Reviewed by Dr. Gautam Thekkayil, MDS (Oral & Maxillofacial Surgery), Assistant Professor, Department of Oral and Maxillofacial Surgery, KMCT Dental College, Calicut, Kerala
A common misconception about tooth-related infection is that it is only confined to the mouth, seldom is the case. One such condition is Ludwig angina, named after the German physician, Wilhelm Friedrich von Ludwig, who described it in 1836.
Ludwig’s Angina is a very serious and rapidly progressing, life-threatening condition that usually occurs as a complication of an infection in your lower molar teeth, especially the last two molars. It causes excessive swelling on both sides of the neck and floor of the mouth along with pain, difficulty in swallowing, reduced mouth opening, and drooling.
Ludwig’s angina is considered a medical emergency because the swelling can progress very fast without timely intervention, this can lead to life-threatening complications like difficulty in breathing, sepsis, and/or even death.
The main cause of Ludwig’s angina is an infection of the lower molar teeth, specifically the 2nd and 3rd molars.
Other causes are:
Oral piercing
Fracture of the lower jaw
Tonsil infection
Trauma from any medical treatment
Most common risk factors of Ludwig’s angina are:
Poor oral hygiene
Dental caries (decay of teeth)
Recent dental treatment
Age older than 65 years
Alcoholism
Diabetes
Malnutrition
Under immunosuppressant medication
MedBound Times connected with Dr. Gautam Thekkayil, Assistant Professor, Department of Oral and Maxillofacial Surgery, KMCT Dental College, Calicut, Kerala and enquired about who is at high risk of developing Ludwig’s angina, he answered that "individuals who are under steroid therapy have a higher chance of developing it Ludwig’s angina."
Signs and symptoms that require emergency intervention are
Significant reduction in mouth opening
Swelling on both sides of the lower jaw
"Hot potato" voice (sounds like you have something hot in your mouth)
Fever
Restricted tongue movement
Difficulty in swallowing/pain while swallowing
Drooling
Obstruction of the airway is the major complication of Ludwig’s angina, which can be life-threatening if left untreated.
Aspiration pneumonia can occur when infection or other oral fluids enter the lungs as a result of difficulty in swallowing
Sepsis, when infection enters the bloodstream, especially in individuals with compromised immunity, can result in multiple organ failure.
Ludwig’s Angina is more dangerous in the cellulitis stage (infection affecting the deeper layers of the skin and underlying tissues), and even though it is rare, in some cases this can lead to mediastinitis (a serious infection of the middle region of the chest which includes vital organs like the heart, lungs and major blood vessels) if the infection progresses downwards from the neck region and into meningitis (inflammation of the thin layer surrounding your brain and spinal cord) if it progresses upwards towards the head.
Dr. Gautam Thekkayil, Assistant Professor, Department of Oral and Maxillofacial Surgery, KMCT Dental College, Calicut, Kerala
Ludwig angina is primarily diagnosed through clinical evaluation. When there are significant signs of airway obstruction, difficulty in swallowing and a change in the voice, Ludwig’s angina should be suspected.
The primary goal of the treatment is to help secure the airway and improve breathing of the patient.
Once the airway is stabilized, the main focus is to control the infection by surgical drainage of the pus, if any abscess is present and using broad-spectrum antibiotics. Most cases involving teeth have to be removed along with the surgical drainage to eliminate the source of infection.
One should never apply heat and/or any ointment (like vapor rubs or pain balms) on the swelling, as this can cause a flare-up of the condition.
Dr. Gautam Thekkayil, Assistant Professor, Department of Oral and Maxillofacial Surgery, KMCT Dental College, Calicut, Kerala
Dr. Gautam added that “the first line of treatment is airway management, followed by empirical antibiotic therapy. A culture and sensitivity test is then performed to identify the most accurate antibiotics. Surgical drainage is done, with placement of a drain to help remove excess fluid.”
See more: Rethinking Use of Wisdom Teeth in Regenerative Medicine
Ludwig’s angina is a rare but very serious and rapidly progressive condition which can quickly lead to obstruction of the airway which, left untreated, can be life-threatening. The condition requires immediate intervention and close monitoring to prevent complications of airway blockage. Although the condition is rare, as it progresses rapidly, knowledge about the warning signs helps early identification and getting the proper medical attention.
Can Ludwig’s Angina occur after tooth removal?
Yes, even though the most common cause is untreated dental infection, in rare cases, tooth removal can also cause this infection.
What is the mortality rate associated with Ludwig’s Angina?
Advances in airway management, antibiotic therapy, imaging, and surgical intervention have decreased mortality to approximately 8% in the modern era.
AL Ghabra Y, Brizuela M, Winters R, et al. Ludwig Angina. [Updated 2025 Jun 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482354/
OG/NK/MSM
