Orofacial Shingles, Complications and Prevention

Figure 1. Distribution of the trigeminal nerve

Branches: Ophthalmic nerve (1), maxillary nerve (2) and mandibular nerve (3)

Shingles (herpes zoster; HZ) is an acute viral infection occurring in individuals that previously experienced chickenpox as a result of infection with the varicella zoster virus.1Centers for Disease Control and Prevention. Shingles (Herpes Zoster). About Shingles (Herpes Zoster). https://www.cdc.gov/shingles/about/index.html. Following this primary infection, the virus becomes latent in sensory ganglia in its host.2Rudd T, Chai BY, Gurunluoglu R, Glasgow M. Mandibular osteonecrosis and Ramsay Hunt syndrome following a case of herpes zoster. J Oral Maxillofac Surg 2014;72(10):1974.e1-6. doi: 10.1016/j.joms.2014.05.004. HZ then develops when the virus is reactivated, often several decades after the primary infection.3Carbone V, Leonardi A, Pavese M et al. Herpes zoster del nervo trigemino. Revisione della letteratura e caso clinico [Herpes zoster of the trigeminal nerve: a case report and review of the literature]. Minerva Stomatol 2004;53(1-2):49-59. Italian. ,4Kennedy PGE, Gershon AA. Clinical Features of Varicella-Zoster Virus Infection. Viruses 2018;10(11):609. doi: 10.3390/v10110609. The reactivated virus migrates along sensory nerves and typically affects a single dermatome – i.e., the region supplied by a given sensory nerve.2Rudd T, Chai BY, Gurunluoglu R, Glasgow M. Mandibular osteonecrosis and Ramsay Hunt syndrome following a case of herpes zoster. J Oral Maxillofac Surg 2014;72(10):1974.e1-6. doi: 10.1016/j.joms.2014.05.004.,3Carbone V, Leonardi A, Pavese M et al. Herpes zoster del nervo trigemino. Revisione della letteratura e caso clinico [Herpes zoster of the trigeminal nerve: a case report and review of the literature]. Minerva Stomatol 2004;53(1-2):49-59. Italian. Thoracic involvement is most common, followed by trigeminal nerve involvement which is reported to account for between 18% and 22% of cases.2Rudd T, Chai BY, Gurunluoglu R, Glasgow M. Mandibular osteonecrosis and Ramsay Hunt syndrome following a case of herpes zoster. J Oral Maxillofac Surg 2014;72(10):1974.e1-6. doi: 10.1016/j.joms.2014.05.004.,5Kosami K, Kenzaka T. Mandibular Herpes Zoster. Intern Med 2019;58(3):459-60. doi: 10.2169/internalmedicine.,6Song JM, Seo JS, Lee JY. Mandibular osteonecrosis following herpes zoster infection in the mandibular branch of the trigeminal nerve: a case report and literature review. J Korean Assoc Oral Maxillofac Surg 2015;41(6):357-60. doi: 10.5125/jkaoms.2015.41.6.357. Involvement of the first branch of the trigeminal nerve (the ophthalmic nerve) is much more common than for the second (maxillary) and third (mandibular) branches.3Carbone V, Leonardi A, Pavese M et al. Herpes zoster del nervo trigemino. Revisione della letteratura e caso clinico [Herpes zoster of the trigeminal nerve: a case report and review of the literature]. Minerva Stomatol 2004;53(1-2):49-59. Italian. ,7Gershon AA, Gershon MD, Breuer J et al. Advances in the understanding of the pathogenesis and epidemiology of herpes zoster. J Clin Virol 2010;48(Suppl 1):S2-S7.

