Orofacial Soft-Tissue Injuries

Assessment follows standard trauma principles, starting with the airway and breathing, then bleeding, which can be brisk given the rich blood supply of the mouth. A bleeding or swelling tongue or floor of mouth can threaten the airway and makes the injury an emergency. Every mouth injury should be explored for foreign bodies, and teeth are the key concern: a tooth or fragment that cannot be found may be embedded in the wound or, more seriously, have been inhaled, so if aspiration cannot be excluded, chest imaging should be considered, and a soft-tissue view if it may be lodged in the lip. Look for the injuries that travel together: avulsed or fractured teeth, which are covered on the dental trauma page, a facial fracture, and concussion or a head and neck injury. A laceration of the gum overlying the jaw may signal an open fracture. Check and update tetanus status.

The decision to repair, and whether to refer, then follows from the site and pattern of the laceration.

The lip has one landmark that governs how a laceration is managed: the vermilion border, the sharp line where the red lip meets the facial skin. The eye readily detects even a small step in this line, so a laceration that crosses the vermilion border needs precise realignment of the border, and unless the clinician is confident and experienced this is a reason to refer to the emergency department, maxillofacial or plastic surgery for repair.

A simple laceration that does not cross the vermilion border can be repaired in the usual way, closing the inner lining with an absorbable suture and the skin with a fine suture. A through-and-through laceration, which passes from the skin through the muscle into the mouth, is repaired in layers, and antibiotic prophylaxis is considered rather than automatic, guided by contamination, a bite mechanism, delayed closure, immunosuppression and local antimicrobial guidance. Before any repair, explore the wound for tooth fragments, and use a regional nerve block rather than injecting into the lip itself, which distorts the anatomy and makes aligning the border harder.

The tongue has a generous blood supply and heals quickly, so many tongue lacerations do not need suturing and settle on their own. Repair is reserved for a laceration that will not otherwise heal well: one that is large and gaping at rest, that keeps bleeding or threatens the airway, that involves the tip or the edge and would heal with a split or a notch, or that has a substantial flap. A through-and-through injury does not by itself always require suturing; the decision rests on these features. Repair uses absorbable sutures, and because holding and suturing the tongue is difficult and often distressing, particularly in a child, these are frequently referred. Always inspect for broken teeth first.

Inside the mouth, most lacerations of the cheek lining and gums also heal well without suturing, and repair is considered only for a large or gaping wound or a loose flap. A laceration in the floor of the mouth deserves particular care, because bleeding and swelling there can compromise the airway. As above, a gum laceration overlying the jaw raises the possibility of an underlying open fracture and should prompt imaging.

The general approach is the same whatever the site: control bleeding with pressure, provide good analgesia, irrigate the wound thoroughly, remove any foreign material, and then decide whether the laceration needs closing or will heal on its own.

Antibiotics are not needed for a simple, clean intraoral laceration, and prophylaxis is considered rather than routine, guided by contamination, a bite mechanism, delayed closure, immunosuppression and local guidance, for example for a heavily contaminated wound, a bite, or a gum laceration overlying a fracture. Tetanus status should be confirmed. Aftercare is mouth-friendly: saltwater rinses to keep the wound clean, a soft diet, and good oral hygiene, with review if there is any sign of infection. Return to sport is usually quick once bleeding is controlled and the athlete is comfortable, provided any associated concussion, fracture or dental injury has been addressed, and a mouthguard is worth recommending to reduce the risk of a repeat injury.

One dental emergency belongs in every pitchside practitioner's working knowledge, because the outcome depends almost entirely on what happens in the first few minutes and the decision falls to whoever is present. An avulsed permanent tooth is a time-critical injury: the survival of the periodontal ligament cells on the root surface determines whether reimplantation succeeds, and that survival falls rapidly once the tooth is dry. Immediate reimplantation at the scene gives the best prognosis, but only once the athlete is conscious, cooperative, able to protect their own airway, and has no more urgent airway, cervical spine, facial or neurological problem taking priority.

Handle the tooth by the crown and never by the root, since touching or scrubbing the root surface destroys the ligament cells that reimplantation depends on. If visibly contaminated, rinse it briefly in saline or milk rather than scrubbing it, then reimplant it in the correct orientation and have the athlete hold it in place or bite gently on a gauze pad. Where immediate reimplantation is not possible, store the tooth in a physiological medium: a specialist tooth preservation medium where one is available, otherwise cold milk, saline, or saliva collected into a clean container. Avoid placing a loose tooth inside the mouth of a young, concussed or otherwise impaired athlete, because of the aspiration and swallowing risk. Water is a poor storage medium because it is hypotonic and lyses the cells, and a dry pocket or tissue is worse still, though a brief rinse with clean water is preferable to leaving gross contamination if nothing else is to hand. Urgent dental assessment follows in every case, and the dental clinician will assess the need for splinting, root canal treatment, systemic antibiotics and tetanus management.

Two qualifications complete the picture. An avulsed primary tooth in a child should not be reimplanted, because doing so risks damaging the developing permanent successor. And a tooth that cannot be found should prompt examination and imaging where aspiration, ingestion or intrusion into the socket is possible, particularly where the athlete was concussed.

• •Control bleeding and protect the airway first; a bleeding or swelling tongue or floor of mouth is an emergency.
• •Assess the airway and breathing first; if aspiration of a tooth cannot be excluded, consider chest imaging.
• •A laceration crossing the vermilion border needs precise alignment and is often best referred.
• •Most tongue and intraoral lacerations heal without suturing; repair those gaping at rest, with tip or edge involvement, a substantial flap, or uncontrolled bleeding.
• •Consider antibiotic prophylaxis by contamination, bite mechanism, delayed closure or immunosuppression, per local guidance, and check tetanus.
• •Look for associated dental injury, facial fracture and concussion, and recommend a mouthguard.