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Dental Avulsion

Question Type:
Intervention
Full 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 (eating, speech), color of the tooth (O)?
Consensus on Science:
We did not identify any evidence to address the important outcomes of infection rate, pain, malfunction, and cosmetic outcome. Egg White (I) Compared With Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 2 randomized studies(Khademi 2008, 25; Ahangari 2013, 244) with 10 extracted teeth in each study, showing benefit in 1 study(Khademi 2008, 25) (MD, 91.80; 95% CI, 90.53–93.07 for cell viability after 1 hour of immersion; MD, 90.00; 95% CI, 87.87–92.13 for cell viability after 2 hours of immersion) and not showing any benefit in the other study(Ahangari 2013, 244) (MD, −4.03; 95% CI, −10.39 to 2.33 for cell viability after 1 hour of immersion; MD, 15.74; 95% CI, −9.76 to 41.24 after 3 hours of immersion). Ricetral (I) Compared With Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 randomized study(Rajendran 2011, 217) with 20 extracted teeth, showing benefit (MD, 44.3; 95% CI, 12.82–75.78) for cell viability after 45 minutes of immersion. Coconut Water (I) Compared With Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 randomized study(Gopikrishna 2008, e61) with 30 extracted teeth, showing benefit (MD, 339.4; 95% CI, 331.65–347.15) for cell viability after 45 minutes of immersion. Lactobacillus reuteri Solution (I) Compared With Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 observational study(Caglar 2010, 383) with 12 extracted teeth, but the MD for cell viability was not estimable (median difference 116 000). Saliva and Thereafter Hank’s Balanced Salt Solution (I) Compared With Saliva and Thereafter Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 observational study(Lekic 1998, 137) with 10 extracted teeth. The study found a lower MD for cell viability (MD 1% lower) after 30 minutes and a higher MD (MD, 2.4% higher) after 60 minutes, but the CI was not estimable. Saliva (I) Compared With Saliva and Thereafter Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 observational study(Lekic 1998, 137) with 10 extracted teeth. The study found a lower MD for cell viability (MD, 8.4% lower after 30 minutes, 2% lower after 60 minutes), but the CI was not estimable. Eagle’s Medium (aMEM) (I) Compared With Saliva and Thereafter Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 observational study(Lekic 1998, 137) with 10 extracted teeth. The study found a higher MD for cell viability (MD, 5% higher after 30 minutes, 12.5% higher after 60 minutes), but the CI was not estimable. EGCG (Epigallocatechin-3-Gallate) (I) Compared With Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 randomized study(Chen 2012, 158) with 20 extracted teeth, showing no benefit (MD, 0.1; 95% CI, −0.09 to 0.28) for cell viability after 2 hours of immersion. Tap Water (I) Compared With Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 observational study,(Pileggi 2002, 186) but the MD for cell viability was not estimable (mean percentage of 45.17±12.03 SD for intervention group compared with the mean percentage of 90.59±3.77 SD for control group). Propolis 10% (I) Compared With Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 randomized study(Ahangari 2013, 244) with 10 extracted teeth, showing benefit for cell viability after 1 hour of immersion (MD, 14.73; 95% CI, 9.53–19.93), and for cell viability after 3 hours of immersion (MD, 45.33; 95% CI, 21.73–68.93). Propolis 50% (I) Compared With Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 2 randomized studies(Martin 2004, 85; Ahangari 2013, 244) with 24 and 10 extracted teeth, showing benefit for cell viability after 45 minutes of immersion (MD, 1 192 290; 95% CI, 720 274.12–1 664 305.28), for cell viability after 1 hour of immersion (MD, 13.96; 95% CI, 4.9–23.02), and for cell viability after 3 hours of immersion (MD, 29.36; 95% CI, 2.37–56.35). Propolis 100% (I) Compared With Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 randomized study(Martin 2004, 85) with 24 extracted teeth, showing benefit for cell viability after 45 minutes of immersion (MD, 1 077 710; 95% CI, 266 920.68–1 888 499.32). Phosphate Buffered Saline (I) Compared With Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 randomized study(Doyle 1998, 221) with 10 extracted teeth, showing no benefit for cell viability after 30 minutes of dry time followed by a 15-minute immersion (MD, 8.31; 95% CI, −0.09 to 16.71), but showing benefit for cell viability after both 60 minutes (MD, 8.76; 95% CI, 4.03–13.49) and 90 minutes of dry time (MD, −5.17; 95% CI, −9.93 to −0.41) followed by a 15-minute immersion. Saline (I) Compared With Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 randomized study with 24 extracted teeth(Martin 2004, 85) showing no benefit for cell viability after 45 minutes of immersion (MD, −143 540; 95% CI, −210 604.01 to −76 475.99). We identified very-low-quality evidence (downgraded for indirectness and imprecision) from 1 observational study(Patel 1994, 1) with 24 teeth in which benefit for cell viability was not shown after 2 hours of immersion (MD, −161 000; 95% CI, −362 186.91 to 40 186.91). We identified very-low-quality evidence (downgraded for indirectness and imprecision) from 2 other observational studies(Pileggi 2002, 186; Caglar 2010, 383) in which the MD for cell viability