Socket to Survival: Narrative Insights into Storage Media for Avulsed Teeth

Socket to Survival: Narrative Insights into Storage Media for Avulsed Teeth

Dr Mahantesha T 1, Dr Gyapona J Kalita *2, Dr Hridya M Menon 3, Dr Suresh B S 4, Dr Nischitha Naik 5, Dr Vijayendra V Kamath 6

 

  1. Professor, Department of pediatric and preventive dentistry, Subbaiah Institute of Dental sciences, Shivamogga.
  2. Postgraduate, Department of pediatric and preventive dentistry, Subbaiah Institute of Dental sciences, Shivamogga.
  3. Reader, Department of pediatric and preventive dentistry, Subbaiah Institute of Dental sciences, Shivamogga.
  4. Head of department, Professor, Department of pediatric and preventive dentistry, Subbaiah Institute of Dental sciences, Shivamogga.
  5. Reader, Department of pediatric and preventive dentistry, Subbaiah Institute of Dental sciences, Shivamogga.
  6. Assistant Professor, Department of pediatric and preventive dentistry, Subbaiah Institute of Dental sciences, Shivamogga.


*Correspondence to: Dr Gyapona J Kalita, Postgraduate, Department of pediatric and preventive dentistry, Subbaiah Institute of Dental sciences, Shivamogga.


Copyright

© 2026: Dr Gyapona J Kalita. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 19 January 2026

Published: 01 February 2026

DOI: https://doi.org/10.5281/zenodo.18453275

 

Abstract:

Dental avulsion, the complete displacement of a tooth from its socket, represents the most severe form of traumatic dental injury due to extensive damage to supporting structures. Immediate replantation is ideal, as extra-oral time is a critical determinant of treatment success and long-term prognosis. Effective management protocols must prioritize the viability of pulp and periodontal ligament (pdl) cells, as an unsuitable transport or storage medium significantly increases the risk of pdl cell necrosis, leading to complications like ankylosis and replacement resorption. Therefore, an informed selection of an appropriate storage medium is essential for a favourable outcome. This review aims to assess various available storage media, highlighting their advantages and disadvantages to identify optimal approaches for periodontal tissue preservation.

Keywords: Dental Avulsion; Periodontal Ligament; Storage media; Traumatic Dental Injuries; Hank's balanced salt solution (hbss); saline; milk; egg white; coconut water; propolis; Replacement Resorption.

Socket to Survival: Narrative Insights into Storage Media for Avulsed Teeth

Introduction

Traumatic dental injuries refer to damage to the teeth, gums, jaws, lips, or surrounding oral soft tissues.[1] Among tdi’s, avulsion is considered one of the most severe forms as it signifies the complete exarticulation of a tooth from its socket caused by trauma, accounting for about 0.5–3% of all dental injuries.[2] The outlook for an avulsed tooth is greatly affected by the immediate treatment given after the injury. If immediate reimplantation cannot be performed, the avulsed tooth must be preserved in a suitable storage solution to maintain cellular health.[3]

A storage medium is defined as a biocompatible solution designed to mimic the oral environment and maintain the survival of periodontal ligament (PDL) cells after avulsion.[4] An ideal storage medium should maintain cellular integrity, possess antimicrobial features to reduce infection risk, and be easily accessible and affordable for emergencies.[5]

This review highlights the importance of awareness and education regarding storage media, examines the advantages and limitations of various options, and emphasizes the role of dental professionals in disseminating knowledge to improve outcomes in avulsion cases.

 

Methods

A literature review was conducted using PubMed/Medline, Lilacs, BBO, and SciELO databases to assess pdl cell viability following storage of avulsed teeth in different transportation/storage media. The search focused on English-language research articles, reviews, and laboratory studies (animal and human cell counting) published between 2000 and 2024, using the keywords: tooth avulsion, tooth replantation, transportation medium, storage medium, and natural storage media.

 

Types of storage media

The type of storage medium used following avulsion affects the prognosis of tooth replantation. As a result of the critical role of these storage media, an informed choice of a suitable medium is essential for successful replantation.

Naturally available

A) Saliva

Avulsed teeth can be temporarily stored in saliva to keep them from drying out. Weine claims that the best immediate transport medium for an avulsed tooth is the patient's own saliva.

  1. pH is 7.4-7.79
  2. Osmolality 60-70 mOsm/kg
  3. Shelf life is less than 30-60 min

Adavantage:  Immediate Accessibility

Disadvantage:

  • Saliva is easily accessible, it can be employed as a storage medium for a brief amount of time 
  • Decreased osmolality (6070 mOsm/kg), which damages PDL cell membranes and induces edema makes it less acceptable as a storage medium

According to a study done by Lekic et al PDL cells from avulsed teeth kept in saliva for 30 minutes had a clonogenic capacity of 7.6%, and after 60 minutes, it was 1.5%.7

B) Tap water

Inadequate features of tap water, such as bacterial contamination, hypotonicity and non-physiological pH, and osmolality, promote the lysis of pdl cells.

