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Herpes Zoster (Shingles) Diagnosis and

Management in the Dental Setting

By Maria Dimino, RDH, BS, MA and Gwen Cohen Brown, DDS, FAAOMP

Introduction Following the resolution of primary vari- Clinical Presentation of Herpes Zoster
Herpes zoster (HZ), or shingles as it is fre- cella, VZV will reside permanently in the (Shingles)/Varicella Zoster Virus (Chick-
quently called, is a common viral infection dorsal root or cranial root ganglia. VZV can en Pox)
of the peripheral nerves which often appears then be triggered to start replicating in the
as a painful rash or cluster of blisters. HZ ganglion, producing severe neuralgia, and Etiology: Following initial exposure to the
is a reactivation of the varicella zoster virus will then spread the virus down the axon varicella zoster virus there is a 10- to 21-
(VZV), commonly known as chicken pox. of the vertebral or cranial nerves an into day incubation period, and the person ex-
posed will most likely develop chicken pox.
The earliest reports of vesicular type rashes the nerve endings of a single dermatome. It Typically, chicken pox is both epidemic and
such as herpes zoster date back to ancient remains unknown what the etiology of re- endemic, occurring in winter and spring.
civilizations. It was not until circa 1888 activation is -what causes the dormant or la- New cases can occur when an unvaccinated
when a direct relationship between herpes tent virion to become active. Once the virus person is exposed to a person with herpes
zoster and varicella zoster virus was thought reaches the basal cell layer, vesicles appear zoster or chicken pox, with an estimated
to be possible. Microbiology was in its in- unilaterally on the skin in the distribution lifetime reactivation rate of 30%, although
fancy at this time and establishing the link pattern of the nerve (dermatome) producing the incidence tends to increase with age.
proved to be a challenging hurdle. Indeed, the characteristic dermatomal rash of shin- Herpes zoster is a disease of high morbid-
most of the evidence could only be gathered gles (Figures 1-3). The vesicles progress to ity, with the potential of severe pain during
through clinical and epidemiological ob- pustules which then crust. the outbreak as well as after,
servations. As microbiology expanded, the
link between chicken pox and herpes zoster
began to be better understood, becoming
confirmed around 1950. The research even-
tually culminated with the complete DNA
sequence of the varicella zoster virus, which
was mapped in 1986. It was during this time
1
that the antiviral drug acyclovir was intro-
duced and proved to have a huge impact on
the prevention and treatment of HZ.
Keywords: Herpes Zoster, Shingles, Vari-
cella Zoster, Oral Manifestations
Description
VZV is an alpha herpesvirus and herpes Figure 1-3. Herpes Zoster on the palate.
zoster, or shingles, is the reactivation or The whole process takes roughly 21 days presenting as post-herpetic neuralgia. This
secondary manifestation of the virus. VZV persisting pain is the most common compli-
transmission is primarily airborne via drop- from initiation through full progression of cation of herpes zoster. 6
the disease. Consequently, scarring can re-
lets and not by direct contact or contact with Clinical: Shingles is unique, as it always
fomites. It is responsible for two distinct sult and changes in pigmentation in the af-
fected area can appear. Unfortunately, post presents unilaterally and is almost always
clinical disorders, primary VZV (chicken herpetic neuralgia can be quite severe in the restricted to a single dermatome, often ac-
pox) and HZ (shingles). VZV is extreme- elderly population and can last for months companied by a prodrome of pain or abnor-
ly contagious but vaccination in the USA mal sensations in the affected dermatome.
has cut the incidence of new chicken pox to years after reactivation. Immunocompro- Following the prodrome a rash develops.
mised patients can be especially at risk since
infections by approximately 80% as most The patient is infectious to persons unvacci-
children began receiving the varicella vac- there can be internal organ involvement, re- nated, or who have not had primary varicella
sulting in high morbidity and mortality.
5
cine in 1995. Currently a shingles vaccine is zoster infection. The clinical stages of HZ
being offered to people over the age of 50, are prodromal phase, acute pho-
with an expected efficacy of 96%. There are tophobia (before rash appears),
over 1 million cases of shingles in the USA and the acute phase (dermatomal
each year as greater than 90% of adults are rash). Following the acute phase,
7
infected with varicella. 2,3 small blisters begin to appear on
the affected dermatome. HZ is
Those primarily at risk for reactivation are always unilateral, and only unilat-
over age 50 or present with a weakened eral, as the virus leaves the spinal
immune system, but reactivation has been cord and will either go to the right
known to occur at any age. HZ can lay dor- or left side but never both (Figures
4
mant for many years before it is reactivated. Figure 4. Herpes Zoster Figure 5. Herpes Zoster 4, 5). The chronic phase occurs
on the tongue. on the tongue and when the vesicles and blisters rup-

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