Title	Hank’s Balanced Salt Solution is a Better Interim Medium than Milk for Avulsed Teeth
Clinical Question	After a complete tooth avulsion, is the likelihood of replantation increased when the tooth is stored in a proprietary medium as compared to milk?
Clinical Bottom Line	Hank’s Balanced Salt Solution (HBSS), sold under the trade name Save-A-Tooth, maintains the viability of PDL cells longer and increases the likelihood of replantation of an avulsed tooth better than any other interim storage medium. HBSS is easy to use for a layman. While superior to milk, HBSS is currently not as readily available as milk when most accidents occur, thus milk is the next best alternative.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 23211073 Udoye/2010 56 articles Systematic Review of Case Studies Key results Search limited to 1981-2010 and English language. Hank’s Balanced Salt Solution (HBSS) is the only medium that can replenish metabolites in depleted PDL cells. HBSS preserves viability of PDL cells for up to 24 hours, while milk does so for 1 hour. HBSS resulted in more PDL cells to remain attached after 72 hours than milk. 21904590 Brullmann/ 2010 6 articles Systematic Review of Case Studies Key results Search limited to 2000-2010 and patients age 6-17. Tooth rescue boxes have been shown to allow for replantation after 24 hours. The public’s and physicians’ knowledge on storage medium of avulsed teeth are abysmally unsatisfactory. Tooth rescue boxes should be a part of every first aid kit that will primarily be used to treat children and adolescents. The use of storing teeth in milk is less ideal than Hank’s Balanced Salt Solution, but if it is the only viable option then one should use UHT milk.
Evidence Search	("Tooth Avulsion"[Mesh]) AND "Hanks Balanced Salt Solution" [Supplementary Concept]
Comments on The Evidence	Both articles were systematic reviews. The Brullmann article limited their search to case studies of a specific patient range. The Udoye article reviewed a broader range articles while maintaining the specific goal of finding the ideal interim transport medium. Although both articles are systematic reviews that identified their search criteria, they can only be regarded as low level evidence since they both utilize case studies. The highest ethical level of research attainable for this in vivo PICO question is only at the case study level. Higher levels of research can be found if the clinical outcome is excluded from the PICO question.
Applicability	This information applies to not only dentists, but also to the general public. Tooth avulsion caused by trauma is a common occurrence in school-aged children. According to the National Youth Sports Safety Foundation, about 3 million teeth per year are avulsed during youth sporting events. According to a 2002 study by the UNC Endodontic department, tooth avulsion accounts for 1-11% of all traumatic injuries to the permanent dentition, most frequently involves the maxillary central incisor, and the most often involved age group is 7-10 years. HBSS sold in the U.S. under the trade name Save-a-Tooth, has a shelf life of 2 years and should be standardized in first aid kits. The cost per storage kit is around twenty dollars, and will save years of expensive dentoalveolar rehabilitation and emotional distress for a child. There has been extensive research conducted to show that HBSS is the gold standard in tooth preservation, however, there is a glaring deficiency in the knowledge that laymen and physicians have regarding it’s availability and applicability. Milk and water are generally utilized, because they are the most readily accessible items. However, water storage will hasten the failure rate of replantation, and milk is only suitable if it itself is stored correctly.
Specialty	(Public Health) (Endodontics) (General Dentistry) (Pediatric Dentistry) (Dental Hygiene)
Keywords	Avulsion, Hank's Balanced Salt Solution, Interim Transport Medium
ID#	2463
Date of submission	03/03/2013
E-mail	JacobJ@livemail.uthscsa.edu
Author	Jerin J. Jacob
Co-author(s)
Co-author(s) e-mail
Faculty mentor	Erica Teixeira, DDS, PhD
Faculty mentor e-mail	TeixeiraE@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available