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 Table of Contents  
Year : 2015  |  Volume : 27  |  Issue : 1  |  Page : 101-104

Mandibular osteonecrosis and teeth exfoliation after herpes zoster infection in an HIV-inflicted individual

1 Department of Oral Medicine, Diagnosis and Radiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India
2 Department of Oral and Maxillofacial Pathology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India
3 Department of Prosthodontics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India

Date of Submission15-Nov-2014
Date of Acceptance14-Sep-2015
Date of Web Publication12-Oct-2015

Correspondence Address:
Preeti Chawla Arora
Department of Oral Medicine, Diagnosis and Radiology, Sri Guru Ram Das Institute of Dental Sciences and Research, GT Road, Mall Mandi, Amritsar, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-1363.167126

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Herpes zoster (HZ) infection of the maxillary and mandibular divisions of the trigeminal nerve manifests orally as unilateral vesicular eruption localized to the skin and mucus membrane of the dermatome innervated by the trigeminal nerve. Herpes zoster infection has been observed in immunocompromised states like uncontrolled diabetes, cancer chemotherapy, lymphoproliferative diseases, and recently in HIV-positive patients. There are only a few case reports of osteonecrosis due to HZ in an HIV-positive patient in an Indian population, this being the first in a North Indian population. We propose that osteonecrosis should be considered as a strong indicator of HIV infection, especially in a developing country like India. The present case highlights the complexities which can arise in an HIV-inflicted individual suffering from HZ infection. Early diagnosis of such infections can lead to effective treatment and prevention of complications.

Keywords: Herpes zoster, HIV, osteonecrosis, tooth exfoliation

How to cite this article:
Arora PC, Manchanda AS, Narang RS, Arora A. Mandibular osteonecrosis and teeth exfoliation after herpes zoster infection in an HIV-inflicted individual. J Indian Acad Oral Med Radiol 2015;27:101-4

How to cite this URL:
Arora PC, Manchanda AS, Narang RS, Arora A. Mandibular osteonecrosis and teeth exfoliation after herpes zoster infection in an HIV-inflicted individual. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2023 Jan 29];27:101-4. Available from: http://www.jiaomr.in/text.asp?2015/27/1/101/167126

   Introduction Top

Herpes zoster (HZ) is a viral infection that is caused by the reactivation of the varicella zoster virus (VZV), which lies dormant in the sensory ganglia. Infections occur unilaterally almost exclusively in middle-aged and elderly patients and may cause considerable distress mainly because of neuralgia that accompanies and may persist after skin eruption. Usually, oral vesicles appear after skin manifestations. Oral vesicles rupture and coalesce presenting as large mucosal erosions. Prodromal pain which mimics toothache or pulpitis may occur in the distribution of the trigeminal nerve some days before vesicular eruptions are observed. [1] Varicella zoster virus infection resulting in HZ is a well-recognized cause of morbidity in HIV-infected individuals and has been considered as an early manifestation of HIV infection. [2],[3]

Herpes zoster is usually self-limiting; however, complications, particularly in the immunocompromised individual, including cutaneous dissemination, prolonged atypical skin lesions, ocular complications, and CNS involvement have been described. [1] There are only few reports of bony and dental complications following HZ infection, all of which were isolated to a single jaw quadrant. These include devitalized teeth, abnormal development of permanent teeth, internal resorption, and spontaneous exfoliation of the teeth with osteomyelitis of the alveolar bone. [1] Osseous alterations associated with HZ infection were first reported by Rose in 1908. [4] Gonnett is credited with being the first to draw attention to HZ infection-related alveolar bone necrosis in 1922. [4] Only few cases have been reported on this rare complication in an HIV patient. Until now, only one case of HZ-induced osteonecrosis in an HIV patient among the Indian population has been reported, this being the first among the North Indian population. [5],[6] This is the case report of a patient who was affected with HZ infection of the trigeminal nerve, with mandibular nerve involvement causing neuralgia. The patient also had ipsilateral hearing deficit. Most significantly, the patient had alveolar bone necrosis and rapid tooth exfoliation of the right mandibular region.

