Ludwig’s angina is a rare type of rapidly spreading cellulitis caused by a bacterial infection in the oral cavity. The floor of the mouth swells, displacing the tongue. Doctors also refer to this condition as sublingual space infection or submandibular space infection. Ludwig's angina predominantly occurs in middle-aged people and can have life-threatening consequences if not treated promptly with antibiotics and surgical procedures.

How It Begins

In about 60 to 85% of Ludwig’s angina cases, an odontogenic — dentalinfection is the culprit, usually involving the second and third mandibular molars. The infection’s course depends on the anatomy of the affected region, the immune system resistance of the patient, and the type and strength of the bacteria. Less commonly, a mouth injury such as a cut on the floor of the mouth, tooth extraction, a mandibular fracture, a tongue piercing, or otitis media can introduce the infection.

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Most people who develop Ludwig’s angina experience symptoms similar to any immune response to infection, including fever and chills. The infected area will usually be tender, with sensitivity or pain extending into the throat in some cases. The tongue may swell up to twice or three times its normal size, forcing it forward or backward, potentially restricting breathing or swallowing.

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Common Presentations

Most people diagnosed with Ludwig’s angina visit their doctor for a sore throat or difficulty swallowing. They often complain of tooth pain, malaise, and painful neck swelling. Other signs of severe Ludwig’s angina include:

  • Halitosis
  • Double tongue sign or swelling of the bottom of the mouth
  • Drooling
  • Earache
  • Confusion or mental changes
  • Stridor
  • Trismus or lockjaw
  • Bluish, discolored skin or cyanosis

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Risk Factors

Diabetes mellitus is one of the most common conditions in people who contract Ludwig’s angina, due to the condition's tendency to slow wound healing and increase the risk of infection. Hypertension and compromised immunity can also increase the risk of Ludwig's angina. Other predisposing factors include poor dental hygiene, obesity, alcoholism, and malnutrition. Fillings, fractures, and abscesses often trigger the onset of the infection.

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When to Get Medical Help

If any mouth infection does not resolve or worsens after a few days, it is important to see a doctor, especially if breathing becomes impaired. A health care provider will examine the head and neck for redness and swelling under the chin. If the test is unclear, the doctor may order a CT scan and take a sample of tissue fluid to test for bacteria. If breathing is impaired or seems likely to become so, they will likely begin treating this symptom immediately, instead of waiting for test results.

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The prognosis for Ludwig’s angina depends on the severity of the infection and how quickly treatment starts. Early detection and intervention can prevent severe complications and facilitate a full recovery. Without immediate care, however, life-threatening issues can arise and progress rapidly. These include upper airway obstruction, pericarditis or swelling around the heart, septic shock, and pus buildup in the lungs or pleural empyema.

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Breathing Intervention

If a patient presents with significant swelling in the mouth, it is essential that the airways be kept open. Doctors may insert a breathing tube through the nose or mouth. Some patients require surgery to drain the fluids that cause swelling. If the blockage is too severe when the patient arrives, a surgeon may perform a tracheostomy to create an opening in the windpipe.

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Doctors administer antibiotics to fight the bacterial infection. Dental treatment may also be needed to target oral infections or fractured teeth that lead to Ludwig’s angina. According to a 2018 report, early surgical intervention with antibiotics may reduce the risk of airway blockage more significantly than antibiotics alone.

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Practicing good oral hygiene can lower the risk of developing Ludwig’s angina, as can regular dental checkups and prompt treatment of any tooth or mouth infections. See a dentist for unexplained or excessive bleeding of the gums or tongue or persistent foul odor from the mouth. Anyone receiving a tongue piercing should ensure they visit a certified practitioner, and see a doctor immediately if the side effects of the procedure are abnormal.

dentist patient teeth Karen Moskowitz / Getty Images


History of Ludwig's Angina

German physician Wilhelm Frederick von Ludwig first described Ludwig’s angina when diagnosing five patients in 1836. He identified the condition as quickly progressive gangrene and edema of the soft tissues in the mouth and neck. The term angina, deriving from angere which means “to strangle,” refers to the deadly strangling effect of respiratory obstruction that commonly befell patients before antibiotics.

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