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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 45-49

GC Tooth Mousse Plus: A potential storage media for avulsed teeth


Department of Pedodontics and Preventive Dentistry, Yenepoya Dental College, Yenepoya University, Mangalore, Karnataka, India

Date of Web Publication2-Jun-2016

Correspondence Address:
Sham S Bhat
Department of Pedodontics and Preventive Dentistry, Yenepoya Dental College, Yenepoya University, Deralakatte, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.183347

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  Abstract 

Context: Avulsion injury is a severe form of dental trauma. Due to the complexity of this injury, the neurovascular supply is severely compromised and usually results in the loss of pulp vitality. A variety of factors can influence the success of replantation especially the storage media and storage period. Casein phosphopeptides are derived from casein which accounts for 80% of the total protein in bovine milk. They can function as carriers for several minerals especially calcium and also have known to have antibacterial properties. Aim: The purpose of this study is to evaluate the efficacy of GC Tooth Mousse Plus in comparison with chilled Homogenous pasteurized whole milk as a storage media. Materials and Methods: Thirty healthy premolars that are extracted for orthodontic purpose will be divided into three groups: (1) Group A: Control (Saline), (2) Group B: Positive control (Chilled Homogenous milk), (3) Group C: Experimental (GC Tooth Mouse Plus). These groups were further divided into two subgroups, each indicating storage period of 30 min and 60 min. The periodontal ligament (PDL) cell viability will be checked using tryphan blue staining. Results: Data were analyzed using Student's t-test. Conclusion: GC Tooth Mousse Plus can be used as a storage media to prevent desiccation of PDL cells up to the duration of 60 min.

Keywords: Avulsed teeth, GC tooth mousse, storage media


How to cite this article:
Hegde SK, Bhat SS, Sargod SS, Rao A, Hegde N. GC Tooth Mousse Plus: A potential storage media for avulsed teeth. Arch Med Health Sci 2016;4:45-9

How to cite this URL:
Hegde SK, Bhat SS, Sargod SS, Rao A, Hegde N. GC Tooth Mousse Plus: A potential storage media for avulsed teeth. Arch Med Health Sci [serial online] 2016 [cited 2019 Sep 16];4:45-9. Available from: http://www.amhsjournal.org/text.asp?2016/4/1/45/183347


  Introduction Top


Avulsion injury is one of the most severe types of traumatic dental injuries, characterized by complete displacement of tooth from the alveolar socket.[1] Following avulsion, periodontal ligament (PDL) tissues are injured, and the vessels and nerves of the pulp rupture at the apical foramen which, in turn, leads pulp tissue to undergo necrosis.[2] The reported incidence of avulsion ranges from 1% to 16% of all traumatic injuries of the permanent dentition.[3]

In the case of avulsion, the main goal is to achieve success in replantation by avoiding or minimizing two possible complications: PDL damage and pulpal infection. Although it has been shown that the ideal treatment of avulsion injury is immediate replantation, this can rarely be achieved.[1] PDL cells can be expected to survive a dry time of 15 min or less [4] but are unlikely to survive a dry time of >60 min.[5] Thus, teeth that have been kept dry for >15 min, but <60 min still pose a treatment problem.[1]

When a tooth is avulsed, the PDL is ruptured or split with some remaining attached to the alveolar bone and some remaining attached to the tooth root. A cascade of healing response follows, and fibroblasts are critical for repair. Increases in the formation and differentiation of fibroblasts have been documented.[6] PDL fibroblasts account for almost a quarter of the PDL cells. The progenitor cells responsible for producing fibroblast phenotypes are located adjacent to vascular channels of PDL cells and alveolar bone.[7] This is closely related to the preservation of a viable mixed population of PDL cells that adhere to the roots of avulsed teeth. The pattern of healing may be repaired with scarring, which is characterised by replacement resorption, or regeneration of PDL tissues with normal function.[6],[8]

The extra-alveolar storage conditions affect the viability of the PDL cells.[9] Immediate replantation of avulsed teeth impacts positively on the viability of PDL cells and results in PDL healing in up to 85% of mature teeth.[2] This is attributed to such factors as the emotional state of the victim and witnesses, knowledge of the appropriate actions to take, the proximity of the scene to a dentist or dental clinic, as well as consent issues.[10] Where replantation is not feasible, the extra-alveolar conditions may be modified by storing the tooth in a physiological storage medium.[11] The use of such media has been associated with favorable healing outcomes.[12]

The storage medium may be defined as a physiological solution that closely replicates the oral environment to help preserve the viability of PDL cells following avulsion.[13] Several storage media have been proposed for the purpose of transporting teeth following avulsion. The ideal storage medium should preserve cell vitality, adherence, and clonogenic capacity and it should be readily available or easily accessible at the site of an accident.[4]

The use of an inappropriate medium potentially increases the risk of cell necrosis, which will then lead to ankylosis and replacement resorption of the tooth root. Both the pH and the osmolality of the storage medium are more important than the chemical composition. Optimal cellular growth is reported to occur at an osmolality of 290-300 mosmol/kg and at a pH between 2.2 and 7.4.[14] Air-drying should be avoided as this leads to cell death and storing the tooth in isotonic liquids is better than dry storage.[15]

Various storage media such as saliva, saline, milk, tap water, physiologic culture media, submucosa, plastic wrap, cryopreservatives, and organ transplant media have been suggested for maintaining the viability of the PDL.[9]

Many studies have been carried out in the search of the most suitable storage media for avulsed teeth. The tested storage media include saliva, tap water, saline, milk, Hank's balanced salt solution (HBSS), Viaspan, and culture medium. Today, there is good evidence that supports the use of HBSS as the most suitable transport medium as it may help reduce replacement resorption by the maintenance of a normal PDL. If HBSS is not available, milk is reported to be the best alternative. The efficacy of milk in maintaining PDL cell viability can be attributed to several factors such as the presence of nutritional proteins and growth factors, physiologic osmolarity, pH buffering system, and the low bacterial content due to pasteurization process.[1]

None of the milk proteins has been tested individually regarding their possible usage as a transport medium. Casein phosphopeptides (CPP) are derived from casein, which accounts for 80% of the total protein in bovine milk. They can form soluble organophosphate salts and may function as carriers for different minerals, especially calcium.[1]

The aim of this study was to evaluate the efficacy of GC Tooth Mousse Plus (CCP-amorphous calcium phosphate [ACP] with fluoride) in comparison with chilled Homogeneous pasteurized whole milk as a storage media.


  Materials and Methods Top


Inclusion criteria

  • Healthy premolars that were atraumatically extracted for orthodontic purposes.


Exclusion criteria

  • Infected carious teeth.


Materials

  • Thirty freshly extracted healthy premolars.
  • 0.9% Saline.
  • Dulbecco's Modified Eagles' Medium (DMEM).
  • GC Tooth Mousse Plus.
  • Chilled homogenous pasteurized milk.
  • Trypan blue.


Methodology

Thirty freshly extracted premolars were divided into three groups, which were further divided into three subgroups:

  • Group 1: 0.9% saline (control).


    • Group 1A: 5 premolars kept for 30 min.
    • Group 1B: 5 premolars kept for 60 min.


  • Group 2: Chilled milk (positive control).
    • Group 2A: 5 premolars kept for 30 min.
    • Group 2B: 5 premolars kept for 60 min.


  • Group 3: GC Tooth Mousse Plus (experimental group).


    • Group 3A: 5 premolars kept for 30 min.
    • Group 3B: 5 premolars kept for 60 min.


For all the groups the same procedure was followed only with variation in time and media. The freshly extracted premolar was placed in 1 g of the desired media for the required period in a sterile container. The premolar was then washed with DMEM, and with the help of a lacron's carver, the root of the premolar was scrapped off to obtain the PDL cells. The lacron's carver was sterilized in an autoclave prior to use. 100 µl of the cell suspension was obtained with the help of a micropipette to which 100 µl of Trypan blue stain was added. The viable cells were counted using a neubauers chamber under the light microscope.

Statistical analysis

The obtained data were analyzed using Student's t -test.


  Results Top


Group 1 (control): In the 30 min group, it was found that 70% of the cells were viable and in the 60 min group 67.95% (±1.85) were viable.

Group 2 (positive control): In the 30 min group, it was found that 98% (±0.41) of the cells were viable and in the 60 min group 97.2% (±0.61) were viable.

Group 3: (experimental group): In the 30 min group, it was found that 96% (±1.53) of the cells were viable and in the 60 min group 94.9% (±1.73) were viable.

Comparing the saline group with milk and mousse group, there was statistical significance found in the percentage of viable cells present.

Comparing the milk and mousse group, there was no statistical significance found in the percentage of viable cells present.


