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Journal of Dental & Oro-facial Research Vol 11, Issue 1.

Jan-Jun 2015 JDOR



Dr.Prachi Chhimwal1*, Dr.Himanshu Shrivastava2, Dr.Rashmi Bhavasar3

*Corresponding Author Email:

1,2,3 Dept.Oral & Maxillofacial Herpes zoster (HZ) (shingles) is a sporadic disease which results due to
Pathology, K. M Shah Dental reactivation of the latent Varicella-zoster virus that is present because of a previous
College & Hospital, Vadodara exposure to varicella infection (chicken pox). C3, T5, L1, L2, and 1st division of the
trigeminal nerve are the most commonly affected nerves; the involvement of 2nd
and 3rd division of trigeminal nerve is a rarity. The condition is marked by the
manifestation of multiple, painful, unilateral vesicles, and ulcerations which show a
typical single dermatome involvement. The elderly and those with an immune-
compromised status such as HIV/AIDS stand at a greater risk to develop HZ. In this
case report, we present a42-year-old male patient with HZ involving the maxillary
division of the trigeminal nerve. The involvement of mandibular and maxillary
branches without the ophthalmic branch involvement is relatively uncommon and
accounts for only 1.7% of the total cases of HZ. The purpose of this article was to
review the literature and report a case along the discussion.


Herpes zoster (HZ) is a well-known viral disease that usually A male patient of 42 years reported to our department
presents as a painful unilateral vesicular rash restricted to the (Department of oral and maxillofacial pathology, K. M Shah
distribution of a sensory nerve. HZ which is also known as Dental College and Hospital, Vadodara) complaining of
Shingles, is an acute infection of viral origin resulting from painful ulcers in the mouth since 3 days. The patient
the reactivation of the DNA virus varicella zoster, which presented with the history of pain which was mild,
causes chickenpox1. It commonly manifests as vesicular continuous, and radiating in nature, and was associated with
rash, which are painful and runs its progression in a matter fever of low grade since 5 days. After 2 days patient
of 4-5 weeks. The pain may persist for months or even years developed fluid-filled blisters distributed over the left half
after healing of the skin lesions. This phenomenon is called of the face. The patient was not able to eat food since 3 days.
as postherpetic neuralgia (PHN)2. The risk of PHN in The patient gave a history of chickenpox infection in
patients with zoster is approximately 10-18%. Nearly, 3% childhood. No relevant drug, dental, and family history was
of patients with zoster are hospitalized. Morbidity due to recorded.
zoster is common among immunocompromised patients3. On general physical examination, the patient was of
HZ can affect any of three branches of the trigeminal nerve. normally built and no abnormality was detected in the nails,
The involvement of mandibular and maxillary branches gait, upper, and lower limbs. Clinical signs of icterus, pallor,
without the ophthalmic branch involvement is relatively rare clubbing, edema, cyanosis, and lymphadenopathy were
and accounts for only 1.7% of the total cases of HZ4. absent. On evaluation of vital signs, temperature was noted
Oral manifestations of HZ appear when the second and third to be 100°F and blood pressure 140/80 mm of Hg.
divisions of the trigeminal nerve are affected5. Dental and On extraoral examination, no abnormality was detected in
osseous manifestations such as non-vital teeth, internal the eyes, nose, and temporomandibular joint. Clusters of
resorption of teeth, abnormal development of permanent vesicles (Figure 1) were present on the left half of face
teeth, spontaneous exfoliation of teeth, and necrosis of involving ala of the nose and upper lip.
maxilla and mandible have been reported6.The purpose of On intraoral examination, multiple ulcers were seen on left
this article is to report one such case along the discussion. half of hard palate and soft palate (Figure 2). The shape of
the ulcers was irregular, measured approximately 3 mm × 4
mm in size. Margins of the ulcer were erythematous and
edges were sloped.

Journal of Dental & Oro-facial Research Vol 11, Issue 1. Jan-Jun 2015 JDOR

Correlating the case history, clinical findings, and

cytological examination, a final diagnosis of HZ was given.
Aceclofenac 500 mg thrice daily was prescribed for
symptomatic relief of pain. Betadine mouthwash was also
advised to improve oral hygiene. Antiviral drug therapy was
started with acyclovir 800 mg 5 times per day for 10 days.
On examination of the patient after 2 weeks, regression of a
number of extraoral (Figure 3) and intraoral (Figure 4)
lesions were noted with the formation of scar tissue and
hypopigmented areas. No fresh vesicles were reported. The
patient was then reviewed after 1-week and tremendous
improvement was noticed regarding the HZ lesions. After 1-
month follow-up, the patient was totally devoid of
symptoms. The lesions healed with scarring, but post-
therapeutic complications were not reported.

Figure 1: Clusters of vesicles on lower left side of nose and upper


Figure 4: Regression of intraoral lesions

Figure 2: Unilateral presentation of ulcers in the left half of hard Discussion

and soft palate
Varicella-zoster virus (VZV) like other herpes viruses
causes both primary and recurrent infections and remains
latent neurons present in the sensory ganglia. VZV is
associated with two major clinical infections of humans:
Chickenpox (varicella) and shingles (HZ)6.Chicken pox is a
primary infection that occurs the first time an individual is
affected by the virus with generalized manifestations. After
the primary disease heals, VZV remains latent in the dorsal
root ganglia of spinal nerves or extramedullary ganglia of
cranial nerves. A person without any prior contact with VZV
can develop chickenpox after coming in contact with an
individual with HZ7.patient complained of mild pain. Hence,
HZ disease patients can have mild to severe pain during
active stage of the disease. Patients with HZ may progress
Figure 3: Regression of extraoral lesions through three stages;
1. Prodromal
2. Active
Based on the history and clinical findings, a provisional 3.Chronic
diagnosis of HZ affecting the left side of face involving The prodromal stage is characterized by sensations such as
maxillary branch of the trigeminal nerve was made. burning, tingling, itching, pricking, occurring along the
Routine hematological and serological investigations were cutaneous distribution of dermatome. Odontalgia and pulpal
done for the patient. Complete blood count was found to be necrosis may result if branches of the trigeminal nerve are
within normal limits except erythrocyte sedimentation rate involved, during this phase.4 These symptoms may be
and red blood cell which were slightly raised. The present up to 1-month in advance of the acute
cytological examination was done after obtaining the smear mucocutaneous lesions, and hence, this stage is difficult to
from the lesions presented intraorally and extraorally. diagnose8.
Acantholytic cells with few exfoliated squamous cells and The active stage is described by the appearance of the rash
inflammatory cells were revealed in the cytological smear. with along with the systemic upset. The skin rash is very

Journal of Dental & Oro-facial Research Vol 11, Issue 1. Jan-Jun 2015 JDOR

characteristic and progresses from erythematous papules, REFERENCES

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HZ of the trigeminal nerve is one such disease that falls
within the diagnostic purview of all dentists. In conclusion,
a case of HZ affecting the maxillary branch of the trigeminal
nerve is reported. This case signifies the importance of a
thorough medical and dental case history and examination of
the patients with sporadic diseases such as HZ. Early
diagnosis and prompt treatment by antiviral drugs in the
prodromal stage of the HZ may aid in reducing the duration
and the severity of pain of HZ infection and also prevent the