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Assessment and management of intra-oral lacerations

Assessment and management of intra-oral lacerations
Literature review current through: Jan 2024.
This topic last updated: Jun 30, 2022.

INTRODUCTION — Intra-oral lacerations represent a small percentage of lacerations, but the repair of them has some important differences relative to lacerations of the skin. Once serious airway compromise is excluded, careful assessment of concurrent oral injuries is necessary. Oral lacerations commonly occur from the impact of teeth on oral mucosa secondary to motor vehicle accidents, contact sports, industrial accidents, and personal violence; fortunately, lacerations that do not gape open often heal well without intervention. Larger, gaping oral lacerations benefit from wound closure to reduce infection and bleeding complications. Most lacerations can be repaired by the emergency clinician; however, there are rare circumstances where specialist referral may be necessary.

Minor wound management, methods of suture placement, repair of adjacent anatomic sites, and evaluation of dental or oropharyngeal trauma are discussed in detail separately:

(See "Minor wound evaluation and preparation for closure".)

(See "Skin laceration repair with sutures".)

(See "Assessment and management of facial lacerations".)

(See "Evaluation and repair of tongue lacerations".)

(See "Oropharyngeal trauma in children".)

ANATOMY — Intra-oral lacerations often heal faster than wounds elsewhere in the body due to the extensive vascular supply in this area. Dental avulsion and luxation injuries associated with oral lacerations should be addressed immediately and prior to wound closure so that, if needed, reimplantation is performed as soon as possible and access to injured teeth is not compromised. Delay in reimplantation can decrease chances of tooth survival. Dental fractures can be repaired hours after injury, and oral lacerations should be addressed first. (See "Evaluation and management of dental injuries in children" and "Mandibular (jaw) fractures in children", section on 'Clinical features' and "Initial evaluation and management of facial trauma in adults", section on 'Temporomandibular joint'.)

Important anatomic considerations when repairing oral lacerations include:

Tongue lacerations can cause extensive hemorrhage and airway compromise if not controlled early in management.

Swelling of the tongue and oropharynx can cause further airway compromise hours after injury if venous injury occurs on the tongue or floor of the mouth [1].

Lacerations of the intra-oral mucosa may be associated with injuries to the salivary glands (figure 1), parotid duct, submandibular duct, teeth, lips, and jaw.

When glandular parotid tissue is involved in a wound, a clear fluid discharge can be seen. In the event of injury to Stensen's duct, specialty consultation should be obtained in order to stent the duct open and preserve its function [2].

EVALUATION — In most instances, intra-oral lacerations result from isolated trauma. However, as for all trauma patients, the initial clinical assessment should focus on rapid identification of potentially fatal conditions. For victims of major trauma, evaluation for airway compromise (while maintaining cervical spine immobilization), impaired breathing, hemorrhagic shock, and altered level of consciousness should be performed immediately upon the patient’s arrival at the emergency department. Systematic evaluation helps ensure detection of potentially life-threatening injuries.

The approach to the injured child or adult is discussed in detail separately (table 1). (See "Trauma management: Approach to the unstable child", section on 'Primary survey' and "Initial management of trauma in adults".)

Intra-oral lacerations should be quickly assessed for airway compromise during the primary survey and, if no compromise is detected, should undergo thorough evaluation during the secondary survey.

History — The clinician should identify the following aspects of the injury:

Traumatic force (eg, a physical assault with significant likelihood of associated injuries versus an isolated injury with no other symptoms)

Associated symptoms of facial bone injury (eg, malocclusion, trismus)

Associated symptoms of head injury (eg, altered mental status, vomiting, headache) (see "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'History' and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'History')

Age of wound (duration of time since the injury occurred)

Likelihood of wound contamination; all intra-oral wounds should be considered to have been exposed to intra-oral bacteria. Additional exposures (eg, dirt, foreign bodies) should also be assessed

Potential presence of foreign body (eg, dislodged teeth, fall onto glass or gravel)

The history should also include a comprehensive review of underlying medical history (eg, diabetes mellitus in adults, cancer), medication use (eg, immunosuppressive agents), and social habits (eg, tobacco use) that may negatively affect healing and increase the risk for a poor outcome. (See "Minor wound evaluation and preparation for closure", section on 'Risks for poor outcome'.)

