In early June, Justin Bieber appeared on news sites and social media, apologizing for his decision to postpone his current tour. In the pictures and videos, Bieber is clearly suffering from partial facial paralysis, as one would see similar to a patient suffering from Bell’s palsy. Bieber explains to his fans that he has been diagnosed with Ramsay-Hunt syndrome, which has affected half of his face. The diagnosis has made it impossible for the performer to currently sing, and he states it is now affecting his ability to eat.
Ramsay-Hunt syndrome (RHS) is a neurological disorder caused by the varicella zoster virus, which is the same virus that causes chickenpox and shingles. The virus lays dormant after a patient has been previously infected ‒ usually as a child with chickenpox ‒ and then is later reactivated in adulthood as shingles. RHS is a rare disease, with five in 100,000 people developing the condition each year in the United States.1
Some symptoms can have a direct influence on oral health, necessitating a considered response by dental professionals.
When this activation of shingles affects the facial nerve, a patient can develop RHS. The facial nerve is the seventh cranial nerve which has five branches. These branches innervate the forehead, eyelids, nose, lips, corners of the mouth, the anterior two-thirds of the tongue, and chin. It runs close to the vestibulocochlear nerve, which controls hearing and balance.5
Ramsay-Hunt Syndrome Symptoms
Much like a typical shingles case, the patient is normally afflicted with a unilateral, painful rash following along the infected nerve from the nerve root in the spine. Prodromal symptoms can include a fever, fatigue, and pain a few days before the appearance of the rash.2
In the case of RHS, the rash can be found in and on the ear, with some people presenting with a unilateral intraoral rash on the buccal mucosa, the palate, tongue, and throat with vesicles similar to intraoral herpetic lesions.3 The rash can cause intense ear pain and pain in the mouth and throat of the patient with an oral manifestation of the infection.
If a patient presents to the dental office with suspected shingles, any other treatment should be postponed until the lesions have crusted over. Dentists may want to prescribe antivirals if shingles are suspected, just as they would if a patient presented with suspected herpetic lesions. The dentist may also recommend or prescribe a topical anesthetic for intraoral pain caused by the rash. An immediate referral should be recommended to the patient’s primary care physician for pain management options and the monitoring and treatment of other symptoms.
Those with RHS also typically suffer from unilateral facial paralysis leaving them unable to blink or move their mouth on the afflicted side.1 Other symptoms of RHS include transient tinnitus, hearing loss, or hyperacusis (patient perceives sounds as uncomfortably amplified). In some cases, these changes to the hearing can be permanent. Patients may experience vertigo due to disturbances in the ear which can lead to falling risk, nausea, and vomiting.
RHS can include oral symptoms such as xerostomia and dysgeusia (altered taste).1
Ramsay-Hunt Syndrome Treatment
As with shingles, time is a factor in the successful treatment of RHS. The sooner antivirals like acyclovir can be administered, the greater the benefit and potential outcome for the patient. Corticosteroids may also be prescribed alongside antivirals for pain management.
Studies show that a course of antivirals within the first 72 hours of onset not only aids in the management of the active infection but shows a moderate reduction in the possibility of postherpetic neuralgia. Medications also prescribed to manage nerve pain are tricyclic antidepressants and certain anticonvulsants.2 For RHS patients, ointment is often used for the affected eye to protect it from corneal damage, and antihistamines may be prescribed for those experiencing nausea from vertigo.1
Though RHS symptoms and postherpetic neuralgia are usually temporary, the amount of time a patient will experience pain varies, and in rare cases, it can be permanent. Generally, symptoms improve within a few weeks if nerve damage is minimal. With greater nerve damage, recovery may take months or could be permanent.
Long-term complications from RHS may include disfigurement of the face, abnormal facial movements, hearing changes, vision loss, and dysgeusia.4
Dental Treatment for Patients with Ramsay-Hunt Syndrome
Dental hygienists treating patients with lingering symptoms of RHS should be prepared to make adaptations during dental treatment. A primary consideration is the loss of facial movement or atypical facial movement due to abnormal nerve repair. Other factors to consider include:
- Eye protection should always be used for patients, and this is especially important for an individual who cannot properly close an eye.
- Hygienists should be mindful of patient positioning and fall risks if the person experiences vertigo.
- The use of ultrasonic scalers and slow-speed handpieces may cause intense discomfort for patients who may be experiencing hyperacusis.
As always, discuss the management of oral symptoms with the patient, especially xerostomia stemming from both the syndrome and the treatments. Acid erosion should be addressed if the patient is experiencing nausea and vomiting. Though probably rare, if the patient is prescribed phenytoin (Dilantin) for longer-term pain management, educate the patient on the possibility of developing gingival hyperplasia.
Dental hygienists care about both the oral health and the systemic health of their patients. Whether we are fans or not, we hope Justin Bieber and any patient managing Ramsay-Hunt syndrome have a full recovery and regain their quality of life.
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- Ramsay Hunt Syndrome. (2011). NORD (National Organization for Rare Disorders). https://rarediseases.org/rare-diseases/ramsay-hunt-syndrome/
- Saguil, A., Kane, S., Mercado, M., Lauters, R. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. American Family Physician. 2017; 96(10): 656–663. https://www.aafp.org/pubs/afp/issues/2017/1115/p656.html
- Jeon, Y., Lee, H. Ramsay Hunt syndrome. Journal of Dental Anesthesia and Pain Medicine. 2018; 18(6): 333-337. https://doi.org/10.17245/jdapm.2018.18.6.333
- Ramsay Hunt Syndrome. (n.d.). Mount Sinai. https://www.mountsinai.org/health-library/diseases-conditions/ramsay-hunt-syndrome
- Facial Nerve: Function, Anatomy & Branches. (2021, December 29). Cleveland Clinic. https://my.clevelandclinic.org/health/body/22218-facial-nerve