ABSTRACT:

The geographic range of Lyme disease is spreading. Once thought to be limited to

coastal New England, it has now been noted in 49 of the 50 states in the U.S..¹

Lyme arthritis has commonly been associated with large peripheral joints such as the knee.¹ Although the majority of affected patients report knee joint pain, a significant number also report temporo-mandibular joint (TMJ) symptoms.² The TMJ is the fourth most commonly affected joint in Lyme disease.^1,3   Therefore, this condition should be included in the workup of patients complaining of TMJ pain and dysfunction.  Questions should be asked about the patient’s home setting, other joint problems and the presence of the diagnostic rash, erythema migrans (EM). Early diagnosis of Lyme disease can minimize the chances of late complications, which may be severe.^3,4  This case report discusses an 8-year, 6-month-old Hispanic male who presented with acute closed jaw lock that led to the diagnosis of Lyme disease.

Key Words: Lyme Disease, Temporomandibular Disorder, TMJ

INTRODUCTION:

Lyme disease is caused by a spirochete known as Borellia burgdorferi.⁵ It is transmitted to humans by the bite of infected blacklegged ticks.⁵ This disease characteristically progresses through 3 stages of infection if left untreated.⁶ Chief complaints of the initial stage are usually fever, arthralgias and myalgias, headache, malaise and stiffness of the neck.^6,7 The secondary stages of Lyme disease often present as lymphocytic meningitis, neuritis, mild encephalitis and cardiac conduction defects.⁸ If left untreated in stage II, the disease can  progress to the third stage with dehabilitating arthritis and chronic CNS disease.^7,8   Lyme disease is diagnosed based on symptoms, physical findings (e.g., rash), and the possibility of exposure to infected ticks. Laboratory testing is helpful in the later stages of disease.^3,9 Most cases of Lyme disease can be treated successfully with a few weeks of antibiotics.¹⁰ Steps to prevent Lyme disease include using insect repellent, removing ticks promptly, landscaping, and integrated pest management.¹¹ The ticks that transmit Lyme disease can occasionally transmit other tick-borne diseases as well.¹¹

CASE REPORT:

An 8-year, 6-month-old Hispanic male presented to the emergency department with a chief complaint of pain in the TMJ and difficulty on opening.    The past medical history was unremarkable.  The patient’s parents reported no known allergies, no past hospitalizations and an up to date immunization record.  Upon extra-oral examination, it was noted that the patient had no ecchymosis, no asymmetry or any other visible signs of trauma.  A stiff neck and frequent headaches were also reported. Intra-oral examination revealed a maximal incisal opening of 10mm.  The patient reported pain in the TMJ upon attempts to open any further.  No soft tissue pathology was noted in the vestibular regions; however, tenderness was noted upon palpation of the masseter muscle. 

The mouth was gradually opened by adding tongue blades until an opening of 30mm was achieved with only mild discomfort over about a 30 min period.  A computed tomography (CT) scan was ordered as well as, a CBC with differential and complete betametabolic panel (CBMP).  The results showed a markedly high erythrocyte sedimentation rate (ESR) of 104mm/hr (norm=15mm/hr).  All other lab values were within normal limits.  Suspecting muscle trismus, the patient was instructed to continue warm compresses, ibuprofen 400mg q6h prn pain, a soft diet and appointed to the dental clinic for a follow-up and evaluation with the orofacial pain specialist 4 days later.

On follow up, the patient reported definite improvement with the use of ibuprofen and warm compresses.  The patient was able to open 31mm freely without any pain or difficulty.  A panoramic radiograph was taken and revealed no pathology.  Interestingly, the CT scan was reviewed by both the oral surgeon and orofacial pain specialists on staff and inflammatory sites were noted bilaterally in the TMJ's.  Upon the findings, the child and parents were specifically asked again of any history of trauma.  The patient revealed that he had fallen in the bathtub about 2 weeks prior and hit the back of his head. 

A tentative diagnosis of TMJ arthralgia was made based on the reported history of falling in the bathtub and inflammation of the TMJ’s. The patient was instructed to continue the ibuprofen 400mg every 6 hours for 7 days.  The patient was referred to his pediatrician for a complete physical examination and laboratory tests including CBC and CBMP. 

