4.03 Lacerations of the Mouth
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agk's Library of Common Simple Emergencies

Presentation
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Because of the rich vascularity of the soft 
tissues of the mouth, impact injuries often 
lead to dramatic hemorrhages that send patients 
to the emergency department with relatively 
trivial lacerations. Blunt trauma to the face 
can cause secondary lacerations of the lips, 
frenulum, buccal mucosa, gingiva, and tongue. 
Active bleeding has usually stopped by the time 
a patient with a minor laceration has reached 
the emergency department.

What to do:
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- Provide appropriate tetanus prophylaxis and 
   check for associated injuries such as loose 
   teeth, mandibular or facial fractures.
- When only small lacerations are present and 
   only minimal gaping of the wound occurs, 
   reassurance and simple aftercare is all that 
   is required. Let the patient know the wound 
   will become somewhat uncomfortable and 
   covered with pus over the next 48 hours and 
   tell him to rinse with lukewarm water or 
   half strength hydrogen peroxide after meals 
   and every one to two hours while awake for 
   one week.
- If there is continued bleeding, the wound 
   edges gape significantly or there is a flap 
   or deformity when the underlying musculature 
   contracts, the wound should be anesthetized 
   using lidocaine with epinephrine, cleansed 
   thoroughly with saline and loosely approxim- 
   ated using a 4-0 or 5-0 absorbable suture. 
   Consider using conscious sedation when 
   suturing children who cannot cooperate. A 
   traction stitch or special rubber-tipped 
   clamp can be very helpful when attempting to 
   suture the tongue of a small child or 
   intoxicated adult. The same aftercare as 
   above applies.
- When the exterior surface of the lip is 
   lacerated, any separation of the underlying 
   musculature must be repaired with buried 
   absorbable sutures. To avoid an unsightly 
   scar when the lip heals, precise skin 
   approximation is very important. One must 
   first approximate the vermilion border, 
   making this the key suture. Fine non- 
   absorbable suture material (e.g., 6-0 nylon 
   or Prolene) is most appropriate for the skin 
   surfaces of the lip while a fine absorbable 
   suture (e.g., 6-0 Dexon or Vicryl) is quite 
   acceptable on the mucosa and vermilion.
- For deep lacerations of the mucosa or lip, or 
   any sutured laceration in the mouth, 
   prescribe prophylactic penicillin (penicill- 
   in VK 500mg tid x 3-4 days) to prevent deep 
   tissue infections (erythromycin may be 
   substituted in penicillin-allergic individ- 
   uals). Recommend acetaminophen for pain.
- Have patients return in 48 hours for a wound 
   reevaluation.
- Recommend cool liquids and soft foods 
   beginning four hours after the repair.

What not to do:
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- Do not bother to repair a simple laceration 
   or avulsion of the frenulum of the upper 
   lip. It will heal quite nicely on its own.
- Do not use non-absorbable suture material on 
   the tongue, gingiva or buccal mucosa. There 
   is no advantage and suture removal on a 
   small child will be an unpleasant struggle 
   at best.

Discussion
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Imprecise repair of the vermilion border will 
lead to a "step-off" or puckering that is 
unsightly and difficult to repair later on. 
Fortunately, the tongue and oral mucosa usually 
heals with few complicating infections and 
there is a low risk of subsequent tissue 
necrosis.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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 1.202.237.0971 fax 1.202.244.8393 electra@clark.net
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