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| REVIEW ARTICLE |
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| Year : 2022 | Volume
: 18
| Issue : 2 | Page : 37-44 |
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Recent advances in transport medium for avulsed tooth: A review
Malini Venugopal
Department of Preventive and Pediatric Dentistry, Amrita School of Dentistry, Amrita Viswha Vidyapeetham, Kochi, Kerala, India
| Date of Submission | 29-Jul-2021 |
| Date of Acceptance | 02-Oct-2021 |
| Date of Web Publication | 30-Jun-2022 |
Correspondence Address:
Malini Venugopal
Department of Preventive and Pediatric Dentistry, Amrita School of Dentistry, Amrita Viswha Vidyapeetham, Kochi, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/AMJM.AMJM_34_21
Avulsion is one of the most severe types of traumatic injuries seen during childhood and adolescence. Apart from physical trauma, it also causes psychological trauma to the affected child. Immediate replantation is very essential for the long-term survival of teeth. However, when immediate replantation cannot be accomplished, the medium in which the tooth is stored becomes very important. The life of the avulsed tooth may be extended by the prevention of desiccation of periodontal ligament fibers by the usage of appropriate storage media. The choice of an ideal storage medium is essential for maximum preservation of traumatized periodontal ligament fibers of avulsed teeth; this also decides the success of the replanted tooth and long-term prognosis. A number of natural and synthetic storage mediums have been studied till date. This review discusses some recent additions in storage media for avulsed teeth. It reviews the characteristics of some less discussed storage media, which would help us to increase awareness among the health-care workers and broaden their horizon. This would, in turn, help them in reducing extraoral dry time of the avulsed tooth in case of emergencies. This review mainly focuses on less commonly discussed storage media for avulsed teeth and the effect of different properties of these media on their efficacy. Keywords: Avulsion, prognosis, replantation, storage medium
How to cite this article:
Venugopal M. Recent advances in transport medium for avulsed tooth: A review. Amrita J Med 2022;18:37-44 |
| Highlight of the Study | |  |
- This review gives an insight into newer alternatives of storage media that are not widely discussed in literature.
- Knowing a wide range of storage media will help in minimizing extraoral time, which is critical for the prognosis of avulsed teeth.
- Properties of different storage media and its effect on viability help to choose appropriate storage media.
| Introduction | | |
Traumatic injuries to teeth and the associated parts are a very common dental problem among children and adolescents throughout the world. Among traumatic tooth injuries, avulsion is considered the most serious because it causes complete exarticulation of the tooth from the socket.[1]
The incidence of avulsion is between 1% and 16% among all types of dental injuries that involve permanent dentition. The most common avulsion is seen between the ages of 7 and 10 years; the reason may be attributed to excessive involvement in outdoor games, which is the characteristic of this age, and their carefree behavior, leading to more frequent injuries.[2]
The two main consequences of the avulsed tooth are attachment damage and pulpal infection. Pulpal infection occurs due to severe damage to the neurovascular supply of the tooth, leaving the tooth nonvital. Also, the periodontal fibers are pulled apart from the socket, leaving them dehydrated. For better prognosis of the replanted tooth such that the replanted tooth is maintained for a longer period in the oral cavity, the remaining periodontal ligament (PDL) cells on the root surface should remain viable and the integrity of the root cementum should be maintained. The bacterial contamination of the root surface should be prevented. All this is possible only by minimizing the extraalveolar time.[3]
Ideally, the exarticulated tooth should immediately be replanted after avulsion to prevent dessication of PDL fibers. However, it is difficult most of the times. A storage media to prevent further damage and to retain the properties of the remaining structures appears to be inevitable during this period.[4]
The complications of the replanted tooth, inflammatory resorption, replacement resorption, and subsequent ankylosis can be prevented to a large extent by the use of an ideal storage medium during the time elapsed before replantation. The ideal storage medium should have the capability of maintaining the vitality of the remaining root surface PDL fibers. Preservation of the remaining PDL cells aids the cell through the process of mitosis and forms clones of the damaged fibroblasts, which will play a vital role in the success of the replanted tooth.[5]
It is difficult to control factors needed for the success of replantation in most of the situations and studies have shown that it can be achieved to some extent with educational programs on traumatic injuries and the importance of storage media for the avulsed tooth. It is essential to create awareness among the general public, health-care workers, especially those working around schools, sports academies, and grounds where most of these injuries occur. A positive attitude should be installed so as to obtain successful treatment.[2] In the literature, a lot of studies have been conducted on storage media such as saliva, milk, and Hank’s balanced salt solution. This review focuses on the current research and studies of few less commonly discussed storage media and highlights their characteristics.