At the subsequent dental visit, 4 weeks later after the initial visit, there was definite improvement in opening and a significant decrease in pain noted.  The patient was advised to continue care with his pediatrician and his regular dentist or return to the dental clinic if any problems persist.

The patient returned to the emergency room 5 months later with bilateral knee joint pain and swelling. On clinical exam the patient had no fever or urticaria. Aspiration of the knee was completed and sent to the lab.  The Western Blot test showed a very high serum antibody count (3.86 Norm=0.00-0.99), strongly suggestive of Lyme disease, and thus the child was given a course of Amoxicillin for 21 days.  The pediatrician states that the family had gone camping in upstate New York, 2 months prior to the child’s first Emergency Department visit.  Eighteen months later the family reported no signs or symptoms of Lyme disease and the child is doing well.

DISCUSSION

Temporo-mandibular Disorder (TMD) symptomatology usually occurs early in the

course of Lyme disease.¹² Patients may present with TMJ pain, ear pain, stiff neck and claudication of the masticatory muscles, which may be secondary to Lyme disease. Neuropathic facial pain, Bell’s palsy, pain of the masticatory musculature, and TMJ pain are characteristic of Lyme disease and may cause a patient to seek a healthcare professional.^5,13

Diagnostic arthroscopy of the TMJ of a Lyme disease-infected patient reveals

significant synovial inflammation and swelling, which is similar to that seen in other Lyme affected joints.³ The pleomorphic and seemingly unrelated clinical manifestations of Lyme disease may mimic other serious medical problems and create a diagnostic challenge that invites misdiagnosis and improper treatment planning.  This can certainly occur when a patient exhibits symptoms that mimic chronic TMD.¹⁴  Questions should be asked about the patient’s home setting, other joint problems and the presence of the diagnostic rash erythema chronicum migrans (ECM). (Figure 1).  Early diagnosis of Lyme disease can minimize the chances of late complications, which may be severe.¹³ A meticulous clinical evaluation and history are vital in arriving at a differential diagnosis since Lyme disease can cause irreversible neurological changes. ^2,14

Lyme disease is not contagious between humans and is spread via an Ixodes genus deer tick bite. ¹⁵ A skin rash is often seen near or around a tick bite, usually on the peripheral extremities, buttocks, or trunk.^8,15 Within three or four weeks of the bite the rash increases in size to a diameter as much as 50 cm, in some patients showing partial clearing and induration of the center of the involved area.^2,8 Over, half of all patients may report no history of a rash, or a rash may often be confused with other dermatologic conditions.^8,15 In children, the rash is commonly found in the head and neck region.^7,8 Patients in several studies reported pain in one or both knees. ^6,8,16   Patients also reported pain in one or both TMJ’s as well as limitation of mouth opening either concurrent or alternating with knee symptoms.¹⁵ Episodes of joint pain are of short duration, one week on average followed by periods of complete remission and recurrence.^16,17

Laboratory findings include elevated ESR, cryoprecipitates, an initially elevated serum IgM antibody titer with a later occurring elevation of serum IgG antibody titer, normal complement C₃ levels, and an absence of rheumatoid factor or antinuclear antibodies.¹⁸  During phases of remission, the ESR shows significant reduction, but not always to normal levels.¹⁹

A positive diagnosis of Lyme disease is confirmed by the appearance of an ECM lesion or with a laboratory test.²⁰  The Western Blot is one testing method where the patient’s blood is cross-reacted with a series of antigens that are derivatives of the proteins of Borrelia burgdorferi.^20,21  Other popular tests are an immunoflorescent assay (IFA Titer) or an enzyme linked immunoassay (ELISA) method.²⁰  

When Lyme disease occurs in children younger than 8 years, or in pregnant or breast-feeding women, they are usually treated with amoxicillin, cefuroxime axetil, or penicillin because doxycycline can stain the permanent teeth developing in young children or unborn babies.²²  People allergic to penicillin are given erythromycin or related drugs.²¹  The standard treatment for Lyme disease in its early stage is Amoxicillin 50 mg/kg/24 hours three times a day for 14 to 21 days.²¹ In children over the age of 12, doxycycline 100mg three times a day for 14 to 21 days can also be used effectively.²²  Steroids are usually not recommend-ed.^16,21,22

The first line of defense against Lyme disease and other tick-borne illnesses is avoidance of tick infested habitats, use of personal protective measures such as repellents and protective clothing, and checking for and removing attached ticks.^11,23  Lyme disease was not suspected initially in this child living in this inner city who presented initially with a chief complaint of acute closed jaw lock with a history of head trauma.  A thorough clinical evaluation and history are vital in arriving at a differential diagnosis.   

