Herpes Zoster

Herpes Zoster: Figure shows  severe vesicular ulcerations over the left side of face, hard palate and lips.The patient is HIV positive.

Herpes Zoster

Introduction

• Herpes zoster is categorized as a viral infection caused by varicella zoster virus. It is commonly known by the names shingles, zona or zoster. 
• Clinically, it can be grouped under 3 phases namely prodrome, acute and chronic. During initial viral replication active ganglionitis develops with resultant neuronal necrosis and severe neuralgia.
•  It is characterized by the occurrence of a painful skin rash(maculopapular lesions) in a stripe or belt-like dermatomal pattern which is limited to one side of the body and does not cross the midline. These rashes convert into vesicles with erythematous base. The vesicles finally turn into scabs and heal in 2-3 weeks.
• Ophthalmic division of trigeminal nerve is most commonly involved.

Pathophysiology

 This particular virus is responsible for the acute onset of chicken pox, usually occurs in children and young adults. Herpes zoster is a continuation of this infection as the virus is not eliminated from the body but becomes latent in the cranial nerves, dorsal roots, nerve cell bodies or autonomic ganglion.The virus may travel from one ganglion to another thereby infecting other dermatomes. 

Herpes zoster mainly occurs in older individuals (50 yrs of age) with imuunocompromise status due to age, psychological stress, cancer therapies,underlying malignancy, mechanical trauma, hereditary or exposure to immunotoxins etc. recurrence is rare; in HIV patients the recurrence rate is quite high.

Clinical features

• Symptoms of herpes zoster include headache, fever, and malaise. These are potentiated by paresthesia –pricking pain, tingling, numbness; burning pain, itching and oversensitivity of the tissues. 
• These skin rashes over a period of time convert into opaque vesicles (1-4 mm) and blisters filled with serous exudates. This exudate is replaced by blood and the vesicles are crusted giving the skin a darkened hue. Finally the crust falls off and the skin heals. This phenomenon takes place within a period of 7-10 days. Scarring remains after the disease subsides.
• Maxilla is frequently involved associated with devitalisation of teeth. Significant bone necrosis with loss of teeth is also present in some cases. 
• Tongue, lips and hard palate are other common sites.
• Pulpal necrosis and internal root resorption.These lesions are often misdiagnosed and endodontic treatment and extractions may be carried out by the dental surgeon .
• Facial paralysis may be observed.
• In the pregnancy period, this infection (chicken pox) may lead to complications in the foetus and newborn.

Complications

Post herpetic neuralgia- When the pain persists in the lesional area after the healing of mucocutaneous lesions that lasts more than 3 months after the initiation of acute rash, it is termed as post herpetic neuralgia. It is a burning, throbbing, stabbing kind of pain which is flared by light, contact with clothes or any other trigger factors. This may take 2 months to 1 year time to resolve completely. Prognosis is bad in such cases. High risk in old age due to decline in cell mediated immunity.

Zoster sine herpete/Zoster sine eruptione – Such patient has all the symptoms of herpes zoster except the characteristic rash.

Herpes zoster opthalmicus - It involves eyes and occurs in approximately 10–25% of cases. It is caused by the virus invading and reactivating the ophthalmic division of trigeminal nerve. It may lead to conjunctivitis, keratitis and optic nerve nerve palsies.

Herpes zoster oticus/ Ramsay Hunt Syndrome II - Involves the ear. Nerves like facial and vestibulocochlear are affected resulting in hearing defects and vertigo/rotational dizziness.

Diagnosis:

Polymerase chain reaction and Dot blot technique-detection of VZV DNA in lymph of blisters.

Specific IgM antibody test of blood/fluorescein conjugated monoclonal antibodies.

Electron microscope examination – For virus particles.

Tsanck smear helps to diagnose acute infection with a herpes virus, but does not distinguish between HSV and VZV.

Differential diagnosis:

Herpes Simplex virus

Treatment:

Aimed to shorten the course of disease, prevent post herpetic neuralgia and dissemination.

Preventive vaccine: Zostavax

              Analgesics

§        Mild to moderate NSAIDs

§        Severe pain-opioid analgesics like morphine

§        Topical calamine lotion

§        Capsaicin cream (Zostrix)

§        Topical lidocaine nerve blocks

§        Gabapentine with antivirals- post herpetic neuralgia

    Antiviral drugs

§        Acyclovir

§        Famciclovir

§        Valacyclovir

These drugs are most beneficial if taken within 72 hours of development of the    first vesicle. People who are at a high risk for repeated attacks of infection, five daily oral doses of acyclovir are usually effective.

Steroid therapy

Controversial results have been mentioned in various studies due to their high risk of inducing post herpetic neuralgia. But, in immunocompromised elderly patients corticosteroids along with antiviral drugs have proved to be useful in healing and crusting of lesions.

Percutaneous nerve stimulation

Biofeedback

               

Normal Radiographic Anatomy

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Normal Radiographic Anatomy

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ALLAGILLE SYNDROME

Alagille syndrome (AS) is an autosomal dominant disorder showing genetic predominance of one parent mainly seen in infants having severe cholestatic jaundice and heart murmurs. Therefore, such patients are diagnosed incidentally while screening a liver dysfunction or cardiac patient. It is associated with various abnormalities in liver, skeleton, impaired growth, eyes, kidneys and heart. Such patients exhibit a peculiar and characteristic facial appearance.

It is also known as arteriohepatic dysplasia.

Pathophysiology: Localized mutation of the JAG1 gene (20p12) occurs with variable expression.

The various features seen in the head and neck region in Alagille Syndrome are broadened forehead, pointed chin, elongated nose with bulbous tip. Mental retardation along with poor growth is also reported. These features become more pronounced as the age progresses.

