Avulsion

Term used to describe complete displacement of tooth from its alveolus. It is also called as exarticulation and most often involves the maxillary teeth.

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Clinical Features

Bleeding socket with missing tooth.

Radiographic Features

• Empty socket.
• Associated bone fractures.
• If the wound is recent then lamina dura is visible otherwise it is obliterated.

Storage media for Avulsed tooth

Effect of Storage Media on Periodontal Healing

Teeth are usually subjected to a period of desiccation between their avulsion and reimplantation. Therefore, it is desirable to reimplant the avulsed tooth as quickly as possible to ensure maximal viability of PDL cells attached to the root surface. As dry storage is detrimental to the preservation of the PDL, the avulsed tooth must be prevented from drying by the use of storage media of correct osmolarity and pH. Andreasen (1981),observed that even 30 minutes of dry storage elicited greater inflammatory resorption compared with saline and saliva storage. Hammarstrom 1986, used logistic regression analysis and confirmed that the treatment of avulsed teeth stored in saliva, milk or saline was more successful than those that were allowed to dry. Patil 1994, showed that extracted teeth stored dry for 120min exhibited significantly lower viable PDL cells per tooth than teeth that were stored wet prior to PDL cell collection. Also with non physiological storage, the chances of pulpal revascularization are minimal. Therefore, in cases where an immediate reimplantation is not feasible, use of a storage medium is prudent to enhance and preserve the vitality of PDL fibroblasts of an avulsed tooth.

Types of Storage Media

Saline solution

• The saline solution provides osmolality of 280mOsm/kg and despite being compatible to the cells of the periodontal ligament, it lacks essential nutrients necessary to the normal metabolic needs of the cells of the periodontal ligament.
• Blomlöf (1981), Courts 1983 and Krasner 1992 have stated that saline solution was harmful to the cells of the periodontal ligament in avulsed teeth if it is used for longer than two hours.

Tap water

• It is an unacceptable storage media for avulsed teeth.
• Blomlöf 1981, found that storing cultured human PDL cells in tap water for 1 hour caused more PDL cell damage than the other physiological and non- physiological storage media tested.
• They attributed the increased cell damage to the cells lysis caused by the very low osmolarity of tap water.
• Thus, tap water is not suitable interim storage medium for retaining the viability of PDL cells.

Saliva

• It can be used as a storing medium for a short period of time, for it can damage the cells of the periodontal ligament if used for longer than an hour.
• Its osmolality is much lower than the physiologic saline (60–70 mOsm/kg),thus it boosts the harming effects of bacterial contamination.
• Its only advantage is it availability

Milk

• The American Association of Endodontics indicate milk as a solution for avulsed teeth, for keeping the viability of the human cellular periodontal ligament.
• Milk is significantly better than other solutions for its physiological properties, including pH and osmolality compatible to those of the cells from the periodontal ligament; the easy way of obtaining it and for being free of bacteria, but it is important that it is used in the first 20minutes after avulsion.
• The favorable results of milk probably occur due to the presence of nutritional substances, such as amino acids, carbohydrates and vitamins.
• The pasteurization of milk is responsible for diminishing the number of bacteria and bacteriostatic substances, also for the inactive presence of enzymes, which could be potentially harmful to the fibroblasts of the periodontal ligament.
• Blomlöf (1983), and Trope and Friedman (1992) recommended milk as an excellent storing solution for 6 hours, however, milk cannot revive the degenerated cells.

Hank’s balanced salt solution

• It is a standard saline solution that is widely used in biomedical research to support the growth of many cells types.
• This solution is nontoxic, it is biocompatible with periodontal ligament cells, pH balanced at 7.2 and has an osmolality of 320mOm/kg.
• It is composed of 8g/L sodium chloride; 0.4g/L of D-glucose; 0.4g/L potassium chloride; 0.35g/L sodium bicarbonate; 0.09 g/L sodium phosphate; 0.14g/L potassium phosphate; 0.14g/L calcium chloride, 0.1g/L magnesium chloride and 0.1g/L magnesium sulfate. It contains ingredients, such as glucose, calcium and magnesium ions which can sustain and reconstitute the depleted cellular components of the periodontal ligament cells.
• It is the best solution for storing avulsed teeth since it does not require refrigeration and it can be kept on the shelf for 2 years and it has been recommended and used successfully as a storage medium by clinicians and researchers.
• It is commercially available as Save-A-Tooth [Pottstown, PA], which has an inner net to receive the avulsed tooth and to minimize cell trauma during transport.

