Treating Shingles in Your Mouth

Oral herpes zoster, also known as oral shingles, is a less common manifestation of shingles but one that can cause a painful outbreak of blisters in the mouth.

Shingles, a disease caused by the reactivation of the chicken pox virus, is typically treated with antiviral drugs to reduce the duration and severity of the outbreak. With oral shingles, over-the-counter painkillers, topical anesthetics, and soothing mouthwashes can also help ease the pain.

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It is estimated that between 20% and 30% of the general population will get shingles at some point in their lifetime. Early diagnosis and treatment may help reduce the risk of long-term nerve damage and other complications.

Symptoms

Shingles is a viral syndrome caused by the reactivation of the same virus, called the varicella-zoster virus (VZV), that causes chicken pox.

Once you are infected with VZV, the virus will remain in a dormant state in nerve tissues adjacent to the spinal cord (called dorsal root ganglia) and along the trigeminal nerve of the face (called the trigeminal ganglion).

When reactivation occurs, the outbreak will be limited to the affected nerve branch, referred to as the dermatome. The vast majority of cases will be unilateral (meaning limited to one side of the body).

Symptoms of oral herpes develop in distinct stages known as the prodromal phase, the acute eruptive phase, and the chronic phase.

Prodromal Phase

The prodromal (pre-eruptive) phase of shingles is the period just before the appearance of blisters. It can last for 48 hours or more, causing nonspecific symptoms that are often hard to recognize as shingles, including:

• Abnormal skin sensations or pain on one side of the jaw, mouth, or face
• Headaches
• Malaise
• Light sensitivity (photophobia)

These symptoms are frequently misdiagnosed as toothache.

Acute Eruptive Phase

The acute stage is characterized by the rapid onset of blisters on the mucous membranes of the upper or lower mouth. The blisters start as tiny bumps, typically in dense clusters, that quickly transform into painful blisters. The area of involvement will be clearly defined on either one side of the face or the other.

If the eruption occurs along the mandibular nerve, the tongue or gums of the lower teeth can be affected. If it occurs along the maxillary nerve, blisters can develop on the palate and gums of the upper teeth.

In addition to the interior of the mouth, it is not uncommon for blisters to form on the skin of the face, either around the cheek or one side of the jaw.

Shingle blisters can easily rupture and lead to canker-like sores that consolidate into larger pitted lesions. During the acute eruptive phase, symptoms can include:

• Burning, shooting, or throbbing pain, often severe
• Mouth sensitivity
• Difficulty chewing
• Altered taste
• Loss of appetite
• Drooling
• Fatigue
• Generalized body aches

Unlike shingles of the skin, which can crust over and dry once the blisters erupt, the moist environment of the mouth does not allow the oral blisters to dry.

Instead, the ruptured blisters can form moist ulcers that are slow to heal and vulnerable to bacterial infection (including herpetic gingivostomatitis). If not treated properly, an infection can lead to severe periodontitis (gum disease), osteonecrosis (bone death), and tooth loss.

Chronic Phase

The chronic phase is the period during which the blisters have largely healed, but pain can continue. The pain, referred to as postherpetic neuralgia, can be chronic or recurrent and may include:

• Dull, throbbing pain
• Burning, prickly, or itchy sensations (paresthesia)
• Shooting, shock-like pain

The types of sensations can vary and may worsen with jaw movement (such as chewing).

Postherpetic neuralgia may be short-lived and gradually resolve over the course of weeks or months. If the nerve damage is severe, the pain can continue for far longer and even become permanent and disabling.

Between 10% and 18% of people over age 60 who get shingles will develop postherpetic neuralgia, the risk of which increases with age. Generally, less than 2% of people under age 60 who get shingles develop postherpetic neuralgia.

Causes

Shingles only occurs in people who have had chicken pox. When a person gets chicken pox, the immune system is able to eradicate the virus from all but isolated nerve clusters called ganglia. If the immune system is intact, it can keep the virus in a state of latency (dormancy) for decades at a time.

Shingles represents a breach in the body's immune defense during which the virus can spontaneously reactivate and cause disease. The causes of reactivation are many and include:

• Aging (characterized by the progressive decline of immune function)
• Acute or chronic illness
• Psychological stress
• Immunosuppressive therapies
• Compromised immunity (such as occur with cancer or advanced HIV)

Even so, shingles can affect people under 50, and there is often no rhyme or reason as to why some people get it and others don't.

This is especially true with respect to oral shingles. Some studies suggest that males are 70% more likely to get oral shingles than females, although it is unclear why.

According to the Centers for Disease Control and Prevention (CDC), around 1 million people in the United States are affected by shingles every year.

