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Lead poisoning after maxillofacial wound with gunshot: A clinical report
Selçuk Oruç, DDS, PhD
Dental Sciences Center, Gülhane Military Medical Academy, Ankara, Turkey
The purpose of this study is to attract attention to lead poisoning after gunshot. Lead particles that were notremoved from the patient’s body may exert toxic effects on several organ systems. Therefore, such patientsliving with unremoved lead particles in their bodies must be warned about health control regularly.
(Int Chin J Dent 2002; 2: 63-66.)
Key words: firearms, lead poisoning, maxillofacial injury.

INTRODUCTION
Lead poisoning is a serious disease, which, if it remains undetected, can lead to development delay andother sequels. Despite the absence of symptoms in the majority of patients carrying bullet fragments in theirbodies, the possibility of lead poisoning should be kept in mind. Especially, retained bullets within or
adjacent to large joints have been implicated as a cause of lead intoxication in several cases.1-6 However, incase that removing bullets is believed to be more hazardous if they are left in the body. In addition,maxillofacial injuries due to gunshot cause serious damage to several tissues including skin, nose, eyes, othersoft tissues and teeth. Dental intervention is generally delayed due to the priority given to surgery of othertissues. This makes the dental intervention more difficult.
The purpose of this study is to attract attention to these matters and to aid these kinds of patients.

CLINICAL REPORTA 19 year-old woman was injured in 1991 (while she was 11 years old) from maxillofacial area by agunshot. The first medical operation was carried out in Cukurova University Medical Faculty. Following thenext operation in Ankara Numune Hospital, the patient was physically examined in GATA Plastic Surgery
Department on March 10, 1999 and multiple soft tissue scars involving full face and 4 x 5 cm soft tissue
depression distorting right nasolabial fold were detected. Any functional deficiency pertaining to the face
was not found. Due to the detection of asymmetric and left deviation on the nostrils surgical operation wascarried out.
On March 22, 1999 as the patient was sent to GATA Dentistry Oral Diagnosis Department her mouth werechecked and her mobile teeth were determined to extract. Therefore she was directed to Prosthetics
Department. As a result of inner mouth examination which is supported via panoramic, cranium andperiapical graphics (Figs. 1, 2, 3) there found impacted left premolars, bone deficiency on the right maxillary

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central tooth, so forth extraction of the right maxillary central tooth was determined from prosthetic point ofview. Although there were whole left teeth on the maxilla of the patient, the right maxilla happened to beedentulous. As for the right mandible, orthodontic problems occurred relevant to the early loss of primarypremolars. For providing both the lost occlusion and the eruption of impacted premolars on the rightmandible, orthodontic treatment was started by bracing lower teeth.

Figs. 1-3. Panoromic and cranio graphies.
The edentulous right maxilla with full teeth resulted in a negativity for the stabilization and the retention of
the prosthetics. So the patient was evaluated from implantation respect with the mere solution of suchproblems of our ages.
Since the systemic diseases are contraindicated for implants, implantation treatment was not selected. The
extracted teeth, lead levels in the blood and urine were sent to GATA Toxicology Department for being
checked with the consideration and apprehension of many lead particles in the maxillofacial area might cause
the chronic lead poisoning, and the following results were acquired (Table 1).
Table 1. Patient’s lead levels.
NormalResultBlood

250 ng/mL

720 ng/mL

Urine

0.884 µg/mL

1.394 µg/mL

Tooth

1.939 µg/mL

71.965 µg/mL

After this analysis, as occasional abdominal cramps, nausea, lethargy in hands and headache occurred in64

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the patient, she was sent to internal diseases department as to investigate the lead poisoning symptoms found,in addition to the prosthetics and orthodontics treatment had been applied.
The contemplated implantation for the patient was halted at least for present, and upper removable Partial
Prosthetics was decided. As to be able to use opposite arch stabilization, the left upper second premolar andthe first molar were crowned and aimed to apply Bonwill clasp. After known prosthetics procedures theremovable partial prosthetics was applied to maxilla.

DISCUSSION
It has come out once again that the early diagnosis and treatment would be more helpful and easier. The
dentist’s intervening to the case in time with the purpose of preventing both difficult and huge financial
solutions is of great importance for all kind of tooth and occlusion loss particularly in maturing age.
For being able to decide whether the lead particles inside the alveolar ridge and soft tissue will effect thedental implantation or not, a detailed research is required. Within the detected lead levels; high lead level inthe teeth is a result of dental arch’s been directly affected from the shotgun. Lead toxicity may present withmany systemic symptoms such as irritability, nausea, abdominal and joint pains, lethargy and muscle
weakness which are easily recognized. In our case, there is a close relationship between lead toxicity and leadlevels pertaining to the amount available in the body.
In recent studies about this subject, it has been stated that hypertension gut, chronicle kidney disordersdepression and congestive heart problems are among the most common symptoms as well.
It is understood that tolerable lead particles not removed from the body in the early years, might cause
toxic effects in the following years. This reveals the fact that these particles are not inert; therefore thesubject must be investigated from this respect as well. The patients must be warned that the overlooked leadparticles might affect the system and periodical checks must be done without delay.
As to accomplish a vast research on the case, which requires the investigation of other patients who haveunremoved lead particles inside the body, studies have been initiated. But for enabling to take the attention ofinterested people to the subject, this article was presented without waiting the results of this firearm injury
case.

CONCLUSION
Since removing lead particles from the body after firearms injuries, causes more damages, most of them
are left in the body. Even though these lead particles are not toxic early years, it is not known what kind ofeffects will be seen in the following years. There are lead particles in the patient’s maxillofacial area andalveolar ridge. Firstly from functional and esthetical respect, removable partial denture was applied to thepatient. The extracted teeth, blood and urine samples of the patient were tested and chronicle lead poisoning
symptoms were detected. It can be concluded that, lead particles that were not removed from the patient’s
body may exert toxic effects on several organ systems. Therefore, such patients living with unremoved leadparticles in their bodies must be warned about health control regularly.

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INT CHIN J DENTREFERENCES
1. Dominic JB. Adult chronic lead intoxication. Arch Intern Med 1991; 151: 1718-201.
2. Beazley WC, Rosenthal RE. Lead intoxication 18 mounts after a gunshot wound. Clin Orthop 1984; 190: 199-203.
3. Kikano GE, Stange KC. Lead poisoning in a child after a gunshot injury. J Fam Pract 1992; 34: 498-500.
4. Madureira PR, Capitani EM, Vieira RJ. Lead poisoning after gunshot wound. Sao Poulo Med J 2000; 118: 78-9.
5. John BE, Boatright D. Lead toxicity from gunshot wound. Sauth Med J 1999; 92: 223-5.
6. Manton WI. Lead poisoning from gunshot a five-century heritage. J Toxicol Clin Toxicol 1994; 32: 387-9.

Reprint request to:
Dr. Selçuk Oruç
8. Cad. 645. Sok. Gonca Evler St. No: 16, Çayyolu 06530 Ankara, Turkey
E-mail: selcukoruc@hotmail.com
Received on August 21, 2001. Revised on November 15, 2001. Accepted on December 22, 2001.
Copyright ©2002 by the Editorial Council of the International Chinese Journal of Dentistry.

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