An estimated 1 in 3 people will experience HZ during their lifetime, with an increased risk for older and immunosuppressed individuals.8Centers for Disease Control and Prevention. Shingles (Herpes Zoster). Shingles Facts and Stats. https://www.cdc.gov/shingles/data-research/?CDC_AAref_Val=https://www.cdc.gov/shingles/surveillance.html. In the US, an overall average rate of approximately 2 to 3 per 1,000 people per year has been reported. Among older individuals in the US the rates peaked in 2015 for individuals 50-59, 60-69 and >70 years-of-age with approximately 7, 8 and 11 cases per thousand, respectively.8Centers for Disease Control and Prevention. Shingles (Herpes Zoster). Shingles Facts and Stats. https://www.cdc.gov/shingles/data-research/?CDC_AAref_Val=https://www.cdc.gov/shingles/surveillance.html. This was data reported several years after the introduction of a live attenuated vaccine against HZ (recommended for individuals age 60 and over), and prior to the introduction of a new vaccine and recommendations in 2018.9The College of Physicians of Philadelphia. History of Vaccines. Shingles (Herpes Zoster). https://historyofvaccines.org/diseases/shingles-herpes-zoster. If a young individual experiences HZ, a weakened immune system should be suspected.10Warman M, Halperin D. [Varicella zoster virus infection involving the maxillary branch of the trigeminal nerve]. Harefuah 2007;146(2):89-91, 167. Hebrew. Triggers for HZ include X-ray irradiation, trauma, infection and malignancy.11Gershon AA, Breuer J, Cohen JI et al. Varicella zoster virus infection. Nat Rev Dis Prim 2015;1:15016. doi: 10.1038/nrdp.2015.16.

An estimated 1 in 3 people will experience herpes zoster during their lifetime, with an increased risk for older and immunosuppressed individuals.

Signs and Symptoms of HZ

Figure 2. Vesicular rash associated with HZ

The onset and progression of HZ occurs in three phases. During the prodromal phase, unilateral tingling, itching, pain or paresthesia is present in the affected area for at least two days.4Kennedy PGE, Gershon AA. Clinical Features of Varicella-Zoster Virus Infection. Viruses 2018;10(11):609. doi: 10.3390/v10110609.,12Shah RA, Limmer AL, Nwannunu CE et al. Shingrix for Herpes Zoster: A Review. Skin Therapy Lett 2019;24(4):5-7.,13Centers for Disease Control and Prevention. Shingles (Herpes Zoster). Shingles Symptoms and Complications. https://www.cdc.gov/shingles/signs-symptoms/index.html. The affected individual may experience fever, general malaise, headaches, or visual sensitivity to light. The prodromal phase is followed by the acute eruptive phase, during which a unilateral erythematous rash appears that rapidly progresses to become a painful vesicular rash.4Kennedy PGE, Gershon AA. Clinical Features of Varicella-Zoster Virus Infection. Viruses 2018;10(11):609. doi: 10.3390/v10110609.,13Centers for Disease Control and Prevention. Shingles (Herpes Zoster). Shingles Symptoms and Complications. https://www.cdc.gov/shingles/signs-symptoms/index.html. (Figure 2) The vesicles then pustulate, form ulcers and crust over/scab in a period of 7 to 10 days.12Shah RA, Limmer AL, Nwannunu CE et al. Shingrix for Herpes Zoster: A Review. Skin Therapy Lett 2019;24(4):5-7.,13Centers for Disease Control and Prevention. Shingles (Herpes Zoster). Shingles Symptoms and Complications. https://www.cdc.gov/shingles/signs-symptoms/index.html. Resolution normally occurs within two to four weeks. However, as discussed later in this article, atypical presentations of HZ also occur.14Brooks JK, Rostami AM, McCorkle DC, Benesh SI. Trigeminal herpes zoster and Ramsay Hunt syndrome in an elderly adult: Presentation with prodromal toothache. Gerodontol 2018;35(3):276-78. doi: 10.1111/ger.12340.

Orofacial HZ

The onset and progression of orofacial HZ occurs in the same manner as at other sites, featuring a uniliteral rash with vesicle formation, pustulation and ulceration. (Figure 3) Oral HZ presents unilaterally in intra-oral soft tissue, with a vesicular rash that then ulcerates. Vesicles may be present on the lip, palatoglossal arch, buccal mucosa and other areas; erosive white lesions unilaterally on the palate and painful white plaques/fibrin patches on the ventral surface of the tongue have been reported.5Kosami K, Kenzaka T. Mandibular Herpes Zoster. Intern Med 2019;58(3):459-60. doi: 10.2169/internalmedicine.,15Vourexakis Z, Vanoy J. Mucosal and cutaneous lesions in mandibular zoster. BMJ Case Rep 2014;2014:bcr2014204459. doi: 10.1136/bcr-2014-204459.,16Hagiya H, Nakagami F, Isomura E. Oral shingles. Case Report. Br Med J 2018;11:e228383. doi: 10.1136/bcr-2018-228383. (Figure 4)

