alveolar bone necrosis and spontaneous tooth exfoliation ... · alveolar bone necrosis and...

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Alveolar bone necrosis and spontaneous tooth exfoliation associated with trigeminal herpes zoster: a report of three cases

Nam-Kyoo Kim1, Bong Chul Kim2, Jung-woo Nam1, Hyung Jun Kim1

1Department of Oral and Maxillofacial Surgery, College of Dentistry, Yonsei University, Seoul, 2Department of Oral and Maxillofacial Surgery, Daejeon Dental Hospital, College of Dentistry, Wonkwang University, Daejeon, Korea

Abstract (J Korean Assoc Oral Maxillofac Surg 2012;38:177-83)

Herpes zoster is a viral infection caused by the reactivation of the varicella zoster virus, an infection most commonly affecting the thoracolumbar trunk. Herpes Zoster Infection (HZI) may affect the cranial nerves, most frequently the trigeminal. HZI of the trigeminal nerve distribution network manifests as multiple, painful vesicular eruptions of the skin and mucosa which are innervated by the infected nerves. Oral vesicles usually appear after the skin manifestations. The vesicles rupture and coalesce, leaving mucosal erosions without subsequent scarring in most cases. The worst complication of HZI is post-herpetic neuralgia; other complications include facial scarring, motor nerve palsy and optic neuropathy. Osteonecrosis with spontaneous exfoliation of the teeth is an uncommon complication associated with HZI of the trigeminal nerve. We report several cases of osteomyelitis appearing on the mandible, caused by HZI, and triggering osteonecrosis or spontaneous tooth exfoliation.

Key words: Human herpesvirus 3, Herpes zoster, Osteonecrosis, Tooth exfoliation[paper submitted 2011. 8. 30 / revised 1st 2011. 10. 13, 2nd 2012. 1. 9 / accepted 2012. 1. 11]

festationcanbeobservedwhenthemaxillaryandmandibular

branchesareaffected4.

Oralvesiclesappearmainlyafteraskinmanifestation3,5.

Sometimes,however, theremaybemucosal involvement

withoutskinlesion5.Thevesicleseruptandleavemucosal

erosionsbutnoscar inmostcases3.Themostsignificant

complicationofHZI is post-herpetic neuralgia5; other

complicationsmayincludefacialscarring,motornervepalsy,

opticneuropathy,blindness,encephalitis,andcalcinosiscutis6.

ThebonychangeinassociationwithHZIwasfirstreported

byRose in19087.AccordingtoDechaumeetal. (1955)8,

Gonnet’spresentationin1922wasthefirstreporttoestablish

interestinosteonecrosisandtoothexfoliationassociatedwith

HZI2.Complicationsuchasosteonecrosiswithspontaneous

toothexfoliationisveryrare.Thus,wereportsomecasesof

osteomyelitis inthemandiblecausedbyHZIaffectingthe

trigeminalnerve.

II. Cases Report

1. Case 1

A78-year-oldmalepatientvisitedourhospitalonFebruary

12,2010withchiefcomplaintofosteonecrosisofmandible

I. Introduction

Thevaricellazostervirus(VZV)produces twoclinical

results:varicellaorchickenpoxandherpeszosterinfection

(HZI)1.VaricellacausedbytheprimaryinfectionofVZVis

abenignchildhooddiseaseproducingeruptivevesicles.Asa

resultofprimaryinfectioninthevaricella,askinvirusmoves

toasensorynerveandremainsinlatentstateinaganglion1,2.

WhenVZVinlatentstateisreactivated,itdevelopsintoHZI,

whichcausesseverepainandpainfulvesiclesintheskinand

mucosaaroundtheaffectedsensorynervedistribution3,4.

Thoracolumbardermatomes(T3-L3)aremostcommonly

affectedbyHZI1,4.HZImayalsoaffectthecranialnerves,

with the trigeminalnervemostfrequentlyaffected(18.5-

22%)1.Herpes zoster affecting the trigeminal nerve is

generallyunilateral; itaffectsasinglebranchamongthree

branches,mainlythefirstbranchoropticnerve.Oralmani-

Hyung Jun KimDepartment of Oral and Maxillofacial Surgery, College of Dentistry, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, KoreaTEL: +82-2-2228-3132 FAX: +82-2-2227-8022E-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

CC

CASE REPORThttp://dx.doi.org/10.5125/jkaoms.2012.38.3.177

pISSN 2234-7550·eISSN 2234-5930

J Korean Assoc Oral Maxillofac Surg 2012;38:177-83

178

Askinlesioninthemandibularrightareawasobserved,

showingahealingpatternbasedontheclinicalexamination.

