Severe Pain After Dental Surgery in Lyme Disease: A PTLDS Case

A woman with post-treatment Lyme disease syndrome (PTLDS) underwent routine dental extraction of four molars. Despite an uneventful surgery and aggressive multimodal pain management, the procedure triggered severe, widespread full-body pain that required ICU admission.

Lim from the University of California in San Francisco documented this case, which illustrates the extraordinary pain vulnerability that some PTLDS patients can experience—and how poorly understood it remains—making it an important consideration when evaluating complex Lyme disease symptoms.

Five years bedbound before surgery

Before the dental procedure, this patient’s functionality was already severely affected. She had been bedbound for approximately five years and required a wheelchair.

Her medical history included fibromyalgia, hypothyroidism, anxiety, depression, and insomnia.

Her skin, spine, bone, and joint pain was severe and difficult to treat. She had frequent emergency department visits with notably poor response to opioids—but pain that responded to ketamine, a pattern consistent with central sensitization rather than peripheral nerve damage.

What happened during surgery?

Prior to the extraction, she was able to taper off methadone.

During surgery, physicians used an aggressive multimodal regimen including fentanyl, ketamine, acetaminophen, and ketorolac intravenously, followed by local anesthetic in all four quadrants.

Despite this, the woman developed severe, widespread pain after surgery. Her oral pain from the extraction itself was minor.

The main issue was total body pain—a flare of her underlying PTLDS symptoms triggered by the physiologic stress of the procedure.

Pain that could not be controlled

In the recovery room, additional fentanyl, hydromorphone, lorazepam, gabapentin, and oral ketamine failed to control her pain.

A ketamine infusion was started. When pain remained severe, she was transferred to the ICU.

For two days, she received around-the-clock multimodal treatment including ketamine infusion, IV acetaminophen, ketorolac, sublingual buprenorphine, oxycodone, and hydromorphone.

She was discharged on day three with an extensive tapering regimen.

This level of pain from a routine dental extraction—requiring ICU-level intervention—underscores the degree of nervous system sensitization present in severe PTLDS.

Why surgery may trigger pain flares in PTLDS

The mechanism behind this response is central sensitization—a state in which the brain and spinal cord become hyper-responsive to pain signals.

In patients with PTLDS, the nervous system may already operate at an elevated baseline. Additional physiologic stress—including surgery, infection, sleep deprivation, or emotional stress—can push the nervous system beyond its threshold and trigger widespread pain that exceeds what the triggering event would normally produce.

This mechanism is also linked to altered autonomic signaling and may overlap with autonomic dysfunction in selected patients.

Lim notes that persistent symptoms may reflect central sensitization, also known as central sensitivity syndrome. However, whether this sensitization reflects a purely post-infectious process or ongoing biologic drivers remains uncertain.

Could central sensitization explain severe pain after surgery?

Several investigators have proposed that chronic widespread pain after Lyme disease may share features with central sensitization syndromes and fibromyalgia.

Ranque-Garnier and colleagues noted overlap between post-treatment Lyme disease syndrome, chronic musculoskeletal pain, and post-infectious pain syndromes. These mechanisms may help explain why physiologic stressors—including surgery—can trigger outsized symptom flares in selected patients.

However, the mechanisms behind persistent symptoms remain debated and likely vary between patients.

Is PTLDS post-infectious — or persistent infection?

This patient met the IDSA 2006 criteria for PTLDS: documented Lyme disease, subsequent fatigue and widespread musculoskeletal pain, symptoms lasting more than six months, and significant functional impairment.

Some clinicians attribute chronic PTLDS pain to inflammatory, musculoskeletal, neuropathic, or mixed mechanisms that persist after infection clears.

Others question whether persistent symptoms may reflect mechanisms related to persistent Lyme disease mechanisms or incompletely treated infection.

There are currently no tests that definitively confirm that “post-treatment” means the infection has resolved.

It would be reasonable to revisit this patient’s clinical history to determine whether earlier treatment decisions or delayed diagnosis contributed to ongoing symptoms.

What are the limitations of this case report?

This is a single patient case report
Severe pain responses may not occur in most PTLDS patients
Preexisting chronic pain conditions may have influenced outcomes
Case reports cannot determine how often surgery triggers flares
Central sensitization remains difficult to measure objectively

Frequently Asked Questions

Can dental surgery trigger a Lyme disease pain flare?

Yes. In selected patients with PTLDS and central sensitization, surgical stress may trigger pain flares that exceed what would normally be expected after routine procedures.

Why didn’t opioids control her pain?

Central sensitization involves amplified pain processing in the nervous system rather than simple tissue injury, which may partly explain why opioid response can be limited in selected patients.

What is central sensitization?

Central sensitization is a state in which the nervous system becomes hyper-responsive to pain signals and may contribute to chronic pain syndromes, including PTLDS and fibromyalgia.

Can surgery trigger Lyme disease symptoms?

Some patients report worsening symptoms after physiologic stressors such as surgery, infections, or sleep disruption, although the mechanisms remain incompletely understood.

Why can dental procedures worsen chronic pain?

Procedures may act as physiologic stressors that amplify preexisting pain pathways, particularly when central sensitization or autonomic dysfunction are present.

Is PTLDS similar to fibromyalgia?

Some researchers have proposed overlap between PTLDS, fibromyalgia, and central sensitization syndromes, although the underlying mechanisms remain debated.

Clinical Takeaway

Patients with PTLDS may have increased vulnerability to physiologic stressors that would be routine for others.

Pre-procedural planning for patients with severe chronic Lyme-related symptoms should consider central sensitization, autonomic dysfunction, and the possibility that standard pain management approaches may be insufficient.

These articles explore chronic pain, neurologic symptoms, recovery challenges, delayed diagnosis, and persistent symptoms after Lyme disease.

Chronic pain in Lyme disease
Neurologic Lyme disease
Recovery from Lyme disease
Delayed Lyme disease diagnosis
Post-treatment Lyme disease syndrome