Dental professionals should be aware that oral HZ may present as odontalgia (dental pain) during the prodromic phase, prior to the presence of a rash.3Carbone V, Leonardi A, Pavese M et al. Herpes zoster del nervo trigemino. Revisione della letteratura e caso clinico [Herpes zoster of the trigeminal nerve: a case report and review of the literature]. Minerva Stomatol 2004;53(1-2):49-59. Italian. ,14Brooks JK, Rostami AM, McCorkle DC, Benesh SI. Trigeminal herpes zoster and Ramsay Hunt syndrome in an elderly adult: Presentation with prodromal toothache. Gerodontol 2018;35(3):276-78. doi: 10.1111/ger.12340.,17Goon WW, Jacobsen PL. Prodromal odontalgia and multiple devitalized teeth caused by a herpes zoster infection of the trigeminal nerve: report of case. J Am Dent Assoc 1988;116(4):500-4. doi: 10.14219/jada.archive.1988.0301. This should be considered in the differential diagnosis of dental pain.18Christoforou J. Neuropathic Orofacial Pain. Dent Clin North Am 2018;62(4):565-84. doi: 10.1016/j.cden.2018.05.005. ,19Kim IH, Mupparapu A, Yablonski JN, Mupparapu M. A Patient with Herpes Zoster of the Maxillary Division of Trigeminal Nerve Presents for Oral Evaluation and Toothache. Dent Clin North Am 2023;67(4):687-90. doi: 10.1016/j.cden.2023.05.022. If HZ is not considered in the differential diagnosis, inappropriate dental treatment may be provided and the patient’s discomfort associated with HZ-related neuropathy prolonged before it is addressed.20Millar EP, Troulis MJ. Herpes zoster of the trigeminal nerve: the dentist’s role in diagnosis and management. J Can Dent Assoc 1994;60(5):450-3.

Zoster sine herpete (ZSH)

ZSH is an atypical variant of HZ, occurring in the absence of a rash/vesicles.21Imai T, Fujita Y. Zoster sine herpete of the trigeminal nerve revisited as a COVID-19-associated disease: Atypical manifestation of herpes zoster masquerading odontogenic symptoms. J Stomatol Oral Maxillofac Surg 2023;124(1):101265. doi: 10.1016/j.jormas.2022.08.008. Systemically, this can present as unexplained abdominal pain. In the orofacial region, ZSH can present as facial palsy that appears similar but is distinct from Bell’s Palsy, or as neuropathic orofacial pain or odontogenic pain. Rarely, ZSH has resulted in encephalitis.

Complications of HZ

Post-herpetic neuropathy (PHN) consists of severe debilitating chronic pain that occurs at the site where the rash had developed and lasts for more than 30 days.13Centers for Disease Control and Prevention. Shingles (Herpes Zoster). Shingles Symptoms and Complications. https://www.cdc.gov/shingles/signs-symptoms/index.html. It is the most common complication of HZ, affecting between 10% and 18% of individuals who suffer from HZ and with an increased risk in older individuals. Incidence of approximately 1 in 8 individuals at 40 years-of-age to 1 in 6, 1 in 4 and 3 in 10 by ages 60, 70, and 80 or older, respectively, is reported. (Figure 5)

