|Year : 2015 | Volume
| Issue : 1 | Page : 11-17
Electrical injuries of the oral cavity: A menace to mankind
Nazish Baig1, Nikita Parasrampuria1, Babita Yeshwante1, Gaurav Tated2
1 Department of Prosthodontics and Crown and Bridge, CSMSS Dental College and Hospital, Aurangabad, Maharashtra, India
2 Department of Orthodontics and Dentofacial Orthopaedics, CSMSS Dental College and Hospital, Aurangabad, Maharashtra, India
|Date of Web Publication||5-Jun-2015|
Dr. Nikita Parasrampuria
137, VIP Road, Natural Heights, Block - 8, Flat - 4D, Kolkata - 700 052, West Bengal
Source of Support: None, Conflict of Interest: None
The rarest of its kind, the electrical injuries of the commissure areas of the mouth pose a potential threat in terms of management to the practitioner. The most commonly affected young toddlers, in their teething period, chew onto the female end of the live extension wire cord. Saliva which acts a medium transports the electrical current to the fragile mucosa of the oral cavity thereby leading to the treacherous burn injuries. Since children have an overall lower fat component and different surface area to volume ratio, which impacts on the risk of deep tissue damage compared to adults with equivalent injury. The review outlines: (1) A detailed review of literature reflecting the various treatment modalities proposed by different practitioners worldwide and (2) the prosthetic therapy for the conservative management of the electrical injuries of the oral cavity.
Keywords: Acrylic splint, burns, commissure, electrical Injuries, infants, microstomia
|How to cite this article:|
Baig N, Parasrampuria N, Yeshwante B, Tated G. Electrical injuries of the oral cavity: A menace to mankind. Indian J Health Sci Biomed Res 2015;8:11-7
|How to cite this URL:|
Baig N, Parasrampuria N, Yeshwante B, Tated G. Electrical injuries of the oral cavity: A menace to mankind. Indian J Health Sci Biomed Res [serial online] 2015 [cited 2019 Jan 16];8:11-7. Available from: http://www.ijournalhs.org/text.asp?2015/8/1/11/158215
| Introduction|| |
Electrical burns of the mouth are the most common electrical injury in children, primarily occurring in the 6- to 36-month age group.  Contemporary understanding of burn management in the pediatric population is underscored by several decades of advancing care in resuscitation, reconstruction, and rehabilitation. 
At the beginning of the present century, the knowledge of electrical burns was very limited.  According to Jellinek, it was commonly stated that death from electric shock was inevitable, that autopsy findings were negative and that the external injuries were just burns.  The prevalence of oral electrical burns among infants has not been comprehensively studied.  Thomson et al. reported that between 1945 and 1963, 45 children with electrical burns to the mouth were admitted for treatment to children's hospital in Toronto. 
Electrical burns may be due to direct tissue contact or tissue reception of an electrical arc.  The effect of the electrical current on tissues of an individual is dependent upon: (1) Voltage (2) amperage (3) type of current (4) resistance at the point of contacts (5) path of current through the body (6) duration of contact and (7) individual susceptibility. 
Electrical burns of the oral cavity are often caused when children chew on the cords of electrical appliances. The burns usually occur in infants who are teething.  The vast majority of these burns are due to the child sucking on the female end of a live extension cord or a partially plugged in appliance. ,, Saliva acts as a contact medium through which the electric current flows resulting in the oral electrical burn. 
Microstomia which is defined as a marked reduction in the size of the oral aperture occurs as a sequel to complications associated with facial burns, traumatic injuries to the face, and loss of tissue elasticity as in diffuse facial scleroderma.  The cause of the burn may be chemical, electrical or thermal, but the scar contracture that occurs is a common sequel to each. Contracture of the tissue that surrounds the oral cavity may affect the patient's ability to obtain optimal dental care and maintain good oral hygiene. 
