This document discusses varicella-zoster virus (VZV) which causes chickenpox and shingles. It describes the clinical presentation and stages of shingles including prodromal, active, and chronic stages. Oral manifestations when trigeminal nerves are involved can include painful ulcers and non-vital teeth. It then presents a case study of a 42-year-old male patient who developed shingles affecting the left side of his face and mouth. He was treated with antivirals and pain medications and showed significant improvement after 2 weeks.

2. By
Dr.Noreen Mohammed

3. Varicella-zoster virus (VZV)
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)

4. Herpes zoster (HZ) (shingles)
Herpes zoster is a well-known viral disease which results due to
reactivation of the latent Varicella-zoster virus that is present because of
a previous exposure to varicella infection (chicken pox)
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 elderly and those with an immunecompromised status such as
HIV/AIDS stand at a greater risk to develop HZ.

5. Clinical features :-
Patients with HZ may progress through three stages;
1. Prodromal
2. Active
3.Chronic

6. 1) The prodromal stage:
characterized by sensations such as burning, tingling, itching, pricking,
occurring along the cutaneous distribution of dermatome.
Odontalgia and pulpal necrosis may result if branches of the trigeminal nerve
are involved, during this phase.
These symptoms may be present up to 1-month in advance of the acute
mucocutaneous lesions, and hence, this stage is difficult to diagnose

7. 2) The active stage
Described by the appearance of the rash with along with the systemic
upset.
The skin rash is very characteristic and progresses from erythematous
papules, edema to vesicles, and finally to pustules within 1-7 days.
Later, these pustules dry, crust, and are exfoliated over the next 2-3
weeks leaving erythematous macular lesions that may scar

8. 3) The chronic stage
Approximately 10% of all patients advances to the chronic stage of HZ, and is
known as PHN which is defined as a short-lived, deep, shooting, and
recurrent pain remaining for over a month or 3 months after the healing of
the mucocutaneous lesions.
Risk of occurrence of PHN increases significantly after sixth decade, which
may be because of decline of cell-mediated immunity

9. Oral manifestations :-
Oral manifestations of HZ appear when the second and third
divisions of the trigeminal nerve are affected5.
Dental and osseous manifestations such as
1)non-vital teeth
2)internal resorption of teeth
3)abnormal development of permanent teeth
4) spontaneous exfoliation of teeth

10. Treatment :-
In majority of the HZ patients, the condition is self-limiting, and
healing is usually complete
Aim of treatment :-
1) To alleviate the symptoms of pain and malaise
2) To restrict the spread as well as duration of the skin lesions and
3) To prevent the development of PHN and ophthalmological
complications

11. Case according to :-
Journal of Dental & Oro-facial Research Vol 11, Issue
1. Jan-Jun 2015
we present 42-year-old male patient with HZ involving the maxillary division of
the trigeminal nerve.
reported to our department (Department of oral and maxillofacial pathology,
K. M Shah Dental College and Hospital, Vadodara
Chief complain :
complaining of painful ulcers in the mouth and not able to eat food

12. History of present illness
Pain since 3 days which was mild, continuous, and radiating in nature, and was
associated with fever of low grade since 5 days.
After 2 days patient developed fluid-filled blisters distributed over the left half
of the face

13. Past medical history
The patient gave a history of chickenpox infection in childhood
No relevant drug, dental, and family history was recorded

14. General examination :
1) the patient was of normally built and no abnormality was detected in the
nails, gait, upper, and lower limbs.
2) Clinical signs of icterus, pallor, clubbing, edema, cyanosis, and
lymphadenopathy were absent.
3) On evaluation of vital signs,
temperature was noted to be 100°F and blood pressure 140/80 mm of Hg

15. Extraoral examination
No abnormality was detected in the eyes, nose, and temporomandibular joint.
Clusters of vesicles were present on the left half of face involving ala of the nose
and upper lip

17. Intraoral examination
Multiple ulcers were seen on left half of hard palate and soft palate
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

19. Diagnosis
Based on the history and clinical findings, a provisional diagnosis of HZ
affecting the left side of face involving maxillary branch of the
trigeminal nerve was made
Labratorty investigation :
1-Routine hematological and serological investigations were done for
the patient
2-Complete blood count was found to be within normal limits except
erythrocyte sedimentation rate and red blood cell which were slightly
raised

20. 3-The cytological examination was done after obtaining the smear from
the lesions presented intraorally and extraorally.
4-Acantholytic cells with few exfoliated squamous cells and inflammatory
cells were revealed in the cytological smear

21. Treatment :-
1-Aceclofenac 500 mg thrice daily was prescribed for symptomatic relief of pain.
2-Betadine mouthwash was also advised to improve oral hygiene.
3-Antiviral drug therapy was started with acyclovir 800 mg 5 times per day for 10
days.
Instructions :- we advised the patient to be in isolation, so as to prevent
the viral transmission to the healthy individuals. The cutaneous lesions were kept
clean and dry to reduce the risk of superinfection with bacteria

22. On examination of the patient after 2 weeks, regression of a number of
extraoral

23. Intraoral 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 1month follow-up, the patient was totally devoid of symptoms. The
lesions healed with scarring, but post therapeutic complications were not
reported.

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