[TAG:2]Ideal Requirements of Transport Media[6],[7][/TAG:2]
Easily available and economical.
Good shelf life.
The cellularity of the remaining PDL should be preserved so that new cells can be generated.
Adherence of osteoclasts to the PDL fibers should be minimized.
Should be capable of reducing inflammatory reactions and root resorption.
Antioxidant property to protect the damage of the cells from oxidative radicals.
For optimal cell growth, osmolarity should be similar to body fluids (290–300 mosmol/ kg) and pH (7.2–7.4).
Chilled storage media below 37oC has been shown to improve extraalveolar storage.
Should not react with body fluids.
Prevent any antigen–antibody reaction.
Different climates and conditions should not reduce its efficiency.
Capable of removing toxic products.
Helps in restoring depleted PDL cells.
Classification of Transport Media[7]
Characteristics of Commonly Used Transport Media[8]
| Newer Transport Medias | | |
Coconut water
Coconut water or tender coconut water is a natural drink available biologically and hermetically inside the hard shell of coconut. It is pure and hygienic and there is no contamination present. It can act as a plasma substitute, because it closely resembles intracellular fluid than extracellular plasma. Coconut water also substitutes sugars, fluids, and electrolytes that are lost from the body and this is regarded as a magic drink. These properties can be utilized for storage of an avulsed tooth. Moreira-Neto et al.[9] compared different storage medias; the coconut water group demonstrated significantly more viable PDL cells than Hank’s balanced salt solution (HBSS) and milk, which is usually considered ideal. There are a few studies that showed that the tooth maintained in coconut water caused inflammatory resorption. Therefore, further studies are recommended before its commercial use as a storage media for the avulsed tooth.[10],[11]
Green tea extracts
Green tea is a widely consumed beverage throughout the world and has become very popular lately due to its antioxidant properties. The most important component of green tea is Epigallocatechin-3-gallate, a polyphenol. The excellent antioxidative, anti-inflammatory, antimicrobial, and antiviral properties of green tea extract (GTE) is the reason for considering it as storage media. It is also seen to prolong allograft survival. Even though the osmolality and pH were not found ideal to be used as a storage medium, interestingly many studies showed that GTE had the best ability for storage of the avulsed tooth, which can be accredited to its anti-inflammatory and antimicrobial properties.[12],[13]
Egg white
Egg white has an osmolality between 251 and 298 mOsm/kg and pH of 8.6–9.3. Sousa et al.[14] showed that teeth stored in milk and egg white had comparable results with respect to collagen fibers organization and the number of viable cells. Due to high pH, loss of cell viability was seen over time and loss of cell viability may also be attributed to the presence of several egg proteins acting as foreign bodies.
