Treating Shingles in Your Mouth

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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.

Older man holding jaw in pain and discomfort
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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).

With oral shingles, the reactivation of VZV occurs along a branch of the trigeminal nerve—either the mandibular nerve that services the lower jaw or the maxillary nerve that services the upper jaw.

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.

The acute eruptive phase can last two to four weeks and is the period during which the virus is most contagious.

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:

Older age is arguably the single greatest risk factor for shingles. While the lifetime risk hovers between 20% and 30%, the risk increases dramatically after the age of 50. By age 85, the lifetime risk is no less than 50%.

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:

What differentiates oral shingles from other mouth sores is the unilateral location of the outbreak, the dense clustering of tiny blisters, the severity of pain, and the scalloped edges of the open ulcers. With that said, intraoral herpes simplex can also sometimes cause multiple open ulcers with scalloped edges and significant pain.

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:

Drug Dose in milligrams (mg) Taken
Zovirax (acyclovir) 800 mg 5 times daily for 7 to 10 days
Valtrex (valacyclovir) 1,000 mg Every 8 hours for 7 days
Famvir (famcyclovir) 500 gm Every 8 hours for 7 days

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.

Some studies have suggested that Valtrex is able to resolve shingles pain even faster than Zovirax.

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.

Drug Availability Typical Dosage
Tylenol (acetaminophen) OTC Up to 3,000 mg daily
Nonsteroidal anti-infammatory drugs (NSAID) OTC or prescription Varies by NSAID type
Percodan (oxycodone) Prescription 5 mg 4 times daily every 2 days
Neurotin (gabapentin) Prescription 300 mg at bedtime or 100–300 mg 3 times daily
Lyrica (pregabalin) Prescription 75 mg at bedtime or 75 mg twice daily
Pamelor (nortryptyline) Prescription 25 mg at bedtime

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.

A 2014 review published in the Cochrane Database of Systematic Reviews concluded with a high level of confidence that Zovirax had no significant impact on the risk of postherpetic neuralgia in people with shingles.

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.

When used as prescribed, the two-dose Shingrix vaccine can reduce the risk of shingles by 91.3%.

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.

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