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FACT SHEET: Shingles (also known as herpes zoster; includes Ramsay Hunt syndrome, also known as Hunt’s syndrome, herpes zoster oticus, and geniculate herpes; caused by reactivation of the varicella zoster virus [VZV], which causes chickenpox in primary infection; following chickenpox, the virus remains dormant in the nervous system, and it may reactivate years later)

Date of Publication: March 11, 2013

Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • Potentially.
  • If you have not had chickenpox or the chickenpox (varicella) vaccine, avoid contact with the rash and blisters on persons with shingles (or chickenpox).
  • If the rash or blisters are on the face, neck, or in the oral cavity (e.g., tongue or palate), dental hygiene care should be postponed until after the rash/blisters have completely healed (or in the case of the face and neck, have at least crusted over with no drainage).

Is medical consult advised?  

  • Yes. A primary care provider (e.g., physician) should be consulted promptly when signs/symptoms of shingles are evident, particularly in individuals who have a weakened immune system, or if symptoms persist or worsen. (Antiviral medications — such as acyclovir, valacyclovir, and famciclovir — work best if initiated as soon as possible after the rash appears, preferably within 72 hours.) Shingles affecting the eye may result in blindness; therefore, this situation requires emergency medical care. Similarly, Ramsay Hunt syndrome (see below) requires urgent medical intervention (including corticosteroids, such as prednisone) to minimize morbidity.

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • Potentially.

Is medical consult advised? 

  • See above.

Is medical clearance required? 

  • No.

Is antibiotic prophylaxis required?  

  • No.

Is postponing treatment advised?

  • Possibly; see above and below.

Oral management implications

  • Mode of transmission is via direct contact with fluid from the rash’s blisters. A person with shingles can spread the virus when the rash is in the blister phase, but that person is not infectious before blisters appear. Once the rash develops crusts (usually 7–10 days), the person is no longer contagious. Shingles is less contagious than chickenpox, and the risk of a person with shingles spreading the virus is low if the rash blisters are covered.
  • As a health care provider, if you develop shingles and until your rash crusts over, avoid contact with: 
    • pregnant women who have never had chickenpox or the varicella vaccine;
    • premature or low birth weight infants; and 
    • immunocompromised persons (such as persons receiving immunosuppressive medications or undergoing chemotherapy, organ transplant recipients, and people with HIV infection).
  • If you, the dental hygienist, are pregnant and have never had chickenpox or the varicella vaccine, you should avoid contact with patients/clients who have non-crusted shingles, particularly uncovered lesions on the face. (Note: Exposure to varicella zoster virus via shingles results in chickenpox in non-immune persons, not shingles. You cannot get shingles from someone who has shingles.)
  • To reduce your risk of developing shingles, the National Advisory Committee on Immunization (NACI) strongly recommends the recombinant subunit herpes zoster vaccine (“RZV”; authorized in Canada in October 2017) for the prevention of Herpes zoster and its complications in persons 50 years and older without contraindications.1 NACI also strongly recommends RZV vaccination in persons 50 years and older without contraindications who have previously been vaccinated with the older live attenuated herpes zoster vaccine (“LZV”, authorized in Canada in 2008) due to the superior efficacy of RZV and its corresponding reduced waning of protection.
  • The dental hygienist should be alert for the appearance of active (non-crusted) shingles lesions on the face and neck of a patient/client. This should prompt rescheduling of the appointment to protect other patients/clients and clinic staff from viral shedding.
  • Reactivation of VZV following dental treatment or orofacial surgery has been occasionally reported.
  • Inappropriate endodontic treatment or extraction can occur if the dentist mistakes VZV-related odontalgia for pulpal necrosis, particularly if the patient/client has minimal signs of rash or vesicles.
  • Herpes zoster can cause severe pain. Pain management options include: topical capsaicin; topical numbing agents (e.g., lidocaine); neuropathic pain medications (e.g., gabapentin); opioids; and injections of local anaesthetics or corticosteroids.
  • Self-care for oral shingles may include: rinsing with alcohol-free mouthwash; opting for soft, bland, non-acidic, and cool foods; and using a soft-bristled toothbrush.