  Discussion Top


Immediate replantation is the recommended treatment for an avulsed permanent tooth,[2] to minimize the risk of postreplantation resorption of either an inflammatory or a replacement nature.[16] However, owing to the various associated factors such as the person's conscious state, lack of first aid knowledge, informed consent issues it is not always feasible to replant the tooth immediately.[17] Thus, an extra-alveolar time interval before replantation always exists before the patient arrives at the dental office. This leads to desiccation of the root surface, increasing the risk of loss of vitality of the PDL cells.[2]

A variety of factors such as age of the individual, width and length of the root canal, stage of root development, mechanical damage during trauma and replantation, type of splinting, mastication, treatment of the socket, endodontic treatment, antibiotics, time of replantation, macroscopic contamination, storage media, and storage period are important and can influence the clinical success of replantation.[18]

In a clinical set-up, a medium should possess certain properties to make it an acceptable storage medium for avulsed teeth. These properties are:[18]

  • Antimicrobial characteristics.
  • Maintenance of the viability of periodontal fibers for an acceptable period.
  • Favors proliferative capacity of the cells (clonogenic and mitogenic capacity).
  • The same osmolarity as that of body fluids (pH balanced).
  • Unreactive with body fluids.
  • Does not produce any antigen-antibody reactions.
  • Reduces the risk of postreimplantation root resorption or ankylosis.
  • Good shelf life.
  • Effective in different climates and under different conditions.
  • Should wash off extraneous materials and toxic waste products.
  • Should aid in the reconstitution of depleted cellular metabolites.


Milk has been studied extensively and has gained acceptance as a medium capable of maintaining PDL viability.[19],[20] Because of its physiological osmolarity, composition, and markedly fewer bacteria, milk is a superior storage medium.[21] The nutritive value of milk and the presence of growth factors in milk are considered to be the contributing factors.[18] Some evidence supports the use of chilled milk as an interim storage medium for avulsed teeth. Avulsed teeth stored in chilled milk for up to 1 h can maintain sufficient numbers of viable PDL cells to support replantation of the tooth and the possibility of PDL healing.[18]

DMEM is a modification of Basal Medium Eagle that contains a four-fold higher concentration of amino acids and vitamins, as well as additional supplementary components. The original DMEM formula contains 1000 mg/L of glucose and was first reported for culturing embryonic mouse cells. Eagle's medium at 37°C is a recommended storage medium as it can preserve the PDL for extended periods before replantation.[18]

Cvek et al . found that a tooth stored in normal saline for 30 min showed less resorption than a tooth stored dry for between 15 and 40 min. However, unlike HBSS, milk and egg white, normal saline contains no nutrients and Lauer et al . showed that physiologic salt solution was unable to maintain the metabolism of the fibroblasts. Udoye et al . showed that normal saline was a poor medium, lacking metabolically essential ions and glucose required by PDL cells.[15]

In this study, it was found that in the when chilled milk was used as a storage medium the percentage of viable cells it was found that there were 98% (±0.41) and 97.2% (±0.61) for 30 and 60 min respectively. This finding suggests that chilled homogeneous pasteurized milk can be used as a storage media for up to 60 min.

The protein fraction of milk contains many valuable components and biologically active substances. Moreover, milk proteins are precursors of many different biologically active peptides which are inactive within the sequence of the precursor protein but can be released by enzymatic proteolysis. Many milk protein-derived peptides, such as casein phosphopeptides, reveal multifunctional bioactivities. Casein phosphopeptides can form soluble organophosphate salts and may function as carriers for different minerals, especially calcium. Furthermore, they have been shown to exert cytomodulatory effects. Cytomodulatory peptides inhibit cancer cell growth, or they stimulate the activity of immunocompetent cells and neonatal intestinal cells.[22]

In the study group of CCP-ACP with fluoride, it was found that there were 95% (±1.53) and 94.9% (±1.73) for 30 and 60 min, respectively. The pH of CPP-ACP was found to be 7.37, which is similar to the pH of the oral cavity thereby promoting a favorable environment to maintain the vitality of the cells. These findings suggest that there is a possibility of using GC tooth mousses Plus (CPP-CCP with fluoride) as a storage media.

Cehreli et al . demonstrated that lower concentrations of CPP-ACP can be effective in maintaining cell viability in vitro . Indeed, stronger dilution of CPP-ACP was effective on both the viability and the morphology of the L929 cells, as the 108 and 1012 dilution groups demonstrated similar fibroblastic morphology and apoptotic response as with the control group.[1]


  Conclusion Top


From the findings of this study, it can be concluded although milk is a better storage media as compared to saline and GC Tooth Mousse Plus. GC Tooth Mousse Plus can be considered as storage media to prevent desiccation of PDL cells up to the duration of 60 min. However, further research is required must be conducted with an increased duration of time to elucidate the benefits of CPP-ACP Plus as an appropriate storage media.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cehreli SB, Gurpinar AO, Onur AM, Dagli FT. In vitro evaluation of casein phosphopeptide-amorphous calcium phosphate as a potential tooth transport medium: Viability and apoptosis in L929 fibroblasts. Dent Traumatol 2008;24:314-9.  Back to cited text no. 1
    