In addition, the clinician should inquire about allergies to any medications, especially local anesthetics, and the patient’s tetanus immunization status. (See "Allergic reactions to local anesthetics", section on 'Evaluation' and "Assessment and management of facial lacerations", section on 'Tetanus prophylaxis'.)

Physical examination — Infiltration of local anesthetics facilitates a comprehensive evaluation of the wound with minimal discomfort to the patient. In young children and other uncooperative patients, sedation may be necessary to perform optimal wound assessment and repair. (See 'Anesthesia and analgesia' below.)

The lips, teeth, and mucosa must be thoroughly inspected for foreign body using adequate lighting. Dental fractures, avulsions, gingival bleeding, lacerations or displacement of the alveolar margin may be associated with mandibular or maxillary fractures, particularly if there is trismus or discomfort at the temporomandibular joint. (See "Evaluation and management of dental injuries in children", section on 'Examination' and "Mandibular (jaw) fractures in children", section on 'Clinical features'.)

Wound assessment should identify the following:

Location (eg, buccal mucosa, tongue, gingiva, teeth, alveolar ridge, mandible)

Depth

Length of wound

Extension of the laceration through external surface of face (through and through)

Damage to deeper structures

Presence of tissue avulsion

Presence of a foreign body

The clinician should also evaluate for the following associated injuries to the face, teeth, and jaw:

Dental trauma – Indicated by loose, displaced, fractured or missing teeth (see "Evaluation and management of dental injuries in children", section on 'Examination' and "Initial evaluation and management of facial trauma in adults", section on 'Dental injury')

Midface fracture – Findings include malocclusion, midface instability, ecchymosis over the cheek, anesthesia of the region supplied by the infraorbital nerve (upper lip, alveolar ridge, lateral nose, lower eyelid) (figure 2) or enophthalmos (see "Initial evaluation and management of facial trauma in adults", section on 'Midface' and "Nasal trauma and fractures in children and adolescents", section on 'Physical examination')

Jaw fracture – Suggested by malocclusion, trismus (unable to open jaw more than 5 cm), pain over the temporomandibular joint, or jaw tenderness (see "Mandibular (jaw) fractures in children" and "Initial evaluation and management of facial trauma in adults", section on 'Temporomandibular joint')

Ancillary studies — Patients with clinical features suggestive of associated fractures warrant additional studies as follows:

Midface fractures – When suspected, visualization of fractures among the complex curves of facial bones is best achieved using computed tomography (CT). CT scans of the face should include fine cuts and both coronal and sagittal reconstructions. CT angiography may be useful if the patient has a significant or expanding facial hematoma or if injury to or dissection of the carotid artery is a concern. (See "Initial evaluation and management of facial trauma in adults", section on 'Facial injury'.)

Mandibular and dental fractures – The U-shape of the mandible and the presence of adjacent bony structures make it impossible to isolate the mandible on a flat radiograph film. Therefore, simple radiographs of the mandible are less sensitive for detecting fractures than CT or panoramic radiographs (ie, Panorex) and can miss fractures of the condyle. CT is the most appropriate imaging study for patients with facial trauma and a concern for mandible fracture. If available, Panorex imaging can be used for isolated mandibular fractures, dental fractures, or fractures of the alveolar ridge. (See "Initial evaluation and management of facial trauma in adults", section on 'Mandibular injury'.)

INDICATIONS FOR SUBSPECIALTY CONSULTATION OR REFERRAL — Consultation with an appropriate specialist (eg, plastic or maxillofacial surgeon, dentist), if available, is warranted in the following situations:

Crush wounds or other wounds with significant amounts of devitalized tissue

Wounds with large defects, particularly of the upper lip, when repair exceeds the expertise of the emergency physician

Luxation injuries in which the teeth are extruded or displaced with malocclusion (see "Evaluation and management of dental injuries in children", section on 'Other luxation injuries')

Permanent (secondary) tooth avulsion (see "Evaluation and management of dental injuries in children", section on 'Avulsions')

Mandibular fracture (see "Mandibular (jaw) fractures in children", section on 'Management')

Midface fracture (see "Initial evaluation and management of facial trauma in adults", section on 'Midface')

Laceration involving the parotid gland or duct

Laceration with injury to the facial nerve or artery

WOUND REPAIR

Indications for primary closure — Most buccal mucosa and gingival lacerations are not widely separated, heal rapidly without repair, and do not warrant primary closure.