Salvia officinalis extract
Salvia officinalis extract contains essential oil and has antimicrobial and antioxidant properties. Oxygen radicals and oxygen tension have been reported to modulate osteoblastic and osteoclastic activities. It is believed that oxidative damage may promote root surface resorption via toxic effects by enhancing resorptive activity of clastic cells and that media containing antioxidants might increase replantation success. The antioxidant effects of S. officinalis are due to its phenolic constituents, namely rosmarinic acid, camosic acid, and salvianolic acid and its derivatives. According to studies, S. officinalis and HBSS were found to have similar effects on PDL cells’ viability at 1–3 h; however, at 24 h, S. officinalis was found to be notably better than HBSS. Thus, S. officinalis can also be considered as a storage medium.[6],[7]
Soy milk
Soy milk is extracted from soybean. It contains only a small amount of saturated fatty acid and is free of cholesterol and lactose. It is used as a culture medium for cell growth and biochemical activities. It was also seen in recent studies that soy milk promoted the viability of PDL fibers, which is almost equivalent to HBSS and milk and can act as a potential media for storing the avulsed tooth.[15]
Morusrubra (Red mulberry)
The contents of morusruba are flavonoids, alkaloids, polysaccharides, and antioxidants favoring cell preservation. In maintaining the viability of PDL cells, it was comparable to that of HBSS. It was also found to keep periodontal fiber cells viable even for a longer period of storage, but the concentration of fruit extract had to be increased. However, it is not locally available and more studies are needed to establish its biological properties.[15],[16]
Emdogain
Emdogain can be considered for storage media, as it is commonly used in periodontal surgeries. It is seen to be effective in the healing of PDL fibers. Even though in periodontal surgeries emdogain was seen to improve the recovery of PDL fibers, periodontal healing after traumatic injuries such as avulsion was doubtful with emdogain and further studies are needed to confirm the same. Delay in the development of replacement resorption, which is the most common reason for the failure of replanted teeth, was appreciated with emdogain but it could not prevent resorption. Regeneration of injured periodontal tissues was not achieved on its own by emdogain.[17]
Propolis
Propolis is a resinous substance used by bees for thermally insulating, sealing, and protecting the hive against microorganisms and is formed by tree exudates mixed with floral sap, salivary bee secretions, wax, and pollen. The main constituents of propolis are polyphenols, flavonoids, phenolic acids, esters, phenolic aldehydes, and ketones. An in vitro study by Ozan et al.[18] suggested that propolis has antimicrobial, anti-inflammatory, and antioxidant properties and the study concluded that propolis extract was more effective than milk and HBSS in maintaining PDL cells. A study by Martin and Pileggi[19] showed that PDL cell viability was highest in propolis when compared with milk, saline, or HBSS. However, the availability of propolis locally is not practical and hence its use as a storage medium is questionable.[20]
Gatorade
Gatorade can be considered for the storage of the avulsed tooth, as it is a common sports drink used for rehydration and readily available at sports centers where most of the injuries take place. The pH of gatorade is 2.91, and osmolality 407 is mOsm/kg.[4] Because of its unfavorable pH and osmolality, cell growth was impossible and studies showed that the remaining cells were damaged when stored for a longer period. However, Gatorade is better than tap water in preserving viable cells and can only be considered for a short time if other media are not available.[21]
Contact lenses solutions
They are essentially saline solutions with antimicrobial properties and therefore can be considered for storage media. Preservatives present in these solutions can be harmful to PDL cells and, hence, not recommended.[22]
Ricetral
Ricetral contains glucose and vital salts and is an oral rehydration formula. The PDL cell viability was evaluated by Rajendran et al.[23] on extracted human teeth. The PDL cell viability was found to be similar to HBSS and better than milk. However, there are not much studies on the efficiency of ricetral and, hence, more research is necessary before its commercial use.
ViaSpan
ViaSpan is a medium for organ transportation. The osmolality is 320 mOsm/kg and pH is 7.4. According to a study by Hiltz and Trope,[24] the vitality of fibroblasts was found to be comparable to HBSS and milk. It has shown superior properties as a long-term storage medium. High cost, refrigeration, short expiration date, and unavailability to public make its use as a storage media for the avulsed tooth difficult.