  1. pH is 7.4-7.79
  2. Osmolality 30 mOsm/kg
  3. Shelf life is less than 15-30 min

Advantage: Easily available

Disadvantage: Tap water has low osmolality of 30 mOsm/kg causing cellular swelling due to hypotonicity.

A Study done by Blomlof et al discovered that, in contrast to saliva and milk, keeping cultured human pdl cells in tap water for one hour resulted in more PDL cell damage.8

C) Milk

Since milk is readily available in practically every circumstance, it is the most practical transport medium for the shortterm storage of avulsed teeth. Vitamins and amino acids are present in milk which can deactivate enzymes that are detrimental to pdl cells.

  1. pH is 6.5-6.8
  2. Osmolality 275 mOsm/kg
  3. Shelf life: It loses its effectiveness after 2 hours

Advantage: Milk is a suitable preservation medium for the avulsed tooth for the reasons listed below:

  1. Pasteurized milk has far fewer microorganisms and offers vital nutrients
  2. Milk's capacity to sustain pdl cell viability is impacted by its fat content.

Disadvantage: Despite being widely accessible, it is uncommon in athletic settings where teeth avulsions could occur.

  • A study by Moura CC et al. compared longlife whole milk and skim milk with pHadjusted coconut water and soy milk and found that longlife whole milk and skimmed milk had fewer PDL viability. 9
  • In a study by Pearson et al., the ability of various milks to sustain the vitality of human periodontal ligament cells on avulsed teeth was compared to that of whole milk. At two hours, it was discovered that milk substitutes outperformed whole milk by a significant margin.[10]

D) Coconut water

A naturally occurring, sterile, and physiologically pure product is coconut water. Proteins, vitamins, minerals, and amino acids are all abundant in it. extensively used to replenish electrolytes (potassium, calcium, and magnesium) and fluids.

  1. pH is 5-5.4
  2. Osmolality 288-378 mOsm/kg
  3. Shelf life: 1- 2 hours

Adavantage:

  • Easily Available and Low Cost

Disadvantage: Following avulsion, the tooth must remain inside the coconut's shell; once it is visible, the liquid rapidly loses much of its nutritional and organoleptic properties and starts to ferment.

  • It was discovered by Ali S. et al. that 100% mature coconut water was superior to 50% dilutions made from either young or mature coconuts.[11]
  • Gopikrishna et al. found that coconut water maintained noticeably more viable periodontal ligament cells.[12]

E) Propolis

Bees utilize propolis, a multipurpose substance, to build and maintain their hives. Resin makes about 55% of its composition, followed by essential oils and wax (30%), pollen (5%), and miscellaneous components (10%).

  1. pH is 5-6.5
  2. Osmolality 280-360 mOsm/kg
  3. Shelf life: 1- 2 year

Advantage: Anti-inflammatory, antibacterial, antioxidant, antifungal, and tissue-regenerative properties are among its many biological activities. Relatively non toxic.

Disadvantage: In a dog experiment, Casarato et al. found that in replanted teeth preserved in propolis, replacement resorption cannot be stopped.

  • Khademi et al. found that 10% propolis was more effective than a 20% solution and more effective than milk, HBSS, tap water, and dmem [13]
  • Thomsson et al. found that, when compared to cells kept in hbss, milk, or saline, propolis cells had the greatest variability.[14]

F) Egg white

Because of its high protein, vitamin, and water content, lack of microbial contamination, and ease of access, egg white is regarded as an excellent option for storage media for teeth undergoing delayed replantation. 

  1. pH is 8.6–9.3
  2. Osmolality 258 mOsm/kg
  3. Shelf life: 10 hours

Advantage: It is readily available

Disadvantage: Egg white as a storage medium suffers the setback of impracticality.

  • De Sousa et al.'s microscopic investigation revealed no distinction in the maintenance of pdl cell viability on avulsed teeth between milk, egg white, and artificial saliva. 15
  • Khademi et al. in order to stop inflammatory resorption in his study extracted thirty teeth from three dogs that had received endodontic treatment. Teeth were kept in egg white for six to ten hours were said to be more successfully repaired than those that were kept in milk. 16

G) Green tea

Green tea is a popular beverage which has many health benefits, mainly due to the presence of polyphenols that contribute to green tea's antiinflammatory and antibacterial properties, such as epicatechin, epigallocatechin, epicatechin gallate, epigallocatechin gallate, epigallate, and catechin.

  1. pH is 6.6-7.8
  2. Osmolality 87 mOsm/kg
  3. Shelf life: 24hrs – freshly made, 6-12 months commercially

Advantage:

  • It is readily available
  • Adans et al. claim that epigallocatechin gallate has a greater ability to encourage positive reimplantation than hbss and can be employed effectively as a storage medium. 17

Disadvantage:

Because of its low osmolality, which can cause pdl cells to die, commercially available green tea is not a good choice for storing avulsed teeth.

Studies:

  • Green tea produced good outcomes, according to Hwang et al. and Jung et al., maintaining 90% cell viability for up to 24 hours, which was comparable to the HBSS control. 18, 19 

H) Pomegranate juice (punica granatum)

Pomegranates are regarded as "pharmacy unto itself" in ayurvedic treatment. It is a remarkable fruit whose juice, skin, and seeds all have full medicinal properties.

  1. pH is 7
  2. Osmolality 282 mOsm/kg
  3. Shelf life: 6-24 hours

Advantage: It encourages robust cell adhesion and possesses powerful anti-inflammatory, anti-carcinogenic, and antioxidant qualities 

Disadvantage: Its efficacy is very less, further research is needed for its role as a storage media

In their investigation, Tavassoli et al. came to the conclusion that pomegranates have an impact on the proliferation of fibroblast cells.At six hours, the greatest improvement in cell viability is seen. 20

I) Aloe vera

Aloe vera is a member of the Liliaceae family and resembles a cactus. The remaining 1-2% of the gel is composed of active ingredients such as aloesin, acemannan, aloeride, naftoquinones, amino acids, and vitamins, while the remaining 98-99% of the gel is composed of water.

  1. pH is 4.5-5
  2. Osmolality 280-300 mOsm/kg
  3. Shelf life: upto 9 hours

Advantage: Naturally Available and Cost effective

Disadvantage: Accessibility

Pattamapun et al. in his study found that the pdl fibers close to the cementum of the tooth preserved in aloe vera were thicker and more intact than those of other teeth. 21

J) Emdogain

Emdogain is a gel made from the matrix proteins of fetal pig tooth enamel, primarily amelogenins It is an enamel matrix derivative, a specialized biomaterial that is sold commercially and is mainly used to encourage the regeneration of missing periodontal tissues.

  1. pH is 7.4-7.7
  2. Osmolality 300 mOsm/kg
  3. Shelf life: 2 years when stored at 2°C – 8°C

Advantage: Delay the development of replacement resorption

Disadvantage: Failure to prevent replacement resorption and regenerate the damaged periodontal tissues.

  • Studies as storage media is quite less
  • In their 2001 study, Iqbal and Bamaas et al. examined histological characteristics and concluded that the emdogain group had a higher incidence of healed pdl than the control group. [22]
  • Fridström et al. (2008) came to the conclusion that emdogain would still be useful for a straightforward healing process following replantation if there were better circumstances surrounding the storage medium and/or extra-oral time. [23]

K) Red mulberry (morus rubra)

The red mulberry tree, or Morus rubra as it is technically known, is indigenous to North America.Flavonoids, alkaloids, polysaccharides, and antioxidants that support cell preservation are among its constituents.

  1. The ph is 4.3-5.0
  2. Osmolality is 280-300 mOsm/kg
  3. Shelf life is 24 hrs

Advantage:

  • It has antioxidant and anti-inflammatory property,

Disadvantage:

  • It has low pH, so it may cause cell lysis.
  • Not easily available.

According to a Study by Ozan et al the effectiveness of 4.0% and 2.5% M. rubra at 3, 6, and 12 hours was found to be considerably better than hbss (P <.05) 24

L) Soy milk

Soybeans are used to make soy milk. It is free of lactose and cholesterol and has a very low content of saturated fat. It serves as a culture medium for biological reactions and cell division.

  1. The ph is 7.0 – 7.4,
  2. Osmolality is 258 mOsm/kg
  3. Shelf life: 90% viability noted after 24hrs

Advantage: Easily available.

Disadvantage:

Its allergic reaction has been well-known. Specific studies are needed to verify its overall physiological compatibility and efficacy.

Silva et al.'s investigation revealed that soymilk's capacity to sustain viability was comparableto that of hbss and milk.[25]

M) Honey

Medicinal Value of honey to treat wounds and a variety of illnesses, such as aphthous ulcers, stomach ulcers, and chronic coughs was utilized in the ancient times.

  1. The ph is 6.07
  2. Osmolality is 280 mOsm/kg
  3. Shelf life 6 months

Advantage:

  • Antibacterial property.
  • Easily Available and Cost Effective

Disadvantage:

It can cause cell lysis and it has a lower pH. • Because pure honey has a high viscosity and hyperosmolarity, making it unsuitable for cell preservation, "honey milk" is utilized instead of pure honey.

A study by Sheth et al. found that honey seems to be just as effective as hbss at storing avulsed teeth for up to six hours. [26]

N) Salvia officinalis

Salvia officinalis, commonly referred to as sage extract, possesses antioxidant and antibacterial qualities in addition to essential oil.

  1. ph is 7-7.4
  2. Osmolality is lesser than 280 mOsm/kg