What is the appropriate management of an oral cavity injury, including hemostasis, wound irrigation, criteria for suturing, imaging, analgesia, antibiotic prophylaxis, tetanus coverage, and follow‑up?

Management of Oral Cavity Injuries

For oral cavity injuries, immediately cleanse the wound with sterile normal saline, control bleeding with direct pressure, assess for dental/bone fractures and nerve injury, close facial wounds primarily if seen within 8 hours (with meticulous irrigation and prophylactic antibiotics), but leave infected wounds open and use delayed closure for most other oral wounds. 1

Initial Assessment and Stabilization

Immediate Priorities

• Protect the cervical spine if cranial injury is suspected and prioritize immediate medical evaluation before addressing oral injuries 1
• Cleanse the face and oral cavity thoroughly with water or sterile normal saline to facilitate accurate examination—avoid iodine or antibiotic-containing solutions as they provide no additional benefit 1
• Palpate the facial skeleton for fractures and assess occlusion (bite) to detect displaced teeth or alveolar/jaw fractures 1
• Inspect for tooth sensitivity to hot/cold exposures, which indicates exposed dentin or pulp requiring immediate dental referral 1

Critical Examination Components

• Evaluate all soft tissues including lips, oral musculature, tongue, floor of mouth, and oropharynx for lacerations 1, 2
• Assess for disproportionate pain near bones or joints, which suggests periosteal penetration and potential complications like septic arthritis or osteomyelitis 1
• Document tooth mobility, abnormal positioning, and fractures in the dental trauma region 1

Hemostasis

• Apply direct pressure as the primary method for controlling oral bleeding 1
• Elevate the injured body part during the first few days after injury, especially if swollen, to accelerate healing 1

Wound Irrigation and Debridement

• Irrigate copiously with sterile normal saline only—there is no need for iodine or antibiotic-containing solutions 1
• Remove superficial debris but avoid deeper debridement as it is usually unnecessary and may enlarge the wound, impairing skin closure 1
• Perform cautious debridement only when absolutely necessary to avoid compromising wound closure 1

Imaging

• Obtain conventional intraoral dental radiographs as the best method for assessing injured teeth, following ALARA principles (as low as reasonably achievable) to minimize radiation exposure 1
• Consider plain radiographs (AP and lateral views) if foreign body sensation persists despite negative visual examination, though be aware of 47% false-negative rate for general foreign bodies and up to 85% for fish bones, wood, plastic, and glass 2
• Obtain CT scan when plain films are negative but symptoms persist, as it has 90-100% sensitivity and 93.7-100% specificity for detecting foreign bodies 2

Suturing Criteria and Technique

When to Suture

• Close facial wounds primarily if seen within 8 hours of injury, provided there has been meticulous wound care, copious irrigation, and administration of prophylactic antibiotics—facial wounds are an exception to delayed closure rules 1
• Do NOT close infected wounds—these must heal by secondary intention 1
• For most other oral wounds, use Steri-Strips for margin approximation followed by delayed primary or secondary closure, as early suturing (<8 hours) is controversial with no studies delineating clear guidelines 1
• Primary closure of intraoral wounds can be performed up to 24 hours after injury, as a mucosal seal decreases infection risk and allows faster, less painful healing than secondary intention 3

Special Considerations

• Achieve exact alignment of vermilion-cutaneous margins when closing lip defects 3
• Use synthetic, nonresorbable, monofilament sutures in small diameters to promote passive wound closure and maintain unchanged physical properties 4
• Ensure firm flap adaptation and stabilization through optimal suturing to promote fibrin clot adhesion 4

Analgesia

• Prescribe over-the-counter acetaminophen or NSAIDs for pain management 2
• Avoid hot beverages, spicy foods, acidic foods (tomatoes, citrus), and crusty/abrasive foods that will aggravate oral injuries 1, 5

Antibiotic Prophylaxis

For Bite Wounds (Human or Animal)

• Administer prophylactic antibiotics for all bite wounds, particularly facial wounds being closed primarily 1
• Use beta-lactam/beta-lactamase combinations (ampicillin-sulbactam) as first-line IV therapy, or second-generation cephalosporins (cefoxitin), piperacillin/tazobactam, or carbapenems (ertapenem, imipenem, meropenem) 1
• Avoid first-generation cephalosporins, penicillinase-resistant penicillins, macrolides, and clindamycin alone as they have poor activity against Pasteurella multocida (animal bites) 1
• Consider single initial parenteral dose before starting oral therapy 1

For Non-Bite Traumatic Wounds

• Antibiotic prophylaxis is not routinely indicated for clean traumatic oral wounds without bite involvement 1

Tetanus Prophylaxis

• Administer tetanus toxoid (0.5 mL intramuscularly) if status is outdated or unknown for all oral cavity injuries 1
• Ensure tetanus prophylaxis status is current before discharge 1

Post-Injury Oral Hygiene Protocol

Brushing Technique

• Use a soft toothbrush or foam swab and brush gently twice daily after meals and before bedtime, avoiding vigorous brushing that could traumatize injured tissues 1, 5
• Replace toothbrush monthly to maintain optimal softness and hygiene 1, 5
• Use mild, fluoride-containing, non-foaming toothpaste to minimize irritation 1, 5
• Store toothbrush with bristles facing upward after thorough rinsing 1, 5

Mouth Rinsing

• Rinse with alcohol-free mouthwash or salt water 4-6 times daily, especially after brushing, for approximately 1 minute with 15 mL solution 1, 5, 2
• Avoid eating or drinking for 30 minutes after rinsing 1, 5
• Completely avoid alcohol-containing mouthwashes as they exacerbate discomfort and dry inflamed tissues 1, 5

Additional Supportive Care

• Drink ample fluids to keep the mouth moist 1, 5
• Apply lip balm or petroleum jelly to lips to prevent cracking, but avoid chronic petroleum jelly use as it promotes mucosal dehydration and infection risk 1, 6
• Inspect oral mucosa daily for changes, worsening inflammation, or signs of secondary infection 1, 5, 6
• Eliminate sources of trauma including ill-fitting prostheses and fractured teeth 1, 6

Follow-Up

• Follow up within 24 hours either by phone or office visit for all outpatients 1
• Consider hospitalization if infection progresses despite good antimicrobial and ancillary therapy 1
• Refer immediately to dentist for tooth sensitivity/pain to temperature, exposed dentin/pulp, or dental fractures 1
• Refer to plastic surgeon for facial wounds requiring primary closure 1
• Reevaluate within 2 weeks for oral ulcers or wounds not responding to treatment 6

Common Pitfalls to Avoid

• Never perform blind finger sweeps or instrumentation in the oral cavity, as this can push foreign bodies deeper or cause additional mucosal injury 2
• Do not rely solely on plain radiographs for radiolucent materials like wood, plastic, or certain food items 2
• Hand wounds are often more serious than wounds to fleshy body parts and require closer monitoring 1
• Watch for infectious complications including septic arthritis (requiring 4 weeks therapy), osteomyelitis (requiring 6 weeks therapy), abscess formation, and tendonitis 1
• Do not start interdental cleaning during acute injury if the patient wasn't already using it regularly, as it can break the epithelial barrier and cause bleeding 1, 5