(Fig.1)Theoralfindingsincludedexposureofnecroticbone

inthemandibularrightarea,pusdischargethroughextraction

socketsforcanine,firstandsecondpremolar,andmalodor.

(Fig.2)Thepatient’soralhygienewaspoorandtherewere

manyrootrestsobservedinthemaxillaryrightsecondmolar,

firstmolar,secondpremolar,firstpremolar,maxillaryleft

firstmolar,mandibularleftfirstpremolar,secondpremolar,

and firstmolar.Therewasno significant finding from

theblood testandchemical test.Additionally,computed

tomography (CT)scanwasconducted.The radiological

findingsincludedalowattenuateintraosseouslesionwithill-

definedborder.Reactiveosteosclerosisaroundthelesion,and

sequestrumwereseeninalesion.Otherfindingsincluded

thebonydestructionpatternof thebuccolingualcortical

bonenearthelesionandmultipleenlargedlymphnodeinthe

submandibularspace.(Fig.3)

WhenthepatientvisitedthehospitalagainontheFebruary

17,theexposurepatternofcorticalboneintherightmandible

showednosignificantchangecomparedtothefirstclinical

examination,and theCTfindingswereexplained to the

after theextractionof themandibular right canine ina

privatedentalclinic.Themandibular right firstpremolar

andsecondpremolarweresaidtohaveexfoliatednaturally

duringamealandwithtoothbrushingtwomonthsbeforehe

cametothehospital,andtherewerenosymptomssuchas

painormobilityinthepast.Fourweeksbeforehecameto

thehospital,theskinlesionappearedalongthepathwaysof

themaxillary/mandibularbranches in theright trigeminal

nerve,andantiviralagentwasgiveninaprivateskinclinic

forsymptomreduction,however,paresthesiainrightchin

appeared.Afteramanifestationofskinlesion, thepatient

complainedofpainandmobilityof themandibular right

canineandthecaninewasextractedinaprivatedentalclinic.

Followingdiagnosisofimpairedhealingandosteonecrosis,

thepatientwasreferredtoourdepartment.

Fig. 1. Case 1. Skin lesions of herpes zoster (healing phase); clusters on the skin on the lower side of the face (V3 area) were observed. Nam-Kyoo Kim et al: Alveolar bone necrosis and spontaneous tooth exfoliation associ-ated with trigeminal herpes zoster: a report of three cases. J Korean Assoc Oral Maxil-lofac Surg 2012

Fig. 2. Case 1. Necrotic bone was exposed on the mandible, right. Nam-Kyoo Kim et al: Alveolar bone necrosis and spontaneous tooth exfoliation associ-ated with trigeminal herpes zoster: a report of three cases. J Korean Assoc Oral Maxil-lofac Surg 2012

Fig. 3. Case 1. Preoperative radiographic findings. A. Large sequestrum was seen on the right mandible, and it was definitely distinguished from the surrounding bone on the orthopantograph. B. Mandibular computed tomography (CT) axial view; large sequestrum can be seen on the right mandible. C. Mandibular CT axial view; exfoliated socket can be seen on #33, 34, 35. Nam-Kyoo Kim et al: Alveolar bone necrosis and spontaneous tooth exfoliation associ-ated with trigeminal herpes zoster: a report of three cases. J Korean Assoc Oral Maxil-lofac Surg 2012


179

gingivaandexposureofcorticalbonebeneath thegum.

Hehadusedmaxillarycompletedentureandmandibular

removablepartialdentureforseveralyears.

Theclinicalexaminationrevealedfindingsoferythematous

edemain therightchinandulcerandpost-inflammatory

hyperpigmentationintherightchinandpreauriculararea.

(Fig.5)Theoral findings included theextractionsocket

(consideredtohavebeendroppedrecently)ofthemandibular

rightcanine, firstandsecondpremolarusedasabutment

oftheremovablepartialdentures,exposureofneighboring

necroticbones,andinflammationofneighboringgingiva.

(Fig.6)Thepatientdidnot remember theexact timeof

patient andhis caregiver.We temporarilydiagnosed it

asmandibularosteomyelitiscausedbyHZI,hospitalized

thepatienton the18thof thesamemonthandyear,and

plannedantibiotherapy,consultationwithdermatologist,and

sequestrectomy.

Thedermatologistdecidednottorequireadditionalantiviral

treatmentbecause theskin lesionhadalreadyenteredthe

healingstage,and just recommend theadministrationof

non-steroidalanti-inflammatorydrug (NSAID)andpre-

gabalintoproviderelieffrompost-herpeticneuralgia.With

antibiotherapy,squestrectomyandextractionofrootrests

wereperformedunderlocalanesthesiaonFebruary,26.The

bonydefectsweredressedwithVaselinegauze,whichwas

replacedonadailybasis.Thepostoperativeradiological

findingsshowednormalhealingpatternoftheareawherethe

bonewasremoved.(Fig.4)Thelesionwasoverlappedwith

softtissueingoodconditionninedaysaftertheoperation,

andthepatientdischargedthehospitalonthe16thdayafter

theoperation.Asaresultofmonitoringuntileightmonths

afterthesurgery,thepatientdidnotcomplainofpost-herpatic

neuralgia,andtherewerenofindingsofrecurrence.

2. Case 2

A77-year-oldmalepatientwasreferredtoourhospital

withchiefcomplaintofsoregingivaandmandibularpainon

December17,2010.Amonthbeforevisitingourhospital,

thepatientcomplainedofpainintherighteararea,vesicles

andswellingswithpainalongthepathwayofthetrigeminal

mandibularbranchontherightsideoftheface,andconsulted

anotolaryngologist,takingantiviralagentmedication.Two

weeksbeforehevisitedourhospital,hefeltpainfromsore

Fig. 4. Case 1. Post-operative radiographic findings post-operative day 8; the necrotic bone and multiple hopeless teeth were removed, and normal healing was noted.Nam-Kyoo Kim et al: Alveolar bone necrosis and spontaneous tooth exfoliation associ-ated with trigeminal herpes zoster: a report of three cases. J Korean Assoc Oral Maxil-lofac Surg 2012

Fig. 5. Case 2. Skin lesions of herpes zoster; erythematous swelling and ulcer with post-inflammatory hyperpigmentation. A. Skin lesion can be seen on the chin, right. B. Skin lesion can be seen on the preauricular area, right.Nam-Kyoo Kim et al: Alveolar bone necrosis and spontaneous tooth exfoliation associ-ated with trigeminal herpes zoster: a report of three cases. J Korean Assoc Oral Maxil-lofac Surg 2012

Fig. 6. Case 2. Necrotic bone was exposed, spontaneous teeth exfoliation on #43, 44, 45.Nam-Kyoo Kim et al: Alveolar bone necrosis and spontaneous tooth exfoliation associ-ated with trigeminal herpes zoster: a report of three cases. J Korean Assoc Oral Maxil-lofac Surg 2012


180

med;sincepost-herpaticneuralgiapersisted,gabapentin600

mg,tramadol37.5mg,acetaminophen325mg,andamino-

triptyline10mgwereadministeredtothepatient.

OnJune8,2011,aftercontinuousfollow-upforsixmonths,

post-herpaticneuralgiasubsided,andsequestrumformed

andnaturallyexfoliated.Biopsyoftheexfoliatedsequestrum

wasperformed,withtheresultreportedasnecroticbone.On

June29,theareawasoverlappedwithsofttissuearoundthe

lesion,healingwell.(Fig.8)

3. Case 3

OnJuly22,2010,a74-year-oldmalepatientvisitedour

hospitalwithchiefcomplaintofswellingoftheleftsideof

thefaceandpain.Hecomplainedofpainintheupperanterior

teeth for threedaysbeforehevisitedourhospital, and

vesiclesandedemawereformedalongthepathwayofthe

lefttrigeminalmaxillarybranchtwodaysbeforehevisited

ourhospital.OnJuly22,hewenttoaprivatedentalclinic;he

wasthenreferredtoourhospital.Hetookprescriptionpills

forhighbloodpressure,whichwasrelativelywell-regulated.

