1810rdhtra P01

Red Flags

Jan. 1, 2019
Lyme disease—you have to go into the wilderness to contract it, right? Nope! Lyme disease can be contracted in urban and suburban areas too, and you just might see a case of it in your dental hygiene operatory sometime. Do you know which signs and symptoms to look out for?
Recognizing the signs and symptoms of Lyme disease

Julie A. Tracy, BS, RDH

Recently, a patient walked into my operatory with bright red knees and a rash of round blotches on her arms and legs. I took one look at her and asked if she had been tested for Lyme disease. She told me how she had gone to the walk-in clinic the week before with a crushing headache and fever, tested negative for Lyme disease, was told the cause was probably viral, and was instructed to take ibuprofen or acetaminophen.

When the rash appeared a few days after that, she went to her primary care physician who diagnosed her with hives, putting her on prednisone and loratadine. “I’ve had hives,” my patient said to me. “These aren’t hives. They don’t itch.” I told my patient that Lyme disease is endemic where we live in upstate New York, and the test is unreliable in the early stages of the disease. I urged her to go back to her doctor.

As dental hygienists, we are partners in our patients’ whole health, and sometimes the red flags we see have nothing to do with their teeth. In the case of this patient, the first red flag I saw was her knees. There was something abnormal about how angry and inflamed they appeared. Swollen, painful joints are a sign of Lyme disease.1 The second red flag was her rash. The classic presentation of erythema migrans, the rash associated with Lyme disease, is the bull’s-eye lesion. An estimated 27% to 80% of Lyme disease cases present with a rash,2 and some people get an atypical rash.3 My patient’s rash was not the classic bull’s eye, but it was suspicious enough for me to ask more questions.

Listening to my patient describe her symptoms, I noticed that the top of her foot looked swollen and was a darker red than the rest of her rash, with what appeared to be the fading remnant of an insect bite in the center. I asked her about her foot, and she said that she had been bitten by something but never saw what bit her. Many people who contract Lyme disease do not see the tick and may not be aware that they have been bitten.4 The tick that transmits the disease, the black-legged tick (Ixodes scapularis), is very small, about the size of a poppy seed. The tick crawls up the body and hides in a warm place, such as the underarm, behind the knee, on the scalp, tucked under the top of a shoe, or under a waistband or clothing strap.

The fact that my patient’s headache and fever were severe enough to send her to the walk-in clinic was another clue that she might have contracted Lyme disease. Flu-like symptoms are common at the onset.5 Given her signs and symptoms, and considering the prevalence of Lyme disease in our area, I advised my patient to seek additional medical attention.

Figure 1: A message the author received after advising a patient to get retested

“But I haven’t been in the woods,” she said. It is a common misconception that people only contract Lyme disease in wilderness areas.6 I informed my patient that she could have gotten it in her own backyard. Ticks will feed on deer, mice, squirrels, birds, and other mammals, and they can be carried into populated areas on their mammal hosts. Wherever mammals are in proximity to humans, humans are at risk of Lyme disease. Wooded suburbs can be a prime tick habitat,7 and even urban areas can be habitats for potential mammal hosts.8

What about the fact that this patient had already tested negative for Lyme disease? As the body is building antibodies during the first four to six weeks after infection, a Lyme disease test may come back negative.9 She was tested during the onset of symptoms, early enough in the course of the disease that a false negative could have occurred. Testing a few weeks later, there would be a better chance for a more accurate result.

Leaving that day, my patient told me that her visit had been very enlightening, and I again encouraged her to go back to her medical doctor. Because of the trusting relationship we had developed over the years, I was someone with whom she felt comfortable sharing her personal health details, and she was receptive to my recommendation, even though it was unrelated to her oral health.

As dental hygienists, we are in a unique position with our patients. Regular recall schedules mean we see our patients on a consistent basis, updating their medical histories and noting any changes. We spend longer periods of time with our patients at each visit than they experience with many other medical professionals. This allows us to ask questions, listen to our patients, and put all the information together into a comprehensive profile of overall health. We have received rigorous training in human biology, nutrition, pharmacology, and the disease process. We can draw from this foundational knowledge when we are considering our patients’ whole health. This does not mean that hygienists should be trying to diagnose—understanding our limitations is critical—but we are in a position to provide sound guidance. We can encourage our patients to seek the proper medical care when we suspect that something is amiss.

