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Trauma & Injuries

Oral Trauma Management

Management of injuries to the oral cavity, including soft tissues (lips, cheeks, tongue, gums, palate), teeth, and supporting structures, resulting from direct physical trauma or chronic irritation.

Also known as: Mouth Injury, Dental Trauma, Oral Lesions due to Trauma

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Referral and warning signs

When to refer

Refer to Dentist / Oral Surgeon (HC4/H/RR) for: Avulsed permanent teeth (URGENT). Displaced or significantly mobile teeth/alveolar segments. Complex tooth fractures (esp. involving pulp). Suspected jaw fracture. Complex facial/oral lacerations requiring layered closure. Non-healing ulcers or suspicious lesions. Lesions requiring excision (Polyp, Mucocele, Ranula). Evidence of head injury associated with oral trauma.

Red flags

  • Avulsed permanent tooth
  • Mobile segment of alveolar bone with teeth
  • Tooth fracture exposing the pulp (pink/red dot or visible nerve)
  • Inability to close jaw properly (malocclusion) / Suspected jaw fracture
  • Uncontrolled intraoral bleeding
  • Signs of associated head injury (LOC, confusion, vomiting)

Signs and symptoms

  • Specific Lesions:
  • - Fibroepithelial Polyp: Localized, firm, sessile or pedunculated lump (often palate/tongue), usually painless, response to chronic low-grade trauma.
  • - Mucocele: Soft, fluctuant, bluish/translucent swelling (often lower lip, floor of mouth), due to minor salivary gland duct rupture.
  • - Ranula: Mucocele specifically arising from sublingual gland in floor of mouth.
  • - Traumatic Ulcer: Painful ulceration related to sharp tooth/restoration, biting, chemical/thermal burn. Often irregular border with surrounding redness.
  • - Thermal/Chemical Burn: Redness, blistering, or white sloughing area corresponding to contact with hot food/liquid or chemical (e.g., aspirin held against gum).
  • Acute Physical Trauma:
  • - Soft Tissue Lacerations (lips, tongue, gums, cheek).
  • - Bleeding.
  • - Swelling, Bruising.
  • - Dental Injuries: Chipped, fractured, displaced (luxated), or knocked-out (avulsed) teeth. Tooth mobility.
  • - Dento-alveolar Fracture: Fracture of the bone supporting the teeth, often with mobile segment of teeth/bone.
  • - Jaw Fracture (Mandible/Maxilla - See Maxillofacial Trauma).
  • - Pain.
  • - Difficulty opening mouth (trismus), Malocclusion (bite feels wrong).

Risk factors

  • Falls, Sports injuries, Road traffic accidents, Assaults (Acute physical trauma).
  • Chronic irritation from sharp teeth, rough restorations, ill-fitting dentures (Polyps, Ulcers).
  • Habitual cheek/lip biting (Mucocele, Ulcers).
  • Consumption of very hot food/liquids (Thermal burns).
  • Holding caustic substances in mouth (Chemical burns).
  • Large dental overjet (increased risk of front tooth trauma).

Diagnosis

Clinical assessment

Based on history of trauma (acute or chronic) and clinical examination of the oral cavity. Inspection and palpation of soft tissues, teeth, alveolar bone. Assess tooth mobility, fractures, displacement, occlusion. Identify specific lesions (polyp, mucocele, ulcer, burn). Rule out associated facial fractures or head injury.

Investigations

  • Dental Examination: Detailed assessment by dentist/oral surgeon.
  • Dental Radiographs (Periapical, Occlusal, Panoramic): Essential for assessing tooth root fractures, bone fractures, displacement, associated pathology.
  • Facial Bone X-rays / CT Scan: If jaw fracture or complex facial injury suspected.
  • Biopsy: For excision of polyps, mucoceles, ranulas, or suspicious lesions.
  • Pulp Vitality Testing.

Diagnostic criteria

Clinical and/or radiographic evidence of injury to oral soft or hard tissues.