Oral manifestations

  • Oral, perioral, and facial shingles (usually unilateral) can occur if the trigeminal nerve (cranial nerve V) is involved. The maxillary and/or mandibular branches may be affected (as may the ophthalmic branch). Odontalgia (toothache) may be an early manifestation. Prodromal symptoms of pain and/or burning often precede the development of vesicles, which in turn progress to ulcers. Oral lesions extend to the midline (although sometimes indistinctly) and affect mucosa of the same quadrant. Uncommonly, VZV reactivation in the trigeminal nerve can lead to pulpal necrosis of the teeth and spontaneous tooth exfoliation. Severe osteonecrosis of the jaw resulting in loss of teeth has been reported.
  • In Ramsay Hunt syndrome, facial nerve (cranial nerve VII) involvement may result in shingles in the mouth; specifically, the palate and the anterior two-thirds of the tongue. A painful intraoral red rash and blistering can occur on the same side as the other unilateral facial manifestations. Complications include alterations to taste and, longer-term, synkinesis (i.e., aberrant regeneration, where the nerve grows back to the wrong areas; this may result in, for example, eye closure while smiling or tear production while chewing). Xerostomia may also result.
  • The unilateral facial droop and weakness in Ramsay Hunt syndrome make eating difficult, and food often falls out of the weak corner of the mouth. As well, smiling and facial expressions are impaired, and speech may be slurred.
  • When the glossopharyngeal nerve (cranial nerve IX) is rarely involved, lesions may be seen on the posterior one-third of the tongue, as well as on the uvula and the oropharynx. Pharyngeal pain may also occur.
  • Herpes zoster can also rarely involve the vagus nerve (cranial nerve X), leading to paralysis of the pharynx and larynx, as well as blisters on the base of the tongue.

Related signs and symptoms

  • About 1 in 3 North Americans will develop shingles in their lifetime.
  • Shingles typically presents as a painful, blistering skin rash along a dermatome (i.e., area of skin supplied by sensory nerve fibers from a single spinal root). The rash usually occurs on one side of the face or body, and it forms blisters that scab over in 7−10 days and resolve in 2−4 weeks. The rash often progresses from maculopapular to vesicular to pustular to ulcerative in character. Before the rash appears, there is often pain, itching, burning, or tingling in the area where the rash will develop. This may occur from 1 to 5 days before the rash appears. The rash usually involves a narrow area from the spine around to the front of the abdomen or chest, but may alternatively involve the face, neck, eyes, mouth, ears, and extremities (i.e., legs and arms).
  • Systemic symptoms (often absent) may include abdominal pain, fever, chills, general malaise, joint pain, swollen lymph nodes, and headache. 
  • Vision loss — temporary or permanent — can happen if shingles affects the eye. Dryness of the eye and corneal ulcers can occur in Ramsay Hunt syndrome2 due to inability to close the eyelid.
  • Hearing and/or balance problems (including vertigo), as well as tinnitus (ringing in the ears) can occur if shingles occurs in or near the ear (as in Ramsay Hunt syndrome). Severe ear pain may also occur.
  • Secondary infection of ulcerative lesions may occur. 
  • The most common complication of shingles is postherpetic neuralgia (PHN), which is chronic severe pain in the areas of the original shingles rash that can last for months or even years. About 10% to 15% of shingles patients/clients have pain for at least 90 days after herpes zoster onset.
  • Shingles can develop in anyone who has had chickenpox, but is more likely to develop in persons over 60 years of age, persons who had chickenpox before their first birthday, or persons with weakened immune systems due to leukemia, lymphoma, human immunodeficiency virus (HIV), and immunosuppressive drugs (e.g., steroids and anti-rejection drugs given after organ transplantation).

References and sources of more detailed information

Date: December 16, 2012
Revised: February 5, 2020; January 22, 2024


1 At the time of updating this Fact Sheet in 2024, additions to this recommendation are under consideration by NACI in light of changes to the product monograph; namely, for adults 18 years of age or older who are or will be at increased risk of herpes zoster due to immunodeficiency or immunosuppression caused by known disease or therapy.
2 Ramsay Hunt syndrome occurs when shingles affects the facial nerve near one of the ears. The main sign of this syndrome is facial paralysis on the side of the affected ear; the characteristic red, blistering shingles rash may or may not occur. Complications include permanent facial muscle weakness and deafness, especially if treatment (primarily antiviral medication and corticosteroids) is not prompt.

* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.