Heworemaxillaryandmandibularpartialdenturesforfive

years.Theclinicalexaminationshowedthattheleftsideof

thefacehaddiffuseerythematousplaquesandvesicleswith

tenderness.(Fig.9.A); theoralfindingsincludedmultiple

mucosalvesiclesandulcer formationon the leftpalate

togetherwithmobilityoftheremainingteethandalveolar

boneresorptioninedentulousstateexceptthemaxillaryright

andleftcentral incisor, lateral incisor,andcanine.(Fig.9.

B)HZIwasconsideredtobeinactivephase,consultation

wereadministeredwithadermatologistandaperiodontistto

preventosteonecrosisandlossofremainingteeth.Afterthe

toothexfoliation,butitwasestimatedtobeaboutoneweek

earlieraccording to theopinionsofhiscaregiverand the

peoplearoundhim.Assumingmandibularosteomyelitis

in associationwithHZI, antibioticswereprescribed to

preventsecondaryinfection,andCTscanwasconducted.

Consultationwiththedermatologistandotolaryngologistwas

administeredfortheskinlesionandotalgia.Theradiological

findingshoweda lowattenuate intraosseous lesionwith

relatively ill-definedborderin themandibular rightarea

butnodestructionofcorticalboneorsequestrum.Someof

theenlargedlymphnodein thesubmandibularspacewas

observed.(Fig.7)Dermatologically,sinceonemonthhad

passedafterHZI,antiviraltreatmentwasnotrequired.For

post-herpaticneuralgia,pregabalinandacetaminophenwere

administered.

Whenhevisitedthehospitalagain,theexposurepatternof

therightmandibularcorticalbonehadnosignificantchange

comparedtothefirstclinicalexamination.Sincetherewas

neithersequestrumnoracute inflammation,weonlyuse

antibioticsandantimicrobials (ChlorhexidineGluconate

Solution)forpreventsecondaryinfection.Surgicalsques-

trectomywasplannedincaseofsequestrumdevelopsinthe

future.Continuousfollow-upanddisinfectionwereperfor-

Fig. 7. Case 2. Radiographic findings; diffuse radiolucent lesion and extraction sockets area seen on the mandible, right. A. Orthopantograph. B. Mandibular computed tomography (CT) view: coronal. C. Mandibular CT view: axial.Nam-Kyoo Kim et al: Alveolar bone necrosis and spontaneous tooth exfoliation associ-ated with trigeminal herpes zoster: a report of three cases. J Korean Assoc Oral Maxil-lofac Surg 2012

Fig. 8. Case 2. Soft tissue covering previous lesion.Nam-Kyoo Kim et al: Alveolar bone necrosis and spontaneous tooth exfoliation associ-ated with trigeminal herpes zoster: a report of three cases. J Korean Assoc Oral Maxil-lofac Surg 2012


181

riskelementsmayincludeexternaldamageoftheaffected

dermatomes,psychologicalstress,andrace9.

The thoracicdermatome ismost commonlyaffected,

accountingfor50%of the totalcases9.Thecranialnerve

mayalsobeaffected,withthetrigeminalnervemostcom-

monlyaffected(18.5-22%of the totalcases)followedby

glossopharyngealnerveandhypoglossalnerve.Incaseof

trigeminalnerveinvolvement, it isunilaterallylimitedtoa

singlebranch,mainlyaffectingtheopticnerve2.

Oralsymptomisobservedwhenthetrigeminalmaxillary

andmandibularbranchesareaffectedandskin lesion is

mainlypreceded,butacasestartingwithparesthesiaof

mentalnervewasalsoreported11.Theerythematousvesicle

isdevelopedintheoralcavity;itruptures,formsanulcer,

andgetscoveredbywhitepseudomembrane2,5,11.Lympha-

denopathymay appear in the submandibular area5. In

addition,patientsmaycomplainofsymptomsimilartoacute

pulpitsoftheaffectedtoothandtoothache12;rootresorption

andperiapical lesionmayalsooccur13.Sincehistological

findings that are not significantly different from the

osteomyelitispatternshownecroticboneandinflammatory

cellinfiltration,thediagnosisoftherelationshipwithherpes

zostercanhardlybeconfirmedonlybysuchhistological

findings;thediagnosisshouldtakeintoaccounttheclinical

findings3,4,14.Amongthefindings,osteonecrosisofthejaw

andnaturaltoothexfoliationareveryrarecomplications4,5,15.

