely, that they are found in in size as the jaw bone grows in length and girth with
children and are reasonably ‘temporary’ in their functional remodeling.3 Eventually, the deciduous tooth germ moves
life.1 These descriptive terms may give the misconception from its site of development into the oral cavity; in order
of the lack of importance of deciduous teeth. Yet, children that it comes into functional occlusion for the purpose of
rely on these deciduous teeth to chew and to obtain mastication. The process of deciduous tooth eruption may
nutrients for their growth and development. They rely on be arbitrarily divided into three descriptive phases, which
these teeth to articulate speech in their tender years; are re-eruptive tooth movement, eruptive tooth movement
prepare them for the next stage in life with the permanent and post-occlusal tooth movement. These phases are
dentition. Further, children and dentists alike may not be ‘continuous’ in the sense that demarcation between each of
able to imagine how children would look and smile when the stages may not always be clear.3,6,7
they are devoid of teeth. How would the children find it? Pre-eruptive tooth movement is made by a deciduous
How would they really feel? What about their parents? tooth germ within tissues of the jaw before it begins to
How would they find their kids?2 As for us, the dentists, we erupt.3,7 Each deciduous tooth originally developed as a
also have to be concerned with orthodontics: space tiny offshoot from the oral epithelium. As the jaw bone
maintenance and growth of the dental arches.1 This grows in length and girth, it is then possible that individual
relatively short-lived dentition should be awarded much deciduous tooth germ, together with its permanent tooth
more appreciation than one could imagine. For, it sheds germ, become housed in their respective bone crypt. As
light on the present situation and that which should guide this happens, the tooth germs appear to move in relation to
the surrounding developing tissues in a three-dimensional
*Corresponding author manner.3
Email: chchu@hku.hk Eruptive tooth movement is the active phase of eruption.7
1
Root portion of the tooth has yet to be formed but the tooth
Faculty of Dentistry, University of Hong Kong germ would begin erupting from its bone crypt, in a three-
dimensional manner.3,6,7 Bone remodeling during this

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Review

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Figure 1: Age estimation according to height and the number of erupted primary teeth.
phase for the deciduous teeth, may not be too apparent Table 1: Reported symptoms attributed to teething.
because the tooth germ is usually not totally covered by

Competing interests: None declared. Conflict of interests: None declared.

dense alveolar bone and is already quite close to the oral Local Symptoms General / Systemic
mucosa.8 Yet, bone in the fundus of the crypt is Symptoms
continuously being remodeled to form a socket that house Drooling/sialorhoea Bowel upset (eg.
Ear rubbing or pulling on the Constipation, loose stools
the erupting tooth, while its root is continuously taking
same side as the erupting tooth and diarrhea)
shape.3,6,7 As the erupting tooth nears surface epithelium of Facial flushing/circumoral rash Cough
the oral mucosa, there is a thickening and transformation Gingival inflammation Ear infection
of the enamel epithelium (giving rise to the reduced Gingival Fever
enamel epithelium) and fusion with the oral epithelium. itching/rubbing/biting/sucking Irritability/malaise
Consequently there is no bleeding on penetration of the Pain Loss of appetite/altered
oral mucosa as the deciduous tooth germ emerges into the fluid intake
oral cavity. Around this time is when the infant Running nose
experiences symptoms of teething.6,9 On emergence of the Rashes eg. in diaper area
Sleep disturbance
deciduous teeth, the speed of eruption begins to
Smelly urine
accelerate.6 This is when the tooth continues to erupt into Vomiting
occlusion, the phase of the pre-occlusal tooth movement. Wheezing/asthma
During this phase, bone forms at the base of the crypt and exacerbation
root of the tooth continues to take shape. Continual
remodeling of connective tissues around the tooth shapes be present to compensate for any tooth wear, attrition and
the periodontium, which, on maturation, maintains the growth of the jaw; in order that the deciduous tooth is kept
erupted tooth in functional position.6,10 functional in occlusion.3,6,7,8,11
Post-occlusal tooth movement is the tooth movement that
maintains the position of the erupted tooth in occlusion Emergence of deciduous teeth
while the jaws continue to grow and compensate for The emergence of deciduous teeth at infancy is commonly
occlusal and proximal tooth wear.3,8,11 There is a referred to as 'teething'.9 Emergence of deciduous teeth
consolidation of the periodontal support of the tooth and usually begins at around six months after birth. Teething
completion of root formation.8 Minor tooth movement may