   Case Report Top

A 58-year-old male presented to the Oral Medicine Department with complaints of pain, paresthesia, and burning sensation in the lower right posterior region of jaw since 1 month. This was followed by the appearance of vesicles after 2-3 days and exfoliation of the lower right teeth after 15 days. The patient's past medical, dental, and family histories were insignificant. Examination revealed multiple coalescing vesicular and crusting lesions on the skin overlying the right mandible, external ear, and lower lip on the right side [Figure 1]. The lesions were confined to the distribution of the right trigeminal nerve involving the maxillary and mandibular divisions. His hearing acuity had diminished. The lesions showed minimal healing with mild scarring evident in some areas. Intraoral examination showed erythema of the alveolar mucosa and attached gingiva of the fourth quadrant. The alveolar bone in the mandibular central incisor to mandibular first molar region was denuded, dry, and yellowish. It was devoid of blood clots and the sockets were visible [Figure 2]. Panoramic radiograph [Figure 3] showed the outlines of the sockets of the exfoliated teeth. Based on the history, clinical and radiographic features, a diagnosis of osteonecrosis and tooth exfoliation following HZ infection was made. Blood assays [enzyme-linked immunosorbent assay (ELISA) and western blot assay] revealed that the patient was seropositive for HIV antibodies. The patient was advised Acyclovir 800 mg five times daily, topical antivirals, Amoxycillin 500 mg three times a day, and chlorhexidine mouthwash. Debridement of the necrotic alveolar bone was done. The patient was then referred to an HIV center for highly active antiretroviral therapy (HAART).
Figure 1: Ulcerative lesions of HZ infection on the ear and right side of face

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Figure 2: Intraoral photograph showing necrotic bone with sockets of exfoliated teeth

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Figure 3: Panoramic radiograph showing bony sockets of exfoliated teeth of the fourth quadrant

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   Discussion Top

The incidence of HZ infection in the general population has been reported to be 5.4%. It has been suggested that approximately 2% of patients with HZ will develop a second episode of the infection. [6] Herpes zoster can develop after situations of stress or local trauma, but it is more frequently associated with diminished immune response as in individuals under systemic corticosteroids, cytotoxic chemotherapy or radiotherapy, immunosuppressive agents, malignancies like chronic lymphocytic leukemia and lymphomas, and HIV-positive patients in the recent times. The increased frequency of HZ infection in individual with AIDS has shifted the incidence towards male and younger individuals. Spontaneous exfoliation of teeth in the area innervated by the affected nerve has been reported. Some authors believe that this is an early event occurring during the first 2 weeks of the infection, while others consider this to be a late complication that will occur between the 3rd and 12th weeks after onset. [1],[7] Loss of teeth is due to alveolar bone necrosis and/or necrosis of the periodontal ligament. [1] In the present case, tooth exfoliation was seen after 3 weeks of HZ infection.

The pathogenesis of osteonecrosis and tooth exfoliation associated with HZ infection is still not clear. Several hypotheses [8] have been discussed including:

  • Local vasculitis caused by direct extension of the neural inflammatory process to the adjacent blood vessels. This eventually may cause an infarction of trigeminal vessels that accompany the trigeminal nerves supplying the jaws.
  • A generalized infection of terminal nerves supplying the periosteum and periodontium is believed to cause avascular necrosis over a large area.
  • Denervation of bone (which seems unlikely to cause bone necrosis).
  • Systemic viral infection can injure odontoblasts and cause degenerative tissue changes that result in pulp necrosis.

The pre-existing pulpal or periodontal inflammatory changes have the potential to contribute to a greater probability of tooth exfoliation and bone necrosis.