REFERENCES:

1. Steere AC, Dwyer E, Winchester RJ.  Association of Chronic Lyme Arthritis with HLA-DR4 and HLA-DR2 alleles.  N Engl J Med 1990;323:219-223.

2. Harris RJ. Lyme disease involving the temporomandibular joint. J Oral Maxillofac Surg 46:78-79,1988.

3. Heir GM, Fein, LA. Lyme Disease: Considerations for Dentistry.   J Orofac Pain 1996;10:1:74-86.

4. Kelsey JH. Lyme Disease: An important consideration in the differential diagnosis of

TMD. J Mich Dent Assoc 1990;72:209-210.

5. MacDonald, AB. Lyme disease: A neuro-opthalmologic view. J Clin Neuro-Ophthal, 7:4, 185-190, 1987.

6. Katusic SK, Beard CM, Wiederhold WC, et al.  Incidence, clinical features and prognosis in Bell’s palsy, Rochester Minnesota, 1968-1982.   Ann Neruol.   1986;20:222.

7. Siwula JM, Mathieu, G.  Acute onset of facial nerve palsy associated with Lyme disease in a 6-year-old child.  Pediatr Dent 2002;24:572-574.

8. Cook S, Macartney K, Rose C, et al. Lyme disease and seventh nerve paralysis in children.  Amer J Otolaryngology.  1997; 18:5:320-323.

9. Goldfarb D, Sataloff RT. Lyme Disease:  A review for the otolaryngologist.  Ear Nose Throat J 1994;73;824-829.   

10. Massoraotti EM, Luger SW. Treatment of early Lyme disease. Am J Med 1992;92:396-403.    

11. Fish D. Environmental risk and prevention of Lyme disease. Am J Med 1995; 24:98:25-85.

12. Duray PH.  Histopathology of human borreliosis.  In: Coyle PK (ed).  Lyme Disease. Chicago: Mosby yearbook, 1992:49-58.

13. The spectrum of Lyme disease. Audio Digest Foundation, Vol 27, No. 2 1987.

14. Bruno, SA. Neuromuscular disturbances causing temporomandibular dysfunction and pain. J Prosthet Dent 26:387, 395,1971.

15.   Belani K, Regelmann W. Lyme disease in children.  Rheum Dis Clin North Am. 1989;15:679-690.

16. Steere AC, Schoen, RT, and Taylor, E. The clinical evolution of lyme arthritis. Ann Int Med 107:725-727, 1987.

17. Dotevall l, and Hagever L. Successful oral doxycycline treatment of Lyme disease and associated facial palsy and meningitis. Clin Inf Dis 28:569-573, 2000.

18. Steere AC, Hutchinson GJ, Rahn DW, et al. Treatment of the early manifestations of Lyme disease. Ann Intern Med 99:22-26, 1983.

19. Shapiro E. Lyme disease.  In: Behrman, et al, eds.  Nelson Textbook of Pediatrics  16^th ed. Philadelphia, Pa: WB Saunders Co; 2000:910-914.

20. Burrascano JJ Jr. Managing Lyme Disease: Diagnostic Hints and Treatment Guidelines for Lyme Borreliosis, ed 10. East Hampton, NY, 1995.

21. Gerber MA, Zemel LS, Shapiro ED. Lyme arthritis in children clinical epidemiology and long-term outcomes.  Pediatrics 1998; 102:905-8.

22. Dummett, CO. Anomalies of the Developing Dentition. In: Pinkham JR, Casamassimo P, Fields H, MiTigue D, Nowak A, eds. Pediatric Dentisty: Infancy    Through Adolescence. 3^rd ed. Philadelphia, Pa: WB Saunders Co; 1999:43-53.

23. Roob G, Fazekas F, Hartung H.  Peripheral facial palsy: Etiology, diagnosis and treatment.  Eur Neruol.  1999; 41:3-9.