Ludwig's Angina: An Uncommon Cause of Chest Pain: Discussion

Dental infections are common in the general population, with a prevalence of more than 40% by age 6 years in the primary dentition and more than 85% by age 17 years in the permanent dentition. [6] They usually have a benign course but sometimes can lead to serious and life-threatening complications. One of these complications is Ludwig's angina. It represents 13% of all the deep neck infections. It is a rare but life-threatening condition that must not be overlooked during the assessment of tooth pain. [4] In 1836, Willhelm Frederick von Ludwig described a gangrenous induration of the connective tissue of the mouth. In 1939, Grodinsky slightly modified Ludwig's definition and established diagnostic criteria.[5, 7] The name given to this type of infection comes from its potentially lethal outcome. Angina is derived from the Latin word angere , meaning to strangle.[3] Other authors have used the terms angina maligna, morbus strangulatoris , and garotillo (Spanish word for hangman's loop).8 Before the antibiotic era, it usually caused death by asphyxiation. With the advent of antibiotics, its incidence and mortality rates have dramatically decreased from more than 50% to less than 10% mortality. The initial use of penicillin in the therapy of odontogenic infections in the 1940s led to the dramatic decline in the mortality rates. In 1940, Williams[9] published a case series of Ludwig's angina, in which 24 of 44 (54%) patients died. Three years later, Williams and Guralnick[10] published a case series of 20 patients with Ludwig's angina, in which 2 of 20 (10%) patients died. The reduced frequency of these infections makes their diagnosis more difficult for the average practitioner, and therefore careful study of severe odontogenic infections is necessary, or preventable deaths can occur. [11] Deep fascial space infections of the head and neck can rapidly progress to threaten vital structures and to obstruct the airway. Timely consultation with a dentist or dental specialist, such as an oral and maxillofacial surgeon, can be lifesaving.[11] The four cardinal signs of Ludwig's angina are bilateral infection in more than one space; gangrene with serosanguineous infiltration; involvement of the connective tissue, fasciae, and muscles but not the glandular structures; and spread by continuity, not by lymphatics. [15] The most commonly affected teeth are the lower second and third molar. The roots of these molars extend into the mylohyoid muscle, providing a route to the mandibular spaces. Other causes include fractured mandibles, foreign bodies and lacerations on the floor of the mouth, traumatic procedures, infection of oral malignancies, otitis media, and peritonsillar abscesses, among other causes [5] The usual symptoms include dysphagia, neck swelling, and pain; other symptoms include dysphonia, drooling, tongue swelling, pain in the floor of the mouth, and sore throat.[16]