FIGURE 105.1 Infraorbital and inferior alveolar main nerves supply the teeth Intraoral examination A good light is essential to inspect the color and quality (i.e., fluctuance or induration) of the lips, gingiva (gums), buccal mucosa, floor of the mouth, tongue, and palate The gingiva should be pink, firm, and stippled (like a grapefruit skin) The mucosa of the cheeks and floor of the mouth should be pink, moist, and glassy in appearance The masseter muscle should be palpated by rolling it between fingers placed intra- and extraorally Using a gauze pad, the clinician should hold the tongue and lift it gently to better view and examine its dorsal, ventral, and lateral surfaces Lifting the tongue also allows for a thorough examination of the floor of mouth Using the thumb and index finger, the clinician should palpate the alveolar ridge in all four quadrants for any swelling, discontinuity, or mobility of the soft tissues and underlying bone The palate should be examined for any swelling or tenderness Any soft tissue swelling, ecchymoses, and/or hematoma should be noted Any inflamed, ulcerated, or hemorrhagic areas, as well as any foreign bodies (e.g., tooth fragments) or denuded areas of bone should be documented Next, the oral cavity should be inspected for any missing, displaced, mobile, tender, or fractured teeth These findings are discussed in more detail in subsequent sections Radiographic examination Radiographs are a valuable supplement to the clinical examination However, in a child with acute orofacial/dental injuries this may be difficult and reserved for a dental office A chest radiograph may be required if an avulsed tooth is not located Panoramic radiographs or computed tomography (CT) scans may be indicated to assess for jaw fracture SOFT TISSUE INJURY CLINICAL PEARLS AND PITFALLS The soft tissues and bones of the lower and midface are well vascularized and bleed profusely when injured Lacerated soft tissues must be evaluated for any debris, foreign body, or tooth fragment Current Evidence Hemorrhage is best controlled by direct pressure and when needed, by ligating any vessels that are easily seen However, vessels of the face often retract when severed making them difficult to visualize If there is extensive blood loss, the patient should be assessed for signs of shock (see Chapter 10 Shock ) The injured area should be thoroughly examined for a foreign body such as a tooth fragment This may include obtaining a soft tissue radiograph or bedside ultrasound before suturing when a foreign body is suspected Infection and poor wound healing are potential sequelae of such an oversight Goals of Treatment The primary goal for treatment of soft tissue injury is to achieve hemostasis The highly vascular tissue in and around the mouth can lead to significant blood loss with seemingly mild injuries Recognizing any embedded foreign materials (e.g., debris, or tooth fragments) is essential to allow wound healing and reduce the likelihood of complications Injuries to the buccal mucosa and inner lip are rarely of cosmetic concern given rapid wound healing with minimal risk of scarring Vermilion border injuries require meticulous alignment for optimal cosmetic outcome, while select intraoral lesions may not require any repair at all Clinical Considerations Management of soft tissue injuries of the oral cavity follows the same emergency care principles used for extraoral soft tissue injuries Injuries to the lip result in significant swelling after minor trauma Lacerations of the tongue and frenum bleed profusely because of the richness of their vascularity However, ligating specific vessels is usually unnecessary because bleeding almost always stops with direct pressure and careful suturing Frenum lacerations often heal spontaneously without suturing When a laceration in the oral cavity is more than hours old, decisions regarding primary closure need to consider the relative risk of secondary infection Management Suturing Suturing the lip must be done carefully to achieve a precise approximation of the edges of the vermilion border to avoid a disfiguring scar If necessary, the lip must be sparingly debrided Wounds are generally closed with 5-0 or 6-0 sutures Nylon sutures may be used in cooperative teenagers; however, fast-absorbing sutures are preferred in younger children given the potential challenge of subsequent suture removal Through and through and other deep lip lacerations require closure in multiple layers, beginning with approximation of the orbicularis oris muscle using 4-0 chromic and then 5-0 or 6-0 sutures (as above) for the skin and vermilion border Most superficial tongue lacerations heal without suturing When necessary, tongue lacerations are usually sutured with 4-0 chromic in superficial wounds and with 3-0 chromic in deeper wounds With tongue lacerations, it is important to consider the excessive muscular movements that pull at the sutures; therefore, tongue sutures should be made deep into the musculature (see Chapter 110 Minor Trauma ) Orthodontic trauma Young patients are frequently undergoing orthodontic treatment, and trauma can result in loosening of wires or ligatures that are attached to orthodontic brackets or bands Acutely, the emergency physician can bend the wire away for analgesic purposes and to avoid further soft tissue injury Once this is temporarily addressed, arrangements for urgent dental evaluation can be pursued Loose wires can be covered with softened wax or removed to allow the traumatized soft tissues to heal If no discomfort is noted and no loose foreign bodies are present, definitive treatment can be delayed until the patient can be seen by an orthodontic specialist Postanesthesia soft tissue trauma Young children may injure oral soft tissues (lips, intraoral mucosa, or tongue) after administration of local anesthesia for a dental procedure The child may be numb for several hours postprocedure This provides an opportunity for injury, which will appear as a whitish ulceration and is very painful A common site for this is the lower lip ( e-Fig 105.1 ) Rarely is this type of injury associated with infection Standard over-the-counter pain medications and keeping a soft, bland diet are sufficient until the wound heals, typically in to weeks Electrical Burns Electrical burns occur when children bite on electrical cords The saliva in the mouth acts as a conductor to complete the circuit Although the commissure of the mouth is most likely affected, the tongue, alveolar ridge, and floor of the mouth are occasionally involved Most children with these injuries can be managed as an outpatient A bland, soft, cold diet is initially recommended If a child refuses oral intake, dehydration may ensue and the administration of intravenous fluids may be required Meticulous oral hygiene using a toothbrush with or without toothpaste should be performed three to four times per day, as well as hydrogen peroxide and water (1:1) rinses in a cooperative child With severe burns of the lips and mouth, labial artery bleeding may occur to days after the injury Although admission to the hospital for wound management has been utilized, the delayed presentation of this late complication makes this impractical The clinician should instruct the parent on the method for digitally compressing the artery if bleeding were to occur To prevent scarring down of the commissure, electrical burns of this area require the fabrication of an intra- or extraoral device to separate the upper and lower segments during healing ( eFig 105.2A,B ) TRAUMATIC DENTAL INJURIES CLINICAL PEARLS AND PITFALLS Avulsed permanent teeth must be reimplanted immediately while primary teeth are generally not reimplanted Displaced teeth should be repositioned as soon as possible Teeth with exposed pulpal tissue require urgent dental treatment Fractured posterior teeth may have an associated mandibular fracture Current Evidence The International Association of Dental Traumatology has detailed, evidencebased guidelines for the management of dental trauma which are updated periodically and can be found online (see References) Focused recommendations ... Clinical Considerations Management of soft tissue injuries of the oral cavity follows the same emergency care principles used for extraoral soft tissue injuries Injuries to the lip result in... loosening of wires or ligatures that are attached to orthodontic brackets or bands Acutely, the emergency physician can bend the wire away for analgesic purposes and to avoid further soft tissue