Overview

What is ludwig’s angina?

Ludwig’s Angina is a dangerous, potentially life-threatening bacterial infection that affects the mouth. Specifically, it is a type of fast-spreading cellulitis (a deep skin infection) that begins in the floor of the mouth, underneath the tongue. It is often followed by a tooth infection, particularly in the lower molars. The infection begins in the molars and then spreads to the tissues beneath the tongue, resulting in significant swelling. As the swelling progresses, it can obstruct the airway, making it increasingly difficult to breathe.¹ 

Given how rapidly the symptoms develop and worsen, early medical intervention is crucial. If it is left untreated, it can lead to severe complications such as aspiration pneumonia, deep abscesses, sepsis, carotid arterial rupture, and, in the most severe cases, death.¹

Symptoms

• Temperature
• Pain in the jaw
• Swelling in the face, jaw, or neck
• Difficulty breathing or swallowing
• Toothache, especially in the lower molars
• Difficulty or inability to speak
• Body chills
• Drooling
• Neck pain or swelling
• A visibly swollen or protruding tongue, jaw, or neck
• Vomiting
• Headaches
• Nausea

Epidemiology

• Although Ludwig’s angina is considered rare, it can affect anyone¹
• Because of its aggressive nature, this form of cellulitis has a mortality rate of around 8%. Before antibiotics became available, the death rate was more than 50%² 
• Interestingly, a study noted an increase in Ludwig’s angina cases following the onset of the COVID-19 pandemic. The severity of complications also appeared to worsen during this period⁴
• Dental and periodontal diseases are responsible for anywhere between 7-905 of cases⁵
• The condition most commonly affects people between the ages of 29-40 and is more frequently seen in males. Diabetic patients are also more commonly affected⁵

Primary risk factors

Dental infections

The most common cause of Ludwig’s angina is dental infections, especially those associated with the second and third molars; molars are the large teeth located at the back of the mouth. These dental issues are responsible for approximately 90% of all cases. Those with poor dental health or immunosuppression (weakened immune system, making them more susceptible to infections) are more vulnerable to developing this condition.¹ 

In some cases, complications from oral surgery, like tooth extractions, can also lead to Ludwig’s angina. This usually occurs when bacteria enter the deeper tissues of the mouth and neck, or after a procedure. It is not the surgery itself that causes the infection, but rather the post-surgical hygiene. If the area is not kept clean and sanitised, it becomes a breeding ground for bacteria, which increases the risk of infection.³

Before the introduction of antibiotics, Ludwig’s Angina was fatal, with a very high mortality rate. Thankfully, the development of antibiotics, along with advancements in surgical treatments, has drastically reduced the number of deaths caused by this condition. For instance, a study conducted between 1996-1002, during the post-antibiotic era, evaluated nine patients diagnosed with Ludwig’s Angina. They found that in 89% of the cases (8 out of 9 patients), the infection had originated from a dental infection.⁶ 

Poor oral hygiene

Poor oral hygiene is another significant risk factor. Inadequate dental care increases the likelihood of developing mouth infections, especially after procedures such as extractions. For example, a case study documenting a 60-year-old man who presented with swelling and pain that radiated from his neck to chest, along with headache, fever, nausea, and a history of toothache and poor oral hygiene. He also had diabetes mellitus. After receiving treatment, he made a full recovery, highlighting the critical importance of good oral hygiene in both prevention and recovery. Other oral risks include piercings or any kind of wounds in the mouth; if these are not cleaned or maintained properly, they too can become infected and potentially lead to Ludwig’s Angina.¹

Immunocompromised States

Those with poor dental health or immunosuppression (weakened immune system, making them more susceptible to infections) are more vulnerable to developing this condition. Sepsis is a frequent and severe complication in people who have a weakened immune system and are battling Ludwig’s Angina. Certain factors can make the condition even more dangerous and increase the risk of complications or even death. These include being over the age of 65, immunosuppression, dealing with diabetes, or regularly having large amounts of alcohol can increase the likelihood of Ludwig’s angina and worsen complications.¹ 

Secondary or contributing risk factors

Ludwig’s angina can also occur in people with underlying health conditions such as diabetes, alcoholism, AIDS, malnutrition, or in those who have undergone an organ transplant. These conditions can weaken the immune system and make individuals more prone to severe infections.¹ 

Health inequality

There are several social and economic factors, including low income, unemployment, and limited access to oral healthcare, that significantly contribute to both the development and severity of Ludwig’s Angina. This condition is found more frequently among individuals from disadvantaged backgrounds, particularly those who cannot afford or access proper dental care.

