Herpes zoster ppt

DR FATHIMATH ZAHRA,MDS
SENIOR LECTURER
ORAL MEDICINE & RADIOLOGY
MALABAR DENTAL COLLEGE & RESEARCH CENTRE, MANOOR

1. Herpes Zoster infection : Oral physician perspective .

2. INTRODUCTION: Painful,vesicular rash From reactivation of HZV Shingles Girdle( latin word : cingulum ). Elders/ immunocompromised / undergone organ transplantation/ recent chemotherapy/ HIV/AIDS

3. Human Herpes Virus Commonly Associated Diseases Herpes Simplex, type 1 (HSV -1) Herpetic oral lesions Herpes Simplex, type 2 (HSV- 2) Herpetic genital lesions Varicella Zoster Virus (VZV) Chickenpox, Herpes Zoster Epstein - Barr Virus (EBV) Infectious Mononucleosis Human Herpes Virus -6 (HHV - 6) Roseola , Mononucleosis syndrome Cytomegalovirus(CMV) CMV Mononucleosis Human Herpes Virus – 7 (HHV - 7) Currently not known Human Herpes Virus – 8 (HHV - 8) Kaposi’s Sarcoma

4. Primary infection : Chicken pox. VZV == highly contagious ,with initial exposure. Virus Host R eticuloendothelial system Blood stream. Respiratory system

5. Herpes Zoster ----Sporadic disease. Incidence– 15 times high in pt with HIV than in non HIV ,25% OF Hodgkin lymphoma develop Herpes Zoster. .

6. Herpes Zoster-is an acute infectious viral disease or extremely painful and incapacitating nature,characterised by inflammation of dorsal root ganglion ,associated with vesicular eruptions of skin and mucous membrane of the area supplied by affected sensory nerve.

7. S ymptoms mainly include: headache,photophobia,malaise,shooting pain,paraesthesia,burning and tenderness----- along course of affected nerve. Unilateral vesicle on erythematous base appears in clusters—course of affected nerve----resembles single nerve involvement. Zoster Sine Herpete – HZ occur with pain along the course of nerve without appearance of dermatome lesion.

8. SPREAD Virus infects cells respiratory tract----enters body via blood stream & lymphatic system----capillary epithelium----epidermis(destroys basal cells).

9. ORAL MANIFESTATION: SITE Buccal mucosa, tongue,palate , uvula, pharynx and larynx. Present as multiple shallow ulcers preceeded with vesicles SYMPTOMS Pain,burning,tenderness usually on palate on one side.

10. SIGNS INTACT VESICLES == RUPTURE== EROSION HEALING Takes place within 10-14 days.

11. Oral and Facial lesion results from HZ of Trigeminal Nerve(V) Involvement of V1: Lesion on upper eyelid ,forehead and scalp. It may lead to acute retinal necrosis . V2: Lesion on mid face and upper lip. Prodrome of pain, burning and tenderness on palate and gingiva on one side—followed by appearance of painful, clustered 1-5mm ulcers. V3: Lesion on lower face &lower lip. Ulcers of tongue and mandibular gingiva.

12. DIFFERENTIAL DIAGNOSIS: HSV PEMPHIGUS PEMPHIGOID Culture can be done to differentiate between HZ and HS infection.Other blistering disease like pemphigus or pemphigoid are chronic and do not present unilaterally.

13. DIFFERENTIAL DIAGNOSIS RECURRENT HERPES SIMPLEX INFECTION HERPES ZOSTER RECURRENT HERPES SIMPLEX INFECTION Prodromal symptoms – fatigue,hyperesthesia,pain Prodromal Symptoms– tension,burning,itching Development— edema,erythema,papulovascular then vesiculopustular lesions and erosion. Development- Vesiculoerosive lesion in crops and clusters ,but not limited to dermatome . Severe pain Moderate pain Lesion limited to course of sensory nerve. No skin lesions Longer course-post zoster neuralgia Fast healing without consequence No recurrence Recurrent appearaance

14. HERPANGINA---- acute infection ,palatal vault is affected.

15. COMPLICATIONS Postherpetic neuralgia Facial scarring Osteonecrosis of underlying jaw bone (NICO-neuralgia induced cavitational necrosis) exfoliation of teeth opthalmic involvement (blindness).

