Mandibular osteomyelitis and tooth exfoliation following zoster-CMV co-infection

Maxillary Osteonecrosis Related with Herpes Zoster: A Case Report and Review of the Literature

Osteonecrosis of the jaw (ONJ) can occur through various mechanisms including radiation, medication, and viral infections such as herpes zoster. Although herpes zoster is a varicella-zoster virus infection that can affect the trigeminal nerve, it rarely causes oral complications. The author reports a rare case of herpes zoster-related ONJ, followed by a review of the relevant literature pertaining to herpes zoster-related oral complications, including ONJ. A 73-year-old woman presented with a scarred skin lesion on her left midface with an exposed alveolar bone of the left maxilla. Based on her medical records, she received a diagnosis and treatment for herpes zoster six months prior and experienced a few teeth loss in the left maxilla following a fall preceding the onset of herpes zoster. Sequestrectomy of the left maxilla was performed and ONJ was diagnosed. The operative site recovered favorably. Although unusual, several cases of localized extensive ONJ in herpes zoster-infected patients have been reported. This case illustrates the possibility of a rare occurrence of unilateral widespread osteonecrosis of the jaw (ONJ) even in the maxilla associated with herpes zoster. The exact mechanism has not been elucidated; nevertheless, surgeons should consider the possibility of oral and dental complications, including ONJ, related to a history of herpes zoster.

Ramsay Hunt syndrome and mandibular alveolar bone necrosis following herpes zoster: A case report and literature review

Background

Reactivation of latent varicella-zoster virus (VZV) can induce herpes zoster (HZ). Ramsay Hunt syndrome (RHS) occurs through the reactivation and proliferation of VZV in the geniculate ganglion, which can lead to vesicular rash in the ear or oral mucosa, accompanied by neurological disorders.

Materials and methods

A 50-year-old man sought a remedy for pain in the right ear and face. Within 1 week, all his lower right teeth fell out, and in the following 3 months, his lower right mandibular alveolar bone gradually became necrotic. In the past 20 days, he experienced blister rash, hearing and taste loss, and slight facial paralysis.

Results

After ruling out tumors and other infectious diseases, he was diagnosed with trigeminal HZ and RHS.

Conclusion

Ramsay Hunt syndrome with tooth loss and alveolar osteonecrosis is rare. It requires long-term treatment of pain, and prevention and treatment of tooth loss and alveolar bone necrosis are difficult and warrant further study.

Herpes Zoster in Four HIV Seropositive Patients and One Patient With Recurrent Carcinoma After Radiotherapy

Herpes zoster is a ubiquitous ultramicroscopic neurotropic virus that causes pruritic acute grouped vesicular eruptions and rashes, these vesicles rupture spontaneously resulting in pustules, crustations, which are pruritic in nature on the affected skin along the course of the dermatome resulting in scab. The scab withers off later leaving a permanent scar and pigmentation. The characteristic clinical finding was that vesicles or ulcers resulting from herpes zoster lesions never cross the midline. Two such reported cases of herpes zoster in seropositive HIV patients that resulted in extensive crustations and periorbital edema, left unilateral facial pain of burning quality in 25-year-old female patient and spontaneous exfoliation of a tooth in another 35-year-old patient, treated with drug therapy comprising acyclovir, gabapentin, amitriptyline are discussed here.

A rare case report and appraisal of the literature on spontaneous tooth exfoliation associated with trigeminal herpes zoster

BACKGROUND

Reports of post herpetic maxillofacial complications have been very rarely documented in the literature that includes periapical lesions, calcified and devitalized pulps, resorption of roots, osteonecrosis, and spontaneous exfoliation of teeth. The atypical feature of the case of concern to the dental surgeon is the rare complication of spontaneous tooth exfoliation following herpes zoster.

CASE REPORT

This case reports a male patient of age 47 years who reported to the Department of Periodontology with the chief complaint of mobility in the left upper central incisor. Patient history revealed herpes zoster infection that began 11 days earlier along with underlying diabetes mellitus condition. We hereby report a known diabetic patient with history of herpes zoster infection who presented with rare complication of spontaneous tooth exfoliation involving the maxillary division of the trigeminal nerve.