Primary closure (ie, wound repair at the time of presentation) is the preferred treatment for the following intra-oral lacerations [2]:

Wounds deep enough to trap food particles

Wounds >2 cm in length

Wounds with a flap of tissue between the occlusal (chewing) surfaces of the teeth

Contraindications and precautions — Wounds with obvious signs of inflammation (redness, warmth, swelling, pus drainage) should not be closed primarily. If not causing airway compromise, oral laceration repair should also not delay further evaluation and definitive care of more urgent traumatic injuries, including underlying midface or jaw injuries.

Since these wounds heal rapidly, delayed primary closure (ie, cleansing and debridement at the time of initial presentation with definitive wound closure performed electively four to five days later) generally does not play a role in oral lacerations and would only be indicated if an infection were to develop.

Preparation — Preparation for the care of intra-oral lacerations includes a discussion of the likely outcomes of repair, the choice of repair, assembly of the appropriate equipment, provision of anesthesia and analgesia, and wound debridement and cleansing.

General consent forms for treatment are commonly part of the registration process for all patients arriving into the emergency department (ED), and a separate written consent for wound repair in the emergency department is not usually obtained [3-5]. However, the patient and/or caregiver must be aware of the general risks of laceration repair, which include infection, pain, and scarring.

Anesthesia and analgesia

Local or regional anesthesia — Local anesthetic infiltration using lidocaine with or without epinephrine or similar agent (table 2) provides analgesia for most simple oral laceration repairs in adults and cooperative children. Buffering of the lidocaine significantly reduces the pain of injection, especially when using lidocaine with epinephrine. Regional nerve blocks are the anesthetic method of choice for wounds that are extensive or involve lacerations of the tongue or mucosal surface of the lip. The discomfort of infiltration may be further decreased by the use of nonpharmacologic interventions such as biobehavioral and cognitive distraction. (See "Subcutaneous infiltration of local anesthetics", section on 'Procedure' and "Procedural sedation in children: Approach", section on 'Nonpharmacologic interventions'.)

Topical lidocaine-epinephrine-tetracaine (LET) solution or gel is an effective anesthetic for pediatric facial and scalp wounds [6]. An alternative topical anesthetic agent is xylocaine spray [7].

Infraorbital nerve block – An infraorbital nerve block (figure 3) provides anesthesia to skin and mucosal surface of the upper lip. This technique is discussed in greater detail separately. (See "Assessment and management of facial lacerations", section on 'Facial nerve blocks'.)

Mental nerve block – The mental nerve block (figure 4) provides anesthesia to skin and mucosal surface of the lower lip and chin. This technique is discussed in greater detail separately. (See "Assessment and management of facial lacerations", section on 'Facial nerve blocks'.)

Inferior alveolar nerve block – An inferior alveolar nerve block (figure 5) is a more proximal nerve block at the mandibular foramen. This block will provide anesthesia to the pulp of the mandibular teeth (inferior alveolar nerve), lower lip and chin (mental nerve), and anterior two-thirds of the tongue. Performance of this block is discussed in greater detail separately. (See "Evaluation and repair of tongue lacerations", section on 'Inferior alveolar nerve block'.)

Supraperiosteal infiltration – Supraperiosteal infiltration provides anesthesia to individual teeth, specifically maxillary incisors, canines and premolars. This may be helpful for gingival lacerations involving dentition. It is performed as follows (figure 6):

Locate the mucobuccal fold above (or below) the tooth.

Insert the needle into the mucobuccal fold centered on the tooth to be anesthetized. The bevel of the needle should be facing the bone (picture 1).

Aim towards the maxilla (or mandible) and once contact is made with the bone withdraw the needle 1 mm.

Aspirate to ensure you are not in a vessel and inject 1 to 2 mL local anesthetic at the apex of the root tip.

If the laceration crosses the midline, bilateral nerve blocks (infraorbital, mental, or inferior alveolar) should be performed.