Drawing a patient’s attention to a suspicious mole or educating a patient about his or her blood pressure are two examples of nondental health screenings that many hygienists already incorporate into their practices. Suspecting that a patient had Lyme disease was a new one for me, but because I knew what to look for and understood the risk of Lyme disease in our area, I had to say something to my patient when she displayed so many of the warning signs.

Even though Lyme disease is most prevalent in the Northeast and upper Midwest regions of the United States, there have been reported cases in all 50 states, Canada, parts of Europe, and Asia, and Lyme disease is emerging in Australia.10 It is the most commonly reported vector-borne disease in the United States.11 The Centers for Disease Control and Prevention estimate that there are 300,000 new cases of Lyme disease annually in the United States.12 As the range of black-legged ticks expands, the number of Lyme disease cases is expected to rise.13 Hygienists across the United States can be alert to the signs and symptoms of Lyme disease and perhaps help a patient get the necessary treatment. The longer Lyme disease goes untreated, the greater the risk for chronic cardiac, neurological, and rheumatological effects.14

Exactly one week after I saw my patient with the rash, our receptionist put a note on my counter: “[Patient’s name] Thank you! You are a lifesaver! She went to the MD and tested positive for [Lyme] disease” (figure 1). Patients may come to see us for their teeth, but we see them for their whole health. By staying on top of emerging diseases and health headlines in your region, you can be prepared for whatever red flags may walk into your operatory.


1. Wright S. Musculo-skeletal and neurological aspects of Lyme disease. Int Musculoskelet Med. 2016;38(3/4):91-94. doi:10.1080/17536146.2016.1226462.

2. Johnson L. How many of those with Lyme disease have the rash? Estimates range from 27-80%. Lymedisease.org. https://www.lymedisease.org/lymepolicywonk-how-many-of-those-with-lyme-disease-have-the-rash-estimates-range-from-27-80-2. Published April 10, 2014.

3. Schutzer SE, Berger BW, Krueger JG, Eshoo MW, Ecker DJ, Aucott JN. Atypical erythema migrans in patients with PCR-positive Lyme disease. Emerg Infect Dis. 2013;19(5):815-817. doi:10.3201/eid1905.120796.

4. Frequently asked questions about Lyme disease. International Lyme Disease and Associated Diseases Educational Foundation website. https://iladef.org/education/lyme-disease-faq.

5. Lyme disease signs and symptoms. Johns Hopkins Arthritis Center website. https://www.hopkinsarthritis.org/arthritis-info/lyme-disease/lyme-signs-and-symptoms. Updated June 6, 2018.

6. Tick habitat. Lyme Disease Association Inc. https://www.lymediseaseassociation.org/about-lyme/tick-vectors/habitat. Published February 13, 2017.

7. Stafford KC. Tick Management Handbook. New Haven, CT: The Connecticut Agricultural Experiment Station; 2004. http://www.ct.gov/caes/lib/caes/documents/special_features/tickhandbook.pdf.

8. Ostfeld RS. Lyme Disease: The Ecology of a Complex System. New York: Oxford University Press; 2011.

9. Halperin JJ, Baker P, Wormser GP. Common misconceptions about Lyme disease. Am J Med. 2013;126(3):264.e1-264.e7. doi:10.1016/j.amjmed.2012.10.008.

10. Schwartz AM, Hinckley AF, Mead PS, Hook SA, Kugeler KJ. Surveillance for Lyme disease—United States, 2008-2015. MMWR Surveill Summ. 2017;66(SS-22):1-12. doi:10.15585/mmwr.ss6622a1.

11. Chomel B. Lyme disease. Rev Sci Tech. 2015;34(2):569-576.

12. Centers for Disease Control and Prevention. How many people get Lyme disease? https://www.cdc.gov/lyme/stats/humancases.html. Updated September 30, 2015.

13. Kugeler KJ, Farley GM, Forrester JD, Mead PS. Geographic distribution and expansion of human Lyme disease, United States. Emerg Infect Dis. 2015;21(8):1455-1457. doi:10.3201/eid2108.141878.

14. Chronic Lyme disease. Lymedisease.org. https://www.lymedisease.org/lyme-basics/lyme-disease/chronic-lyme.

Julie A. Tracy, BS, RDH, is a clinical hygienist in Binghamton, New York. She graduated from Broome Community College, holds a bachelor’s degree in public health from State University of New York Empire State College, and is currently pursuing a master’s degree in health sciences from the University of Central Arkansas. Her focus is on health education and promotion, and her master’s program is preparing her for credentialing as a certified health education specialist.