DISCUSSION

Limited number of cases has been reported in the literature regarding spontaneous teeth exfoliation secondary to herpes zoster. The exact pathogenesis regarding the spontaneous exfoliation of teeth in herpes zoster patient is still controversial. Thus, an oral health care provider should be aware of this rare complication while managing a case of tooth mobility with the previous history of herpes zoster of trigeminal nerve.

Osteonecrosis of the Jaw in the Absence of Antiresorptive or Antiangiogenic Exposure: A Series of 6 Cases

PURPOSE

Medication-related osteonecrosis of the jaws (MRONJ) is a well-described complication of antiresorptive and antiangiogenic medications. Although osteonecrosis can be associated with other inciting events and medications, such as trauma, infection, steroids, chemotherapy, and coagulation disorders, these are rarely reported in the literature.

MATERIALS AND METHODS

This is a six case series of MRONJ associated with medications other than antiresorptive or antiangiogenic drugs.

RESULTS

Patient demographics, inciting event, location, stage, imaging findings, and outcome are reported.

CONCLUSION

With the continued development and clinical use of new biologic medications for diseases such as cancer and rheumatoid arthritis, it is important to continue to evaluate their effects on the oral cavity. The degree of risk for osteonecrosis in patients taking these new classes of drugs is uncertain but warrants awareness and monitoring.

RANKL inhibitors induce osteonecrosis of the jaw in mice with periapical disease

Antiresorptive medications are essential in treating diseases of pathologic osteoclastic bone resorption, including bone cancer and osteoporosis. Bisphosphonates (BPs) are the most commonly used antiresorptives in clinical practice. Although inhibition of bone resorption is important in regulating unwanted malignant and metabolic osteolysis, BP treatment is associated with potential side effects, including osteonecrosis of the jaws (ONJ). Recently, non-BP antiresorptive medications targeting osteoclastic function and differentiation, such as denosumab, have entered the clinical arena. Denosumab treatment results in a similar rate of ONJ as BPs. Animal models of ONJ, using high-dose BP treatment in combination with tooth extraction or dental disease, provide valuable tools and insight in exploring ONJ pathophysiology. However, the ability of other antiresorptives to induce ONJ-like lesions in animal models has not been explored. Such studies would be beneficial in providing support for the role of osteoclast inhibition in ONJ pathogenesis versus a direct BP effect on oral tissues. Here, we tested the ability of the receptor activator of NF-κB ligand (RANKL) inhibitors RANK-Fc (composed of the extracellular domain of RANK fused to the fragment crystallizable [Fc] portion of immunoglobulin G [IgG]) and OPG-Fc (composed of the RANKL-binding domains of osteoprotegerin [OPG] linked to the Fc portion of IgG) to induce ONJ in mice in the presence of periapical disease, but in the absence of dental extractions. We demonstrate radiographic evidence of ONJ in RANK-Fc-treated and OPG-Fc-treated mice, including inhibition of bone loss, increased bone density, lamina dura thickening, and periosteal bone deposition. These findings closely resembled the radiographic appearance of an ONJ patient on denosumab treatment. Histologic examination revealed that RANK-Fc treatment and OPG-Fc treatment resulted in absence of osteoclasts, periosteal bone formation, empty osteocytic lacunae, osteonecrosis, and bone exposure. In conclusion, we have successfully induced ONJ in mice with periapical disease, using potent osteoclast inhibitors other than BPs. Our findings, coupled with ONJ animal models using high-dose BPs, suggest that osteoclast inhibition is pivotal to the pathogenesis of ONJ.

Stage 0 osteonecrosis of the jaw in a patient on denosumab

Osteonecrosis of the jaws (ONJ) is a complex disease involving multiple tissue and cell-type responses to wound healing or infection. AAOMS defines bisphosphonate related ONJ (BRONJ) as exposed, necrotic bone in the maxillofacial region that has persisted for more than 8 weeks in a patient with current or previous antiresorptive treatment, without a history of radiation therapy to the jaws. Since the first reported ONJ cases in 2003 and 2004, there has been little advancement in understanding the etiology and pathophysiology of ONJ. Many hypotheses have been proposed, including bisphosphonate (BP) toxicity to oral epithelium, altered wound healing after tooth extraction, high turnover of the mandible and maxilla, oral biofilm formation, infection and inflammation, and suppression of angiogenesis and bone turnover. The current classification system of ONJ involves stages 0 to 3 and is based on patient clinical presentation. This report describes a case of stage 0 ONJ in a patient on denosumab and indicates the full-spectrum similarities between BP- and denosumab-associated ONJ clinically, radiographically, and histologically.

