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Every tooth is connected to its surrounding bone by the periodontal ligament, through which teeth receive nourishment. When teeth are avulsed, they end up on an artificial surface—the floor, the ground or material like carpeting. When picking up a tooth, grasp it by the enamel on the crown, as finger pressure on the root cells will cause cell crushing. For the same reasons, the method for transporting the knocked-out teeth must be carefully selected. The type of container in which the teeth are stored has an additional potential root cell-crushing possibility. Normally, metabolizing tooth root cells have an osmolality (concentration) of 280–300 mOs and a pH of 7.2. Water and ice, although appealing to common sense, have actually been shown to damage tooth root cells.5 The reason for this is that the osmolality (concentration) and pH of water and ice are low.
Placing the tooth in the saliva under the accident victim’s tongue has been recommended; however, saliva as a storage medium is twice as problematic. Milk has been also recommended as a storage medium for avulsed teeth, because it has a compatible osmolality and it is thought to be readily available.
Dental research has shown that the amount of root damage can be reduced by soaking the teeth in an HBS for 30 minutes prior to replantation, with teeth showing 50% less root damage following replantation.7 It has also been shown that keeping the teeth cold while in the HBS does not affect success. Although some dentists advise that the best treatment for an avulsed tooth is immediate replantation, a variety of reasons make this difficult for EMTs. For all of the above reasons, EMS should have an optimum storage device available in every ambulance. There is a commercially available product—Save-A-Tooth—that fulfills all of the requirements for safe storage and preservation of knocked-out teeth and is accepted by the American Dental Association for this use.8 This product contains a removable basket and net that suspends knocked-out teeth to allow for debridement and atraumatic removal. Having optimum storage devices available for knocked-out tooth storage will prepare EMTs for every contingency and will provide dentists with the best possible condition for the replantation procedure. We recognize that you may have an emergency situation arise and we will do our best to respond to your problem promptly. If the situation is not that severe, but one where you wish to contact us, please call us and the doctor will be in touch with you either directly or through office personnel as soon as possible.
The bite is this photo is of unknown origin and may well be a staph infection rather than a spider bite. Cleaning the ambulance between patients is as important as wearing gloves for helping to prevent the spread of MRSA. When a tooth is knocked out, this ligament is stretched and splits in half: Half stays on the tooth root and half on the socket wall.
When the knocked-out teeth arrive for replantation, the dentist is faced with the difficult task of removing them from the container. When there is an uninterrupted blood supply, all of the metabolites and glucose that the cells require are provided.
When a knocked-out tooth is placed in water, the cells attempt to equalize with the surrounding environment and burst. Its low osmolality causes bursting, and the normal flora of microorganisms in saliva severely infects the tooth root. However, like physiologic saline, it lacks the necessary metabolites and glucose for normal cell physiology.6 In addition, milk is not usually readily available in an ambulance.



