Sometimes a toothache is not a tooth problem at all. When the shingles virus wakes up in one of the nerves that supply the face, the first sign can be a burning or throbbing ache in the upper or lower teeth on one side, days before any blisters show. If that ache is treated as a dental problem, a healthy tooth can end up drilled or even removed while the real cause goes unnoticed.
The chickenpox virus never fully leaves
After chickenpox clears, the varicella zoster virus stays in the body, resting quietly inside nerve cells, sometimes for decades. Shingles (herpes zoster) is what happens when it becomes active again. It travels along the nerve it was resting in and causes pain and a rash in the patch of skin, or lining of the mouth, that nerve supplies.
Reactivation is more likely as people get older and when the immune system is weakened by illness or some medicines, and it may also follow periods of major stress. Most people picture shingles as a stripe of blisters around the chest. The same thing can happen in the trigeminal nerve, which carries feeling from the face, teeth, gums, palate and tongue, and then the symptoms show up in and around the mouth.
A line down the middle is the giveaway
The trigeminal nerve has three main branches on each side of the face, and shingles usually affects just one branch on one side. That gives it a pattern few other mouth problems share: symptoms stop sharply at the midline.
- The upper (maxillary) branch covers the cheek, side of the nose, upper gum, upper teeth and palate. Ulcers may run across one half of the roof of the mouth and end exactly at the centre.
- The lower (mandibular) branch covers the lower jaw, lower teeth and gum, the floor of the mouth and part of the tongue, along with the skin of the lower face.
- The top (ophthalmic) branch covers the forehead, upper eyelid and the eye itself. This is the branch that most needs urgent attention.
Ulcers on one side of the tongue but not the other, or a cluster of sores on half the palate with a matching rash on the same cheek, should make a dentist or doctor think of shingles.
Pain often comes first, then the sores
Many people feel unwell before anything can be seen. Burning, tingling, aching or shooting pain builds in one area, sometimes with tiredness or a temperature. Because there is pain and nothing visible, this early stage is when shingles is most easily mistaken for toothache.
A day or several days later the blisters arrive. On the skin they look like small fluid-filled bumps on a red base. Inside the mouth the blisters are delicate and burst quickly, so what you usually see are clusters of shallow ulcers on the gum, palate, cheek lining or tongue, all on one side. The gums along the same stretch may look red and sore.
According to the Better Health Channel, the rash usually lasts about 10 to 15 days, crusting over and healing as it settles. The pain normally eases with it, but not for everyone.
When to get urgent medical help
If you think you might have shingles, see your GP the same day if you can. The Better Health Channel notes that antiviral treatment works best when started within 3 days of the rash appearing, and ideally within 24 hours. Waiting to see whether it settles can mean missing that window.
Get urgent medical care the same day, from your GP, an urgent care clinic or an emergency department, if:
- the rash is near your eye, on your forehead or on the tip or side of your nose, or your vision changes, since the eye can be involved
- you have ear pain or blisters in or around the ear together with weakness on one side of the face, hearing changes or dizziness, which can point to Ramsay Hunt syndrome
- you feel very unwell, or you have a weakened immune system
What can follow an attack
Most people recover without lasting problems. The most common complication is post-herpetic neuralgia, defined by the Better Health Channel as pain in the area lasting longer than 3 months. The risk rises with age, which is part of why early treatment and vaccination are encouraged.
Much more rarely, shingles in the jaw has been linked with damage to the bone around the teeth, and with teeth loosening or being lost in the affected area. These events appear mainly in individual case reports, but they are one reason a dentist may want to see the area again after the acute illness has settled.
How it differs from toothache and ordinary ulcers
| Clue | Shingles in the mouth | Dental toothache | Common mouth ulcers |
|---|---|---|---|
| Where it is | One side only, ending at the midline | Around one tooth, sometimes spreading vaguely to the jaw or ear | Anywhere, often both sides |
| Skin | Often a matching rash on the same side of the face | No rash, though an infection can cause swelling | No rash |
| What tests show | Teeth and X-rays may look normal | Usually decay, a crack, a deep filling or infection | Teeth are normal |
| General health | Feeling unwell, tired or feverish is common early on | Only with a spreading infection | Usually well |
| Coming back | Usually a single episode, although shingles can recur | Returns if the cause is not treated | Often come and go over years |
Cold sores are caused by a different virus, herpes simplex. They usually appear on or near the lips and tend to come back in the same spot, rather than spreading across one nerve's territory inside the mouth.
Any mouth sore or patch that has not healed or changed within 3 weeks should be checked by a dentist or GP, whatever you think the cause is.
Why your dentist may not treat the tooth
This can be frustrating when you are in pain. If a tooth feels like the source but examination, sensitivity tests and X-rays show no decay, crack, infection or nerve problem, there is nothing in the tooth to fix. A root canal or extraction will not relieve pain that is coming from an irritated nerve, and tooth structure that is removed cannot be put back.
In that situation a careful dentist will say the pain does not look dental, treat any real dental problems that are found, and send you to your GP. If one-sided blisters appear over the next day or two, the diagnosis usually becomes clear. If the pain does have a dental cause, our guides to tooth abscess signs and root canal versus extraction explain the options, and the article on seeing a dentist without an appointment covers getting in quickly.
Keeping your mouth comfortable while it heals
None of these steps treat the virus, and they do not replace seeing your GP, but they can make eating and cleaning easier.
- Choose soft, cool, bland foods. Spicy, acidic, crunchy or very hot foods tend to sting.
- Sip water often to stay hydrated.
- Use an alcohol-free mouth rinse, as alcohol stings open ulcers. A warm salt water rinse is gentle.
- Keep brushing with a soft brush and a light touch. Stopping altogether lets plaque build up on already sore gums.
- Ask your GP or pharmacist which pain relief suits you. Our comparison of ibuprofen and paracetamol covers the general differences.
What patients ask about shingles in the mouth
Can I catch shingles from someone else?
No. You cannot catch shingles itself from another person. Fluid from the blisters can, though, pass the virus to someone who has never had chickenpox or the vaccine, and they may then develop chickenpox. Cover skin lesions where possible, wash your hands, and avoid close contact with newborns, pregnant people who have not had chickenpox and anyone with a weakened immune system until the sores have crusted. Your GP can advise on your situation.
Should I see a dentist or a doctor first?
If you suspect shingles, see your GP first, because the antiviral decision is time-sensitive. A dental check is still worthwhile if the pain feels like it is coming from a tooth, so a real dental problem is not missed.
Is there a vaccine?
Yes. The Australian Government funds shingles vaccination for some people under the National Immunisation Program, including people aged 65 and over. Your GP or pharmacist can tell you if you are eligible and if vaccination suits you.
Getting one-sided mouth pain checked
If you have pain on one side of your face or mouth and are not sure why, get it assessed rather than waiting. See your GP promptly if shingles is a possibility. At Lumi Dental we can examine the area and take the X-rays needed to find out whether there is a dental cause, so a healthy tooth is not treated unnecessarily. You can read about our general dental care or see what is available for new patients on our current offers page.
This article is general information only and is not a substitute for medical or dental advice. Shingles is a medical condition requiring assessment by a doctor. Please see your GP promptly if you suspect it, and seek urgent care for eye involvement, facial weakness or severe illness.