Jainetal.4conductedareviewofliteratureon41casesof

osteonecrosisofthejawcausedbyHZI.Theonsetagerange

wasfrom6to85,with8casesofpatientsundertheageof40,

treatmentbyadermatologist,antiviralagent(famciclovir750

mg),tramadol37.5mg,acetaminophen325mg,levocetirizine

HCl5mg,andmupirocin0.2%ointmentwereprescribed;

forperiodontal treatment, scalingandmonitoringwere

performed.OnJuly29,theskinlesionshowednormalhealing

patternbytheformationofcrust(Fig.10.A);theoralvesicles

alsohealednormallywithnosignificantscar.(Fig.10.B)On

August26ofthesameyear,monitoringrevealednomajor

abnormalityexceptmoderatemobilityof the remaining

maxillaryteeth,andthatpost-herpaticneuralgiasubsided.

III. Discussion

TheprevalencerateofHZIinallagesisreportedtobe

1.2-4.8per1,000peopleeveryyear,with7.2-11.8people

over theageof609.Theprevalencerateandseriousness

increasewithage.40-50%ofthepatientswithHZIareover

theageof60everyyear,with50%ofpersonsover85years

oldrecordingprevalencerateofat leastonce10.Asto the

reasonforsuchprevalencerateincrease,naturalimmunity

declineaccordingtoage increasemaybeconsidered; the

declineinVZV-specificcellularimmunityaccordingtoage

increaseissupported1,10.Theprevalenceratealsoincreases

among immunocompromisedpatients such as patients

infectedwithhumanimmunodeficiencyvirus,hematologic

malignantdisease,andimmune-mediateddisorderandorgan

transplantpatients,andtheriskofHZIforsuchimmune-

suppressedpatientsalsoincreasesaccordingtoage1,9,10.Other

Fig. 9. Case 3. Lesions of herpes zoster (active phase). A. Extraoral view; diffuse erythematous plaques and vesicles were seen on the upper side of the face (V2 area) with tenderness. B. Intraoral view; multiple mucosal vesicles and ulcer formation observed on the maxilla, left.Nam-Kyoo Kim et al: Alveolar bone necrosis and spontaneous tooth exfoliation associ-ated with trigeminal herpes zoster: a report of three cases. J Korean Assoc Oral Maxil-lofac Surg 2012

Fig. 10. Case 3. Lesions of herpes zoster (healing phase). A. Extraoral view; clusters on the skin on the upper side of the face (V2 area) were seen. B. Intraoral view; normal healing state on mucosal lesion. No visible scar formation.Nam-Kyoo Kim et al: Alveolar bone necrosis and spontaneous tooth exfoliation associ-ated with trigeminal herpes zoster: a report of three cases. J Korean Assoc Oral Maxil-lofac Surg 2012


182

the intervalcloselyassociatedwith themanifestationof

herpeszosteraffectingthetrigeminalnerveandtheprogress

ofosteonecrosisandosteomyelitisaccompaniedby tooth

exfoliationintherelatedquadrantonly,weconfirmedthe

diagnosisofosteonecrosisofthejawtobeassociatedwith

HZI.SincethepatientinCase2hadonlymandibularright

firstandsecondpremolarsandcanineastheremainingteeth,

andtherewasnotopicalfactorintheotherquadrants,itmay

bemoredifficulttodistinguishfromgeneralosteomyelitis.

Nevertheless,consideringtheclinicalhistoryandpatterns,

wecannotruleouttherelationshipwithherpeszoster.