The best known and most extensively tested is Hank’s Balanced Solution (HBS), which has all of the metabolites like Ca, P04, K+ and glucose that are necessary to maintain normal cell metabolism for long periods of time.
Since a cell that has been cut off from its blood supply depletes its stored metabolites after 15 minutes, a tooth that has been extra-oral for one hour has 45 minutes fewer vital cells to reconnect with the bone ligament cells. First, the accident victim may have other more serious injuries that require immediate attention. In the event of a severe situation, or one in which you are in doubt, go immediately to the emergency room of the nearest hospital and ask them to contact our office. There is a possibility of death in some poisonous spider bites, but as a group they are much more likely to be colossally annoying than fatal. Those hairy tarantula-size monsters that crawled around on Indiana Jones are teddy bears compared to a black widow.4   There are known to be only two medically significant species of spider in the United States. The Internet is full of brown recluse bite "victims" vigorously defending their homegrown diagnoses without suitable specimens to identify. In many cases, the prehospital assessment and history will provide the best clues for a diagnosis. The most common cause of spider-bite-looking skin lesions is methicillin-resistant Staphylococcus aureus (MRSA).
Using gloves has always been the standard, but only required on patients when contact with bodily fluids is likely.
Laundering uniforms outside the home is probably the best way to prevent bringing your work home with you.
If these two halves can be kept alive, the tooth can be replanted, the ligament halves will reattach and the tooth will remain vital. Since the cells remaining on the tooth root are delicate, additional trauma to the tooth root cells must be avoided to prevent more root cell crushing.
Placing them in glass or cardboard containers care are also potentially damaging to the cells.
If the tooth was retrieved from a muddy or dirty accident site, such as a grass field or sand, the solution in which it is transported will become murky and opaque, making it difficult for the dentist to see.
When the tooth is knocked out, however, the normal blood supply is cut off and, within 15 minutes, most of the stored metabolites have been depleted and the cells begin to die. Second, as already mentioned, the teeth are often covered with debris that must be washed (not scrubbed) off with a physiological solution.
Ever since purveyors of urban myth discovered e-mail and YouTube, recluse spiders (also known as brown recluses, brown spiders or Loxosceles spiders) are blamed for almost all lesions of unknown origin.2 We even get calls to 9-1-1 for "spider bites" from patients who are, in reality, suffering from some sort of inflammation that has nothing to do with spiders. Definitively identifying a brown recluse is too difficult for the average healthcare provider and should be left to the professional arachnologist. The desire to know what causes such lesions is so strong, it concocts recluse spiders where none exist. We have the unique opportunity to talk to patients in their natural habitats, and the observations we make there often lead to much clearer histories.   When ruling out causes of abdominal pain, take clues from the patient's home environment. Local reactions suspected to be bites should still be treated as possibly infectious, just in case. 2006 Annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS).
Reports of envenomation by brown recluse spiders exceed verified specimens of Loxosceles spiders in South Carolina.


Clinical presentation and treatment of black widow spider envenomation: A review of 163 cases. The epidemiology, syndromic diagnosis, management, and prevention of spider bites in the South. Arachnids submitted as suspected brown recluse spiders (Araneae, Sicariidae): Loxosceles spiders are virtually restricted to their known distributions but are perceived to exist throughout the United States. Reports of presumptive brown recluse spider bites reinforce improbable diagnosis in regions of North America where the spider is not endemic.
Common house spiders are not likely vectors of community-acquired methicillin-resistant Staphylococcus aureus infections. Skin lesions in barracks: Consider community-acquired methicillin-resistant Staphylococcus aureus infection instead of spider bites. Environmental contamination due to methicillin-resistant Staphylococcus aureus: Possible infection control implications.
If a lesion is noticed, asking the patient about it will likely result in the patient saying it's "just a spider bite." That is likely not the case.
With the amount of MRSA contamination found in ambulances, wearing gloves for any patient contact is not unreasonable.11   Just wearing gloves is not enough, however. In the hospital, gowns and scrubs regularly become contaminated through common nursing procedures.10 There's no reason to think an EMS jumpsuit is any less contaminated unless precautions are taken to prevent contact with patients and environments where colonization of MRSA is suspected.
Since the half that stays on the socket wall remains connected to the bone’s blood supply, it is naturally kept alive (see Figure 1). In addition to the potential damage that the hard surface can cause, glass containers have the added possibility of breakage or leakage of the physiologic storage fluid. If multiple teeth are knocked out, EMTs won’t know into which socket an individual tooth belongs. A clean, uncluttered home is less likely to harbor spiders than the alternative.4 Ask the patient about activities that may have resulted in a spider bite.
However, the ligament cells that remain on the tooth’s root must be artificially maintained and protected from two potentially destructive processes: cell crushing and loss of normal cell metabolism.
If he can’t clearly see the tooth and has to feel blindly for it with his fingers or dental forceps, he may inadvertently crush the root cells.
The patient may have other injuries, such as a severely lacerated lip or gum that prevent easy visualization of the socket. Working in dark, out-of-the-way places is likely to bring patients in contact with black widows or other arachnids.
If the knocked-out teeth are placed in a carton of milk, for example, there would be no other recourse for retrieving them except by spilling out the milk.
Finally, the patient may be in severe pain and may not allow replantation of the teeth into the sockets. Transferring that contamination to the next patient in the back of that ambulance would be easy if surfaces aren't cleaned between patients.



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