Figure 5. Ratio of individuals with HZ later experiencing PHN by age

Other potential complications include vasculopathy and an increased risk for stroke; giant cell arteritis with the associated risk of sudden blindness; myelopathy and muscle weakness of limbs, sphincters, the diaphragm and intercostal area; and encephalitis.4Kennedy PGE, Gershon AA. Clinical Features of Varicella-Zoster Virus Infection. Viruses 2018;10(11):609. doi: 10.3390/v10110609. HZ affecting the scalp can lead to permanent hair loss due to the destruction of hair follicles.22Hayderi LE, Nikkels-Tassoudji N, Nikkels AF. Hair loss after varicella zoster virus infection. Case Rep Dermatol 2013;5(1):43-7. doi:10.1159/000348648. In the orofacial region, HZ affecting the facial nerve may result in Ramsay Hunt syndrome which, while rare, is characterized by ear involvement that causes tinnitus (ringing in the ears) deafness, vertigo, loss of taste in the anterior two-thirds of the tongue, and ipsilateral facial paralysis.2Rudd T, Chai BY, Gurunluoglu R, Glasgow M. Mandibular osteonecrosis and Ramsay Hunt syndrome following a case of herpes zoster. J Oral Maxillofac Surg 2014;72(10):1974.e1-6. doi: 10.1016/j.joms.2014.05.004.,23Gao H, Xu J, Cheng S, Chen J. Case of auricular herpes zoster associated with contralateral facial paralysis. J Dermatol 2016;43(1):110-1. doi:10.1111/1346-8138.13144.,24Monsanto RD, Bittencourt AG, Bobato Neto NJ et al. Treatment and prognosis of facial palsy on Ramsay Hunt syndrome: results based on a review of the literature. Int Arch Otorhinolaryngol 2016;20(4):394-400. doi: 10.1055/s-0036-1584267. HZ of the ophthalmic branch of the trigeminal nerve can result in serious complications including eye pain; inflammation of the sclera, iris and retina; blurring and, in severe cases, blindness.4Kennedy PGE, Gershon AA. Clinical Features of Varicella-Zoster Virus Infection. Viruses 2018;10(11):609. doi: 10.3390/v10110609.,25Tran KD, Falcone MM, Choi DS et al. Epidemiology of herpes zoster ophthalmicus: recurrence and chronicity. Ophthalmology 2016;123(7):1469-75. doi: 10.1016/j.ophtha.2016.03.005. Other reported complications of HZ include residual skin hyperpigmentation and a persistent and recurring burning sensation at the site where the rash had developed.15Vourexakis Z, Vanoy J. Mucosal and cutaneous lesions in mandibular zoster. BMJ Case Rep 2014;2014:bcr2014204459. doi: 10.1136/bcr-2014-204459. Hospitalization and death from HZ is rare in the US, with up to 4% of affected individuals hospitalized and less than 100 deaths annually among old and/or immunocompromised individuals.8Centers for Disease Control and Prevention. Shingles (Herpes Zoster). Shingles Facts and Stats. https://www.cdc.gov/shingles/data-research/?CDC_AAref_Val=https://www.cdc.gov/shingles/surveillance.html.

Post-herpetic neuropathy is the most common complication of HZ, affecting between 10% and 18% of individuals with HZ, and causes severe debilitating chronic pain that lasts for more than 30 days.

Oral Complications of HZ

As with other regions, PHN can occur following oral HZ. In addition, cases of HZ that resulted in devitalization of teeth, neuralgia, and burning and stinging sensations intraorally have been reported.15Vourexakis Z, Vanoy J. Mucosal and cutaneous lesions in mandibular zoster. BMJ Case Rep 2014;2014:bcr2014204459. doi: 10.1136/bcr-2014-204459.,17Goon WW, Jacobsen PL. Prodromal odontalgia and multiple devitalized teeth caused by a herpes zoster infection of the trigeminal nerve: report of case. J Am Dent Assoc 1988;116(4):500-4. doi: 10.14219/jada.archive.1988.0301.
Rare complications include pulpitis, periodontitis, mandibular or maxillary osteonecrosis, and tooth exfoliation.2Rudd T, Chai BY, Gurunluoglu R, Glasgow M. Mandibular osteonecrosis and Ramsay Hunt syndrome following a case of herpes zoster. J Oral Maxillofac Surg 2014;72(10):1974.e1-6. doi: 10.1016/j.joms.2014.05.004.,6Song JM, Seo JS, Lee JY. Mandibular osteonecrosis following herpes zoster infection in the mandibular branch of the trigeminal nerve: a case report and literature review. J Korean Assoc Oral Maxillofac Surg 2015;41(6):357-60. doi: 10.5125/jkaoms.2015.41.6.357.,26Zhou Y, Zhao N, Huang H et al. [Left mandibular osteonecrosis following herpes zoster of the third branch of left trigeminal nerve: A case report]. Beijing Da Xue Xue Bao Yi Xue Ban 2024;56(2):366-70. Chinese. doi: 10.19723/j.issn.1671-167X.2024.02.027.,27Mendieta C, Miranda J, Brunet LI et al. Alveolar bone necrosis and tooth exfoliation following herpes zoster infection: a review of the literature and case report. J Periodontol 2005;76:148-53. In a recent case report, a patient with oral HZ had initially experienced unilateral lingual pain followed by a unilateral facial rash diagnosed as HZ.26Zhou Y, Zhao N, Huang H et al. [Left mandibular osteonecrosis following herpes zoster of the third branch of left trigeminal nerve: A case report]. Beijing Da Xue Xue Bao Yi Xue Ban 2024;56(2):366-70. Chinese. doi: 10.19723/j.issn.1671-167X.2024.02.027. Subsequently, the patient had experienced gingival pain, a mandibular molar had exfoliated, and other teeth were mobile. It was determined that irregular loss of mandibular bone and severe alveolar resorption had occurred as a complication of HZ of the mandibular nerve. (Table 1) In another report, a patient with HZ experienced a facial rash confined to the area supplied by the left maxillary branch of the trigeminal nerve accompanied by swelling of the buccal mucosa and maxillary gingivae.28Graham AJ, Russell JL. Golden-crusted rash. Letters to the Editor. Br Dent J 2013;215(1):3. doi: 10.1038/sj.bdj.2013.633. He received antibiotics and acyclovir, which were later found to be ineffective. The patient suffered osteitis, tooth exfoliation and mobile teeth necessitating treatment with intravenous antibiotics, extractions, debridement and dressing of the affected area. One report noted osteonecrosis in edentulous patients.29Badjate SJ, Cariappa KM, Shenoi SR, Nakhate S. Ramsay-Hunt syndrome complicating osteonecrosis of edentulous maxilla and mandible: report of a rare case. J Maxillofac Oral Surg 2009;8(2):188-91. doi: 10.1007/s12663-009-0046-3.