An altered oral environment, decreased host immunity, or immune reconstitution inflammatory syndrome (IRIS) could further compromise the viable periodontal status, leading to alveolar bone necrosis and tooth exfoliation. Immune reconstitution inflammatory syndrome is the circumstance in which pre-existing subclinical or mildly symptomatic infections or inflammatory conditions undergo paradoxical worsening with a substantial increase in inflammation during the initial months of host immune reconstitution. This condition is an immunopathogenic hyperinflammatory response to a pathogen that was already there, as the host immune response is rapidly reconstituted. [9] Ortega et al. reported a case of mandibular osteonecrosis in a HIV seropositive patient who was on HAART therapy, signifying the effects of IRIS. [10] In a review of literature till 2006, 40 reports of osteonecrosis after HZ reactivation have been found to be reported, out of which very few were HIV positive. [5] One of the cases presented a co-infection with HZ and cytomegalovirus (CMV). [11]

This condition is managed mainly by a conservative approach: Good oral hygiene instructions, frequent irrigation of the wound, sequestrectomy and extraction of affected teeth, and antibiotics to control secondary infections and frequent serious complications. [7] Patients of HZ may report to a skin specialist only, but with the exfoliation of teeth and osteonecrosis, these patients may report to a dental practitioner. Hence, the responsibility of diagnosing such cases which may go unnoticed lies on the dental fraternity. Because of lack of awareness of HIV in the earlier years, it is assumed that no systemic illness was noted in many of the patients with osteonecrosis in HZ infection. With the emerging trends, in recent times, HZ infection has been associated as a manifestation of HIV. We also propose that osteonecrosis in HZ should be considered as a strong indicator for HIV.

   Conclusion Top

The exact mechanism of osteonecrosis induced by HZ infection remains unclear. It is possible that decreased host immunity or IRIS could compromise an already fragile periodontal ligament status, leading further to osteonecrosis. Through the present case, we have highlighted the complexities which can arise in an immunocompromised individual suffering from HZ infection. More studies are essential to fully understand the pathophysiology and complications associated with HZ infection for a prompt and improved prevention, early detection, and management.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Mintz SM, Anavi Y. Maxillary osteomyelitis and spontaneous tooth exfoliation after herpes zoster. Oral Surg Oral Med Oral Pathol 1992;73:664-6.  Back to cited text no. 1
Glesby MJ, Moore RD, Chaisson RE. Clinical spectrum of herpes zoster in adults infected with human immunodeficiency virus. Clin Infect Dis 1995;21:370-5.  Back to cited text no. 2
Van de Perre P, Bakkers E, Batungwanayo J, Kestelyn P, Lepage P, Nzaramba D, et al. Herpes zoster in African patients: An early manifestation of HIV infection. Scand J Infect Dis 1988;20:277-82.  Back to cited text no. 3
Wright WE, Davis ML, Geffen DB, Martin SE, Nelson MJ, Straus SE. Alveolar bone necrosis and tooth loss: A rare complication associated with herpes zoster infection of the fifth cranial nerve. Oral Surg 1983;56:39-46.  Back to cited text no. 4
Kamarthi N, Narsimaha GE, Lingappa A. An unusual case of osteonecrosis and spontaneous tooth exfoliation following trigeminal Herpes Zoster in a HIV seropositive patient. Int J Oral-Med Sci 2009;8:52-9.  Back to cited text no. 5
Mendieta C, Miranda J, Brunet LI, Gargallo J, Berini L. Alveolar bone necrosis and tooth exfoliation following herpes zoster infection: A review of the literature and case report. J Periodontol 2005;76:148-53.  Back to cited text no. 6
Hall HD, Jacobs JS, O'Malley JP. Necrosis of maxilla in patient with herpes zoster. Report of a case. Oral Surg Oral Med Oral Pathol 1974;37:657-62.  Back to cited text no. 7
Siwamogstham P, Kuansuwan C, Reichert PA. Herpes zoster in HIV infection with osteonecrosis of the jaw and tooth exfoliation. Oral Dis 2006;12:500-5.   Back to cited text no. 8
Feller L, Wood NH, Lemmer J. Herpes zoster infection as an immune reconstitution inflammatory syndrome in HIV-seropositive subjects: A review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:455-60.  Back to cited text no. 9
Ortega KL, Rezende NPM, Lotufo MA, Magalhães MH. Mandibular lesion in an HIV-positive patient. J Oral Maxillofacial Surg 2008;66:2140-4.  Back to cited text no. 10
Meer S, Coleman H, Altini M, Alexander T. Mandibular osteomyelitis and tooth exfoliation following zoster-CMV co-infection. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:70-5.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3]


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