A 60-year-old man visited the Oral Medicine Clinic at the Dental Hospital of Universitas Indonesia with symptoms that initially appeared ordinary: spreading lesions on the left side of his chin, swollen lips, and numbness. One week earlier, he had visited the emergency department of a private hospital in Bogor. He was discharged with three prescriptions: amoxicillin, omeprazole, and mefenamic acid. None improved his condition.
What initially appeared to be a routine infection turned out to be herpes zoster, commonly known as shingles, affecting a branch of the trigeminal nerve. Because the condition was not appropriately managed at first, the man returned to the clinic three weeks later, this time with facial deviation to the left and complete loss of movement on that side.
The case was documented by drg. Tjut Intan Permata Sari, Sp.PM, together with a team from the Department of Oral Medicine, Faculty of Dentistry, Universitas Indonesia, and published in the Journal of International Dental and Medical Research, Volume 18, Issue 3, in 2025.
When an Old Virus Reactivates
Herpes zoster is not a new disease. Its causative agent, varicella-zoster virus (VZV), is the same virus responsible for chickenpox. After the initial infection resolves, however, the virus does not truly disappear. Instead, it remains dormant in sensory nerve ganglia and can reactivate when the immune system becomes weakened.
In this patient, the initial symptoms consisted of fever, fatigue, and restlessness, followed by vesicles on the chin and oral cavity. The man, who worked as an acupuncturist and had a history of typhoid fever two months earlier, did not recall ever having chickenpox. Extraoral examination revealed vesicles with yellowish crusting on the left side of the chin, edema of the left lower lip, and palpable lymph nodes. Intraoral examination revealed vesicles on the left lower labial mucosa and multiple ulcers extending to the floor of the mouth and the ventral surface of the tongue.
The patient was diagnosed with herpes zoster and prescribed oral acyclovir 800 mg five times daily for seven days, 5% acyclovir cream for the extraoral lesions, and a doxycycline mouth rinse prepared by dissolving 100 mg of doxycycline in 0.9% NaCl solution for the intraoral lesions. Multivitamins were also prescribed to support immunity.
A follow-up appointment was scheduled for one week later. The patient did not return until three weeks afterward.
Two Weeks That Changed Everything
This was where the case took a sharp turn. One day after the initial visit, the patient began experiencing nausea whenever he took acyclovir, causing him to take the medication inconsistently. His family subsequently brought him to an emergency department, where he was hospitalized. On the third day of hospitalization, he noticed that his face was being pulled toward the left and that he could no longer move it.
He was transferred to another hospital, where a new diagnosis was established: Ramsay Hunt syndrome (RHS). This syndrome occurs when VZV affects the geniculate ganglion of the facial nerve, causing facial paralysis accompanied by a rash around the ear. The incidence of RHS is estimated at 5 per 100,000 people and accounts for approximately 12% of all cases of facial nerve paralysis.
“Severe complications of herpes zoster can occur when patients do not take their medication appropriately. Early detection is equally important, along with adequate patient education to prevent disease progression.” — drg. Tjut Intan Permata Sari, Sp.PM, in the case report
At the second visit, examination revealed facial asymmetry with deviation to the left, hypotonia of the left eyelid, scarring on the chin, and a small residual ulcer on the lower anterior gingiva. The patient was subsequently managed by a neurologist with gabapentin, amitriptyline, mecobalamin, methylprednisolone, and several other supportive medications.
The Often-Unexpected Role of Dentists
This case highlights an issue that is often overlooked: dentists can play a frontline role in detecting herpes zoster because its initial manifestations frequently occur in the oral cavity and facial region.
During the prodromal stage, before vesicles appear, patients may experience toothache, paresthesia, or a burning sensation on one side of the face. These symptoms can easily be misdiagnosed as pulpitis, trigeminal neuralgia, or even a routine bacterial infection, as occurred in this case when the patient was initially examined and prescribed antibiotics.
The report also highlights the importance of adherence to antiviral therapy. Acyclovir should be taken on schedule and for the full prescribed course. The interval between trigeminal herpes zoster and the development of RHS ranges from 12 days to three weeks, consistent with the reported incubation period of VZV of 10 to 21 days. In this patient, the progression occurred within approximately two weeks.
At the third visit, the patient's condition had improved. Facial movement had begun to recover, while the remaining small ulcer was diagnosed as recurrent aphthous stomatitis rather than a residual herpes zoster lesion. Doxycycline therapy was discontinued and replaced with 0.2% chlorhexidine gluconate compresses.
One Case, Many Reminders
This case report, published in an international journal, is more than a clinical record. It is a reminder that severe complications of herpes zoster are not limited to patients with profound immunocompromise. Older age, a weakened physical condition, and poor medication adherence are all genuine risk factors.
For dentists, the message is simple but urgent: recognize the prodromal signs of herpes zoster, do not immediately assume that unilateral facial pain is purely a dental problem, and ensure that patients understand why adherence to antiviral therapy is not optional but essential.
The facial paralysis could potentially have been prevented—provided that the disease was recognized early and the medication was taken as prescribed.
Source DOI: https://doi.org/10.5281/zenodo.20719795
Authors: Anny Anggraini; drg. Achmad Zam Zam Aghasy, M.Kes.
Photo: Pexels