Table 1. Potential complications of oral HZ
Post-herpetic neuralgia
Pulpitis and tooth devitalization
Burning and stinging sensations
Swelling of soft tissue, including gingivae
Periodontitis
Tooth mobility
Severe alveolar resorption
Tooth exfoliation
Osteonecrosis

Risk factors for recurrence of HZ in any location include weakened immunity, being female, predisposing conditions such as diabetes, and long-duration PHN after the initial episode of HZ.30Parikh R, Spence O, Giannelos N, Kaan I. Herpes Zoster Recurrence: A Narrative Review of the Literature. Dermatol Ther (Heidelb) 2024;14(3):569-92. doi: 10.1007/s13555-024-01101-7.

Treatment for HZ

While it is beyond the scope of this article to address the treatment of HZ, antiviral agents prescribed for adults include oral acyclovir, famciclovir and valacyclovir, and in patients with severe disease intravenous acyclovir is used.31Saguil A, Kane S, Mercado M, Lauters R. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. Am Fam Physician 2017;96(10):656-63. It is recommended that antiviral agents be prescribed as early as possible and within 72 hours of onset of the HZ rash, to help reduce the duration and severity of HZ and potentially the risk of PHN.19Kim IH, Mupparapu A, Yablonski JN, Mupparapu M. A Patient with Herpes Zoster of the Maxillary Division of Trigeminal Nerve Presents for Oral Evaluation and Toothache. Dent Clin North Am 2023;67(4):687-90. doi: 10.1016/j.cden.2023.05.022. Adjunctive therapies include the use of corticosteroids, which help to speed up healing and resolve pain, as well as NSAIDs and other analgesics. In patients with PHN, topical application of 0.075% capsaicin or 5% lidocaine has been recommended. Systemic treatments for PHN include gabapentin, amitriptyline and pregabalin all of which have significant side effects.31Saguil A, Kane S, Mercado M, Lauters R. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. Am Fam Physician 2017;96(10):656-63. Referral to a pain specialist is required for individuals with severe PHN.4Kennedy PGE, Gershon AA. Clinical Features of Varicella-Zoster Virus Infection. Viruses 2018;10(11):609. doi: 10.3390/v10110609.

Disease Transmission and Chickenpox

Chickenpox is a highly infectious disease that affected 99% of individuals born before 1980.1Centers for Disease Control and Prevention. Shingles (Herpes Zoster). About Shingles (Herpes Zoster). https://www.cdc.gov/shingles/about/index.html. Transmission of VZV occurs through inhalation of aerosolized virus (respiratory transmission) and direct contact with vesicular fluid from the chickenpox rash. While the virus is dormant following primary infection, there is no transmission risk. However, in patients with HZ the virus has been reactivated and the vesicular rash contains infectious virus.4Kennedy PGE, Gershon AA. Clinical Features of Varicella-Zoster Virus Infection. Viruses 2018;10(11):609. doi: 10.3390/v10110609. Viral transmission from a patient with HZ can cause chickenpox but not HZ. Appropriate infection control measures are necessary to help prevent the transmission of disease.