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Table 2: Mean age of eruption (months) of primary teeth from various countries.
Tooth Nigeria Saudi Iraq Iceland USA
Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls
51, 61 9.3 10.2 11.2 11.2 10.7 10.6 9.0 9.2 9.4 8.8
52, 62 12.0 13.0 13.1 13.3 10.1 11.4 10.4 10.2 12.0 11.8
53, 63 17.8 18.3 21.1 21.1 18.8 19.9 17.6 18.0 21.0 20.8
54, 64 16.0 16.9 16.9 16.9 16.3 16.4 15.1 15.0 17.5 16.3
55,65 26.1 26.1 28.2 28.3 26.0 27.0 26.1 25.1 31.0 31.4
81, 71 7.6 7.9 8.4 8.5 9.2 8.4 8.0 6.9 7.2 7.7
82, 72 12.4 12.9 14.4 14.6 14.0 14.3 12.1 11.8 13.1 13.3
83, 73 18.2 18.8 21.0 21.1 19.0 20.3 19.2 18.2 20.9 20.5
84, 74 16.3 16.0 17.2 17.1 16.9 17.0 16.2 15.4 16.6 16.4
85, 75 24.1 24.2 27.9 28.0 26.0 25.1 25.6 23.7 30.0 29.5
*Adapted from Oziegbe et al, 2008.

for the twenty deciduous teeth completes at around thirty any hard and fast rule on the right-left order of
months after birth.12,13 The period of teething coincides emergence.21 Mihailids and co-workers23 observed that the

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
with a diminution of circulating maternal antibodies and right-left emergence is kind of symmetrical and that each
developmental changes. As such, this could be a period antimeric pair emerges within two weeks of each other.
when the child is relatively prone to illness.14,15
Coincidentally as well, is that, over this period, it has been Mechanisms of Eruption
observed that teething is usually accompanied by ‘teething Mechanisms for eruption are still not entirely apparent.
symptoms’. Teething symptoms could be local symptoms, Proposed Mechanisms of Eruption includes root
such as pain and gingival itching, and systemic symptoms, elongation, hydrostatic pressure (tissue fluid pressure),
such as fever and irritability (Table 1). As can be seen, periodontal ligament traction, bone remodeling and
teething symptoms can appear rather ‘general’ or ‘obscure’ genetic pre-programming (cellular-molecular

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in nature. This could be especially cumbersome trying to determinants).7
arrive at the correct diagnosis. Root elongation is proposed as mechanisms for eruption
because root of the erupting tooth is not yet fully formed
Sequence and timing of eruption upon eruption. Even after emergence, the root continues to
The sequence of eruption of deciduous teeth is reasonably develop and elongate into its final length. It is thus

Competing interests: None declared. Conflict of interests: None declared.

constant. The sequence follows in the order of central postulated that the elongation of the root could exert a
incisor, lateral incisor, first molar, canine and second force on the underlying bone and propels the erupting
molar. Usually, mandibular teeth emerges prior to the tooth occlusally into the oral cavity.10 Of course, for such a
maxillary counterpart.1,9,12,13,16,17 Some minor ethnic mechanism to work, there needs to be a concrete base
variations exists18,19 as shown in Table 2. apical to the developing root, capable of withstanding the
Unlike the sequence of eruption, there could be force or pressure from the elongating mass of the root
considerable variation in the timing of eruption, as ‘digging’ into the alveolar bone.7 Yet, some researchers
measured by the emergence of erupting teeth.1,19,20,21 As far suggested that root elongation cannot be the mechanism
as timing of the emergence of teeth is concerned, there because rootless teeth erupts.7,11 It is unlikely that the
appeared to be some amount of variation between the three-dimensional path of eruption could be possible
different genders and amongst different ethnic groups through relying on root elongation alone.6,7
(Table 2). On the whole, it appears that deciduous teeth Hydrostatic pressure (tissue fluid pressure) is proposed to
emerges earlier in boys; and that eruption completes be a mechanism for eruption because the vascular system
earlier in boys.19 Hagg et al22 found that gender difference inside or apical to the tooth germ could have a greater
in the time of emergence of the various teeth was small and pressure than that outside of the tooth germ. Pressure
insignificant. Folayan et al18 found no observable effect of from the interstitial fluids may push the bell-shaped tooth
socio-economic status and breast feeding on the timing of germ occlusally into the oral cavity.7,10,24,25 A pressure
the emergence of deciduous teeth. gradient appeared to be present within and outside of the
erupting crown.11 Yet, the hydrostatic pressure theory does
Pattern of Eruption not always explain eruption fully. A tooth would still erupt
Studies suggested that deciduous teeth emerge earlier in on excision of its growing roots, and hence, the periapical
boys than in girls.18,19,22 The range of the length of time for vasculature.7
all the deciduous teeth to emerge is about 20 to 30 Periodontal ligament traction is also a proposed
months.18,19,21,22 Some ethnic, gender and temporal mechanism of tooth eruption.7 It is postulated that
variations are observed. Further, it does not appear to be fibroblasts, which developed from the dental follicle, in the
connective tissues provided the force required for

