CASE REPORT/CLINICAL TECHNIQUES

Isabel Mello, DDS, MSc, PhD,

Neuropathy Mimicking Dental FRCD(C),* John Peters, DDS,
FRCD(C),† and Chris Lee, DDS,
Pain in a Patient Diagnosed MSc*

with Lyme Disease

ABSTRACT
SIGNIFICANCE
This report documents the case of a patient who developed neuropathy that presented as
dental pain and was later diagnosed with Lyme disease. A healthy female patient presented to Lyme disease is a serious
the endodontist with toothache symptoms. Her symptoms included intense pain in the left illness with symptoms that may
mandible irradiating into the temporalis area and through her neck and tingling on the lower left present in the orofacial area.
lip and left side of her tongue. She also reported feeling of sweats and chills the night before, as This case report demonstrates
well as an altered sensation in her shoulder and arm. The pain was not alleviated by over-the- the importance of considering
counter analgesics. Both intraoral and radiographic examinations did not reveal any Lyme disease as differential
abnormalities, and the patient was presented with the following differential diagnoses: cardiac diagnosis of orofacial pain and
issues, trigeminal neuralgia, and temporomandibular dysfunction. She presented to the the role of the endodontist in
emergency department at the local hospital for assessment on the same day. After some tests the diagnostic process.
were performed, both a stroke and myocardial infarction were ruled out. The following
morning, she noticed a bump in the posterior area of her left upper thigh where an erythema
with a bull’s-eye appearance was observed. She presented to her family doctor’s office on the
same day and was diagnosed with Lyme disease. Because Lyme disease can present with
symptoms similar to a toothache, dentists should be knowledgeable of its manifestations.
Lyme disease should be considered as differential diagnosis in patients who present with
compatible symptoms and signs, which may occur in the orofacial region. (J Endod
2020;46:1337–1339.)

KEY WORDS
Differential diagnosis; Lyme disease; orofacial pain

Lyme disease is the most common vector-borne disease in the United States and causes an estimated
300,000 illnesses annually1,2. Lyme disease is associated with a variety of multisystemic symptoms that
usually present in 3 stages, which may occur sequentially if an earlier stage was untreated. The early
localized disease (usually , 30 days from exposure) usually presents as an acute illness usually
characterized by erythema multiforme (EM) (.5 cm in diameter, painless, and slowly expanding), fever,
arthralgias, and headache. In addition, in the early disseminated disease (,3 months after exposure),
patients may present with lymphadenophathy, carditis, meningitis, and neuropathy. In the late
disseminated disease (.3 months after exposure), patients may present with oligoarticular arthritis,
encephalopathy, axonal polyradiculoneuropathy, and chronic encephalomyelitis3. From the *Department of Dental Clinical
Pain in the orofacial area is not uncommon in patients with Lyme disease and may include Sciences, Faculty of Dentistry, Dalhousie
temporomandibular joint pain, headache, and neuralgia4. In particular, symptoms of neuropathy in the University, Halifax, NS, Canada; and
†
Private practice, Halifax, NS, Canada
orofacial area include gradual onset of numbness, prickling or tingling, and sharp, jabbing, throbbing, or
burning pain that may mimic dental pain4–6. In this case, patients may seek the care of a dentist for Address requests for reprints to Dr Isabel
Mello, Endodontics, Department of Dental
assessment and treatment.
Clinical Sciences, Faculty of Dentistry,
This report documents the case of a patient who developed neuropathy that presented as dental Dalhousie University, 5981 University
pain and was later diagnosed with Lyme disease. Avenue, PO Box 15000, Halifax, NS, B3H
4R2 Canada.
E-mail address: isabel.mello@dal.ca
CASE REPORT 0099-2399/$ - see front matter

A healthy (American Society of Anesthesiologists I) female patient felt pain in the lower left jaw before Crown Copyright © 2020 Published by
Elsevier Inc. on behalf of American
going to bed and woke up in the middle of the night in extreme pain. She booked an urgent appointment Association of Endodontists.
with her general dentist in the morning to address what she identified as a toothache. The general dentist https://doi.org/10.1016/
could not determine a diagnosis and referred her to an endodontist for further assessment. The patient j.joen.2020.06.011