The purpose of this article is to review the different types of prosthetic therapy which have been used in the recent studies to prevent or reduce the contracture and the complications which occur as result of the electrical burns in the oral cavity.
| Various Treatment Modalities - A Literature Review|| |
Sturmer (1961)  presented a case report on electric burns in which he described the distribution of the burns on the various victims and transmission of the current from one to the other. A series of electrical burns is presented in the paper demonstrates the ability of a current to travel through several bodies as it would any series of conductors joined by contact points. As on February 4, 1960, when four young men inadvertently struck a wire with a potential of 4700-6000 volts. Various sites of involvement of the burns for the four victims were neck, thighs: Feet and hands. In the operating room, the wounds were thoroughly cleansed with phisohex and rinsed with sterile water. Sterile aluminum powder was applied according to the method of farmer. The arm was covered with Tiburon gauze and dry sterile dressings and then placed on a cock-up splint to maintain a position of function. He was given antibiotics, vitamins, and protein supplements.
Nagel and Werthmann  presented a case report, which illustrated the healing of an electric burn of the mouth followed by delayed repair. The paper describes a 4-year-old boy, chewing on a light cord, was burned at the right oral commissure and adjacent lips. 5 months post the burn the commissure was reconstructed and lip resurfaced with local mucosal flaps. A further "Z" plastic procedure was performed on the skin incision.
Chasmar  used a conservative approach in his series of case reports for the management of electrical burns. In the report 4 patients with electrical injuries have been spoken about and the report outlines the management and potential complications encountered in the treatment. The complications include skull defects, nerve lesions in continuity, nerve defects, limb or digit necrosis, and electrical cataracts.
Rock and Stögmann  presented a case report where 11 children were admitted with electrical injuries to the Department of Pediatrics, University of Graz, over the ten years period 1965-1974. All children showed the characteristic skin lesions of electrical injury (current marks of linear, round or spidery form). The modes of electrical injury in childhood, the various forms of the resultant lesions, especially of the skin and the treatment of electrical burns have been described.
Orgel et al.  presented a retrospective study, which reported a 15 years experience with electrical burns of the mouth in children. In addition a method has been described by which surgical results to date can be measured. It states that the extent of injury is the crucial factor for electrical injuries. The concept of initial delayed primary excision has been favored in the report.
Crikelair and Dhaliwal  presented an epidemiological review of the electrical burns of the mouth in children which pinpoint the cause to the female end of extension cords. The use of protective cuff, designed to prevent these disfiguring injuries has been suggested.
Colcleugh and Ryan (1976)  presented an appliance to prevent the microstomia, which occurs as a result of the electrical burns of the mouth. A mouth splint has been designed which is to be worn through the healing period of the burn. The splint is custom fitted for each child and it is easily removed. Six children have been treated and followed up for four years. The results to date have been excellent in preventing microstomia.
Wood et al.  in their report said that a plastic surgery is needed to correct the defect (scarring, contractures) resulting from the electrical burns of the lip commissures, when a special burn obturator is used. The obturator is worn for a year and can prevent or reduce the need for corrective surgery.
Ryan  proposed the prosthetic treatment for electrical burns. A procedure was presented to provide an esthetic result in the treatment of electrical burns to the mouth. A removable prosthesis controls the degree of scarring, contracture, and deformity that often occurs from surgical repair of these burns.
Su et al.  proposed that the preferred technique for the reconstruction of average oral commissure utilizes available vermilion for reconstruction of the lower lip by a rotation flap and a mucosal advancement flap for the upper lip.
Lecompte and Goldman  presented a case report of an electrical burn of the lips in a 22-month-old child. The principles of early medical and dental treatment sequence are detailed. The appliance fabrication utilized is unique because it is an intraoral treatment approach to a commissural burn in a child that had not yet erupted primary second molars.
De La Plaza et al.  conducted a study with 58 cases of burns produced in the mouth by electricity where a comparison between three kinds of treatment modalities have been made: (1) Conservative (2) surgical after debridement and (3) early of primary surgical. The results obtained concluded that surgery allows the problem of burns to be resolved in less time with shorter stay in the hospital.
Leake and Curtin  described the fabrication and use of a "dynamic microstomia prevention splint" which appears to be beneficial in eliminating the need for or decreasing the degree of surgery in children with electric burns of the commissure of the mouth.
Czerepak  described the treatment, which included the use of an orally anchored splint to hold the lip commissures at their current positions during healing. After wearing the appliance for a period of 1 year, the burn site was evaluated for the corrective surgery, and it was concluded that the use of a commissure appliance decreased the need for surgery.
