Are there recommended guidelines for reducing the incidence of shingles in a patient that has a history of developing shingles after dental care?
This question was submitted by a general dentist: Are there recommended guidelines for reducing the incidence of shingles in a patient that has a history of developing shingles after dental care?
Dr. George Sandor, DDS MD and Dr. Suham Alexander, Oasis Clinical Editor provided this initial response.
Shingles (herpes zoster) is the reactivation of the chicken pox virus (varicella zoster) which typically establishes dormancy in dorsal root or cranial nerve ganglia during childhood. Reactivation usually occurs later in life mainly affecting thoracic and lumbar dermatomes; however, a small proportion of patients present with trigeminal nerve involvement.
Herpes zoster may occur spontaneously or in an immunocompromised host. Other predisposing factors may include: increasing age, physical trauma including dental manipulation, psychological stress, malignancy, radiation therapy and HIV infection.
There are 3 phases of the infection:
- Prodrome
- Initial viral replication with resultant necrosis of neurons and neuralgia
- Intense burning, itching and tingling pain as virus travels down the nerve
- Accompanied by fever, headache and malaise
- Occurs 1-4 days prior to development of cutaneous lesions
- Pain may present as sensitive teeth, earache, migraine, myocardial infarction or appendicitis depending on the affected dermatome
- Acute
- Clusters of erythematous vesicles form on skin and terminate at the midline
- Vesicles ulcerate day 3-4 and crust day 7-10
- Resolution within 2-3 weeks
- May leave scarring with hypo/hyperpigmentation
- Chronic
- Affects ~15%
- Post-herpetic neuralgia persisting >3 months after the initial rash
- Characteristic throbbing, burning, aching and itching pain worsening with contact with clothing or rubbing of skin
- Pain resolves within 1 year but, can last longer in some cases
The involvement of the trigeminal nerve leads to oral lesions extending to the midline and affect mucosa of the same quadrant. Maxillary involvement may lead to pulpal necrosis of the teeth. There have been reported cases of severe osteonecrosis resulting in the loss of teeth.
Dental Management
The early treatment of shingles involves the use of antivirals such as acyclovir, valacyclovir and famciclovir which have the best result when used within the first 72 hours after the development of the first vesicle.
Neuralgia is managed with various medications including analgesics, narcotics TCAs, anticonvulsants and topical anesthetics. Corticosteroid use may also be employed; however, there have been documented reports of increased side-effects in those treated with corticosteroids.
With respect to the prevention of recurrent incidences of shingles, the patient may be treated with a course of antiviral medication if the prodrome phase presents (ie tingling in a previously affected zone).
References
- Guttiganur N, Devanoorkar A, Aspalli S, Shetty S. Herpes zoster of trigeminal nerve after dental extraction. Indian J Dent Res 2013; 24:396-396.
- Jan A, McGuire TP, Clokie CML, Sándor GK. Unilateral facial swelling resembling odontogenic infection caused by Ramsay Hunt Syndrome. Journal of the Canadian Dental Association. November 2006; 72(9): 829-832 .
- Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 2009. Elsevier Saunders. St. Louis, Missouri.
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Last year a patient had an immediate complete upper denture and a lower chrome partial. The follow up was unremarkable and the ridges appeared to be healing normally and well. Some months later she told me that she couldn’t touch her mucosa due to a burning sensation that prevented her from wearing the dentures. On examination the mucosa appeared normal but was extremely sensitive even though she had not been wearing the dentures for several weeks. There appeared no sign of allergy to the denture base materials since she had not been wearing the dentures and the mucosa looked pink and healthy. Reading this post leads me to thinking that this patient could well have had a herpes zoster incident which had resolved and that she now has post herpetic neuralgia. Any comments?
With respect to this patient – I would believe that a herpes zoster incident with post herpetic neuralgia would occur unilaterally and occur with respect to the limitations of the nerve affected (i.e. follow the path of the innervation of the nerve affected without crossing the midline).
Although I do not believe that post-zoster Herpes Zoster vaccination has yet been shown to reduce the chance of another occurrence, the CDC does recommend vaccination regardless of history of zoster for patients over 50. Besides pre-operative antiviral prophylaxis, Herpes Zoster (Zostavax) vaccination may be prudent.