Download Herpes zoster along Maxillary Nerve with Osteonecrosis

Volume 2 Issue 1
February 2011
Herpes Zoster
Case report
Herpes zoster along Maxillary Nerve with Osteonecrosis
Dr K.R.Kashinath1, Dr.Chandra Shekar.L2
1
Prof. & HOD, Dept of Prosthodontics, 2Senior Lecturer, Dept of oral medicine and
Radiology, Sri Siddhartha Dental College, Tumkur.
Abstract
Herpes zoster (HZ) presents as a cutaneous vesicular eruption in the area
innervated by the affected sensory nerve, usually associated with severe
pain. Oral manifestations of HZ appear when the mandibular or maxillary
divisions of the trigeminal nerve are affected. A case, of zoster involving the
maxillary nerve with oseto necrosis of the maxilla is described.
Keywords: Maxilla, Osteonecrosis, Tooth exfoliation, Varicella zoster
Journal of Dental Sciences & Research 2:1: Pages 12-17
with circulating varicella antibodies
Introduction:
Zoster
is
a
common,
develop a localized zoster.1
and
Zoster probably results most
neurologic disorder caused by the
often from a failure of the immune
varicella-zoster virus (VZV), a virus
system to contain latent varicella-
morphologically and antigenically
zoster virus replication. Whether
identical
other factors such as radiation,
predominantly
to
dermal,
the
virus
causing
varicella (chickenpox). Difference
physical
in clinical manifestations between
medications, other infections, or
varicella
stress also can trigger zoster has
and
zoster
apparently
trauma,
depends on the immune status of
not
individual patients; those with no
certainty. Nor is it entirely clear
prior
why circulating varicella antibodies
immunologic
varicella
children,
virus,
exposure
most
develop
to
commonly
the
clinical
syndrome of varicella, while those
and
been
cell-mediated
mechanisms
recurrent
12 Journal of Dental Sciences and Research
determined
certain
do
overt
not
disease,
with
immune
prevent
as
is
Volume 2 Issue 1
February 2011
Herpes Zoster
common
with
most
other
On examination extra orally
viral
1
illnesses.
scarring
and
pigmentation
was
Pathophysiology
seen on right cheek region one
commonly
centimetre below the lower eye lid
manifests in 1 or more posterior
spreading inferiorly towards the ala
spinal ganglia or cranial sensory
of the right nose and commissure
ganglia, presumably because viral
of the right lip, superolaterally a
particles
scar was also seen on right temple
Zoster
most
have
been
preserved
within these ganglia in a dormant
region (fig-1a &1b).
state since the original episode of
varicella. This results in pain and
characteristic
cutaneous
findings
along the corresponding sensory
dermatomes
of
the
involved
Fig -1a
On
ganglia. Less often, involvement of
Fig-1b
intra
oral
examination
anterior and posterior horn cells,
open tooth socket with respect to
leptomeninges,
13
nerves
is
and
peripheral
observed,
with
tooth
region
(fig
-2)
and
exposed alveolar bone with respect
consequent muscle weakness or
to
palsy, pleocytosis of spinal fluid,
receded
and/or
with respect to 14,15,16 (fig -3)
sensory
loss.
Rarely,
myelitis, meningitis, encephalitis,
or
visceral
involvement
14,15,16
region
palatal
along
gingival
with
margin
was seen.
may
occur.1,2,3,4
Case report:
A
58-year-old
male
Fig -2
Fig -3
presented to the Oral medicine
Department
with
complaints
of
pain and exfoliation of the upper
right front teeth since two days .
On
enquiry
patient
gave
history of severe pain along with
vesicular eruptions over the right
cheek for 12 days. Eruptions were
13 Journal of Dental Sciences and Research
Volume 2 Issue 1
February 2011
Herpes Zoster
noted in successive crops over the
right cheek, side of the nose, upper
lip
and temple. Eruptions were
heralded by mild fever, malaise,
Fig -4
and piercing pain over the right
Intra
cheek for initial two days. The
vesicles were followed by pain in
the right upper teeth with difficulty
in chewing, on consultation with a
dermatologist
vesicular
the
pain
eruptions
and
oral
radiograph
periapical
showed
sever
destruction of the alveolar bone
extending to 11 mesially and 14
distally with missing 12,13 (fig -5).
reduced
gradually and later he was referred
to
the
dentist
with
a
clinical
diagnosis of herpes zoster along
Fig -5
the neural distribution of the right
Discussion:
maxillary nerve.
Zoster
The patient was treated with
may
begin
systemic
day for seven days, supplemented
anorexia, and lassitude, although
by
non-
symptoms frequently are mild and
anti-inflammatory
may not be associated by either
steroidal
B1-B6-B12,
analgesics
along
application
of
eg,
a
oral acyclovir 800 mg. five times a
injection
response,
with
fever,
local
patient or physician with the classic
ciprofloxacin
zoster signs and symptoms that
with
ointment 0.3% over the vesicles.
