© 2007 Nature Publishing Group PRACTICE Bullets in the mandible over 12 years: a case report F. A. Fernandes 1 and A. Fernandes 2 Foreign bodies that enter a patient as a result of trauma are contaminated and produce a range of symptoms. We report a case in which radiographic evidence of foreign bodies in the mandible exposed a history involving a gunshot injury to the chin. The patient did not have any major complaints relating to the bullets lodged in his mandible or any symptoms of lead poisoning. These foreign bodies have remained clinically silent for more than 12 years. INTRODUCTION Traumatic injuries often drive foreign objects into the human body. Commonly, foreign bodies are glass, wood, thorns, plastic and metal. A foreign object in the body causes infection 1 and toxicity. 2 Some foreign objects remain isolated by encapsulating themselves with a granu- lation tissue reaction and pose very lit- tle danger. 2,3 Foreign bodies like teeth, dental instruments, burs, glass, wood, dental materials and a solitary bullet have been found in the oral and maxil- lofacial area. 1 Given that the presence of a foreign body like a bullet would cause infection and poisoning, this is an unu- sual case in which the foreign objects have remained asymptomatic for more than a decade. CASE REPORT A 50-year-old male patient presented to the Department of Prosthodontics this year for replacement of ill-fitting dentures. The patient had a history of a single gunshot injury to the face around 12 years earlier. He mentioned that he was shot from close range with a home made gun, which from the description sounded like a Muzzleloader. Recalling events at the time of the injury, he said that the spherical pellets caused dam- age to the soft tissue and fracture to the jawbone with avulsion of a few teeth. He could not, however, elaborate on the management procedures, but said that the attending doctor had removed some of the bullets and the rest of the teeth affected by periodontal disease. He was advised at that time to undergo regular evaluation to keep a check on any toxic effects. After an uneventful healing, a set of complete dentures was made, which he had not had replaced until now, even though they were causing him mild discomfort from the time they were first fitted. He did not report for regular eval- uation either. The gunshot had left a scar to the mental region approximately 2 cm x 1 cm in dimension. A firm nodular greyish mass 0.5 x 0.5 cm was palpable in the left buccal soft tissue along with a hard mass palpable at the floor of the mouth. There was no loss of sensation over the facial skin. Intraorally, a palpa- ble depressed alveolar ridge in the man- dibular anterior region (Fig. 1) with an elongated bony extension on the lingual aspect was present. An object, firm in consistency, in the left retromylohyoid region was found to be responsible for the discomfort. Radiographic investigation carried out revealed multiple dense scattered radio- pacities about a resorbed mandible and the surrounding soft tissue (Fig. 2). The divergent spread of the bullets was seen on a lateral oblique radiograph (Fig. 3). A concentration of these radiopacities and an enlarged and elongated genial tubercle was evident in the mental area on a mandibular true occlusal (Fig. 4). In order to evaluate the patient further, a complete haemogram, histopathologi- cal investigation and metal analysis was carried out. The haemogram showed no tell-tale signs of an ensuing plumbism in the body. Tissue surrounding the bullet subjected to histopathology showed the presence of chronic non-specific inflam- mation with hyperplasia of the lining 1 *Resident, Goa Dental College & Hospital, Bam- bolim-Goa, India; 2 Assistant Professor, Department of Prosthodontics, Goa Dental College & Hospital, Bambolim-Goa, India *Correspondence to: Dr Fara A. Fernandes, Rector’s Quarters, Govt. Polytechnic Campus, Altinho, Panjim- Goa, India Email: sansrival78@hotmail.com Refereed Paper Accepted 3 August 2006 DOI: 10.1038/bdj.2007.273 © British Dental Journal 2007; 202: 399-401 BRITISH DENTAL JOURNAL VOLUME 202 NO. 7 APR 14 2007 399 • Foreign bodies such as bullets can remain silent for a long period of time without giving rise to clinical symptoms. • It is important for the dentist to consider removal of a foreign body/bullet only if there is a serious health hazard, keeping in mind the possibility of causing a pathologic fracture. • As age advances, a periodic assessment of blood lead level is advised due to various metabolic changes which may occur and which might lead to mobilisation of the lead from its stores. IN BRIEF