Eagle’s medium
Eagle’s medium contains glutamine, penicillin, streptomycin, nystatin, and calf serum. Preservation of PDL fibroblasts of the avulsed tooth for a longer period of time before reimplantation was satisfactory with Eagle’s medium. It acts by the proliferation of the PDL cells. According to the study by Pohl et al.,[25] cell viability of PDL was preserved when stored in Eagle’s medium for almost 48 h. Its availability at the trauma site does not seem to be practical, but it can be used for the tooth auto-transplantation procedure. However, more in vivo studies are required.
The supplementation of Eagle’s medium with growth factors and antibiotics showed better results. Dulbeco’s storage medium is a variation of Eagle’s medium. It contains vitamins and amino acids around four times and glucose around two to four times when compared with the regular formulation. It also contains iron and phenol red. However, its availability to the general public is questionable.[26]
Honey milk
Honey milk contains proteins, carbohydrates, natural honey calcium, phosphorous and minerals, and solid milk with no fat. It can be stored for almost six months without refrigeration. Honey milk can be considered ideal for storage media, as it has a good shelf life and it is comparable to HBSS and milk. However, more studies are needed before its commercial use.[7]
Dentosafe
Dentosafe contains a special cell culture medium and it is the commercial name given to a tooth rescue box. It contains amino acids, vitamins, and glucose. The shelf life is 3 years if unopened. In a study by Pohl et al.,[27] functional healing was seen when avulsed teeth were placed in Dentosafe solution. It is highly recommended that at all the places where the incidences of avulsion are common, such as schools, sports grounds, as well as ambulances, dentosafe must be included along with the emergency kit. The use of dentosafe is simple as well as easily understandable to the common man. This medium is very effective but it is still not easily available in many countries.
Probiotic solution
Probiotics are living microorganisms, principally bacteria that have beneficial effects on human health, beyond basic nutrition. Different studies have shown that probiotic may be comparable to HBSS, milk as a storage media.[28],[29]
Growth factors
Growth factors can be supplemented in storage medium to function as potent biological mediators that can help in the promotion of PDL regeneration. Studies have shown that growth factor supplementation in storage median improved the effectiveness of the media when it is stored for a longer period.[26]
Casein phosphopeptides
Casein phosphopeptides is a non-fluoridating remineralizing agent. It contains 80% of protein. It prevents demineralization and helps in the remineralization of tooth enamel. HBSS is the best storage medium till date, and milk is considered the next best alternative. Hence, milk proteins individually can be considered as an option for transport medium. They contain nutritional proteins and growth factors. The osmolarity and pH is physiologic; they also have a low bacterial content due to pasteurization and, hence, can be efficient as a storage media.[3]
Patient’s own serum
The patient’s own serum can be used as storage medium. The tooth stored in serum had been shown to have viable PDL fibers during the time lapse between avulsion and replantation. When the histologic picture of the avulsed tooth that was stored in serum was studied, the tissues stained well, indicating a viable periodontal membrane.[26]
Catalase supplementation
Antioxidants can be used as supplements along with storage medium, as they are seen to significantly reduce surface resorption of the root. A few media containing hydrogen peroxide may be toxic to PDL cells and the addition of an antioxidant such as catalase can have beneficial effects on PDL cells.[30]
Custodiol
Custodiol is used as a preservation solution for organ transplantation. Its composition is similar to that of extracellular fluid. It has an osmolality of 310mOsmol. The preservation of cells when the avulsed tooth was stored in custodial was found to be equally efficient as HBSS. The availability of custodial to the public as a storage media for the avulsed tooth remains questionable.[31]
Conditioned medium
Conditioned medium is the supernatant of human gingival fibroblasts that are cultivated in culture media. It contains growth factors, extracellular matrix proteins, and metabolites, which could have a stimulatory effect on root surface cells of the avulsed tooth. It has shown to be a good medium for the storage of dogs’ teeth. It is not readily available at an accident site and hence cannot be considered of much use as a storage medium.[26]