2.
Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors 4. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995;11:76-89.  Back to cited text no. 2
    
3.
Andreasen JO. Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1,298 cases. Scand J Dent Res 1970;78:329-42.  Back to cited text no. 3
    
4.
Donaldson M, Kinirons MJ. Factors affecting the time of onset of resorption in avulsed and replanted incisor teeth in children. Dent Traumatol 2001;17:205-9.  Back to cited text no. 4
    
5.
Trope M. Clinical management of the avulsed tooth: Present strategies and future directions. Dent Traumatol 2002;18:1-11.  Back to cited text no. 5
    
6.
McCulloch CA, Bordin S. Role of fibroblast subpopulations in periodontal physiology and pathology. J Periodontal Res 1991;26(3 Pt 1):144-54.  Back to cited text no. 6
    
7.
Lekic P, McCulloch CA. Periodontal ligament cell population: The central role of fibroblasts in creating a unique tissue. Anat Rec 1996;245:327-41.  Back to cited text no. 7
    
8.
Kenny DJ, Barrett EJ. Pre-replantation storage of avulsed teeth: Fact and fiction. J Calif Dent Assoc 2001;29:275-81.  Back to cited text no. 8
    
9.
Patel S, Dumsha TC, Sydiskis RJ. Determining periodontal ligament (PDL) cell vitality from exarticulated teeth stored in saline or milk using fluorescein diacetate. Int Endod J 1994;27:1-5.  Back to cited text no. 9
    
10.
Andreasen JO, Borum MK, Andreasen FM. Replantation of 400 avulsed permanent incisors 3. Factors related to root growth. Endod Dent Traumatol 1995;11:69-75.  Back to cited text no. 10
    
11.
Courts FJ, Mueller WA, Tabeling HJ. Milk as an interim storage medium for avulsed teeth. Pediatr Dent 1983;5:183-6.  Back to cited text no. 11
    
12.
Mackie IC, Worthington HV. An investigation of replantation of traumatically avulsed permanent incisor teeth. Br Dent J 1992;172:17-20.  Back to cited text no. 12
    
13.
Ingle JI, Bakland LK, Baumgartner JC. Ingle's Endodontics. 6th ed. Hamilton, ON: B.C. Decker Inc.; 2008.  Back to cited text no. 13
    
14.
Blomlöf L. Milk and saliva as possible storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J Suppl 1981;8:1-26.  Back to cited text no. 14
    
15.
Udoye CI, Jafarzadeh H, Abbott PV. Transport media for avulsed teeth: A review. Aust Endod J 2012;38:129-36.  Back to cited text no. 15
    
16.
Cvek M, Granath LE, Hollender L. Treatment of non-vital permanent incisors with calcium hydroxide 3. Variation of occurrence of ankylosis of reimplanted teeth with duration of extra-alveolar period and storage environment. Odontol Revy 1974;25:43-56.  Back to cited text no. 16
    
17.
Hamilton FA, Hill FJ, Mackie IC. Investigation of lay knowledge of the management of avulsed permanent incisors. Endod Dent Traumatol 1997;13:19-23.  Back to cited text no. 17
    
18.
Malhotra N, Cyriac R, Acharya S. Clinical implications of storage media in dentistry: A review. ENDO (Lond Engl) 2010;4:179-88.  Back to cited text no. 18
    
19.
Sigalas E, Regan JD, Kramer PR, Witherspoon DE, Opperman LA. Survival of human periodontal ligament cells in media proposed for transport of avulsed teeth. Dent Traumatol 2004;20:21-8.  Back to cited text no. 19
    
20.
Ashkenazi M, Marouni M, Sarnat H. In vitro viability, mitogenicity and clonogenic capacity of periodontal ligament cells after storage in four media at room temperature. Endod Dent Traumatol 2000;16:63-70.  Back to cited text no. 20
    
21.
Trope M, Chivian N, Sigurdsson A, William FV. Traumatic injuries. In: Cohen S, Burns RC, editors. Pathways of Pulp. 8th ed. 11830, Westline Industrial Drive, St Louis, Missouri 63146: Mosby; 2002. p. 603-50.  Back to cited text no. 21
    
22.
Meisel H, FitzGerald RJ. Biofunctional peptides from milk proteins: Mineral binding and cytomodulatory effects. Curr Pharm Des 2003;9:1289-95.  Back to cited text no. 22
    



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