What are the primary causes of Ludwig's angina?

Primary Causes of Ludwig's Angina

Ludwig's angina is primarily caused by odontogenic infections, with dental infections accounting for approximately 90% of cases. 1, 2

Etiology

Most Common Causes

• Dental infections (70-90% of cases)
  • Infected second and third mandibular molars (most common)
  • Dental caries
  • Periodontal disease
  • Recent dental procedures
  • Poor dentition

Other Causes

1. Oropharyngeal infections

   • Peritonsillar abscess
   • Parapharyngeal abscess
   • Submandibular sialadenitis (inflammation of submandibular salivary gland)

2. Traumatic causes

   • Mandibular fractures
   • Oral lacerations/wounds
   • Tongue piercing
   • Facial trauma

3. Predisposing factors

   • Diabetes mellitus
   • Alcoholism
   • Immunocompromised states
   • Malnutrition
   • Pre-existing vascular disease 3

Microbiology

Ludwig's angina is typically polymicrobial in nature, involving both aerobic and anaerobic bacteria:

• Streptococcus species (most common isolates) 2
  • Particularly Streptococcus constellatus, known for its tendency to form abscesses 3
• Staphylococcus species
• Anaerobic bacteria
  • Bacteroides
  • Peptostreptococcus
  • Fusobacterium

Pathophysiology

Ludwig's angina involves a rapidly spreading cellulitis characterized by:

1. Bilateral involvement of submandibular, sublingual, and submental spaces
2. Rapid progression due to the absence of anatomical barriers in these spaces
3. Brawny induration of the floor of the mouth
4. Elevation and posterior displacement of the tongue
5. Potential for life-threatening airway compromise due to progressive edema 1, 4

Clinical Implications

Understanding the etiology is crucial because:

1. Airway management is the immediate priority due to risk of obstruction
2. Antibiotic selection must cover both aerobic and anaerobic organisms
3. Source control is essential, often requiring dental extraction or drainage
4. Complications can be severe, including:
   • Airway obstruction (most feared)
   • Spread to deep neck spaces
   • Descending necrotizing mediastinitis
   • Sepsis and septic shock
   • Rare cases of type 2 myocardial infarction due to supply-demand mismatch 1, 5

Prevention

• Regular dental care and hygiene
• Prompt treatment of dental infections
• Early intervention for oropharyngeal infections
• Management of underlying conditions like diabetes

With early recognition and appropriate management, mortality has decreased significantly from historical rates of 50% to current rates of 8-10% 1.