Transmission of VZV occurs through inhalation of aerosolized virus (respiratory transmission) and direct contact with vesicular fluid.

Preventing HZ

The CDC recommends two doses of recombinant zoster vaccine (RZV, Shingrix), given two to six months apart, for the prevention of HZ and related complications in adults 50 years and older as well as immunocompromised adults 19 years-of-age and over.1Centers for Disease Control and Prevention. Shingles (Herpes Zoster). About Shingles (Herpes Zoster). https://www.cdc.gov/shingles/about/index.html. ,4Kennedy PGE, Gershon AA. Clinical Features of Varicella-Zoster Virus Infection. Viruses 2018;10(11):609. doi: 10.3390/v10110609. This FDA-approved vaccine was recommended in 2018, has been shown in clinical trials to be 97.2% effective in adults at least 50 years-of-age, and also protects against PHN.4Kennedy PGE, Gershon AA. Clinical Features of Varicella-Zoster Virus Infection. Viruses 2018;10(11):609. doi: 10.3390/v10110609.,12Shah RA, Limmer AL, Nwannunu CE et al. Shingrix for Herpes Zoster: A Review. Skin Therapy Lett 2019;24(4):5-7. In individuals age 70 and older, the vaccine was 91.3% effective.9The College of Physicians of Philadelphia. History of Vaccines. Shingles (Herpes Zoster). https://historyofvaccines.org/diseases/shingles-herpes-zoster.

Implications for dental professionals

Dental professionals should consider HZ in the differential diagnosis of oral and peri-oral rashes and be aware of potential complications. Similarly, if a patient complains of symptoms of HZ, or presents with a unilateral facial rash (which would be visible in the dental office), HZ should be considered, and the patient referred to their medical providers. Furthermore, HZ can result in significant adverse events, primarily PHN, including orofacially. Dental professionals should also consider oral HZ in the differential diagnosis of odontalgia, particularly when there is no obvious cause, due to its reported occurrence during the prodromic phase of HZ.3Carbone V, Leonardi A, Pavese M et al. Herpes zoster del nervo trigemino. Revisione della letteratura e caso clinico [Herpes zoster of the trigeminal nerve: a case report and review of the literature]. Minerva Stomatol 2004;53(1-2):49-59. Italian. ,14Brooks JK, Rostami AM, McCorkle DC, Benesh SI. Trigeminal herpes zoster and Ramsay Hunt syndrome in an elderly adult: Presentation with prodromal toothache. Gerodontol 2018;35(3):276-78. doi: 10.1111/ger.12340.,17Goon WW, Jacobsen PL. Prodromal odontalgia and multiple devitalized teeth caused by a herpes zoster infection of the trigeminal nerve: report of case. J Am Dent Assoc 1988;116(4):500-4. doi: 10.14219/jada.archive.1988.0301.,18Christoforou J. Neuropathic Orofacial Pain. Dent Clin North Am 2018;62(4):565-84. doi: 10.1016/j.cden.2018.05.005. ,19Kim IH, Mupparapu A, Yablonski JN, Mupparapu M. A Patient with Herpes Zoster of the Maxillary Division of Trigeminal Nerve Presents for Oral Evaluation and Toothache. Dent Clin North Am 2023;67(4):687-90. doi: 10.1016/j.cden.2023.05.022. If HZ is not considered in the differential diagnosis, inappropriate dental treatment may be provided and delays in addressing the patient’s discomfort associated with HZ-related neuropathy may occur.20Millar EP, Troulis MJ. Herpes zoster of the trigeminal nerve: the dentist’s role in diagnosis and management. J Can Dent Assoc 1994;60(5):450-3.

Conclusions

HZ is a common disease in older adults, with potentially severe complications including debilitating PHN. It is important to consider HZ in the differential diagnosis of a unilateral intraoral rash or white patches. In addition, patients should be referred as soon as possible to their primary care providers if systemic HZ is suspected, and some may need a referral to an oral medicine specialist or pain specialist. Early diagnosis of oral and non-oral HZ enables early treatment. As necessary, individuals may also be referred to oral medicine departments for the management of oral HZ. Dental professionals can also play an important role in HZ prevention by advising patients on the benefits of vaccination against HZ.