Diagnosis

Oral shingles can often be diagnosed by a physical exam and a review of a person's medical history. The appearance of clustered blisters on one side of the mouth coupled with severe pain and prodromal symptoms is often enough to render a diagnosis. This is especially true if the person is older and has no prior history of mouth sores.

Even so, oral herpes can be mistaken for other diseases, including:

• Intraoral herpes simplex type 1 (more commonly linked to cold sores)
• Intraoral herpes simplex type 2 (more commonly linked to genital herpes)
• Primary syphilis
• Recurrent aphthous ulcers

If there is any doubt as to the cause, a swab of the sores can be sent to the lab for evaluation using a polymerase chain reaction (PCR) test. This is a test that amplifies the DNA in a sample of bodily fluids to positively identify the viral cause.

There are also blood tests that can detect VZV antibodies. They can look for IgM antibodies that are present at the initial infection with VZV and again if it reactivates (but not while the virus is dormant). Or, they may look for rising levels of IgG antibodies, which are developed after the initial VZV infection or immunization but will increase when the virus reactivates.

Treatment

The early treatment of oral shingles is key to reducing the severity and duration of an outbreak. Compared to oral herpes, oral shingles is treated much more aggressively due to the risk of postherpetic neuralgia and other complications.

Antiviral Therapy

Shingles is primarily treated with antiviral drugs. Therapy is ideally begun within 72 hours of an outbreak using one of three oral antivirals: Zovirax (acyclovir), Valtrex (valacyclovir), and Famvir (famciclovir). After 72 hours, the benefits of therapy are low.

The dose and duration of use vary by the drug type:

Zovirax is considered by many to be the first-line option for shingles, but Valtrex and Famvir have shown similar efficacy with easier dosing schedules.

Adjunctive Therapy

In addition to antiviral drugs, there are other drugs used to support the treatment of oral shingles. These are referred to as adjuvant therapies.

Among them, oral corticosteroids like prednisone are sometimes prescribed to reduce inflammation and aid with healing. These are generally only considered if the pain is severe and are never used on their own without antiviral drugs.

Oral shingles is also commonly treated with analgesics and other pain medications depending on the severity of the mouth pain. This may involve over-the-counter (OTC) painkillers or stronger prescription drugs.

Topical oral anesthetics can also be applied to the sores for short-term pain relief. This includes OTC and prescription options such as Xylocaine (2% lidocaine hydrochloride) gel.

At-Home Care

You can do other things at home to aid with the healing of oral shingles and reduce the risk of complications.

Alcohol-free antibacterial mouthwashes may not only reduce the risk of bacterial infection but help relieve mouth pain. These include OTC mouthwashes containing benzydamine hydrochloride, such as Oral-B Mouth Sore Special Care. Those containing menthol (like Listerine) also appear to help.

In addition to oral care, a mechanical soft food diet and the cessation of smoking can help ease pain and speed healing. Good oral hygiene further reduces the risk of a secondary bacterial infection.

Prognosis

Shingles outbreaks can take up to five weeks to fully resolve. With the early initiation of antiviral therapy and the appropriate supportive care, resolution times can be cut significantly.

Without treatment, the time between the eruption of a blister and the onset of crusting and healing is 7 to 10 days. If antivirals are started within 72 hours of an outbreak, the time can be cut to 2 days. Moreover, the severity and duration of the outbreak can be reduced.

By way of example, studies have shown that the early initiation of Valtrex can reduce the duration of shingles pain by 13 days compared to no treatment.

Although antivirals can significantly reduce the severity and duration of a shingles outbreak, there is little evidence that they can reduce the likelihood of postherpetic neuralgia. Age (rather than treatment) appears to be the single most influential risk factor in this regard.

Prevention

Shingles can be prevented with a DNA vaccine known as Shingrix. Approved for use by the U.S. Food and Drug Administration (FDA) in 2017, Shingrix is recommended for all adults 50 and over.

This includes people who have been previously vaccinated with Zostavax (an earlier generation live vaccine voluntarily discontinued in 2020) or those who have had a previous bout of shingles.

Shingrix is delivered by injection in two doses, with each dose separated by two to six months. The only contraindication for use is a severe allergic reaction to a previous dose of Shingrix or a known severe allergy to any of the vaccine ingredients.

A Word From Verywell

Oral shingles has its own distinct challenges separate from those of "traditional" shingles of the skin. Because the symptoms can be mistaken for other diseases, particularly in the early stages, you may inadvertently miss the window of opportunity for treatment if you wait for more telltale signs to develop.

Because it is important to start antiviral therapy within 72 hours of an outbreak, do not hesitate to see a doctor if you develop painful, blister-like bumps in your mouth. If your primary care doctor cannot see you immediately, consider seeking urgent care or telehealth services so that you can access treatment as soon as possible.