What is the optimal therapy for a 14-year-old hockey player struck in the mouth by a stick?

Immediate Management of Oral Trauma in a 14-Year-Old Hockey Player

The optimal therapy is immediate removal from play, rapid assessment for concussion and dental injuries, control of any bleeding, and urgent dental referral within 30-60 minutes for avulsed or displaced teeth. 1

Immediate On-Ice Assessment and Actions

First Priority: Rule Out Life-Threatening Injuries

• Assess airway patency immediately – ensure no obstruction from blood, broken teeth, or soft tissue swelling that could compromise breathing 1
• Evaluate for concussion – any blow to the mouth/face region requires immediate concussion screening, even if the primary impact was to the oral area 2, 3
• Check for cervical spine injury – if significant force was involved or the mechanism suggests possible neck trauma, maintain c-spine precautions 1

Second Priority: Assess Neurological Status

• Look for obvious concussion signs: altered consciousness, balance problems, memory issues, confusion 2
• Ask about symptoms: headache, dizziness, nausea, blurred vision, ringing in ears 2
• Critical pitfall: Never allow same-day return to play after ANY head/face impact with symptoms – "When in doubt, sit them out!" 3

Third Priority: Oral/Dental Examination

• Control active bleeding with direct pressure using gauze 1
• Examine for tooth avulsion (complete tooth loss) – this is the most time-sensitive dental emergency 1
• Check for tooth displacement or mobility – malocclusion (abnormal bite) may indicate displaced teeth or jaw fracture 1
• Inspect for soft tissue lacerations of lips, tongue, gingiva, or oral mucosa 1
• Assess for jaw fracture – inability to close mouth properly, severe pain with jaw movement 1

Time-Critical Dental Management

If Permanent Tooth is Avulsed (Knocked Out Completely)

This is a dental emergency requiring action within 30-60 minutes for optimal outcomes 1:

• Handle tooth by crown only – never touch the root surface 1
• Rinse gently with saline or milk if contaminated, do not scrub 1
• Reimplant immediately if possible – have player bite on gauze to hold in place 1
• If reimplantation not possible, store tooth in:
  • Best: Hank's Balanced Salt Solution 1
  • Second best: Cold milk 1
  • Acceptable: Saline or saliva (have player hold tooth in mouth between cheek and gum) 1
• Never store in water – this damages root cells 1
• Transport to dentist immediately – prognosis worsens significantly after 60 minutes 1

If Primary (Baby) Tooth is Avulsed

• Do NOT reimplant primary teeth – risk of damaging permanent tooth bud 1
• Refer to dentist within 24 hours for evaluation 1

If Tooth is Displaced or Mobile

• Do not manipulate – refer urgently to dentist 1
• Soft diet only until evaluated 1

Equipment Removal Considerations

For protective equipment removal in hockey players 1:

• Remove faceguard/cage first to access airway and assess oral injuries 1
• Keep helmet on unless absolutely necessary for airway management or if c-spine injury suspected and proper technique available 1
• Practice proper technique – requires two-person coordination to maintain c-spine alignment if helmet removal needed 1

Concussion Management Protocol

If ANY concussion symptoms present 2, 3:

• Remove from play immediately – no return same day under any circumstances 2, 3
• Complete physical and cognitive rest for first 24-48 hours 3
• No return to play until completely asymptomatic at rest AND with exertion 3
• Follow stepwise return-to-play protocol taking minimum 5 days, with each stage lasting at least 24 hours 1, 3

Transport and Referral

Immediate Emergency Department Transfer If:

• Severe or worsening headache 3
• Repeated vomiting 3
• Loss of consciousness 3
• Seizure activity 3
• Suspected jaw or facial bone fracture 1
• Uncontrolled bleeding 1

Urgent Dental Referral (Within 30-60 Minutes) If:

• Any avulsed permanent tooth 1
• Displaced or significantly mobile teeth 1
• Crown fractures exposing pulp (visible pink/red tissue or bleeding from tooth) 1

Routine Dental Referral (Within 24 Hours) If:

• Uncomplicated crown fractures (chipped tooth without pulp exposure) 1
• Soft tissue lacerations requiring evaluation 1
• Any primary tooth avulsion 1

Common Pitfalls to Avoid

• Never dismiss oral trauma without proper concussion screening – facial/mouth injuries commonly occur with concurrent head trauma 2, 4
• Never delay reimplantation of avulsed permanent teeth – every minute counts for tooth survival 1
• Never store avulsed teeth in water – use milk or saline 1
• Never attempt to reimplant primary teeth – risk of permanent tooth damage 1
• Never allow return to play with any concussion symptoms – even if "minor" 2, 3
• Never assume absence of loss of consciousness rules out concussion 2

Prevention Counseling for Future

Mouthguards significantly reduce dental injury risk 1:

• Custom-fitted mouthguards provide superior protection compared to boil-and-bite or stock varieties 1
• Mandatory use recommended for all contact hockey 1, 5, 6
• Full-face protection should be maintained in youth hockey – facial injuries are 3 times more common in games than practice 6

Mechanism Context

Hockey stick injuries to the mouth are the most common mechanism for oral trauma in ice hockey, accounting for approximately 40-50% of dental injuries 5, 6. These injuries typically result in crown fractures, soft tissue lacerations, and tooth avulsions 5, 6. The injury rate increases significantly with age and level of competition 7.