Page 9 - GP spring 2023

final impressions for the implant crown for and, therefore, no contraindications for the to treat the condition during its prodromal
tooth #20. The patient then reported that af- placement of implant #20. It can also be ap- stage and provide the patient with the op-
ter the last visit, she began feeling the signs preciated that the post-treatment radiograph tion of using antivirals such as Valacyclo-
and symptoms of lower left jaw paresthe- (Figure 3) shows the successful placement vir (1 gram, q8h x 21 days), Acyclovir (800
sia and kept biting the left lateral border of implant #20 without any complications. mg, 5/day x 21 days), or Famciclovir (500
of her tongue and cheek. The patient then mg, TID x 21 days), using tricyclic antide-
returned for an emergency visit to address pressants for post herpetic neuralgia symp-
the paresthesia, in which an internal con- toms, or receive the shingles vaccine.
6,7
sult was sent to the Orofacial Pain (OFP) Treatment should be postponed to prevent
department. The patient was seen by the the spreading of the virus.
OFP specialist and diagnosed with Her-
pes Zoster reactivation. The symptoms of Ocular Modifications:
paresthesia, which the patient experienced, Herpes Zoster patients may experience oc-
were diagnosed as post-herpetic neuralgia ular complications such as but not limited
unrelated to implant placement of tooth to corneal scarring and irregularity, kera-
#20 and any other dental work done. The titis, uveitis/iritis, and conjunctivitis. This
paresthesia was believed to be caused by Figure 3. Post-treatment periapical could be from VZV’s migration along the
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secondary trauma/stress in conjunction radiograph. trigeminal ganglion’s ophthalmic division.
with other factors, such as a lowered im- Patients should be referred to an ophthal-
mune system which triggered the reactiva- TREATMENT PLAN: mologist to evaluate their ocular health.
tion of the VZV, causing Herpes Zoster. The patient’s treatment plan will remain
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as planned, with the modification of offer- Neurological Modifications:
SOCIAL HISTORY: ing the patient the use of viral prophylaxis Patients with VZV are prone to experi-
The patient complained that she had a stress- before a procedure. The treatment plan in- encing neurological complications such
ful move to her current residence before ex- cludes the following: as post-herpetic neuralgia (PHN), Bell’s
periencing the onset of paresthesia. Due to 1) Implant crown (Porcelain fused to met- palsy, and even Ramsay Hunt syndrome.
unforeseen events that made her move diffi- al) for tooth #20 Studies have shown that PHN affects 20%
cult, the patient exhibited high distress and 2) Ceramic crown for tooth #19 of people with herpes zoster; 50% of peo-
frustration. Even while she was seated in 3) Tooth #7 mesial-incisal-lingual com- ple with post-herpetic neuralgia are over
the dental chair, the patient showed a high posite restoration 60, and 75% of people with post-herpetic
level of anxiety as she explained having to 4) 6 month recall with prophylaxis cleaning neuralgia are over 70. Management con-
pack all her belongings without assistance siderations for patients with PHN are to: 1)
and transferring all her billing information DISCUSSION: treat acute mucocutaneous shingles using
to her new residence. The patient also men- Herpes Zoster is highly prevalent among antivirals such as Valacyclovir, Acyclovir,
tioned that she had been sleep-deprived the geriatric population and should always and Famciclovir; 2) Prevent future recur-
from the move and appeared very fatigued be considered when reviewing a patient’s rent mucocutaneous shingles with the shin-
during her appointment. medical history and any planned dental gles vaccine (Shingrix); 3) Reduce the risk
treatment. In our case, this patient present- of patients at risk of PHN using the antivi-
RADIOGRAPHIC EVALUATION: ed with paresthesia of her lower left man- rals as mentioned earlier with the addition
Figures 1 and 2 are pre-treatment radio- dible that had gone unnoticed by her prior of Tricyclic Antidepressants (TCA) such as
graphs that indicate no prior pathology dental providers because it did not present amitriptyline and nortriptyline; 4) Treat-
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in its typical form where superficial ment of established PHN strictly using
skin lesions would be located on a TCA’s. On the other hand, reactivation of
dermatome. The pre-operative dental VZV can cause neuritis of the facial nerve
modifications offered to this patient (CN-7) within the facial canal causing viral
included getting the shingles vaccine compression neuropathy affecting the low-
(Shingrix), using antivirals during the er motor neurons, which results in unilater-
prodromal stage of the virus, and using al paralysis of the face. Treatment of Bell’s
tricyclic antidepressants for post-her- palsy should be a combination of Acyclovir

Figure 1. Pretreatment panoramic radiograph. petic neuralgia symptoms before re- and prednisone within three days of the on-
ceiving any dental treatment. 6,7 set. Lastly, reactivation of VZV within the
geniculate ganglion can present symptoms
Cutaneous Modifications: such as a vesicular rash of the outer ear,
VZV migrates from a ganglion to neural ipsilateral Bell’s palsy, neuralgia pain, and
tissue, and its corresponding dermatome ipsilateral Bell’s palsy loss of taste of the
resulting in clinically visible skin lesions anterior two-thirds of the tongue. The com-
that generally present as a burning/stinging bination of “Bell’s” palsy, geniculate neu-
sensation, followed by the appearance of ralgia, and shingles is known as Ramsay
blistering, which eventually crust over and Hunt syndrome and must be recognized by
heal. The provider must educate the patient the dental provider. Treatment for Ramsay

Figure 2. Pretreatment periapical radiograph. www.nysagd.org l Spring 2023 l GP 9