Procedural sedation — Procedural sedation is likely to maximize patient comfort and cosmetic outcomes in the following situations:

Complex oral lacerations that require extensive revision

Young children or highly anxious or otherwise uncooperative patients, especially when the safety of clinician and staff may be compromised

When performing sedation in patients undergoing oral laceration repair, the clinician should ensure adequate suction of secretions and blood and positioning of the patient in the semirecumbent position to prevent aspiration of secretions. Agents that preserve airway reflexes (eg, ketamine) are preferred in children. Increased oral secretions associated with ketamine administration may be managed by giving atropine or glycopyrrolate at approximately five to 10 minutes prior to sedation. In most patients, these precautions provide sufficient protection of the airway. (See "Pediatric procedural sedation: Pharmacologic agents", section on 'Ketamine'.)

In situations where bleeding from the wound is brisk and not easy to control or the patient has existing airway compromise, securing of the airway with endotracheal intubation and performance of repair under general anesthesia is warranted.

Procedural sedation in children and adults is discussed in more detail separately. (See "Procedural sedation in children: Approach" and "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

Wound preparation — Local or regional anesthesia prior to initiating irrigation and wound cleansing improves patient comfort. In young children and patients with heavily contaminated wounds, procedural sedation may also be necessary so that wound preparation can be tolerated. (See "Assessment and management of facial lacerations", section on 'Anesthesia and analgesia'.)

Oral and perioral wounds are contaminated wounds since saliva typically contains one million bacteria per milliliter [8]. Local wound inoculums of 100,000 bacteria per gram of tissue are sufficient to cause wound infection. However, copious irrigation does not prevent ongoing contamination. Thus, we typically perform limited irrigation with 100 mL of sterile normal saline after removal of nonviable tissue and any visible foreign bodies (eg, dirt, grass, or superficially embedded objects). Wounds with extensive devitalized tissue warrant consultation with a plastic or oromaxillofacial surgeon. (See 'Indications for subspecialty consultation or referral' above and "Minor wound evaluation and preparation for closure", section on 'Debridement'.)

Antiseptics, such as chlorhexidine, povidone-iodine solution (Betadine), or hydrogen peroxide, should be avoided, as they are potentially toxic if swallowed [2,9].

The clinician should not shave facial hair near the laceration because shaving is associated with the deposition of bacteria into the wound [9]. If facial hair impedes visualization of the wound, it can be clipped with scissors or smoothed down away from the wound edge with normal saline or petrolatum.

Equipment — The following equipment should be assembled for oral laceration repair:

Gloves

Surgical mask

Eye protection

For patients who pose an infection control risk, other personal protective equipment as indicated based upon type of infectious transmission (eg, contact, droplet, or airborne)

Buffered 1 percent lidocaine (with or without epinephrine) or similar local anesthetic (table 2); lidocaine with epinephrine is preferable for patients with ongoing bleeding and for most regional blocks

Small volume syringe (eg, 3 or 6 mL) with small gauge needle (eg, 25 or 27 gauge) for infiltration of local anesthetic; a short needle (eg, 0.625 in) is preferable for young children or other patients in whom movement is anticipated

Needle holder

Hemostat

Tissue forceps

Scissors

Surgical probe

4 x 4 gauze

Absorbent towels

Sterile field drapes

Emergency departments generally are well-equipped with minor surgical or suture trays that contain the instruments, sterile gauze, towels, and drapes listed above.

Suture selection — Intra-oral mucosa should be closed with absorbable suture such as 4.0 or 5.0 chromic gut suture which resists break down by saliva or polyglactin 910 (eg, Vicryl) (table 3).  

Techniques — Techniques for intra-oral laceration closure vary depending upon the structures involved:

Buccal mucosa and gingival lacerations – Once assessment has determined the absence of major injury to the parotid duct or facial nerve or artery, closure of large gaping wounds of the buccal mucosa or gingiva can be achieved by placing deep buried polyglactin 910 (eg, Vicryl) or poliglecaprone 25 (eg, Monocryl) in the submucosal region if needed followed by interrupted sutures of 4-0 or 5-0 chromic gut or polyglactin 910 on the mucosal surface.

Because the wound is in a contaminated region and to avoid local irritation during chewing and other mouth and tongue movement, the clinician should use the minimal amount of sutures necessary to approximate the wound edges.