Thepathophysiologicalmechanismofosteomyelitisof

thejawcausedbytrigeminalherpeszosteriscontroversial,

and several hypotheses areunderdiscussion.The first

hypothesis is that localvasculitis causedby thedirect

extensionofneural inflammatoryresponsetotheadjacent

bloodvessels.Thiseventuallymaycauseaninfarctionof

thetrigeminalvesselsthataccompanythetrigemicalnerves

supplyingthe jawsandcausebonenecrosisbytriggering

ischemia16.Thesecondhypothesis is that thegeneralized

infectionof terminalnervessupplyingtheperiosteumand

periodontiumisbelievedtocausevasculitisoftheperiosteum

andperiodontiumand avascular necrosis over a large

area5,15,17.AccordingtoGildenetal.18,sinceVZVcanalsobe

invaginatedtothevascularendothelialcellintheperipheral

nervoussysteminsteadofbeinglimitedtothebrainorspinal

cord, itcausessmall ischemiclesion,possiblydeveloping

intonecrosisanddemyelination.Thereportcanserveas

groundsforthetwohypothesesabove18.Thethirdhypothesis

canbeadenervationofbone,butdenervationonlycan

hardlybethoughttocauseseriousbonedamageinashort

time15.Thefourthhypothesisisthatsystemicviralinfection

rendersdamagetoanodontoblastandbringsabout tissue

denaturation,causingpulpalnecrosis.Thefinalhypothesisis

thattheexistingpulpits,periodontitis,orsurgicalprocedure

around theHZI area can cause seriousnecrosisof the

alveolarbone3. IncomparingCase1,Case2,andCase3

above,theregulationofinitialresponseandtopicalfactorsis

meaningfulinpreventingcomplicationssuchasosteomyelitis

andosteonecrosisof the jaw,and the local factorcanbe

consideredacauseofthemechanisminthedevelopmentof

osteomyelitisassociatedwithtrigeminalherpeszoster.

Thecasesaboveandliteraturereviewrevealthat,incaseof

theoutbreakoftrigeminalherpeszoster,thepromptapplication

ofantiviralagents,activeuseofpainkillers,andeffective

regulationof topicalfactorswillbehelpful inpreventing

suchcomplications1,4,9,10.Ifosteomyelitisandosteonecrosis

10casesofthosebetween40and60,and12casesofthose

over60.Theprevalencerateincreasedaccordingtoage,with

nodifferencebygender4,16.Itmainlyappearedunilaterally

inthemaxillaormandibleoftheaffectedskin.13patients

haditinthemaxilla,and18patients,inthemandible.There

were31lostteethinthemaxillaand44teethinthemandible,

makingthemandibleapredilectionsite.Sincetheanterior

teethnumbered64andtheposteriorteethwere61,therewas

nosignificantdifferenceintheanteroposteriorposition.The

exfoliatedteethperpatientwere0-7; infivecases,all the

teethoftheaffectedquadrantwerelost4.

Withregardtothetimeintervalbetweentheoutbreakof

HZIandosteonecrosisaccompaniedby tooth loss,Mintz

andAnavi3presentedin1992areportontheintervalofan

averageof21.2daystogetherwiththeoccurrenceofnatural

toothexfoliationabout2-6weeksafterHZImanifestation

throughareviewof14studies.Severalauthors5,11reported

thatitoccurredbetweentwoweeksafterearlyinfectionwith

complicationofosteonecrosisandtoothexfoliation,butother

authors4reportedthatitoccurredbetween3-12weeksafter

HZImanifestationasa latecomplication.Inthefirstcase

reportedinthispaper,theextractionofthemandibularright

caninewasperformedabout4weeksafterHZImanifestation

eventhoughthemandibularfirstandsecondpremolarswere

ruledoutbecause thosepremolarswere lost fourweeks

beforetheoutbreakofskinlesion.Inthesecondcase,natural

toothexfoliationoccurredaboutthreeweeksafterHZImani-

festation.

Taking intoaccount thecomparisonofgeneralosteo-

myelitis, incaseof findings thatshowamedicalhistory

ofherpeszoster recentlyaffecting the trigeminalnerve

andvesicular lesionin therelatedfacialareawithproper

interval,andthatthelesionislimitedonlytoquadrantofjaw

withtheaffectednervedistributed,itmaybediagnosedas

osteomyelitisofthejawcausedbytrigeminalherpeszoster.

