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A previously healthy 70-year-old man who underwent dental treatment for left maxillary toothache 1 week previously presented to us with facial swelling. He had experienced facial tenderness along with a tingling sensation in his mouth for several days. Physical examination revealed puffy skin on the left side of his face, reaching his left lid margin, without apparent vesicular rash. There was no facial paralysis. We initially suspected a bacterial soft tissue infection induced by the preceding dental procedure. However, intraoral inspection uncovered white erosion produced at the left hard palate clearly separated at the midline (figure 1). Specific antibodies for human herpes virus were negative, while the serum level of varicella-zoster virus specific IgG level was highly elevated at 1240 (enzyme immunoassay; reference range, <2). Accordingly, we diagnosed the patient with reactivation of herpes zoster involving the maxillary nerve (V2) dermatome of the left trigeminal nerve. The symptoms subsided following intravenous administration of acyclovir for 1 week; however, postherpetic neuralgia remained, causing a left-sided burning sensation on his face and hard palate.
Oral shingles pose diagnostic challenges among dentists because the prodromal stage of the disease can precede an emergence of mucosal or dermatological manifestations possibly by several days.1 Toothache, which the patient experienced at the beginning, could be an initial presentation of oral shingles in this case. Actually, previous cases referred to the potential of herpes zoster reactivation mimicking odontogenic pain.2 3 Delay in the appropriate treatment as a direct consequence of delayed diagnosis could be responsible for the development of postherpetic neuralgia as a sequela. This case highlights the importance of prudent intraoral examination and watchful waiting in diagnosing oral shingles.
Reactivation of herpes zoster involving the trigeminal nerve may mimic odontogenic pain during the prodromal stage of the disease.
Careful intraoral inspection can lead to an early diagnosis of oral shingles.
Patient consent for publication Obtained.
Contributors All the authors, HH, FN and EI, contributed to management of the patient. HH mainly wrote the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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