16. TEETH Occurs during tooth formation cause pulpal necrosis and internal resorption . Several non vital teeth can be seen. Some cases osteomyelitis can also be seen.

17. Herpes Zoster Ophthalmicus Ocular disease which usually manifests as a unilateral painful skin rash in a dermatomal distribution of the trigeminal nerve shared by the eye and ocular adnexa .

18. ZOSTEFORM PATTERN : Unilateral vesicle on an erythematous base appear in clusters ,chiefly along the course of nerve and giving picture of single dermatome involvement. HUTCHINSON SIGN Cutaneous zoster infection of side of tip of nose .

19. JAMES RAMSAY HUNT SYNDROME (Hunt syndrome; Herpes zoster oticus ; Geniculate ganglion zoster) Zoster infection of geniculate ganglion with involvement of external ear and oral mucosa. Clinical manifestation : Facial paralysis/ pain in external auditory meatus and pinna ear.

20. confirmed by viral culture,direct immunoflouroscene assay and PCR technique. Viral culture is possible but VZ virus is labile and difficult to recover from swabs of cutaneous lesion. Direct immunofluorescene assay is more sensitive PCR is useful for detecting VZ virus DNA in fluid tissue. Diagnosis of HZ :

21. Objective of Conventional therapy ---accelerate healing of lesion ,reduce accompanying pain and prevent complications. Medications include: Antiviral agents Corticosteroids Analgesics NSAIDS Tricyclic Antidepressants. MANAGEMENT

22. ANTIVIRAL AGENTS: Three most antiviral agents are Acyclovir,Valacyclovir and Famciclovir . Well tolerated Common side effects: Nausea ,Abdominal pain, Headache and Vomiting . Medication Dosage Acyclovir 800 mg orally five times daily for 7 to 10 days,10 mg per kg IV every 8 hours for 7 to 10 days Famciclovir 500 mg orally three times daily for 7 days Valacyclovir 1,000 mg orally three times daily for 7 days

23. CORTICOSTTEROIDS: Use for pain management in HZ , although clinical trials have showed inconsistent results for reducing development of post herpetic neuralgia. ANALGESICS AND NSAIDS Topical or oral analgesics (Aspirin ,Acetaminophen or ibuprofen)gives relief for mild – moderate pain. Severe pain : use of narcotics may be indicated. Nerve block injections is another option .LA –injected around affected nerve ---pain relief lasting for 12-24 hrs.

24. TRICYCLIC ANTIDEPRESSANTS(TCA): Low dose TCAs have been used for post herpetic neuralgia but they require at least 3 months for positive results. OTHER NATURAL OPTIONS GOAL: Strengthen cell mediated immunity –body natural defence mechanism ---control virus and prevent recurrence.

25. DIETARY/MULTIPLE NUTRIENT EFFECTS: When consumed collectively in form of fruits and vegetables intake showed related reduction in HZ risks. VITAMIN A: Observational trial by High et al –association between an increased incidence of hyporetinolemia and incresed risk of HZ infection. It function as fat soluble vit and hormone---contributing gene transcription that allows for normal proliferation and differentiation of epithelial cells.

26. Nutritional Consideration -Botanicals with specific efficacy for HZ : Capsaicin ----important in treatment of post herpetic neuralgia ---effects on C fibers sensory neurons . Neurons inflammatory peptide Neurogenic inflammation and chemical initiated pain . Licorice – widely use herbs in traditional medicine. Antiinflammatory , mucoprotectant and antiviral activity . release mediates

27. Other treatment options TENS : Use of combinationtherapy ( Amitryptilline,topical capsaicin and TENS)recommended for treatment of post herpetic neuralgia over antiviral therapy. VACCINE : ZOSTAVAX or other active or inactive formulations of zoster vaccine can be used

28. CORTICOSTEROIDS Corticosteroids have anti-inflammatory properties . Some authors find benefit in the short-term use of steroids to help manage herpes zoster Some evidence exists to suggest a decreased incidence of PHN in patients who received steroids. PREDNISOLONE: 5-60 mg/day in daily dose or divided q6-12hr

