Question: Among adults and children with an avulsed permanent tooth (P), does storage of the tooth in any solution prior to replantation (I) compared with storage in whole milk or the patient’s saliva (C) change success of replantation, tooth survival or viability, infection rate, pain, malfunction (eg, eating, speech), or color of the tooth (O)?

Results: Eight studies were identified comparing the success of replantation and survival in Hank’s balanced salt solution (4), propolis (2), egg white (2), coconut water (1), Ricetral (1), saline (2), or phosphate-buffered saline (1) compared with whole milk. Based upon the available data, early immersion in Hank’s balanced salt solution, propolis, egg white, coconut water, Ricetral, whole milk, saline, or phosphate-buffered saline is beneficial (in order of preference). There is insufficient evidence for or against temporary storage of an avulsed tooth in saliva compared with alternative solutions. There was no evidence to address the important outcomes of infection rate, pain, malfunction, and cosmetic outcome.

Discussion: An avulsed tooth constitutes a dental emergency and can result in permanent loss of the tooth. Tooth survival is dependent on early replantation. Previous recommendations state that the tooth should be placed in a variety of storage media in situations that do not allow for immediate replantation. Based upon current data, rapid assistance with replantation should be sought. The use of a particular storage medium should depend upon availability and should not delay efforts at replantation.

Recommendation: If a tooth cannot be immediately replanted, the preferred storage medium is Hank’s balanced storage solution (weak recommendation, very-low-quality evidence). Whole milk is preferred to saline solution as a temporary storage solution (weak recommendation, very-low-quality evidence).

Note from Dr. Sztajnkrycer: The dental guidelines assume an ideal world in which Hank’s balanced salt solution is available to first-aid providers, especially in a remote setting in which immediate replantation is not a viable option. While there was insufficient evidence supporting the use of saliva as a temporary medium, there was also insufficient evidence against this. Whole milk is also an option.

“Nine studies showed benefit from repeat administration of epinephrine, while a single study demonstrated no difference in resolution of symptoms when comparing one dose versus two doses. None of these studies specifically addressed adverse effects or complications from multiple epinephrine doses.”

ANAPHYLAXIS (FA 500)
Recommendation Author: Eric C. Funk, MD
Dr. Funk is a member of the emergency medicine residency training class of 2017 at the Mayo Clinic School of Graduate Medical Education/Mayo Clinic.