JOE  Volume 46, Number 9, September 2020 Neuropathy Mimicking Dental Pain in Lyme Disease 1337

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was seen on the same day of referral and
described the pain as a toothache radiating
from the angle of her left jaw into the temporalis
area and through her neck, and she was
unsure whether it was originating from the
maxilla or the mandible. She complained of
tingling on her lower left lip and left side of her
tongue and reported feeling of sweats and
chills the night before, as well as an altered
sensation in her shoulder and arm. The patient
tried over-the-counter analgesics and hot and
cold pads that did not alleviate her pain. She
was visibly distraught and held her hands to
her face in an attempt to relieve her symptoms.
During general examination, the patient
presented in general good physical health.
Blood pressure measurements were 162/98
mm Hg. She indicated that her blood pressure
is usually below 120/80 mm Hg and was
advised to discuss it with her family physician.
She reported no allergies and was taking no
medications except analgesics for the pain.
She reported she had been feeling unwell for a
few days before her presentation to the dental
office. She was under stress and feeling chest
pain for the past few days.
CLINICAL EXAMINATION
Extraoral exam revealed tenderness to
palpation of submandibular lymph nodes and
muscles of mastication, which did not
reproduce or exacerbate her symptoms.
Intraoral exam was focused on both maxillary
and mandibular left side. Soft tissues in the
area presented with normal appearance. Minor
restorations were present in her posterior
teeth. There was no pain or tenderness elicited
on both palpation (buccal and lingual areas)
and percussion. Cold test elicited sharp pain of
short duration on the posterior teeth. All teeth
presented with physiological mobility, and
probing depths were below 3 mm
circumferentially. Transillumination did not
show any evidence of cracks. Periapical
radiographs revealed no caries, shallow
restorations, and normal periodontal ligament
space, lamina dura, and bone.
Pulpal and apical diagnoses for all teeth
in maxillary and mandibular left side were
determined to be normal. There was no
evidence that her pain was of odontogenic
origin. Differential diagnoses presented to
patient were: cardiac issues, trigeminal
neuralgia, and temporomandibular
dysfunction.
The patient was advised to see a
physician. She presented to the emergency
department at the local hospital for
assessment on the same day. After having had
some tests performed and remaining in
observation, both a stroke and a myocardial
1338 Mello et al.
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infarction were ruled out. She was prescribed
gabapentin 100 mg twice a day.
The following morning, she noticed a
bump in the posterior area of her left upper
thigh. On inspection, an erythema with a bull’s-
eye appearance was observed (Fig. 1). She
presented to her family doctor’s office on the
same day and was diagnosed with Lyme
disease. She was prescribed doxycycline
100 mg twice a day for 3 weeks. After 3 weeks
of having taken the prescribed medications
and over-the-counter analgesics, her pain had
resolved, and the tingling on her lower left lip
and left side of her tongue had subsided
considerably. All of her other symptoms had
also resolved.
DISCUSSION
The range of Ixodes ticks, the vector for
Borrelia, has expanded greatly during the last
20 years, making Lyme disease an emerging
infection in North America1,2. As the Ixodes tick
continues to expand its range not only in North
America but also in Europe, more people will
be exposed to the bacterium Borrelia
burgdorferi. Dental practitioners should be
knowledgeable of signs and symptoms of
Lyme disease and consider it as a differential
diagnosis for atypical pain in the orofacial
region, arrange for appropriate referrals, and
also avoid subjecting patients to unnecessary
treatment1,3,5.
A further follow-up with the patient
revealed that she had gone camping in the
month prior (August) to 2 different high-risk
areas for ticks. The first trip was 3 weeks
before presenting with symptoms, and the
second trip was 1 week before. Most
transmission to humans in the Northern