Vecchione  in his article described the treatment of the late effects of oral commissure scarring, especially after electrical cord injuries. The combination of mucosal advancement flaps plus split vermilion grafts and full thickness periauricular skin grafts were used and illustrated in 2 patients.
Schneider  illustrated an extra oral approach using a reverse pull headgear for the management of an electrical burn to the commissure of an infant's lip. This treatment was effective for the minimally cooperative patient and the appliance was well retained without any need for dental abutments. The results, in this case, demonstrated that such an appliance is well tolerated to prevent microstomia and to reduce the need for cheiloplasty subsequent to a commissural electrical burn.
Baker and Chiaviello  reviewed the medical records of all children with household electrical injuries. The most frequent cause of injury identified was oral contact with electrical cords or cord sockets or contact with wall sockets either directly or via conductive foreign objects such as keys or pins. Data reported to the consumer product safety commission were also analyzed and corroborated the findings. A new wall outlet cover design is described.
Pensler and Rosenthal  in his article described a functional reconstructive surgery which combined excision of the burn scar with lateral advancement of the orbicularis oris muscle, recreation of the modiolus labii, and reestablishment of the vermilion continuity, which appeared to significantly decrease the postoperative wound contracture.
Linebaugh and Koka  provided clinical guidelines for the various prosthodontics treatment options for the oral electrical burns. They also discussed the etiology and histopathology of the same.
Barone et al.  presented a retrospective analysis of 29 patients who sustained perioral electrical burns. Children were divided into three groups: (Group 1) No surgery and no splint (n = 21), (Group 2) nonsurgical management with splint appliance (n = 8), and (Group 3) commissuroplasty (n = 9). Mean age was three years and the minimum follow-up period was 1 year. The results concluded that the application of easily constructed splint yielded the best cosmetic result.
Donelan MB (1995)  utilized a composite ventral tongue flap mucosa and muscle for the reconstruction of the commissure, which permitted the effective release of scar contracture and replaced the destroyed mucosa and muscle bulk. The use of this flap in 21 patients yielded very good results.
al-Qattan et al.  stated that the need for commissuroplasty was significantly decreased in the splinted group of patients, which he had used for the study (by the Fischer's exact test).
Zubair and Besner  proposed the management strategies for the pediatric electrical burns. The purpose of the study was to analyze the course of patients hospitalized with electrical burn wounds in the past 25 years at a major hospital in the United States in order to devise safe and cost effective management strategies for these patients. The results concluded that the number of admissions to the hospital for children with low voltage minor electrical injuries can be safely reduced.
Fish  presented an article where he said that patients with electric injury present a significant challenge. Possible mechanisms of injury include electrical disruption of cardiac rhythm and breathing burns of several types and inhalation of gases from fires. Mechanical trauma may come from electric arc blast, the explosion of gases, falls, and strong muscle contractions.
Edlich et al.  described an organized approach to the management of these complications is outlined in this article. The best treatment of burn injuries remains prevention. Because the majority of burn injuries are due to occupational electrical injuries, the regional burn centers must work effectively with industry to prevent these potentially life-threatening accidents.
Egeland et al.  in the paper discussed that pediatric facial burns present the same reconstructive challenges seen in adults, with additional developmental and psychologic concerns. In the paper, the basic principles of facial burn care in the pediatric burn population, with a specific focus on lower-eyelid burn ectropion and oral commissure burn scar contracture leading to microstomia with several cases have been demonstrated.
Arnoldo and Purdue  said that electrical injuries to the extremity can result in significant local tissue damage and systemic problems. An understanding of the path physiology of electrical injuries is critical to the medical and surgical management of patients who sustain these injuries.
Valencia et al.  describes a case report where 14 years results are shown in a severe electrical burn sustained in a 1 year 2-month-old girl, involving 90% of the lips and commissures, tongue, alveolar ridges, and teeth (primary central incisors and permanent dental germs). Two weeks after she was out of danger, an active splint expansion device was built and used for eight months to prevent secondary microstomia. Later a new active splint device was used for a year after lip plastic surgery. At age 13, orthopedics and orthodontics were accomplished with a lip tattoo completed at age 15. However, no matter how good the final esthetic and occlusal results are prevention is always the best option.