References

  • 1.Centers for Disease Control and Prevention. Shingles (Herpes Zoster). About Shingles (Herpes Zoster). https://www.cdc.gov/shingles/about/index.html.
  • 2.Rudd T, Chai BY, Gurunluoglu R, Glasgow M. Mandibular osteonecrosis and Ramsay Hunt syndrome following a case of herpes zoster. J Oral Maxillofac Surg 2014;72(10):1974.e1-6. doi: 10.1016/j.joms.2014.05.004.
  • 3.Carbone V, Leonardi A, Pavese M et al. Herpes zoster del nervo trigemino. Revisione della letteratura e caso clinico [Herpes zoster of the trigeminal nerve: a case report and review of the literature]. Minerva Stomatol 2004;53(1-2):49-59. Italian.
  • 4.Kennedy PGE, Gershon AA. Clinical Features of Varicella-Zoster Virus Infection. Viruses 2018;10(11):609. doi: 10.3390/v10110609.
  • 5.Kosami K, Kenzaka T. Mandibular Herpes Zoster. Intern Med 2019;58(3):459-60. doi: 10.2169/internalmedicine.
  • 6.Song JM, Seo JS, Lee JY. Mandibular osteonecrosis following herpes zoster infection in the mandibular branch of the trigeminal nerve: a case report and literature review. J Korean Assoc Oral Maxillofac Surg 2015;41(6):357-60. doi: 10.5125/jkaoms.2015.41.6.357.
  • 7.Gershon AA, Gershon MD, Breuer J et al. Advances in the understanding of the pathogenesis and epidemiology of herpes zoster. J Clin Virol 2010;48(Suppl 1):S2-S7.
  • 8.Centers for Disease Control and Prevention. Shingles (Herpes Zoster). Shingles Facts and Stats. https://www.cdc.gov/shingles/data-research/?CDC_AAref_Val=https://www.cdc.gov/shingles/surveillance.html.
  • 9.The College of Physicians of Philadelphia. History of Vaccines. Shingles (Herpes Zoster). https://historyofvaccines.org/diseases/shingles-herpes-zoster.
  • 10.Warman M, Halperin D. [Varicella zoster virus infection involving the maxillary branch of the trigeminal nerve]. Harefuah 2007;146(2):89-91, 167. Hebrew.
  • 11.Gershon AA, Breuer J, Cohen JI et al. Varicella zoster virus infection. Nat Rev Dis Prim 2015;1:15016. doi: 10.1038/nrdp.2015.16.
  • 12.Shah RA, Limmer AL, Nwannunu CE et al. Shingrix for Herpes Zoster: A Review. Skin Therapy Lett 2019;24(4):5-7.
  • 13.Centers for Disease Control and Prevention. Shingles (Herpes Zoster). Shingles Symptoms and Complications. https://www.cdc.gov/shingles/signs-symptoms/index.html.
  • 14.Brooks JK, Rostami AM, McCorkle DC, Benesh SI. Trigeminal herpes zoster and Ramsay Hunt syndrome in an elderly adult: Presentation with prodromal toothache. Gerodontol 2018;35(3):276-78. doi: 10.1111/ger.12340.
  • 15.Vourexakis Z, Vanoy J. Mucosal and cutaneous lesions in mandibular zoster. BMJ Case Rep 2014;2014:bcr2014204459. doi: 10.1136/bcr-2014-204459.
  • 16.Hagiya H, Nakagami F, Isomura E. Oral shingles. Case Report. Br Med J 2018;11:e228383. doi: 10.1136/bcr-2018-228383.
  • 17.Goon WW, Jacobsen PL. Prodromal odontalgia and multiple devitalized teeth caused by a herpes zoster infection of the trigeminal nerve: report of case. J Am Dent Assoc 1988;116(4):500-4. doi: 10.14219/jada.archive.1988.0301.
  • 18.Christoforou J. Neuropathic Orofacial Pain. Dent Clin North Am 2018;62(4):565-84. doi: 10.1016/j.cden.2018.05.005.
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