Emergency Management of a Bullet Lodged in Tooth Socket
Immediate Airway Assessment and Stabilization
The first priority is securing the airway and preventing aspiration of the bullet or tooth fragments, as airway obstruction is the most serious life-threatening complication following maxillofacial trauma. 1, 2
- Inspect the oral cavity and upper airway thoroughly before any intervention to identify the bullet location and any loose tooth fragments that could be aspirated 1
- Remove any accessible foreign bodies from the mouth and throat immediately, despite the stressful emergency conditions 1
- Assess airway patency, as maxillofacial trauma can compromise the airway through hemorrhage, soft-tissue edema, or loss of facial architecture 3
- Be prepared for difficult intubation if needed, as maxillofacial trauma patients often present complex airway management challenges 4, 5
Control Hemorrhage
- Apply direct pressure with gauze or cotton to control bleeding from the tooth socket 6
- Clean the wound with saline solution or tap water 6
Clinical Examination
Perform a systematic examination to assess the extent of injury and rule out associated fractures:
- Check occlusion by asking the patient to say "cheese" or the letter "e" to visualize whether posterior teeth fully interdigitate—disturbances indicate displaced tooth, alveolar fracture, or jaw fracture 3
- Palpate the facial skeleton systematically for tenderness, step-offs, or crepitus along the mandible and maxilla 3
- Assess for trismus, gingival hemorrhage, mucosal tears, loose or fractured teeth, and facial asymmetry 3
- Observe for mandibular deviation during mouth opening, which suggests condylar or ramus fracture 3
Imaging
Obtain CT maxillofacial without IV contrast to localize the bullet, assess for jaw fractures, and evaluate surrounding structures. 3, 7
- CT is the first-line imaging modality with sensitivity approaching 100% for detecting mandibular or maxillary fractures 3
- CT provides multiplanar and 3-D reconstructions critical for surgical planning 3
- Rule out cervical spine injury and intracranial trauma first, as facial trauma can transmit force to these structures 3
Definitive Management
Immediate referral to oral and maxillofacial surgery is mandatory for bullet removal and socket management. 6
- The bullet must be surgically removed by a specialist to prevent infection, lead toxicity, and further tissue damage
- Do not attempt to remove the bullet in the emergency department without surgical consultation
- The tooth socket will require debridement and possible bone grafting depending on the extent of injury
Critical Pitfalls to Avoid
- Never attempt endotracheal intubation without first inspecting and clearing the oral cavity of foreign bodies, as pushing the bullet or tooth fragments into the upper respiratory tract can be life-threatening 1
- Do not dismiss the injury as minor without proper imaging—bullets can cause occult fractures and vascular injuries 3
- Do not delay surgical consultation, as infection risk increases with retained foreign bodies in contaminated oral wounds
Adjunctive Care
- Administer tetanus prophylaxis if indicated based on immunization history
- Consider systemic antibiotics to prevent infection, particularly if there is significant soft tissue injury or contamination
- Assess for associated dental injuries including avulsed, luxated, or fractured adjacent teeth requiring specific dental management 3
- Screen for neurologic injury including questions about loss of consciousness, dizziness, headache, nausea, or vomiting to identify possible concussion 3