Euro-Collins
Euro-Collins solution is mainly used in organ transplantation. It is a hypothermal medium. Studies on a dog’s avulsed teeth showed comparable results with the immediate replanted tooth. They also showed good repair of supporting tissues, vessels, and periodontal fibers and neoformation of the cementum. The high cost and difficult availability limit its use only in special cases, such as tooth auto-transplantation procedures and laboratory studies.[32]
Powdered milk
Powdered milk can act as an alternative to milk and major disadvantages with milk, spoiling of the milk can be avoided. Powdered milk is similar to bovine milk in terms of all their properties and is considered as a more practical medium when the tooth is considered for replantation. Till date, various other milk substitutes have already been proposed for use as storage medium as they have shown to maintain the PDL cell viability.[33]
Pomegranate
Pomegranate is a remarkable fruit with exceptional medicinal value contained in its juice, peel, and seeds. It has potent antioxidant, anticarcinogenic, and anti-inflammatory properties.[34] Fibroblast cell proliferation was shown in a study by Transsoli-Hojjati et al.[35] At lower concentrations of 1% and 2.5%, proliferative effects were observed for 1 h; however, at higher concentrations such as 5% and 7.5%, general proliferative effects were exhibited. Cell attachment was seen to be stronger in pomegranate juice. Pomegranate juice and HBSS exhibited comparable results in the preservation of a spindle-like morphology of periodontal fiber 24 h after storage. Further research is recommended to understand the role of pomegranate juice as storage media.
Aloe vera
Aloe vera is a cactus plant with medicinal value. It has tapered leaves that are filled with a transparent gelatinous substance. It is rich in vitamins, enzymes, minerals, sugars, salicylic acids, and amino acids.[36]Aloe vera has anti-inflammatory, antioxidant, antibacterial, antifungal, and anticarcinogenic properties. The antioxidant property is considered to help in the preservation of the viability of PDL cell fibers.[37] Badaksh et al.[38] studied aloe vera at a concentration of 10%, 30%, and 50% and reported that it was comparable to supplemented culture media for up to 9 h and superior to egg white. Hence, aloe vera can be considered a storage medium.
Rice water
Rice water was a common energy drink in olden days due to its high nutritious value. It has high potassium, niacin, thiamin, iron, and zinc content and low sodium content. Due to all these properties, it was considered a storage medium. It aids in the prevention of acute inflammation and also helps in collagen synthesis. Studies on different storage media showed that rice water retained high amounts of live PDL cells even after 30 min; due to the high nutritive content of the rice water, an increase in the number of viable PDL cells was noticed.[39]
Dragon’s blood sap
Dragon’s blood sap is a medicinal plant. Dragon’s blood sap has anti-inflammatory, healing, anticancer, antimycotic, antiviral, antifungal, antibacterial, and antioxidant properties. Evidence about its efficacy in preserving the viability of PDL fibers is still lacking. However, its capability to induce osteogenesis, mineralization followed by bone formation was reported. Its use has been suggested for a variety of treatment in the oral cavity, such as oral cancers, herpes, and postoperative healing after implants, in periapical lesions. A study by Martins et al.[40] showed efficacy of the sap in the preservation of the integrity of different cell membranes. It also had the potential to maintain PDL cell viability.[41]
Cranberry (Vaccinium macrocarpon)
Cranberry is regarded as a super fruit and has been used in the treatment of scurvy, gastrointestinal disorders, and urinary tract infections. It also prevents Helicobacter pylori bacteria adhesion onto the gastric mucosa. Cranberry was seen to be effective in viral diseases and cardiovascular diseases. Colonization of dental surfaces by streptococcal bacteria can also be prevented by the use of cranberry. When extraalveolar time interval was less, the reduction in the number of viable cells was seen to be minimal and it was able to preserve a considerable amount of viable cells even when extraalveolar time was prolonged.[42]
Basil (Tulsi) Ocimum sanctum
