Delayed Apical Pathology during Trigeminal Postherpetic Neuralgia Managed with Antiviral-Antibiotic Therapy: A Case...

Postherpetic neuralgia (PHN) is a possible chronic sequela of trigeminal herpes zoster characterized by persistent neuropathic pain that can complicate odontogenic pain assessment. Little is known about potential associations between zoster/PHN and periapical complications years after the acute episode, or whether such pathology might respond to conservative antiviral-antibiotic therapy. This case report describes a 40-year-old man with a childhood varicella history who developed trigeminal herpes zoster in the right mandibular division-preceded by prodromal odontalgia, followed by a vesicular rash, and mild PHN persisting thereafter. At age 46, despite no clinical symptoms in the affected region beyond stable PHN and no prior radiographic evidence of periapical abnormality, a new periapical radiolucency appeared at tooth #29 (Universal), while tooth #30 showed an area of altered opacity. Tooth #29 was nonresponsive to cold testing and was diagnosed with pulp necrosis with asymptomatic apical periodontitis, requiring endodontic treatment. In contrast, tooth #30 remained responsive to cold testing, indicating a vital pulp, but developed acute localized pain and gingival inflammation several weeks later; this resolved with valacyclovir-amoxicillin, and the tooth has remained radiographically stable for over 2 years without further intervention. This case illustrates successful conservative management of delayed apical pathology in chronic trigeminal PHN and the diagnostic challenge of distinguishing neuropathic from odontogenic pain. Future research should explore links between varicella-zoster virus reactivation/PHN and periapical disease, including PHN as a potential risk factor or marker.