FIGURE 1 – Bull’s-eye appearance of tick bite on the posterior area of the patient’s thigh.
hemisphere occurs from late May to late
September, coinciding with the activity of
nymphs and with the increasing recreational
use of tick habitats by the public1. The patient
discovered a bite on her upper thigh the
following day of her presentation to the
endodontist. The classic sign of the localized
infection phase is EM, which is defined as a
gradually expanding annular lesion .5 cm in
diameter. Approximately 70%–80% of
persons with Lyme disease present with EM,
which is considered a pathognomonic sign of
the disease1,7. However, misidentification of
EM represents a serious problem in the
community, because opportunities for
accurate diagnoses and appropriate treatment
decrease after the rash disappears. Reports
suggest that EM may be absent or mainly go
undetected in up to 50% of cases of Lyme
disease5.
Although the patient had been feeling
unwell, the symptom for which she sought
treatment was what she described as a
toothache. Neuropathies usually occur in
the early disseminated phase. The patient
reported symptoms of neuropathy, which
included extreme pain in the lower jaw area
(referred and radiating), tingling of the
tongue, and numbness of the lower left lip
and jaw. Spontaneous, referred, and
radiated dental pain in clinically healthy
teeth has been reported in patients with
Lyme disease4–6. Numbness in the tongue
and lips has also been reported in the
literature6.
She also presented with symptoms of
lesser intensity that may occur with Lyme
disease, such as tender lymph nodes,
tenderness to palpation of muscles, and even
the chest pain and elevated blood pressure
JOE  Volume 46, Number 9, September 2020
that may have been related to an early
carditis6. The patient had signs and symptoms
that overlapped with the early localized disease
(usually , 30 days from exposure) and early
disseminated disease (,3 months after
exposure). The often-used division of the
disease into stages is somewhat theoretical
and sometimes not in agreement with clinical
findings7.
Lyme disease involves the cranial
nerves, and it may be manifested by
nonspecific symptoms. Nonodontogenic
causes of pain in the dentoalveolar area
include referred myofascial pain, headache,
neuropathic disorders, and pain stemming
from various pathologic conditions8.
Endodontists are experts in diagnosing dental
pain and are commonly faced with cases of
nonodontogenic origin. Because of their
training, endodontists are capable of
determining whether pain in the dentoalveolar
area is of endodontic origin or nonodontogenic
origin.
CONCLUSIONS
This clinical case shows how Lyme disease
can present with symptoms similar to a
toothache. Health professionals should be
knowledgeable about the clinical
manifestations and epidemiologic risk factors
of Lyme disease. Lyme disease should be
considered as differential diagnosis in patients
who presents with compatible symptoms and
signs, which may present in the orofacial
region.
ACKNOWLEDGMENTS
The authors deny any conflicts of interest
related to this study.

REFERENCES
1. Stanek G, Wormser GP, Gray J, Strle F. Lyme borreliosis. Lancet 2012;379:461–73.
2. Kuehn BM. CDC estimates 300,000 US cases of Lyme disease annually. JAMA 2013;310:1110.

3. Hatchette TF, Davis I, Johnston BL. Lyme disease: clinical diagnosis and treatment. Can Commun
Dis Rep 2014;40:194–208.
4. Heir GM. Differentiation of orofacial pain related to Lyme disease from other dental and facial pain
disorders. Dent Clin North Am 1997;41:243–58.
5. Heir GM, Fein LA. Lyme disease: considerations for dentistry. J Orofac Pain 1996;10:74–86.

6. Wolanska-Klimkiewicz E, Szyman ska J, Bachanek T. Orofacial symptoms related to borreliosis:

case report. Ann Agric Environ Med 2010;17:319–21.
7. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention
of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by
the Infectious Diseases Society of America. Clin Infect Dis 2006;43:1089–134.
8. Mattscheck DJ, Law AS, Nixdorf D. The nonodontogenic toothache. In: Cohen S, Hargreaves KM,
editors. Pathways of the Pulp. St Louis, MO: Elsevier; 2010. p. 684–705.

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personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.