Pathology · patient case question
Which virus can produce pain that closely mimics irreversible pulpitis before any rash appears?
Patient case: Shingles, neuralgia and a toothache that is not one
demo: 62-year-old male
chief: Severe pain in the upper right teeth for three days, with no obvious dental cause.
history: Recent bereavement and poor sleep. Chickenpox as a child.
meds: None.
findings: All maxillary right teeth respond normally to pulp testing and are non-tender to percussion. Two days later a unilateral vesicular rash appears on the right cheek and hard palate, stopping abruptly at the midline. Separately, another patient describes brief, electric-shock facial pain triggered by shaving.
Show answer and explanation
Correct answer: A. Varicella-zoster virus
- A. Correct. Prodromal zoster pain precedes the rash by two to four days and can be severe, deep and poorly localised along the affected trigeminal division, which is exactly how it comes to be mistaken for pulpitis. Patients have received root canal treatment and extractions for it. Normal pulp testing across several adjacent teeth with pain that does not localise should raise suspicion.
- B. Hepatitis C has oral associations including lichen planus and sicca symptoms, but not facial neuralgic pain.
- C. CMV causes systemic disease in the immunocompromised and occasional oral ulceration, but not this prodromal neuralgic pain.
- D. HPV causes papillomas, condylomas and focal epithelial hyperplasia, all painless.
Note: The practical rule: before irreversible treatment, confirm that the pain localises to one tooth with a reproducible pulpal and periapical picture. Unilateral non-localising pain with normal testing warrants a pause.