was not estimable (median difference 376 000; mean percentage of 77.8±2.92 SD for intervention group versus mean percentage of 90.59±3.77 SD for control group). For the critical outcome of viability (periodontal healing), we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 observational study(Werder 2011, 312) with 25 avulsed teeth showing no benefit (RR, 0.99; 95% CI, 0.48–2.04). For the critical outcome of success of reimplantation (replacement resorption and extraction due to replacement resorption), we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 observational study(Werder 2011, 312) with 25 avulsed teeth showing no benefit (RR, 1.07; 95% CI, 0.33–3.46; and RR, 0.89; 95% CI, 0.09–8.50, respectively). Hank’s Balanced Salt Solution (I) Compared With Milk (C) For the critical outcome of viability, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 4 randomized studies(Gopikrishna 2008, e61; Khademi 2008, 25; Rajendran 2011, 217; Ahangari 2013, 244) including 10 to 30 extracted teeth, showing benefit for cell viability after 45 minutes of immersion (MD, 261.13; 95% CI, 249.7–272.56),(Gopikrishna 2008, e61-65) for cell viability after 45 minutes of immersion (MD, 64.2; 95% CI, 32.59–95.81),(Rajendran 2011, 217) for cell viability after 1 hour of immersion (MD, 93.4; 95% CI, 91.81–94.99),(Khademi 2008, 25) for cell viability after 2 hours of immersion (MD, 89.8; 95% CI, 87.95–91.65),(Khademi 2008, 25) and for cell viability after 3 hours of immersion (MD, 25.59; 95% CI, 1.13–50.05).(Ahangari 2013, 244) We identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 3 studies(Martin 2004, 85; Chen 2012, 158; Ahangari 2013, 244) that did not show benefit for cell viability after 45 minutes of immersion (MD, 22 090; 95% CI, −64 812.53 to 108 992.53(Martin 2004, 85); MD, 0.85; 95% CI, −9.31 to 7.61(Ahangari 2013, 244); MD, 0.05; 95% CI, −0.16 to 0.25(Chen 2012, 158)). We identified very-low-quality evidence (downgraded for indirectness and imprecision) from 1 study, from which the MD for cell viability was not estimable (mean percentage of 87.04±5.7 SD for intervention group versus mean percentage of 90.59±3.77 SD for control group).(Pileggi 2002, 186) Another’s Saliva (I) Compared With Storage in the Patient’s Mouth (C) For the critical outcome of viability (pulpal healing), we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 observational study(Andreasen 1995, 59) with 10 avulsed teeth, showing no benefit (RR, 1; 95% CI, 0.08–11.93). Saline (I) Compared With Saliva (C) For the critical outcome of viability (pulpal and periodontal ligament healing), we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 2 observational studies(Andreasen 1995, 59; Andreasen 1995, 76) with 24 and 66 avulsed teeth, showing no benefit (RR, 0.6; 95% CI, 0.18–1.97 for pulpal healing and RR, 0.67; 95% CI, 0.21–2.15 for periodontal ligament healing). Storage in Another Person’s Mouth (I) Compared With Storage in the Patient’s Mouth (C) For the critical outcome of viability (periodontal ligament healing), we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 observational study (Andreasen 1995, 76) with 18 avulsed teeth, showing no benefit (RR, 1; 95% CI, 0.27–3.96). Dentosafe Box Compared With Milk For the critical outcome of viability (periodontal healing), we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 observational study(Werder 2011, 312) with 24 avulsed teeth showing no benefit (RR, 1.33; 95% CI, 0.74–2.40). For the critical outcome of success of replantation (replacement resorption and extraction due to replacement resorption), we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 observational study(Werder 2011, 312) with 24 avulsed teeth showing no benefit (RR, 0.40; 95% CI, 0.06–2.87 and RR, 1.00; 95% CI, 0.11–9.44, respectively).
Treatment Recommendation:
We suggest the use of Hank’s Balanced Salt Solution, propolis, egg white, coconut water, or ricetral in comparison with whole milk as a temporary storage solution for an avulsed tooth that cannot be immediately reimplanted (weak recommendation, very-low-quality evidence). The order of priority for tooth storage is listed in Table 4. We suggest the use of whole milk in comparison with saline as a temporary storage solution for an avulsed tooth if none of the above solutions are available (weak recommendation, very-low-quality evidence). There is insufficient evidence for or against temporary storage of an avulsed tooth in saliva compared with alternative solutions. Values, Preferences, and Task Force Insights In making this recommendation, we recognize that survival of an avulsed tooth requires that it must be reimplanted as soon as possible, but this procedure may not be possible in the first aid setting. The use of a suitable temporary storage solution for an avulsed tooth should not delay efforts at reimplantation, but it may aid in the survival of the tooth before reimplantation. No treatment recommendation was formulated regarding the use of phosphate-buffered saline (PBS) as a storage solution, as in the PBS study there was a dry time from 60 to 90 minutes, which is not representative of a typical situation. However, this could be relevant for settings where it is not possible to immediately store the tooth in a storage solution.
CoSTR Attachments:
20150108_Dental avulsion_GRADE table.pdf    
20150326_Dental avulsion_CoSTR.pdf    

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