Management

Non-pharmacological management

  • General Measures (Acute Trauma):
  • - Assess ABCs, rule out head/neck injury.
  • - Control bleeding (direct pressure).
  • - Clean wounds gently (saline/water).
  • - Check for missing teeth/fragments (risk of aspiration/ingestion/embedding in soft tissue).
  • Specific Lesion Management:
  • - Fibroepithelial Polyp/Mucocele/Ranula: Surgical excision (Referral - RR).
  • - Traumatic Ulcer (due to sharp edge): Smooth sharp tooth/restoration edge. Advise soft diet, avoidance of irritation. Usually heals once source removed.
  • - Thermal/Chemical Burn: Reassurance, healing expected. Avoid further irritation.
  • - Ulcer due to Local Anesthetic Bite: Reassurance, usually self-limiting. Maintain oral hygiene.
  • Acute Dental/Alveolar Trauma:
  • - Avulsed (Knocked-Out) Permanent Tooth: Immediate replantation is critical. Handle tooth by crown only, rinse gently (saline/milk/water - do not scrub root), replant into socket immediately. If cannot replant, transport tooth in milk, saline, or patient's saliva (buccal vestibule) to dentist URGENTLY (<1 hour ideal).
  • - Displaced/Mobile Teeth/Alveolar Fractures: Gentle repositioning and splinting by dentist/oral surgeon.
  • - Fractured Teeth: Management depends on extent (enamel chip, dentin exposure, pulp exposure, root fracture) - requires dental assessment/treatment (filling, root canal, extraction).
  • - Soft Tissue Lacerations: Clean, debride, suture with resorbable sutures (e.g., 3/0 or 4/0 Vicryl/Chromic) if necessary.
  • Oral Hygiene: Maintain good oral hygiene. Gentle rinsing with warm salt water (1 tsp salt in 200ml water) or diluted hydrogen peroxide (15ml 6% H2O2 in 200ml water) 3 times daily may help for ulcers/lacerations.

Pharmacological treatment

  • Analgesia: Paracetamol or Ibuprofen for pain.
  • Topical Anesthetic: Lidocaine 2% gel/solution for temporary relief of ulcer/burn pain.
  • Tetanus Prophylaxis: Update booster if needed, especially with contaminated wounds/soil exposure.
  • Antibiotics (Prophylactic/Treatment):
  • - Generally NOT needed for minor ulcers/burns unless secondarily infected.
  • - Consider for significant soft tissue lacerations (especially through-and-through lip/cheek), dento-alveolar fractures, delayed presentation, or immunocompromised host.
  • - UCG Rec: Amoxicillin 500mg PO TID for 5-7 days (Adult) if prophylaxis indicated or secondary infection of anesthetic ulcer occurs.
  • - Broader coverage may be needed for complex/contaminated injuries.

Monitoring

Follow up depends on injury type. Monitor wound healing, signs of infection. Dental follow-up crucial for tooth injuries (pulp vitality, root development in children, splint removal).

Complications

  • Infection (oral soft tissue, dental abscess, osteomyelitis)
  • Pain
  • Bleeding
  • Delayed healing
  • Loss of tooth vitality / Need for root canal treatment
  • Tooth loss
  • Malocclusion
  • Ankylosis (tooth fused to bone after trauma)
  • Damage to developing permanent teeth (if primary teeth injured)
  • Scarring / Cosmetic deformity
  • Airway compromise (rare, severe swelling/bleeding)

Prevention

  • Use of mouthguards during contact sports.
  • Use of seat belts / appropriate child restraints in vehicles.
  • Fall prevention.
  • Prompt dental care to smooth sharp teeth/restorations.
  • Caution with hot foods/liquids.
  • Early orthodontic treatment for large overjets.
  • Be alert for evidence of child abuse.

Patient education

  • Explain the specific injury and treatment plan.
  • Instruct on oral hygiene measures (gentle cleaning, salt water rinses).
  • Advise on soft diet if needed.
  • Explain importance of dental follow-up.
  • Discuss pain management.
  • Educate on prevention (mouthguards, etc.).
  • Advise on signs of infection or complications requiring return.

Uganda-specific notes

Access to dental and oral surgical care is limited, especially outside urban areas. Urgent management of avulsed teeth (replantation/transport in milk) is critical but often delayed. Emphasis on basic wound care, pain relief, antibiotics if indicated, and timely referral for definitive dental/surgical management is key. Be alert for non-accidental injury.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 23, Section 23.4 (23.4.1, 23.4.2, 23.4.3)

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