Patel et al.  presented a case report of an oral electrical burn of a 36-year-old female patient, who unknowingly came into contact with live electric wire at her home, while her attempt to peal it off. Following which she sustained massive burn of the oral commissure, lips, tongue, and floor of the mouth. This is one of the rarest cases of the electrical injuries of the lip commissure.
Cowan et al.  proposed a retrospective summary of 75 patients treated from January 1999 to January 2009 at the Tertiary Children's Hospital. Data collected included demographics, etiology of burn, site of injury, medical and/or surgical treatments, the need for endoscopy, duration of hospitalization, and complications. Mean age was 4.3 years (median 2.7 years). Main sites of injury included buccal mucosa (77.3%), lips (56%), tongue (48%), and palate (22.7%).
| Prosthetic Therapy|| |
As per the classification given by William D. Gay (1984)  the oral burns can be classified into two basic groups.
Those that involve one or both commissures without involving other circumoral tissues. 
- Static microstomia orthoses [Table 1] and [Table 2] 
- Dynamic lip expander.  - It derives retention from embracing the buccal and lingual surfaces of the maxillary teeth, as well as the embrasures. Wrought wire clasps may be used if necessary
- Cheuk and Kirkland  [Figure 1] used two plastic mouth retractors and a 12 inch piece of round elastic tourniquet for the fabrication of an extra oral splint for an edentulous patient, which could be fabricated with minimum time and effort with easily available materials
- Schneider  used a reverse pull headgear with outer bow covered with acrylic contoured to the lip commissures. The headgear was scaled down in its vertical dimension so the chin cup and forehead rest could be appropriately being positioned onto the infant's head
- Ryan  - Double post burn stent [Figure 2].
Method of fabrication
- Impressions are made using stock impression trays (modified as necessary) and irreversible hydrocolloid impression material
- A millimeter ruler is used to measure the contour of the mouth from the normal side to the midline. This serves as a guide to where the tissue should be placed on the traumatized side
- A wax centric relation record is made and the stone casts are mounted on a simple articulator
- Two layers of baseplate wax are adapted over the maxillary cast. The palate, teeth, and labial and buccal surfaces to the sulcus are covered. This will increase the vertical dimension slightly
- The occlusal surface of the wax is warmed to index the cusp tips of the mandibular teeth into the wax
- Wax extensions are adapted to the wax covering the maxillary arch. The extensions will retract the angles of the mouth and hold them under tension. The extensions are located using the following guides: (1) Measurements ready to insert. Obtained in the operating room (2) distal of maxillary cuspids for mesiodistal width and (3) incisal edges of maxillary canines for locating the vertical placement
- The wax extensions are molded to curve outward and backward. These act to retract both angles of the mouth and hold the tissue in position. The wax form is sealed to the maxillary cast. Following normal laboratory procedures the wax form is processed into a clear acrylic resin prosthesis, which is trimmed and polished and is ready to insert
- The prosthesis is worn 24 h a day after the initial healing of the open wound. It can be removed to clean the teeth and replaced.
Those that involve all circumoral tissues including the commissures. 
- Microstomia prevention appliance 
- Cheek retractor prosthesis  [Figure 3] - Commercially available lip and cheek retractors mounted on heavy gauge wrought wire frames
- Circumoral retractor  - Acrylic resin frame with two lip and cheek retractors mounted on the frame with screws placed in the slots with the retractors
- Buccal paddles (Clark and McDade).
| Conclusion|| |
The management of electric burns of the mouth is a long and laborious endeavor. Canady et al.  in their review concluded that (1) younger children with more severe burns have a less favorable outcomes (2) no hemorrhage was observed immediately after the burn or at eschar separation and (3) conservative surgical treatment after scar maturation and in some cases following steroid injections - resulted in a successful functional and esthetic outcomes.
Thomas  described the dilemma between conservative treatment and immediate reconstruction procedures. Early intraoral splinting has been suggested in the literature. The incidence of electrical burns has been on the decline, but those affecting the mouth still continue to be a major problem in management.
Appropriate assessment and evaluation grounded in contemporary knowledge and care must be performed for all the presentations of burns in order to best medically manage these injuries. Ideally the best reduction in the healthcare burden of this devastating mode of childhood injury is achieved through preventive measures.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]