Sir, a 41-year-old Caucasian male presented with severe pain from his upper and lower right molars consistent with irreversible pulpitis. He had type 1 diabetes mellitus, which was poorly controlled, and vitiligo affecting his hands and feet (Fig. 1), and described previous episodes of transient thyroid abnormalities. A traveller of eastern European origin, he had received no orthodontic treatment in the past and although his brother also had type 1 diabetes mellitus, vitiligo and had lost his permanent dentition at an early age, the cause was unknown.

Figure 1
figure 1

Vitiligo affecting hands and feet

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The patient had a minimally restored dentition, poor oral hygiene, supragingival and subgingival calculus, generalised gingivitis and 3-5 mm pocketing around the posterior teeth. The teeth were non-mobile and of normal clinical appearance although 17, 18 and 46 were extensively carious. An OPT radiograph showed external apical root resorption affecting all teeth, periapical areas associated with 17, 18 and 46 and calcification in several of the molar pulp chambers (Fig. 2).

Figure 2
figure 2

Panoramic radiograph showing generalised external apical root resorption

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Teeth 17, 18 and 46 were extracted under local anaesthesia and blood investigations were performed to identify any systemic causes. Full blood count, urea and electrolytes, liver function tests, bone biochemistry, thyroid function tests, parathyroid hormone, random blood sugar and an autoimmune screen were all within normal limits. The root resorption has remained static over a one year period. Long term follow up of his dentition in the form of radiographs and pulp testing is planned in liaison with his general dental practitioner. He continues to attend the endocrine medicine clinic.

External apical root resorption affecting multiple permanent teeth is rare with 14 reported cases in the literature.1 Only three of these cases report resorption affecting the entire permanent dentition. Several systemic abnormalities have been associated with external root resorption, including Paget's disease, hypophosphataemia, hyperparathyroidism, bone dysplasia, Papillon-LeFèvre syndrome, renal disease, liver disease and Ehlers-Danlos syndrome Type VIII.1,2 However, no associated systemic condition was evident in the three previously reported cases affecting the entire permanent dentition.1 Genetic susceptibility to idiopathic external root resorption has been reported with autosomal dominant, autosomal recessive patterns and spontaneous phenotype demonstrated.2 Unfortunately the nature of his brother's tooth loss could not be confirmed and thus a genetic association is uncertain in this case.

The root resorption process involves complex interactions between inflammatory cells, resorbing cells, cytokines and enzymes.3 Changes in the host cellular immune system may be implicated in altering the resorption process and producing clinically significant external root resorption.4 Although not proven, this patient's type 1 diabetes mellitus and vitiligo are conditions associated with immunoendocrinopathy that may have caused sufficient change within the host cellular immune system to be the causative factor in his root resorption. As this combination of conditions may represent a new syndrome we are curious if it has been encountered elsewhere.