A study conducted in Nigeria aimed to investigate the impact of health inequality on the occurrence of Ludwig’s Angina. Researchers collected data from major maxillofacial and oral centres across three cities, Benin, Lagos, and Kano. They gathered demographic and health information from patients to better understand the context of their illnesses. The study revealed that:

• Diabetes was the most common underlying health issue, affecting 21% of the patients
• However, poverty stood out as the most consistent contributing factor across the board
• An example of this was the employment status of patients: in Kano, 90% of those affected by Ludwig’s Angina were unemployed, compared to just 23% in Lagos and 8% in Benin
• Mortality rates also varied significantly by region, with the lowest being 4% in Benin, followed by 12% in Lagos, and the highest at 19% in Kano

Overall, the study highlighted that having poor access to oral health services, low socio-economic status, and lack of employment are major contributing risk factors that increase the vulnerability to Ludwig’s Angina.⁷

Substance use

Alcohol abuse is recognised as one of the risk factors that can contribute to the development of Ludwig’s angina. In addition to alcohol, drug misuse, particularly substances like cocaine, has also been identified as a contributing factor. 

One case study involved a 53-year-old man with a history of heavy drinking and cocaine use. He came to medical attention complaining of severe pain in his lower jaw and was no longer able to eat or speak. On both physical and oral examination, multiple oral health issues were noted, including a large 8cm ulcer on the floor of his mouth that extended across the sublingual gland ducts. Further assessment led to the diagnosis of Ludwig’s angina, along with three other oral conditions. Ultimately, his condition was linked to chemical stomatitis caused by cocaine use, with Ludwig’s angina as the final diagnosis.⁸ 

Another study looked into the deep neck tissue infections related to intravenous drug use. While it found that drug injection is a relatively uncommon cause of deep neck space infections, the researchers emphasised that it should still be considered, especially when a patient presents with unexplained swelling in the soft tissues of the neck.⁹ 

Malnutrition

Malnutrition is recognised as a significant risk factor for developing Ludwig’s angina. Research has shown a clear connection between starvation and a weakened immune system. This link was first observed in famine situations, where people were more prone to infections. Later studies confirmed that malnourished individuals have impaired immune responses, making it harder for their bodies to fight off infections. Starvation, in particular, compromises the body’s natural defences, increasing vulnerability to serious diseases like Ludwig’s angina. 

Although Ludwig’s angina typically develops from a dental infection, research has pointed out that malnutrition and starvation alone can also lead to its development by weakening the immune system. One documented case involved a woman who developed Ludwig’s angina after being trapped and starved after falling in a well without food for 14 days. Her condition was so severe that it did not respond well to standard treatment approaches, highlighting how critical nutritional status can be. The case emphasised the importance of assessing a patient’s overall nutrition, especially in cases of Ludwig’s angina that are not responding to conventional therapies. Even if the initial infection stems from another cause, the illness often makes eating difficult, which can lead to further malnutrition. This, in turn, makes it even harder for the body to recover. In short, starvation and poor nutrition not only increase the risk of developing infections like Ludwig’s angina but also affect the body’s ability to fight them off, and healthcare providers should be mindful of this when managing such cases.¹⁰ 

Summary

Ludwig’s angina is a severe bacterial infection of the mouth that spreads rapidly. If it is left untreated, it can lead to serious complications or even death. Among various risk factors, dental infections stand out as the primary cause. In fact, the majority of Ludwig’s angina cases are linked to dental issues, often following oral surgery or tooth extractions. This is why keeping the mouth clean and the surgical site properly sanitised is important for lowering the risk.

Another major contributor is immunosuppression. When the immune system is weakened, whether it is due to illness, medication, or other conditions, the body becomes far more vulnerable to infections like Ludwig’s angina. Similarly, poor oral hygiene plays a significant role. Neglecting daily oral care does not just affect the teeth; it can open the door to serious infections, making oral hygiene a vital part of overall health, not just a cosmetic concern.

Research also sheds light on the issue of health inequality in relation to Ludwig’s angina. The condition tends to be more prevalent in communities with lower socioeconomic status. Factors such as poverty, unemployment, limited access to oral healthcare, and financial hardship contribute to the higher incidence in these areas. Additionally, substance misuse, such as alcohol and drug abuse, has been identified as a risk factor, as has malnutrition, all of which weaken the immune system and make recovery more difficult. 

While these contributing factors are well documented, there is still a need for more research focused on how health inequality impacts Ludwig’s angina, particularly in countries or regions with high poverty rates and limited healthcare access. Public health interventions and improved treatment efforts should be prioritised in these areas to help reduce the number of deaths associated with this condition. Finally, raising awareness is key. More education is needed about Ludwig's angina: what it is, how it develops, and why it is so dangerous, so that individuals, communities, and healthcare systems can respond more effectively and prevent its devastating outcomes.