PatientsshowingosteomyelitisofthejawinCase1andCase

2wereold,takingprescriptionpillsforhighbloodpressure

andhavingmedicalhistoryofcoronaryarterybypasssurgery

toavoidanginapectoris andcerebral artery infarction,

respectively.Since theywereoldandweakpatientswith

blooddiseases, itmightbediagnosedasgeneralchronic

pyogenicosteomyelitiscausedbylocaldentalinfection.In

Case1,however,manyremainingteethwereaffectedby

dentalcariesorrootrests;sincetheradiopaquelesionsaround

therootapexweredistributedinthemaxillaandmandible,it

couldbejudgedthattherewaslocaldentalinfectioncausing

chronicosteomyelitis.Takingintoaccountthefindingsof


183

maxilla:casereport.JOralMaxillofacSurg1999;57:1249-51.7. RoseF.Postherpeticneuralgia; trophic lesions inhand'sbones

similartorheumatoidarthritis.NouvelleIconogrdelaSalpêtrière,SocNeurol1908;9:64.[French]

8. DechaumeM,DescrozaillesC,GarlopeauF,RobertJ.Localizedmandibularnecrosisduring trigeminalherpes.RevueStomatol1955;56:516-21.[French]

9. SchmaderKE,DworkinRH.Naturalhistoryand treatmentofherpeszoster.JPain2008;9(1Suppl1):S3-9.

10. WeaverBA.Herpeszosteroverview:naturalhistoryandincidence.JAmOsteopathAssoc2009;109(6Suppl2):S2-6.

11. SchwartzO,KvorningSA.Toothexfoliation,osteonecrosisofthejawandneuralgiafollowingherpeszosterofthetrigeminalnerve.IntJOralSurg1982;11:364-71.

12. SigurdssonA,JacowayJR.Herpeszoster infectionpresentingasanacutepulpitis.OralSurgOralMedOralPatholOralRadiolEndod1995;80:92-5.

13. RamchandaniPL,MellorTK.Herpeszosterassociatedwithtoothresorptionandperiapicallesions.BrJOralMaxillofacSurg2007;45:71-3.

14. ArikawaJ,MizushimaJ,HigakiY,HoshinoJ,KawashimaM.Mandibularalveolarbonenecrosisaftertrigeminalherpeszoster.IntJDermatol2004;43:136-7.

15. GartyBZ,DinariG, SarnatH,CohenS,NitzanM.Toothexfoliationandosteonecrosisofthemaxillaaftertrigeminalherpeszoster.JPediatr1985;106:71-3.

16. WrightWE,DavisML,GeffenDB,MartinSE,NelsonMJ,StrausSE.Alveolarbonenecrosisandtooth loss.ararecomplicationassociatedwithherpeszosterinfectionofthefifthcranialnerve.OralSurgOralMedOralPathol1983;56:39-46.

17. HallHD,JacobsJS,O'MalleyJP.Necrosisofmaxillainpatientwithherpeszoster.Reportofacase.OralSurgOralMedOralPathol1974;37:657-62.

18. GildenD,CohrsRJ,MahalingamR,NagelMA.aricellazostervirusvasculopathies:diverseclinicalmanifestations, laboratoryfeatures,pathogenesis,andtreatment.LancetNeurol2009;8:731-40.

ofthejawoccurascomplications,suchcomplicationscanbe

treatedthroughtheproperuseofantibioticstoavoidsecondary

infection,squestrectomy,removalofinflammatorytissue,and

regularfollowup2,4,13-15.Inthesecases,whenosteomyelitisof

thejawandosteonecrosisaccompaniedbytoothexfoliation

asrarecomplicationsaftertheoutbreakoftrigeminalherpes

zosteroccur,activeuseofpainkillers,regulationoftopical

factors,andproperextractionofdeadboneandaffectedteeth

bringaboutgoodresults.

References

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2. MendietaC,MirandaJ,BrunetLI,GargalloJ,BeriniL.Alveolarbonenecrosis and tooth exfoliation followingherpes zosterinfection:areviewoftheliteratureandcasereport.JPeriodontol2005;76:148-53.

3. MintzSM,AnaviY.Maxillaryosteomyelitisandspontaneoustoothexfoliationafterherpeszoster.OralSurgOralMedOralPathol1992;73:664-6.

4. JainMK,ManjunathKS,JagadishSN.Unusualoralcomplicationsofherpeszosterinfection:reportofacaseandreviewofliterature.OralSurgOralMedOralPatholOralRadiolEndod2010;110:e37-41.

5. MutoT,TsuchiyaH,SatoK,KanazawaM.Toothexfoliationandnecrosisof themandible--a rarecomplication followingtrigeminalherpeszoster:reportofacase.JOralMaxillofacSurg1990;48:1000-3.

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alveolar bone necrosis and spontaneous tooth exfoliation ... · alveolar bone necrosis and...

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