We usually blame bacteria for causing pulpitis but………. This patient complained of severe irreversible pulpitis symptoms for four days, which were only just starting to settle. She couldn’t isolate to either the upper second premolar or molar. Her dentist had extirpated the molar but symptoms hadn’t changed. Pulp testing showed the premolar was also responding negatively.

Take a look at the image below. This presentation is consistent with herpes zoster, commonly referred to as shingles. It is caused by the varicella zoster virus, also responsible for chicken pox. The trigeminal nerve is an unusual location for an outbreak (approximately 1-2% of cases), but when it occurs the virus affects a particular dermatome. If this dermatome also includes teeth, the pulp can also be affected. I can only imagine how painful this would be. Long term follow up is required as multiple teeth may lose vitality.

Notice how the viral outbreak is only affecting the greater palatine nerve distribution. If the nerve innervating the teeth are involved, this can lead to pulpitis and necrosis of the pulp tissues.

Diagnosing this initially may prove difficult, as the lesions on the mucosa don’t show up until a few days after symptoms appear, but some things to look out for include pulpitis symptoms from multiple teeth and a tingling or burning sensation in the distribution of the trigeminal nerve.

Pat Caldwell