Dentition shows hypoplastic lesions with heavy discoloration of teeth. Due to poor oral hygiene and the ill effects of medications prescribed to the patient to counter the effects of graft rejection (liver and heart). The gingival condition is bad showing signs of inflammation and edema. So, a dental consultation is must for a patient planned or undergoing treatment of this syndrome.

The various medications given to improve the bile flow and reduce itching are Ursodiol, Hydroxyzine, Cholesysteramine and Phenobarbitol. High doses of multivitamins like A, D, E, K prove to a successful measure to treat Alagille syndrome. Oral prophylaxis is mandatory. Corrective surgeries are also done in these cases.

Radiographic buzz: Dilaceration

Bull’s eye appearance: Unique variation of dilacerations, seen when the roots of mainly posterior teeth hides itself behind the crown giving it a floating appearance .It occurs as a result of 90 degree deviation of the roots.

ANALGESICS IN TRAUMATIC DENTISTRY

Analgesics are drugs that selectively relieve pain by acting in CNS or on peripheral pain mechanisms without significantly altering consciousness.

Analgesics are mainly divided into 2 groups:

1. Opioid Analgesics
2. Non Opiod Analgesics and NSAIDS

OPIOID ANALGESICS

• Natural Opium alkaloids

                        -Morphine & Codeine

•  Semi synthetic opiates

                        -Diacetylmorphine

                        -Pholcodeine

•  Synthetic opioids

            -Pethidine

             -Fentanyl

             -Methadone

            -Dextropropoxyphene

            -Ethoheptazine

             -Tramadol

NON OPIOID ANALGESICS ; NSAIDS

-          Salicylates – Aspirin, Salicylamide, Benorylate, Diffunisal.

-          Pyrazolone derivatives – Phenyl butazone, Indomethacine, Oxyphenyl-butazone.

-          Propionic acid derivatives – Ibuprofen, Naproxen, Ketoprofen, Fenoprofen, Flurbiprofen, Oxaprozin.

-          Indole derivatives – Indomethacin, Sulindac.

-          Anthranilic acid derivative – Mephanimic acid, Enfenamic acid, Flufenamic acid.

-          Aryl acetic acid derivative – Diclofenac, Tolmetin, Phenyl acetic acid derivative.

-          Oxicam derivative – Piroxicam, Tenoxicam.

Another classification:

Agonists             - Morphine and compounds

Partial agonists -Buprenorphine                                                                                 

Mixed agonist-antagonists

                           -Nalbuphine

                           -Pentazocine

                           -Meptazinol

                           -Butorphanol

Oral Piercing and its Complications

Oral piercing is the most happening fashion trend in youngsters now a days. A dentist should be well informed about such procedures as it is invasive in nature and is carried out without the use of anaesthetics. It involves the use of needles in order to create a hole in the following structures i.e. tongue(most common),lips, eyebrows, cheeks for inserting metals in the form of studs, rings or barballs. It can turn out to be dangerous as the various neural supplies of the tongue may get hampered while performing such procedures. This post will focus on some short and long term oral complications related to oral peircing

Short- term complications:

1. Immediately after the operation certain complications may arise including:
2.    Infection is the major concern after such procedure if the needle used are not properly sterilized and placed in antiseptic solutions. Life-threatning complications like the transmission of HIV and hepatitis viruses can take place.
3.    Postoperative pain is present.
4.   The tongue usually swells after piercing. In some cases it can be so massive leading to obstruction of airway and dyspnoea.
5.    Aspiration of the inserted jewellery can take place thereby asphyxia and death of the person can take place.
6.    Slight/excessive bleeding can occur depending on the severage of the blood vessels.

        Long-term complications:

1. Chipping and fracture of teeth occurs in due course of time due to constant trauma to teeth by the barbells and studs in tongue. Cracked tooth syndrome is a characterstic feature resulting in microscopic cracks in teeth making it difficult to masticate and is extremely painful. The tooth may have to be finally removed if it does not respond well to some splinting techniques.
2. Neural deficiencies can arise due to incorrect piercing techniques like facial paralysis, ageusia/dysgeusia, disarticulation of speech, eye problems, loss of deglutition reflex etc.
3. The gums and buccal mucosa experience continuous irritation from the jewellery which may lead to the following lesions in the oral cavity like irritational keratosis, frictional keratosis, lichenoid reaction, lichen planus, peripheral giant cell granulomas, fibroma, epulis fissuratum, carcinoma etc.
4. There is a risk of infection due to foreign debris and bacteria accumulating in the pierced site.  
5. Hypersensitivity and galvanism may occur due to interaction between other restorations in the teeth and allergy due to a particular metal in gums.
6. Due to untreated or unknown infections the pain and swelling may exacerbate and take a different route to reach and create complications systemically like infective endocarditis etc.

Safety measures :

The risk of oral complications can be minimised by following these suggestions:

·         Oral piercing should be get done by a professional who is well aware of the anatomy of the oral cavity.

·         The place should be completely hygienic and disposable needles and gloves should be used. All the procedures should be carried out with sterilized instruments and accessory equipments.

·         Ice packs should be applied on the site of inflammation to reduce swelling and bleeding.

·         Immediate referral to a medical hospital should be done to avoid any systemic complications and ensure safety of the patient.

·         Blood tests should be performed before doing piercing to decrease the chance of inadvertent infections.

·          Generally pain subsides within 4-6 weeks of piercing, if it does not reduces seek medical advice.

·         One should prefer wearing plastic jewellery in place of metal ones to avoid potential damage to the teeth, gums, palate.

·         Remove all the inserted elements before sleeping and playing sports.

·         Once u are stabilized with the piercing, a must visit to a dentist to evaluate if the piercing has caused any trauma to the oral cavity in any way.