Basil leaves have been used since centuries as a medicinal plant. The suggestion for its use as a storage medium may be attributed to the high content of phenolic compounds. It also contains phytochemicals such as flavonoids, tannins, terpenoids, and saponins in the leaves and the stem. Basil leaves have high antioxidant, anti-inflammatory, antifungal, and antibacterial properties due to the presence of anion radicals. Further studies are needed before making them available for commercial use.[43]
Mimusops elengi (Bakul)
The antimicrobial, anti-inflammatory, analgesic, and antipyretic properties of bakul have been known since a long time and these properties have been used to treat conditions such as arthritis, bronchitis, skin diseases, and diabetes. In the oral cavity, it has been used for treating bleeding gums. Studies have been done to determine its efficacy as a storage medium. The results showed that the pH and osmolality of the prepared solution was not favorable for the growth of the PDL cells. Hence, its use as a storage media was dismissed.[44]
Psidium guajava
Psidium guajava, commonly known as guava, is a fruit and is also considered to have medicinal properties. Its use is recommended in gastroenteritis, diarrhea, dysentery, rheumatic pain, wounds, ulcers, respiratory disturbances, miscarriages, scabies, and sore throats. Its use has also been suggested for dental pain and gingivitis. Guava leaves showed cell proliferative capacity and also maintained viable PDL cells.[42]
Prunus domestica
Another fruit, Prunus mume (plum), has been used in Chinese medicine. It is shown to have antimicrobial and anti-inflammatory properties against oral pathogens. Prunus domestica showed an increase in the cell viability of PDL fibers even after a 3-h interval, suggesting that it might have a proliferative capacity and can be used as a storage medium, but more studies may be required.[42]
Castor oil
Castor oil is derived from the seeds of the plant Ricinus communis. Castor oil is a vegetable oil with a distinct taste. It has antimicrobial and antioxidant properties, low toxicity, and glutathione preservation capability. Another advantage is its low cost and easy availability. This substance has been used as a suitable medium for the storage of rat lenses and it has also shown the capacity to repair bone defects. Its use for storage of the avulsed teeth can be considered. A study was designed by Nabavizadeh et al.[45] to investigate the potency of castor oil in preserving the PDL cells’ viability. Results showed that castor oil was not able to preserve the viability of PDL cells efficiently when compared with HBSS and milk.
| Research on Newer Storage Media | | |
Ascorbic acid
Ascorbic acid is a newer material that can be considered as a potential storage medium. Ascorbic acid causes the stimulation of osteoblasts, which further result in the formation of Type I collagen fibers on the surface of the PDL. Ascorbic acid also increases alkaline phosphatase activity, which is vital for the binding of PDL cells to Type 1 collagen; hence, it can improve the life of the replanted teeth when used as a storage medium.[46]
Levodopa
Secretion of the growth hormone from the pituitary gland is stimulated by Levodopa. Levodopa augments the healing process. According to a study by Partovi et al.,[47] when used as a storage medium, levodopa has shown a local effect on human PDL cells, aids in the growth of cells, and can have an impact on avulsed teeth.
Cryoprotective agents
The success of chilled milk over other medium is already known, so the effect of other low-temperature storage media on reimplantation has been studied. When the effects of the cryopreserving agents, 5% and 10% dimethyl sulfoxide and 10% glycerol, was studied by Schwart and Andreasen,[48] it was seen that these agents when used under controlled freezing temperature helped in the preservation of PDL of reimplanted teeth.
| Conclusion | | |
The best storage media for the avulsed tooth when comparing their efficacy as per literature include Eagle’s culture medium = ViaSpan = Euro-Collins = Custodiol = HBSS > Milk ≥ Propolis ≥ Green tea ≥ Egg > coconut water ≥ Ricetral.[16]
The literature till date suggests, when comparing the practicality, cost-effectiveness, and ease of availability to the general public, that milk seems to be the most ideal transport medium for the avulsed tooth. The patient’s own serum seems to be an ideal storage media for tooth autotransplant procedures.[8],[49]
However, it is important to consider the circumstances of the accident, the location while suggesting an appropriate transport medium for the avulsed tooth especially in case of emergencies.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]
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