Herpes zoster (shingles) can clinically resemble pulpitis. What is the clinical feature that MOST helps distinguish herpes zoster from pulpitis?

Correct answer: D. Pain confined to a dermatome, not relieved by local anesthetic, with skin vesicles erupting subsequently

• A. Both pulpitis and zoster pain may or may not respond to NSAIDs.
• B. Cold test may be positive on multiple teeth in the distribution — not diagnostic for VZV vs pulpitis.
• C. True pulpitis can eventually show periapical changes; zoster would have normal periapical X-rays.
• D. Correct. Pre-eruptive herpes zoster can cause severe burning/throbbing pain in a specific dermatome (including the trigeminal distribution, causing dental pain) BEFORE the characteristic skin vesicles appear. The key clinical distinction: (1) the pain does not respond to local anesthetics (cannot isolate to a single tooth), (2) multiple teeth in the distribution are positive to pulp tests, (3) skin vesicles eventually appear unilaterally, (4) no periapical pathology on X-ray.