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Dental injuries are one of the most common drivers of emergency and Urgent Care visits. Approximately 4.1% of all emergency visits in Australia are attributable to dental traumatic injuries1 and U.S. pediatric providers treat at least one oral trauma every 2 to 3 days.2 A vast majority of the services rendered were limited to simple palliative measures even when their treatment did not require specialized dental training.3
Lacerations and soft tissue injuries are the most common sequelae of maxillofacial trauma.4 Fortunately, punctures and lacerations measuring less than 1 cm typically do not require formal closure especially when they occur on proliferative surfaces like oral epithelia. These wounds should be gently debrided of gross debris and irrigated thoroughly. Patients should also be instructed to practice good oral hygiene and to remain on a soft food diet without small, firm components such as seeds or grains for approximately two weeks.
Suture closure is the preferred method of addressing lacerations 1 cm or longer in length. As always, the injured site should be debrided and irrigated prior to closure using size 3-0 or 4-0 resorbable suture. Any visible underlying muscle tears should also be reapproximated. Mucosal closures can be completed with relative ease because they do not scar easily and tolerate poor or even mis-approximations well. A course of antibiotics that cover common oral flora – such as one week of amoxicillin (500mg q8h) or clindamycin (300mg q6h), or a 5-day course of azithromycin (500mg 1st day, 250mg q24h subsequently) – may be appropriate for patients with complex lacerations, increased risks of pathogenic contamination (especially from animal bites), and immunocompromised states.5
Chromic gut sutures (CGS) provide adequate strength, handling, and half-life when compared to non-coated traditional or plain gut sutures. Braided polyglycolic-acid (PGA) sutures (i.e. Vicryl®, Polysorb®) are similarly easy to handle but their weeks-long life spans can lead to mucosal irritation and food entrapment. Long lasting but unbraided Poliglecaprone-25 sutures (i.e. Monocryl®, Biosyn®) minimize tissue inflammation but their glossy texture and coil memory risk fraying the already-injured tissues. Many oral surgeons utilize CGS for mucosal closures and PGA sutures for sub-surface muscles where the risk of food entrapment is minimal and tensile demands are prolonged.
Table 1: Common Resorbable Sutures in Oral Surgery
| Time to Lose 50% Strength | Resorption Time | Suture Texture |
Plain Gut | 24 hours | 3 to 5 days | Rough, brittle |
Chromic Gut | 5 days | 7 to 10 days | Rough, coated |
Polyglycolic Acid | 21 days | 21 to 28 days | Flexible, braided |
Poliglecaprone 25 | 14 days | 90 to 120 days | Flexible, glossy |
Abrasions, burns, sores, ulcers, large punctures, and even partially or completely closed lacerations may benefit from the placement of oral dressings. Resorbable, porous matrix dressings like the collagen tape and plug (ZimVie® Dental, Westminster, COPalm Beach Gardens, Florida) are particularly versatile in a wide variety of traumatic injuries. The collagen tape is a rectangular, thin, absorbent collagen barrier that may be cut to size and placed over the injured mucosa where it adheres to and protects the internal tissues. While the tape’s collagen surface aids in hemostasis, its greatest benefit may be the relief it provides against pain and the insults of the oral environment. There are anecdotal indications that the collagen matrix may also serve as a porous scaffold for the migrating new epithelial cells – somewhat like the collagen of the underlying connective tissues – though additional studies are needed.6
Deep and bleeding osseous openings from missing teeth (from dental extractions or avulsions) are difficult to treat via closure only. The collagen plug is a tooth root-shaped collagen matrix that can be inserted into a hemorrhagic dental socket. This aids in obtaining hemostasis, preventing impaction of oral debris, and preserving the contour of the nearby soft tissues. The plug expands as it absorbs fluid to prevent dislodgement and to aid in further compression hemostasis. It can also be cut to better match the anatomic variations of the various tooth roots. A figure-of-eight suture may be placed over the socket as an additional measure of protection.
A dentally-mindful Urgent Care provider may use a similar collagen plug from the same manufacturer that is also impregnated with bone-graft materials (RegenerOss® Bone Graft Plug). The bone and gingiva surrounding missing teeth atrophy rapidly within the first six to twelve months, leading to an esthetic defect of “shrunken gums” that also complicate the any future dental implant surgeries of the area.7 Bone-graft impregnated plugs contain not only collagen to for hemostasis and protection but also calcified osteoconductive materials which help delay undesirable periodontal bone atrophy.
Regardless of the material and technique used to manage oral wounds, the provider must perform a detailed examination to rule out any other significant underlying injuries such as concussion, fracture, or infection. If neurological or osseous complications are suspected, specialist referrals should be considered to oral-maxillofacial surgery, otolaryngology or plastic surgery. Sutures and dressings should not be placed in obviously infected areas. Most importantly, the contents of any literature should not replace the judgments of the evaluating clinician.
References
1. Dang K, Day P, Calache H, Tham R, Parashos P. Reporting dental trauma and its inclusion in an injury surveillance system in Victoria, Australia.
Australian Dental Journal. 2015;60(1):88-95. doi:10.1111/adj.12273
2. Nelson LP, Shusterman S. Emergency management of oral trauma in children. Current opinion in pediatrics. 1997;9(3):242-245.
doi:10.1097/00008480-199706000-00010
3. Matsunaga M, Chen JJ, Donnelly P, Fok CCT, Partika NS. Emergency Room Visits with a Non-Traumatic Dental-Related Diagnosis in Hawaii,
2016–2020. International Journal of Environmental Research and Public Health. 2022;19(5):0-7. doi:10.3390/ijerph19053073
4. Khan TU, Rahat S, Khan ZA, Shahid L, Banouri SS, Muhammad N. Etiology and pattern of maxillofacial trauma. PLoS ONE. 2022;17(9
September):1-10. doi:10.1371/journal.pone.0275515
5. Katsetos SL, Nagurka R, Caffrey J, Keller SE, Murano T. Antibiotic prophylaxis for oral lacerations: our emergency department’s experience.
International Journal of Emergency Medicine. 2016;9(1). doi:10.1186/s12245-016-0122-7
6. Seok H, Jo YY, Kweon HY, Kim SG, Kim MK, Chae WS. Comparison of Bio-degradation for Ridge Preservation Using Silk Fibroin-based Grafts and a
Collagen Plug. Tissue Engineering and Regenerative Medicine. 2017;14(3):221-231. doi:10.1007/s13770-017-0055-0
7. Hämmerle CHF, Araújo MG, Simion M, 2011 OB of the OCG. Evidence-based knowledge on the biology and treatment of extraction sockets.
Clinical Oral Implants Research. 2012;23(s5):80-82. doi:https://doi.org/10.1111/j.1600-0501.2011.02370.x