Oral trauma encompasses a number of injuries, including fractured teeth and surrounding bones, as well injury to the soft tissues of the mouth. In this talk we will focus on the soft tissues of the mouth, however the reader should be reminded that these injuries can all occur at the same time and any case with pain or bleeding emanating from the oral cavity should undergo a comprehensive wider examination to ensure there is no evidence of concomitant injuries. Common sites of oral trauma include the lips, the lip commissures, the tongue, pharynx, salivary ducts and glands, the hard and soft palate, the palatine artery and the cheeks. Falls, catching the lips and nostrils on external objects, bits and tack, as well as iatrogenic and idiopathic injuries can all be implicated as sources of trauma. In addition, conditions altering the usual mastication of the horse may also result in inadvertent trauma to the buccal mucosa.

The lips, and lip commissures particularly, are prone to damage from the bit and trauma from objects in the patient’s environment. In addition, the rostral aspect of the 06 teeth, either due to sharp overgrowths and altered dynamics due to overzealous rostral profiling can also cause damage to the lip commissures and the adjacent buccal mucosa. Presenting signs will depend on the nature and duration of the injury and range from fresh bleeding wounds, ulcers and chronic scar tissue. It may be that the patient presents with resentment to ridden work with a bit or, less frequently, problems grazing or prehending food. Clinical signs can also include inappetence, halitosis, ptyalism and pyrexia.

Superficial to partial thickness wounds will often heal spontaneously and quickly by secondary intention, especially once any inciting cause is removed. In these cases, lavage of the oral cavity, to reduce any contamination, may expediate the healing. In particularly painful cases, analgesia may be indicated. Any full thickness injuries at this site are invariably always contaminated, and the stability of any repair is limited, and are often unsuccessful as a result. However, attempts at repair should be considered to improve the functional and cosmetic outcome in these patients. Any surgical repair needs meticulous apposition of the individual epithelial, muscular and mucosal layers involved, following thorough cleaning and debridement of the contaminated tissues. Use of hydrosurgical equipment for debridement may be of benefit in these cases. If extensive contusion is present then delayed primary closure may be indicated.

Standing surgery can be considered, but a more successful outcome is likely obtained when completed under general anaesthesia. Once debrided and clean the skin and oral mucosa should be undermined (1-1.5cm) on each side, which will help to reduce the movement on the suture line. Vertical mattress sutures with quills (0-1 non-absorbable) are advised in most cases, from extra oral through the lip musculature. The intraoral mucous membrane can then be closed with simple continuous or interrupted sutures (2-0 monofilament absorbable). The skin margins are then apposed with simple interrupted or, in locations with tension still present, vertical mattress sutures (2-0 monofilament non-absorbable). A vertical mattress suture of the same material should be placed at the mucocutaneous junction. In addition, an additional vertical mattress suture place rostral to the lip commissure may provide extra stability.

Tongue lacerations can have very similar clinical signs to lip and cheek lacerations, but in some cases the haemorrhage can be profuse, and a tourniquet at the base of the tongue may be indicated. Sharp enamel overgrowths can be implicated, but in severe, acute cases they are usually caused by direct trauma to the tongue from tack (e.g. a bit or tongue tie) or inappropriate restraint. Oral examination with a speculum, light and usually heavy sedation is necessary. In some cases diazepam can be useful at reducing movements of the tongue for a short period of time to allow a more detailed examination.

Superficial tongue wounds will usually heal with second intention healing in a short space of time. More severe wounds may be candidates for repair, as the rostral tongue is important in both the prehension of food and ridden contact, so as much as possible should be conserved. As a general rule – if 25% or more of the cross-sectional area of the tongue remains attached and vital then an attempt to repair should be made. The neurovascular structures are in the ventral aspect, and if unsure, intravenous fluorescein can be used to assess perfusion of tissues. Any non-vital tissues should be removed and wounds edges thoroughly debrided. Once again, hydrosurgery can be useful. Vertical mattress sutures are initially placed in the exposed deep muscles, but delaying the tying until all sutures are placed (0 to 1 absorbable monofilament). Additional buried rows of sutures (2-0 to 0 absorbable monofilament) are placed to reduce the dead space. The initial vertical mattress sutures can then be tied. The mucosa is then closed with simple interrupted or continuous sutures.

Glossectomy can also be considered in cases in which the rostral tongue is not viable; this will help control haemorrhage, reduce pain as well hasten healing of the wound. Debridement is the first step, and consideration should be given for removing a wedge of muscle tissue to aid in apposition of the mucosal margins. The muscle edges are closed followed by the mucosal edges (simple interrupted absorbable monofilament). Foreign bodies are also a source of oral trauma, and a challenge to diagnose. The clinical signs are similar to other causes of oral trauma, and require systematic and careful oral examination and palpation to identify the foreign body directly, or more commonly ulceration and soft tissues swellings associated with the foreign bodies.

Radiography may be useful with radiodense foreign bodies, but is greatly retarded in the head by superimposition. Computed tomography (CT) can eliminate the effect if superimposition and is useful in identifying radiodense and some organic bodies that would not usually be identified with conventional radiography. Ultrasonography, using a 5-10MHz rectal scanner for example, can be useful in cases with suspicion of foreign bodies in the tongue, cheeks or the masticatory muscles. Nasopharyngeal endoscopy is also warranted in most cases, to ensure foreign bodies are not located there and/or a cause of trauma to this region too. Removal of the foreign body is dictated by the individual lesions, but careful avoidance of neurovascular and ductal tissues is essential to ensure good healing with minimal complications.