Three Generations of Inherited Dental Defect

ENDOCARDITIS [HMEDICALJOUINAL 9 CASE III Male, aged 53, suffered from a sudden attack of auricular fibrillation in September, 1927.He came under the care of Professor T. G. Moorhead, who has kindly permitted me to record Iris case.During a period of eighteen months after his initial attack of irregularity, repeated attacks occurred of paroxysmal fibrillation with some flutter.The heart showed moderate enlargement, with a systolic murmur maximal in the mitral area.Complete examination failed to show any catuse for the irregularity.His teeth were carefully examined by a dentist in November, 1928, and were pronounced sound.Early in 1929 the patient began to suffer from some discomfort with his teeth, and a general deterioration of health was noted, as evidenced by considerable loss of weight, with in- creasingly frequent incidence of fibrillation.In April, 1929, he consulted a London cardiologist.His teeth were x-rayed and two roots were condemned.Removal of all his teeth under local anaesthesia was recommended.In May, after an abortive attempt to improve the con- dition of pyorrhoea which then existed, two teeth were removed without difficulty, the only anaesthetic employed being cocaine, which was simply painted on the gums.On June 27th another tooth was removed.This ex- traction proved difficult, and some novocain was injected into the gums.Following the extraction the gums continued to bleed for three days.The bleeding ceased after application of adrenaline.On July 1st a purpuric eruption occurred all over the body.On the next day there was pronounced haematuria, and oozing of blood was noted all over the surface of the palate and from the gums.Haemostatic serum and antistreptococcal serum were administered and the bleeding ceased.Four days later there was haemorrhage from the stomach and bowel, and, from this on, the patient was mildly pyrexial.Blood culture was negative.At this time I saw the patient in consultation on two occasions.No marked change was noted until August 14th, when he was apparently much better and able to go for a drive.On the next day he was not so well, and was again feverish.Haematuria once again appeared, and there were more purpuric spots.Two days later it was noticed that the left arm was paralysed.HIalf an hour later the left leg was paralysed, and still later the left side of the face.Towards evening there was severe haematemesis, after which the patient sank into coma and died.COMMENTARY It will be seen that in two of the cases recorded above there was no symptom or sign of endocarditis until the removal of septic foci.The first patient had experienced no disability whatever from his heart lesion, and consulted a dentist because of trouble with his teeth.The second patient was led to consult a cardiologist because of re- jection for the Army.His valve lesion had not inter- fered with indulgence in strenuous exercise.The third patient had presented a number of symptoms before the removal of teeth, but the terminal illness was closely associated with an extraction.I feel justified in including his case in this paper in spite of negative blood culture, as the circumstances associated with his death point the same moral as the other cases.