ViaSpan (Dupont, USA)

• It is a cold transport organ storage medium that has been suggested for the storage of avulsed teeth.
• Its osmolarity is 320mOsm/L, with a pH=7.4, which is ideal for cell growth.
• Hiltz and Trope(1991), observed ViaSpan to be effective storage medium, with 33 percent vital cells at 144 hours. Trope reported that replanted dog incisors that were stored in ViaSpan for upto 12 hours showed no signs of replacement or inflammatory resorption. However, since this product is presumably even less available than HBSS, the practicality of using ViaSpan as a storage medium must be considered judiciously

Gatorade (Quaker Oats Company, USA)

• It is a transport medium commonly found at sporting events.
• It is a noncarbonated sports drink often consumed by nonathletes as a snack beverage.
• It contains water, sucrose and glucose, fructose syrups, citric acid, sodium chloride, sodium citrate, monopotassium phosphate and flavoring/coloring agent.
• It has a pH3 and osmolarity ranging from 280 to 360mOsm/L.
• Gatorade preserves more viable cells than tap water but fewer than all other media, both at room temperature and on ice. Therefore, Gatorade can only serve as a storage medium if other more acceptable media are not available, rather than allowing the avulsed tooth to dry out.

Propolis

• It is a sticky resin that seeps from the buds or bark of trees, chiefly conifers. It consists of resin, waxes fatty acids, essential oils, pollen proteins and other organic compounds and minerals.
• It has antiseptic, antibiotic, antibacterial, antifungal, antiviral, antioxidant, anticarcinogenic, antithrombotic and immunomodulatory properties.
• Margaret and Pileggi(2004), reported that teeth stored in propolis demonstrated the highest viability for PDL cells, when compared with HBSS, milk and saline.
• Shaher(2004), observed that with propolis, the viability of PDL fibroblasts can be maintained for as long as 20hours. Hence propolis can act as a good alternative natural storage medium for avulsed teeth.

Contact lens solution

• It is a convenient preservation medium for teeth after avulsion injuries as these solutions are available in school or athletic grounds and at home, where most injuries occur.
• They contain buffered, isotonic saline solutions with the addition of preservatives that may preserve the viability of PDL cells
• These solutions preserve significantly more viable cells than tap water and Gatorade but are not as effective as HBSS and milk.

Emdogain

• According to Ashkenazi and Shaked (2006), Emdogain diminishes the percentage of fibroblasts of the periodontal ligament with capability of forming colonies and that lowers the capability for the fibroblasts to repopulate the dental radicular surface after dental avulsion
• It can delay, but not stop the development of replacement resorption, one of the worst complications of dental trauma.
• On its own, it is not efficient in the regeneration of injured periodontal tissues of the avulsed tooth.

Egg white

• Khademi(2008),had compared milk and egg white as solutions for storing avulsed teeth, and the results have shown that teeth stored in egg white for 6 to 10hours had a better incidence of repair than those stored in milk for the same amount of time.

Eagle’s medium

• It contains 4 mL of L-gluta-mine; 105IU/L of penicillin;100µg/mL of streptomycin, 10µg/mL of nystatin and calf serum [10%v/v].
• It has high viability, mitogenic and clonogenic capacity up to 8 hours of storage at 4°C.
• When the storage time was upto 24 hours, Eagle’s medium was less effective than milk or Hank’s balanced salt solution, which could be attributed to the low temperature [4°C] which may have induced aggregation and thus lowered the cell’s functional capacity.

L-Dopa(levodopa; Sigma chemicals, Perth, Australia)

• It is a drug with possible mitogenic effects.
• Levodopa stimulates dopaminergic systems in the anterior portion of the pituitary gland to secrete growth hormone, which is considered a promoter of the healing process.
• Levodopa can also have a local effect on the growth of cells, including the PDL cells and can preserve as a preserving medium for avulsed teeth.

Coconut water

• Biologically pure tender coconut water, which aids in replenishing the fluids, electrolytes and sugar lost from the body during heavy physical work, has been suggested as a promising storage medium for avulsed teeth
• Gopikrishna(2008), observed coconut water to be superior to HBBS, milk or propolis in maintaining the viability of PDL cells.

Treatment

• Reimplantation depends on extraoral time.
• If apical foramen is not closed endodontic therapy is delayed till first signs of apical closure are seen.
• If apical foramen is closed endodontic therapy is done after 1 to 2 weeks depending on type of reimplantation.

Prognosis

• Tooth survival: 51 to 89 percent
• PDL healing: 9 to 50 percent
• Pulp healing: 4 to 15 percent

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