Alveolar Osteonecrosis and Tooth Exfoliation in Herpes Zoster: A Rare Pediatric Case Report and Review of Literature

Abstract

Varicella-zoster virus (VZV) is an envelope, spherical, 150–200 nm in diameter virus, with the single, linear, double-stranded DNA molecule, 125,000 nt long. It belongs to the genus Varicellovirus, family.

How to cite this article: Singh G, Mehrotra A, Garg K, et al. Alveolar Osteonecrosis and Tooth Exfoliation in Herpes Zoster: A Rare Pediatric Case Report and Review of Literature. Int J Clin Pediatr Dent 2020;13(S-1):S106–S109.

Introduction

Before the late 19th century, varicella (chickenpox) has not been consistently differentiated from smallpox. Since ancient times herpes zoster (HZ) (shingles) has been known and identified in the early medical literature. Clinical findings of the varicella-HZ interaction were reported by Von Bokay in the year 1888, as sensitive children developed varicella following contact with HZ. In 1954, Weller isolated vesicular fluid from the varicella virus (VZV) from both chickenpox and zoster lesions in cell culture.¹

Varicella-zoster virus (VZV) can be the origin of a duo yet separate clinical entities: Varicella as well as HZ. Chickenpox is a highly transmissible and potentially lethal omnipresent condition; normally, a childhood disorder distinguished by an exanthematous vesicular rash and is a benign condition. The virus inside the skin spreads the sensory receptors during the initial varicella infection to become permanent in the sensory ganglia. With the reactivation of inactive VZV, HZ constitutes in the region of innervations by the infected sensory nerve as a cutaneous vesicular blowing up, often linked with extreme torment.^2–5

An intense viral illness that impacts the trigeminal nerve (CN V) is the acute HZ (shingles). Reactivation could be due to immunosuppression, or it could be connected to age. It is the result of the VZV retrieval that remained dormant in the trigeminal ganglion upon exposure or clinical manifestation of chickenpox.⁶ Trigeminal (V cranial) nerve HZ targeting the ophthalmic (V1), maxillary (V2), or mandibular (V3) segment is a significant diagnostic source for oral and maxillofacial-related clinicians. Odontalgia, trigeminal neuralgia, could even create misinterpretations throughout painful stages. In the year 1908, Rose first described osseous specifics of HZ infection, which was later attributed to Gonnet et al. in 1922, being the first to draw awareness toward alveolar bone necrosis and tooth exfoliation in correlated to HZ.^2,7 Acute pulpitis and the complications described in the literature, such as tooth resorption, periapical lesions, periodontal damage, exfoliation of the dents, osteomyelitis as well as jaw osteonecrosis promoting the dentist's involvement in the patient's management and therapy.⁸

Implicating trigeminal nerve divisions may contribute to disorders that appear on the face, mouth, eye, or tongue. When the mandibular or maxillary section of the trigeminal nerve becomes impaired, oral manifestations of HZ grow. However, the most frequent trigeminal nerve disease (50% of all trigeminal incidences) is eye involvement, it is important to note that the Hutchinson's sign (cutaneous zoster projections on each side of the tip of the nose) is pathognomonic for branch involvement with V2 (maxillary).⁹

Case Description

A 13-year-old adolescent girl patient who had previously been diagnosed with HZ registered to the Department of Pedodontics and Preventive Dentistry, Rama University, Faculty of Dental Sciences, with an avulsed 11 (maxillary right central incisor) main complaint and pain, mobility in the lateral and canine maxillary right incisors.

Her history included a description of unilateral (right side) eruptions with HZ infection about 15–20 days ago, along with itching and burning sensation on the face and head region which was accompanied by spontaneous exfoliation of a tooth.

Extraoral examination revealed persistent scarring and pigmentation to the right half of the face (cheek area and nose) with features on the same side of the scalp, giving it a characteristic Hutchinson's HZ sign (Figs 1 and 2).

Figs 1A and B.

Profile photograph showing facial scarring and hyperpigmentation, post-herpes zoster involving V2 dermatome

Figs 2A and B.

Scarring and itching in the right side of the scalp

On intraoral examination, it was found that 11 was avulsed, while 12 and 13 presented grade I mobility, gingival recession, and alveolar bone exposed in the first quadrant in the maxillary arch extending from 11 till 17. Marked vague gingivitis and early periodontitis lesions were observed in the teeth concerned (Fig. 3).

Fig. 3.

Intraoral photograph showing completely detached maxillary right central incisor tooth and grade I mobility in 12 (maxillary right lateral incisor) and 13 (maxillary right canine)

Radiographic examination revealed completely detached 11 (maxillary right central incisor) from the alveolar socket with necrosis and destruction of alveolar bone and localized moderate bone destruction in maxillary right quadrant ranging from central incisor tooth up to second molar tooth (Fig. 4).

Fig. 4.

Orthopantomogram

Based on the clinical examination, the case was provisionally diagnosed as sudden tooth loosening out of socket and light alveolar osteonecrosis along with HZ contamination of the maxillary division of trigeminal nerve. A differential diagnosis of osteomyelitis was also considered (Fig. 5).

Fig. 5.