29. ANALGESIC Pain control is essential to quality patient care. Most oral narcotic analgesics have sedating properties that are beneficial for patients who have skin lesions. OXYCODONE (OXYCONTIN, ROXICODONE ,) Oxycodone is a narcotic analgesic that is indicated for the relief of moderate to severe pain. Patients with herpes zoster usually experience pain. I mmediate release form: 5 milligrams (mg) to 15 mg, every four to six hours IBUPROFEN (ADVIL, MOTRIN, CALDOLOR, ADDAPRIN) Pain/Fever OTC: 200-400 mg q4-6hr; not to exceed 1.2 g unless directed by physician Prescription: 400-800 mg PO/IV q6hr

30. NAPROXEN (ALEVE, NAPROSYN, NAPRELAN ) 500 mg initially, then 250 mg 8hr or 500 mg 12hr ; not to exceed 1250 mg/day naproxen base on day 1; subsequent daily doses should not exceed 1000 mg naproxen base.

31. TCAs – Nortriptyline , amitriptyline, or desipramine 25 mg; adjust up to 75 mg at bedtime; continue for several weeks if necessary. Lidocaine ( Lidoderm ®) skin patches.  These are small, bandage-like patches that contain the topical, pain-relieving medication lidocaine

32. Anticonvulsants.   Medications for treatment of seizures also can lessen the pain associated with postherpetic neuralgia. Stabilize abnormal electrical activity in your nervous system caused by injured nerves. Gabapentin( Neurontin®) :30-600 mg 3 times daily) Pregabalin ( Lyrica ®) or another anticonvulsant to help control burning and pain.

33. Capsaicin for Shingles Capsaicin It can affect the body's pain messages. Chemicals called substance P carry pain messages to the brain, but are temporarily reduced with capsaicin. Capsaicin ( Capzasin -P, Zostrix ) can cause a burning sensation and irritate your skin, but these side effects usually disappear over time.

34. Vitamins In the form of beta carotene, 25,000 IU twice a day for 2 weeks, then once daily to promote healing and potentiate the immune system. Vitamin B12 -- preventing nerve damage, 100 mcg sublingual daily or B12 shots, 6,000 mcg weekly Vitamin B complex, 50 mg three times daily

35. Vitamin C Supports the immune system and acts as an antiviral agent. Destroys the virus, help prevent postherpetic neuralgia, and boost the immune system. Bioflavonoids improve the absorption and use of vitamin C in the body. 1,000 to 4,000 milligrams of Vitamin C in divided doses throughout the day.

36. L-lysine for Shingles Effective against the herpes virus. Studies show that when taken at the onset of shingles, helps inhibit viral action to reduce the severity and duration of symptoms. 500 milligrams twice daily.

37. TENS therapy Acute HZ placement of two patches on the skin at the dermatome infected: 30 minutes five times a week for 2 or 3 weeks. The patches were connected to a low output (1–5 mA ) electrical generator and stimulated at frequences ranging from 20 to 40 Hz.

38. Spinal cord or peripheral nerve stimulation Similar to TENS, but are implanted underneath the skin. Before the device is surgically implanted, doctors do a trial first using a thin wire electrode. The trial is done to ensure that the stimulator will provide effective pain relief. The electrode is inserted----skin into the epidural space---- over the spinal cord or---- under skin above a peripheral nerve .

39. Herpes Zoster infection leads to various complication in affected region if left untreated ,oral physician should have a through knowledge about this condition ,the treatment and prevention of complications. Early diagnosis and prompt management of HZ can go a long way to reduce the discomfort of the patient long term follow up should also be done to avoid further complications . CONCLUSION

40. References Herpes Zoster infection of Maxillary and Mandibular Branch: A Case Report and Current Trends in Management. Narendra Prakash Rai,Jayanta Chattopadyay,Abhinandran,Soumi Ghanta. International Journal Of Contemporary Medical Research 2016;3(5);1437-1440. Tidwell E, Hutson B, Burkhart N, Gutmann L, Ellis D. Herpes zoster of the third branch of trigeminal nerve, a case report and review of literature. Int Endod J. 1999;32;61-6.