In children, placement of deep buried submucosal sutures without placement of mucosal sutures may prevent loss of repair caused by the inevitable manipulation of surface sutures (pulling on or tonguing of the sutures).

Gingival avulsion – These wounds may occur on the gingiva overlying the mandibular or maxillary ridge leaving a flap of tissue. Occasionally, the flap can appear too small or retracted to approximate. Typically, direct pressure with wet gauze can stretch the tissue for reapproximation. Less commonly, blunt dissection is necessary to mobilize the flap.

Because of the limited amount of submucosa to anchor the stitch, the technique for closure involves use of the mucosa on the inner side of the teeth for anchoring as follows [2] (figure 7):

Pass the needle and suture (4-0 or 5-0 chromic gut or polyglactin 910 (eg, Vicryl)) through the tip of the flap and between the teeth to the palatal portion of the gums. If the teeth are too close together to permit passage of the needle, floss the suture between the teeth and then take a bite through the palatal portion of the gums.

Pass the needle circumferentially around the tooth so that it comes out through the flap on the facial portion of the gums and tie. If the teeth are too close to permit passage of the needle, floss the suture between the teeth to the facial portion of the gums and then take a bite of tissue and tie.

Repeat as needed until the flap is approximated.

For edentulous patients be sure that the suture knots and loops are not located in regions of contact with the bridge of the denture.

Tongue laceration – (See "Evaluation and repair of tongue lacerations", section on 'Laceration repair with sutures'.)

Lip laceration including through and through lacerations – (See "Assessment and management of lip lacerations", section on 'Techniques'.)

OTHER CONSIDERATIONS

Tetanus prophylaxis — Tetanus prophylaxis should be provided as for contaminated wounds as indicated (table 4). Pregnant women should receive immunization based upon their immunization history, as discussed in detail separately. (See "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination'.)

Prophylactic antibiotics — We suggest that most patients with gaping oral lacerations receive prophylactic antibiotics selected to cover oral flora (eg, penicillin, amoxicillin, cephalexin, or in penicillin-allergic patients, clindamycin) rather than no treatment.

The frequency of wound infection following intra-oral laceration varies from 9 to 27 percent [10-14]. One single center observational study suggests that there is significant practice variation for the prescribing of prophylactic antibiotics to patients with oral lacerations [15]. Randomized trials have not shown a significant benefit of empiric antibiotics but have enrolled low numbers of patients and have not been blinded [12,13,16]. One study did find fewer infections in compliant patients with mucosa-only intra-oral lacerations compared to no treatment (10 versus 5 percent) although these results were not statistically significant [13].

Taken together, the evidence suggests that antibiotics may decrease the rate of wound infection after repair of oral lacerations with significant mucosal involvement and is a reasonable therapy given that oral and perioral lacerations are contaminated by abundant facultative species and obligate anaerobes. Similarly, antibiotics are warranted in immunocompromised individuals [15].

Bite wounds — Bites, scratches, abrasions, or contact with animal saliva via mucous membranes or a break in the skin can all transmit rabies. Early wound cleansing is an important prophylactic measure, in addition to timely administration of rabies immune globulin and vaccine (table 5). Indications for rabies prophylaxis are discussed separately. (See "Indications for post-exposure rabies prophylaxis" and "Rabies immune globulin and vaccine".)

In general, the risk of contracting HIV, hepatitis B, or hepatitis C from a human bite is negligible unless blood exposure has also occurred. If the biter has been exposed to blood from an infected bite victim, then prophylaxis may be appropriate as discussed separately. (See "Management of nonoccupational exposures to HIV and hepatitis B and C in adults".)

AFTERCARE — Patients with intra-oral lacerations should be advised as follows:

Eat soft foods for two to three days.

Rinse the mouth with water after eating.

Avoid spicy or salty foods until the wound is healed.

Avoid the use of straws (negative pressure may increase ecchymosis or bleeding at the wound site).

Caregivers should also be aware of these recommendations.