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Review

eruption. The obliquely inclined fibroblasts have been Discussion: Practical Implications of Eruption
shown to contract and possibly pull the erupting tooth out Age estimation for children
during eruption.11 It has been argued that the structural Given the relative constant sequence and reasonably
elements of frequent cell-to-cell contacts between similar timing of the process of eruption, it is possible to
periodontal ligament fibroblasts could permit summation derive an educated estimation of the age of a child up to 5
of the contractile forces necessary for eruption.7 There are to 6 years of age.20,29,30 Bastos et al4 reported on a previous
some, who would argue that the traction force is only proposed formula by Bailey31. The formula produces a
present after the commencement of the process of rough estimation of age for children aged 6 to 24 months of
eruption; hence, does not account for the initial phase of age when the date of birth is unavailable. The formula is
eruption.10 Furthermore, teeth with periodontal ligament simple and is as follows: Age (in months) = 6 + number of
may not always erupt, such as in the case of osteopetrotic emerged deciduous teeth. Notwithstanding is that other
mutations.6 Consequently, it has been concluded that this information, such as socio-demographics (e.g. low birth
particular mechanism of periodontal ligament traction may weight) and medical history (e.g. chronic diseases and
not be the sole mechanism behind eruption.7,10,25 conditions), if available are also of bearing.4
Bone remodeling is also proposed as a mechanism for Children’s dental age may also be assessed
tooth eruption because alveolar bone forms during tooth radiographically or clinically. However, a young child may
development, and tends to be deficient where tooth fails to not be co-operative with radiographic examination. On the
develop.7 It thus seems that alveolar bone growth, tooth

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
other hand, clinically counting the number of teeth present
development, and eruption are interdependent. Naturally, in the mouth appears to be a more appropriate quick
it has been proposed that formation of alveolar bone apical simple alternative.29,30 Charts may be employed for
to developing tooth germs is conducive to eruption.6 The estimating age of a child (Figure 1). Age estimation by the
mechanism being that bone formation apical to the deciduous teeth could be quite informative in the sense
erupting tooth germ propels the tooth germ occlusally that the teeth erupts in a reasonably linear fashion, at
while osteoclastic activities present coronal to the erupting rather regular intervals of approximately 2 to 2.5 months. 1
tooth germ opens up the path of eruption. Interesting is One drawback of this method is that dental history of the
that base of the crypt of the permanent first and third child could be crucial. This is because the method relies on
molars continually resorbs on eruption of these teeth. all emerged teeth being present and recognizable.32 Other

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However, for the second premolar and molar bone information of the child, such as medical and social history,
deposition was observed on the floor of the respective socio-demographics (e.g. height and weight, gender,
crypts.7 In addition, experiments done by various ethnicity), should also be collected. For, the current
investigators have since demonstrated that dental follicle literature suggests that such variables may have bearing on
is actually the essential element in the process of the growth of the child, and thus, masking the temporal age

Competing interests: None declared. Conflict of interests: None declared.

eruption.6,7,11 Gorski et al26 reported that teeth without of the child.32
dental follicles simply do not erupt. It appears that the Various investigators have found some minor differences
dental follicle is central the element inducing formation of in the emergence of deciduous teeth present between the
cells capable of bone remodeling observed over the different genders.30,32 In general, boys appear to have their
process of eruption.6,7,26,27 first teeth erupted earlier than girls; and girls tend to have
Genetic pre-programming / cellular-molecular all their deciduous teeth present a bit earlier than boys. 30,32
determinants was suggested as a mechanism of tooth Studies suggested that the height and age of a child has
eruption because a study found a large number of genes significant correlation with the number of deciduous teeth
involved in tooth development and eruption.8 Various present, and a taller child is likely to have more deciduous
molecular determinants, such as growth factors, colony teeth present.4,29 The number of deciduous teeth present
stimulating factor, monocyte chemotactic protein-1 have may be useful in estimating age of a child. However, other
been implicated in the process of tooth eruption. There has variables, such as dental history, height and socio-
been suggestions of hormonal control of eruption, since demographic data, should also be taken into account.20
that a circadian rhythm of eruption exists in human
subjects, in the case of premolar eruption.11 It is postulated Teething Issues
that complex interactions between growth factor, Given the local and systemic symptoms (Table 1), it
transcription factors and hormones, etc. drives the appears that teething could easily be the scapegoat for
eruption process.27 many common conditions. This could be potentially
To summaries, it is unlikely that any single one of the worrisome when the process of teething could spread over
above postulated mechanisms explains the entire eruption approximately 20 to 30 months.8 Yet, it is also true that
process. Rather, given the available evidence, it is likely sometimes genuine underlying medical and/or
that there is some sort of complicated genetic pre- developmental condition, such as undiagnosed herpetic
programming of the eruption process. It is also possible gingivostomatitis, could be present.9,14,33 Therefore,
that the pre-programmed process response to certain accurate diagnosis and careful observation of the
environmental cues26,27,28 and employs various different concerning child is important. Some reported historic
mechanisms at various stage of the eruption process.

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management of teething included local measures such as in order to cater for these growing little darlings who got
lancing, applying leeches directly onto the gingiva; troubled by their deciduous dentition –This is most likely
systemic medicaments like opiates, lead acetate; even non- the time for minimal intervention and best to keep closing
pharmacological asinine therapies such as dietary changes, observation and monitoring, as in the case of teething.
emetics and laxatives.16,33,34 Contemporary managements
of teething can be non-pharmacological use of pacifiers, References
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All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
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All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
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Competing interests: None declared. Conflict of interests: None declared.

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Competing interests: None declared. Conflict of interests: None declared.

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