On radiographic examination
follow. Symptoms typically include
prodromal
sensory
phenomena
panoramic image showed missing
along 1 or more skin dermatomes
12, 13 and severe alveolar bone
lasting 1-10 days (averaging 48 h),
destruction in the 12, 13 region
which usually are noted as pain or,
(fig -4).
rarely,
pain
paresthesias.
typically
is
Prodromal
described
as
muscle or toothache like in origin
14 Journal of Dental Sciences and Research
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February 2011
Herpes Zoster
Unfortunately, resolution of
but may simulate headache, iritis,
pleurisy, brachial neuritis, cardiac
the
pain,
always accompany
appendicitis
or
other
associated
pain
does
not
resolution of
intraabdominal disease, or sciatica,
erythema and vesiculation. PHN,
which
which usually is confined to the
can
result
in
incorrect
tentative diagnoses. The prodromal
area
interval of pain prior to onset of
involvement, can persist for weeks,
cutaneous
been
months, or years and often is
believed to represent spread of
severe. The reason some patients
viral
with
findings
particles
has
along
sensory
of
original
zoster,
dermatomal
and
not
others,
approximately
experience PHN is not understood
10% of patients report onset of
fully, but patients who are older
pain and rash simultaneously. After
(>60 y), particularly patients who
the onset of prodromal symptoms,
are debilitated or arteriosclerotic,
the following signs and symptoms
are affected far more frequently
occur:
than patients who are younger. 1, 2
nerves;
however,
Patchy
erythema,
occasionally
accompanied
indurations,
appears
in
In addition, PHN is observed
by
the
more
frequently
after
cases
of
dermatome area of involvement.
herpes zoster ophthalmicus and in
Regional
lymphadenopathy
instances
appear
at
this
stage
may
or
of
dermatomal
upper
body
involvement.
Other
subsequently. The classic finding of
less common postherpetic sequelae
grouped
include
herpetiform
vesicles
hyperesthesia,
or
more
develops upon the erythematous
rarely, hypesthesia or anesthesia in
base.
the area of involvement.
usually
At
this
has
inflammation
point,
induced
of
the
the
virus
significant
involved
1, 2
Zoster
of the maxillary branch of the fifth
CN
(CN
V2):
Involvement
is
sensory nerve causing severe pain,
localized to the ipsilateral cheek,
stopping abruptly at the midline of
lower eyelid, side of the nose,
the limit of sensory coverage of the
upper eyelid, upper
involved dermatome.1, 2
mucous membrane of the nose,
15 Journal of Dental Sciences and Research
teeth,
and
Volume 2 Issue 1
February 2011
Herpes Zoster
nasopharynx, tonsils, and roof of
trigeminal nerve involvement that
the mouth. In our case similar
led to a rapid loss of alveolar bone
findings were found along with
and exfoliation of two teeth, the
severe
the
initial intraoral examination showed
alveolar bone along with exfoliation
redness of the alveolar mucosa and
13.
gingiva of the lower right quadrant
osteonecrosis
of
At times, only the oral mucus
with multiple well-delimited and
membrane is involved without skin
painful erosive lesions affecting the
manifestations. Early pre-eruptive
attached gingiva around the teeth.
herpetic pain can simulate a severe
Two weeks later, teeth number 43
toothache
in
(lower right canine) and 44 (lower
unnecessary oral surgery or dental
right first premolar) had class III
treatment. It is very unusual for
mobility, flow of purulent exudate
zoster
from the gingival sulcus, and deep
and
to
result
involve
mandibular
maxillary
nerve
ophthalmic
division
or
without
involvement
which was seen in our case.5
segment
with
of
necrosis
mandibular
(>11
radiological
advanced
A case of 76-year-old man
presenting
pockets
of
a
alveolar
mm).
examination
alveolar
The
showed
bone
loss
around both teeth. The prognosis
for teeth number 27 and 28 was
considered
hopeless,
and
they
bone and spontaneous exfoliation
were extracted7 , which was similar
of the corresponding teeth 1 month
to our case except the involvement
after
of maxilla and exfoliation of the
acute
varicella
zoster
infection of the mandibular branch
of
the
reported
trigeminal
in
Japan6,
nerve
was
which
was
teeth.
In
a
extensive
south
African
osteonecrosis
study
and
similar to our case except the
exfoliation of teeth in the area
involvement
innervated by the nerve affected
of
maxilla
and
exfoliation of teeth within 15 days
by HZ
In
sero positives8, but in
another
woman
with
case
HZ
63-year-old
infection
with
16 Journal of Dental Sciences and Research
was more common in HIV
our case
Volume 2 Issue 1
February 2011
Herpes Zoster
exfoliation of teeth was seen in HIV
recrudescence
of
sero negative..
infection. Postgrad
VZ
virus
Med
J. Nov 1970; 46(541):653-8.
Conclusion:
5.
Extensive osteonecrosis and
Jarrett
WH.
Horner's
syndrome with geniculate zoster:
exfoliation of teeth in the area
Occuring
in
innervated by the nerve affected
trigeminal
herpes
by HZ has been reported after HZ
ophthalmic division
infection.
Am J Ophthalmol 1967;63: 326-
Clinicians
should
be
aware of this possible outcome
association
in
with
which
the
was spared.
30.
after a trigeminal HZ infection.
6.
Alveolar Osteonecrosis of the
Mandible
References:
after
Varicella
Zoster
Infection of the Trigeminal Nerve
1.
Edgerton
ophthalmicus:
G. Herpes
a
review
zoster
of
the
Asian J Oral Maxillofac Surg. 2004;
16:204-208.
literature. Arch Ophthalmol. 1945;
7.
34:40-62; 114-53.
Alveolar bone necrosis and
tooth exfoliation following herpes
2.
Barker
B. Herpes
review. Arch
zoster
Dermatol
Syphil. 1939;40:974
3.
zoster infection: a review of the
literature
and
case
report.
J
Periodontol. 2005 Jan;76(1):148-
Burgoon CF Jr, Burgoon JS,
53.
Baldridge GD. The natural history
8.
of
spontaneous tooth exfoliation in an
herpes
zoster. J
Am
Med
Assoc. May 18 1957;164(3):265-9
4.
Blank
Goldfaden
H,
Eaglstein
GL. Zoster,
WH,
a
Alveolar bone necrosis and
HIV-seropositive
herpes
zoster.
Mar;63(2):106-10
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subject
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SADJ.
2008