Nerve afflictions of maxillofacial region: a report of two cases

Neurological disorders and conditions affecting the maxillofacial region result in disabilities that affect an individual's functioning. Sensory or motor disturbances of the nerves may be caused by trauma, infections, pressure effect or infiltration by tumours or other health conditions. Two rare cases of nerve afflictions are described here with their typical clinical features. The first case had an involvement of maxillary, mandibular and ophthalmic divisions of the trigeminal nerve (sensory) due to herpes zoster infection in a very young patient and the second case had a unilateral isolated hypoglossal nerve palsy (motor) secondary to infiltration of the nerve by carcinoma of pyriform fossa.

Noma (cancrum oris) in the South African context

Noma (cancrum oris) is a destructive necrotising disease affecting orofacial tissues predominantly of malnourished young children. It is characterised by a rapid acute onset which usually starts in the mouth, spreads intra-orally destroying soft tissue and bone and progresses to perforate the facial skin, causing disfigurement. Polybacterial anaerobic infection is critical too, but is not alone sufficient for the initiation of noma. Cofactors, first and foremost malnutrition, but also systemic viral and bacterial infections are crucial to the development of noma. A patient with necrotising stomatitis or noma must be admitted to hospital for antibiotic treatment, fluid and electrolytes as well as nutritional supplementation and general supportive treatment. The epidemiology of noma in the South African population is unknown, and the clinicopathological features are poorly characterised. Although worldwide there is no evidence that HIV infection is a strong risk factor for noma, HIV infection may play a substantial role in the pathogenesis of noma in South Africa.

Periodontal disease and bisphosphonates induce osteonecrosis of the jaws in the rat

Bisphosphonates (BPs) are medications used commonly to treat primary and metastatic bone cancer, as well as osteoporosis. Although BPs improve bone mineral density, reduce fracture risk, and reduce hypercalcemia of malignancy, some patients develop BP-related osteonecrosis of the jaws (BRONJ). This devastating complication is defined as clinically exposed bone in the maxillofacial region for more than 8 weeks. Despite an increasing number of BRONJ cases since first reported, the disease pathophysiology remains largely unknown. Since published studies suggest a significant role for dental disease in the pathophysiology of BRONJ, we developed a BRONJ animal model where aggressive periodontal disease is induced by ligature placement around the crown of the right maxillary first molar in the presence of vehicle (veh) or zoledronic acid (ZA), a potent BP. Ligature placement induced significant alveolar bone loss, which was attenuated by ZA treatment. Osteonecrosis was observed associated with ligature-induced periodontitis in the ZA-treated group. This was seen as sequestration and extensive periosteal alveolar bone formation on micro-computed tomography (µCT) in the ligated site of BP-treated animals. Histologic examination confirmed these findings, seen as necrotic bone with diffuse loss of osteocytes and empty lacunae, rimming of the necrotic bone by squamous epithelium and inflammation, and exposure to the oral cavity. Importantly, the rat lesions were strikingly similar to those of BRONJ patients. Our data suggest that dental disease and potent BP therapy are sufficient for BRONJ development in the rat.

Ostéonécrose maxillaire sous bisphosphonates et implants dentaires

INTRODUCTION

Bisphosphosnates are reference products used to treat osteoporosis, malignant bone disease, Paget's disease, and hypercalcemia. However these drugs seem to induce osteonecrosis of the jaws. This osteonecrosis is frequently observed and must be evoked in patients presenting with oral ulceration under bisphosphonate therapy.

OBSERVATION

We report the case of a long-term fully dental implanted patient treated by bisphosphonates who presented a maxillar ostenecrosis with no previous radiotherapy.

DISCUSSION

The risk factors and mechanism of this induced osteonecrosis are described. But could long term osseo-integrated dental implants be a triggering factor?