Localized moderate bone destruction in maxillary right quadrant ranging from central incisor tooth up to second molar tooth

As the prognosis of teeth number 11 was considered hopeless, it was removed from the socket followed by removal of fragments of necrotic bone at the time of extraction. The soft tissue from the region gave no signs of malignancy or vasculitis on histopathologic examination. A thorough ultrasonic scaling was performed (Fig. 6).

Figs 6A and B.

After removal of the maxillary right central incisor tooth

The patient was kept under symptomatic drug therapy for 1 week, including antiviral; acyclovir 400 mg (5 times a day), vitamin—Cobadex CBZ (1 time a day), antiallergic—Levocetirizine 5 mg (1 time a day), antidopaminergic agent—Ranidom RD (2 times a day), Ointment Herpex (to be applied 3–4 times a day extraorally), and methylcobalamin—Nerve Shine-SR (1 time a day).

A proper medical referral and necessary investigations, blood sugar investigation, quantitative PCR or viral culture, posteroanterior chest X-ray, and ELISA for HIV were prescribed. Patient reported back after a week with symptomatic treatment relief (Fig. 7) and prosthetic rehabilitation was done by providing a removable partial denture in relation to tooth number 11 (Fig. 8). Further continuation of the medicines was instructed and the patient was recalled after a week. But the parents of the child refused to undergo any investigation and then never reported back.

Fig. 7.

Relief in scarring and hyperpigmentation involving V2 dermatome after symptomatic drug therapy

Figs 8A and B.

Prosthetic rehabilitation—removable partial denture for teeth number 11

Discussion

Herpes zoster is a sporadic disease. In 1.5–3 of every 1,000 individuals and most commonly affecting nerves are C3, T5, L1, L2, and first division of Trigeminal (V) nerve.¹⁰ With the presence of dental complications along with postherpetic neuralgia about 46 cases have been reported and published to date. Among which 20 cases were those with underlying systemic disease and 26 cases were immune-competent patients.¹⁰ Many scholars stated that the unexpected shedding of teeth in the region of the damaged nerve is an early sign that happens, while some claim it is a slow development in the first 2 weeks of the outbreak, as can be seen in our case.

Figure 8 shows average age spanning from 6 to 85 years; four have been under 40 years old, eight were between 40 and 60 years old, and eight have over 60 years old. The maxilla (n = 9; 33 teeth exfoliated) while in the mandible (n = 11; 33 teeth lost) have been similar through prevalence. Thirty-one of the teeth lost were anterior teeth and thirty were after teeth. As not all cases were recorded about both the individuals’ gender, but the data available showed more in accordance with females (N = 9) than males (N = 7).² Only two cases were reported in the pediatric patient, with only one of the two involved loss of teeth, as it is a rare trait.

Ocular involvement is the most prevalent trigeminal nerve infection (50% of all trigeminal occurrences), then it is important to mention that Hutchinson's sign (cutaneous zoster lesions on one side of the nose tip) is a pathognomic branch involvement of V2 (maxillary).⁹ The patient suffers spontaneous exfoliation of the teeth on the affected side and also osteonecrosis on the further resolution of the acute/active phases. As in the present case, the contralateral side of the patient's jaw remains within normal limits.¹¹

The increasing number of HZ infection in AIDS patients has moved the frequency to older and younger individuals.¹² This may develop after stress or severe injury circumstances but is more closely associated with compromised immune response conditions, including those under systemic corticosteroid medications, cytostatic chemotherapy, immunosuppressants or radiation treatment, or with chronic lymphocytic lymphomas and lymphomas associated with malignancies.^13–18

Herpes zoster disease can spread cranial nerves, with both the trigeminal nerve being one of the most frequently affected (18.5–22% of total cases), followed by glossopharyngeal nerve and hypoglossal nerve and limited to a single division, more often the ophthalmic.^19–21 Oral symptoms may also, take place when influencing the maxillary and mandibular trigeminal divisions.

Ocular swelling and corneal denervation are potential significant complications. In the maxillary branch (V2) HZ the evidence is about V2 dermatome, i.e., cheek, lateral nose, nasal mucosa, lower eyelid, cheek mucosa, maxillary gums, palate, tonsil, and nasopharynx. Sometimes there have been no skin symptoms except for the oral mucosa.²²

Sudden exfoliation of teeth has been reported in the innervated area of the affected nerve. Some studies have indicated that this is an early occurrence that occurs within the infection's first 2 weeks,^14–17 while others consider it a late complication that happens between the third and twelfth weeks after it begins.²³ Alveolar bone necrosis and/or periodontal ligament necrosis are responsible for the loss of teeth.¹⁴ After the extraction of the tooth, the healing of the periodontal tissue is usually slower than usual and sometimes fragments of the necrotic bone persist following extraction^15,17,24 to protect the alveolar height.¹⁶ In our case, the tooth was extracted as it was completely avulsed out of the socket with no bone and periodontal support, which occurred 5 weeks after HZ infection ends. At about the same time, it eliminated necrosed osseous tissue.

Conclusion

Herpes zoster includes the trigeminal nerve and also has dental complications.

A rare observation yet is an alarming situation for the patient as well as the dentist. Hence, a thorough knowledge regarding the same is a mandatory affair. The success lies in a proper detailed history (medical as well as dental) which helps to reach an early diagnosis and treatment.