Wounds should heal rapidly (within three to five days). Patients with risk factors for infection (eg, diabetes mellitus, immunocompromised) should undergo reevaluation 48 to 72 hours after repair to ensure proper healing. Patients capable of self-assessment might not need physician evaluation at this time.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Human bites" and "Society guideline links: Pediatric trauma".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Mouth and dental injuries in adults (The Basics)")

SUMMARY AND RECOMMENDATIONS

Evaluation – Patients with intra-oral lacerations require careful evaluation to determine the presence of life-threatening associated injuries, historical features that increase the risk of complications after wound repair, and characteristics of the wound including extent, degree of contamination including the presence of foreign bodies, and injury to adjacent structures, such as the parotid duct and facial nerve (figure 1 and figure 2). (See 'Evaluation' above.)

Indications for consultation or referral – The following injuries may warrant consultation with an appropriate specialist (eg, plastic or maxillofacial surgeon, dentist), if available (see 'Indications for subspecialty consultation or referral' above):

Injury to the parotid duct or gland

Laceration of the facial nerve or artery

Dental luxations or avulsion of permanent teeth

Mandibular or midface fractures

Wounds with large defects, especially of the upper lip or with significant amounts of devitalized tissue

Indications for primary closure – Most buccal mucosa and gingival lacerations are not widely separated, heal rapidly without repair, and do not warrant primary closure (ie, wound repair at the time of presentation). Wounds with obvious signs of inflammation (redness, warmth, swelling, pus drainage) should not be closed primarily. Primary closure is appropriate for the following wounds (see 'Indications for primary closure' above and 'Contraindications and precautions' above):

Intra-oral mucosa that are >2 cm in length

Deep enough to trap food particles

Flap of tissue between the chewing surfaces of the cheek is present  

Anesthesia – Local anesthetic infiltration using lidocaine with or without epinephrine or similar agent (table 2) provides analgesia for most simple oral laceration repairs in adults and cooperative children. Regional nerve blocks are the anesthetic method of choice for wounds that are extensive or involve lacerations of the tongue or mucosal surface of the lip (figure 3 and figure 4 and figure 5). (See 'Local or regional anesthesia' above.)

Procedural sedation – This is appropriate in young children or highly anxious or otherwise uncooperative patients or for complex oral lacerations that require extensive revision. However, frequent suctioning and positioning of the patient in a semirecumbent position is important to prevent aspiration of secretions during sedation. (See 'Procedural sedation' above.)

Wound irrigation – Oral and perioral wounds are highly contaminated wounds. However, copious irrigation does not prevent ongoing contamination. Thus, we typically perform limited irrigation with 100 mL of sterile normal saline after removal of nonviable tissue and any visible foreign bodies (eg, dirt, grass, or superficially embedded objects). (See 'Wound preparation' above.)

Suture selection – Intra-oral mucosa should be closed with absorbable suture such as 4.0 or 5.0 chromic gut suture, which resists breakdown by saliva or polyglactin 910 (eg, Vicryl) (table 3). (See 'Suture selection' above.)

Techniques – Buccal mucosa and gingival lacerations can be closed in one or two layers. Gingival avulsion closure involves use of the mucosa on the inner side of the teeth for anchoring (figure 7). (See 'Techniques' above.)

Viral and antimicrobial prophylaxis – In patients with gaping intra-oral lacerations, we suggest prophylaxis with antibiotics selected to cover oral flora (eg, penicillin, amoxicillin, cephalexin, or in penicillin-allergic patients, clindamycin) rather than no treatment (Grade 2C). (See 'Prophylactic antibiotics' above.)

Most facial (not intra-oral) wounds do not warrant empiric antibiotic treatment.

Patients should receive tetanus prophylaxis as needed (table 4). (See 'Tetanus prophylaxis' above.)

Bite wounds from animals may warrant rabies prophylaxis (table 5). (See 'Bite wounds' above.)

The need for prophylaxis for hepatitis B virus or human immunodeficiency virus should be assessed when treating human bites. (See 'Other considerations' above.)

Aftercare – Patients with intra-oral lacerations should be advised to eat a soft diet for two to three days, rinse the mouth with water after eating, avoid spicy or salty foods until the wound is healed (three to five days), and avoid the use of straws. (See 'Aftercare' above.)

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  2. Armstrong BD. Lacerations of the mouth. Emerg Med Clin North Am 2000; 18:471.
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