Dental Surgery Triggers Severe Pain Flare in Post-Treatment Lyme Disease Syndrome

Dental surgery can trigger severe pain flares in patients with post-treatment Lyme disease syndrome (PTLDS). In one reported case, a routine extraction of four molars led to widespread, uncontrolled full-body pain requiring ICU admission.

Lim from the University of California in San Francisco documented this case, highlighting the degree of pain sensitivity that can occur in PTLDS and how poorly understood it remains.

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Five Years Bedbound Before Surgery

Before the dental procedure, the patient had been bedbound for approximately five years and required a wheelchair. Her medical history included fibromyalgia, hypothyroidism, anxiety, depression, and insomnia.

She experienced severe skin, spine, bone, and joint pain that was difficult to manage. Despite frequent emergency department visits, opioids were largely ineffective. Her pain responded better to ketamine, suggesting central sensitization rather than a purely peripheral pain process.

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What Happened During Surgery

Prior to the extraction, she tapered off methadone. During surgery, physicians used an aggressive multimodal regimen including fentanyl, ketamine, acetaminophen, and ketorolac intravenously, along with local anesthetic in all four quadrants.

Despite this approach, she developed severe, widespread pain after surgery. The oral pain from the extraction itself was minimal. Instead, the procedure triggered a full-body pain flare consistent with her underlying PTLDS.

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Pain That Could Not Be Controlled

In the recovery room, additional fentanyl, hydromorphone, lorazepam, gabapentin, and oral ketamine failed to control her symptoms. A ketamine infusion was initiated. When her pain remained severe, she was transferred to the ICU.

For two days, she required around-the-clock multimodal therapy including ketamine infusion, IV acetaminophen, ketorolac, sublingual buprenorphine, oxycodone, and hydromorphone. She was discharged on day three with a structured tapering regimen.

This level of pain following a routine dental extraction underscores the degree of nervous system sensitization that can occur in severe PTLDS.

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Why Surgery Can Trigger Pain Flares in PTLDS

The likely mechanism is central sensitization, in which the brain and spinal cord become hyper-responsive to pain signals. In PTLDS, the nervous system may already be operating at an elevated baseline. Additional physiologic stress—such as surgery, infection, sleep disruption, or emotional stress—can trigger widespread pain disproportionate to the initial stimulus.

This process is related to allodynia, where normally non-painful stimuli become painful. In this case, surgical stress amplified an already sensitized system.

Lim notes that persistent symptoms may reflect central sensitization, also referred to as central sensitivity syndrome. Whether this represents a post-infectious process or ongoing infection remains uncertain.

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Is PTLDS Post-Infectious or Persistent Infection?

This patient met the IDSA 2006 criteria for PTLDS, including prior Lyme disease, persistent symptoms for more than six months, and functional impairment.

Some clinicians attribute these symptoms to residual inflammatory or neurologic changes after infection. Others consider the possibility of persistent infection, particularly given the lack of tests confirming eradication.

Clinical trials suggesting limited benefit from antibiotics have important limitations, and the underlying biology of persistent Lyme-related symptoms remains incompletely understood.

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Clinical Perspective

This case illustrates the vulnerability of PTLDS patients to severe pain flares following routine procedures. Dental surgery, orthopedic interventions, and other stressors may trigger symptoms that are difficult to control with standard protocols.

Pre-procedural planning may need to account for central sensitization, autonomic dysfunction, and the possibility that typical pain management strategies may be insufficient. For patients, this case supports the clinical observation that their pain responses reflect altered nervous system processing rather than exaggeration.

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Frequently Asked Questions

Can dental surgery trigger a Lyme disease pain flare?
Yes. In patients with PTLDS, physiologic stress from surgery can trigger widespread pain beyond what is expected from the procedure.

Why didn’t opioids control the pain?
Central sensitization involves altered pain processing in the central nervous system. Opioids may be less effective, while agents such as ketamine may provide more relief.

What is central sensitization?
Central sensitization is a state in which the nervous system becomes hypersensitive to pain signals and contributes to chronic pain conditions.

Should PTLDS patients avoid surgery?
Not necessarily, but careful planning and monitoring are important given the risk of pain flares.

Does this case prove persistent infection?
No. It highlights the severity of symptoms but does not determine whether infection persists.

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References

1. Lim S, Kinjo S. Exacerbation of chronic pain after dental extractions in a patient with post-treatment Lyme disease syndrome. Saudi J Anaesth. 2018;12(1):112–114.
2. Cameron DJ, Johnson LB, Maloney EL. Evidence assessments and guideline recommendations in Lyme disease. Expert Rev Anti Infect Ther. 2014;12(9):1103–1135.

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Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention