Ludwig Angina Dry Socket

7/28/2019 Ludwig Angina Dry Socket

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Ludwig's angina

Ludwig's

Classification and external resources

Swelling in the submandibular area in a patient with Ludwig's angina.

ICD-10 K12.2

ICD-9 528.3

DiseasesDB 29336

MedlinePlus 001047

MeSH D008158

Ludwig's angina, otherwise known as angina ludovici, is a serious, potentially life-threateningcellulitis[1][dead link]

, or connective

tissue infection, of the floor of the mouth, usually occurring in adults with concomitant dental infections and if left untreated, may

obstruct the airways, necessitating tracheotomy. It is named after the German physician,Wilhelm Friedrich von Ludwigwho first

described this condition in 1836.[2][3]

Other names include "angina Maligna" and "Morbus Strangularis".

Ludwig's angina should not be confused withangina pectoris, which is also otherwise commonly known as "angina". The word

"angina" comes from theGreekword ankhon, meaning "strangling", so in this case, Ludwig's angina refers to the feeling of

strangling, not the feeling of chest pain, though there may be chest pain in Ludwig's angina if the infection spreads into the

retrosternal space.

The life threatening nature of this condition generally necessitates surgical management with involvement of critical care

physicians such as those found in an intensive care unit[4]

.

Causes
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Dental infections account for approximately eighty percent of cases of Ludwig's angina.[5]

Mixed infections, due to both aerobes

and anaerobes, are of the cellulitis associated with Ludwig's angina. Typically, these includealpha-hemolytic streptococci,

staphylococci andbacteroidesgroups.[5]

The route of infection in most cases is from infected lowermolarsor frompericoronitis, which is an infection of the gums

surrounding the partially erupted lower (usually third) molars. Although the widespread involvement seen in Ludwig's usually

develops inimmunocompromisedpersons, it can also develop in otherwise healthy individuals. Thus, it is very important to

obtain dental consultation for lower-third molars at the first sign of any pain, bleeding from the gums, sensitivity to heat/cold or

swelling at the angle of the jaw.

Ludwig's angina is also associated withpiercingsof thelingual frenulum.[6][7][8]

Symptoms and signs

True Ludwig's Angina is a cellulitic facial infection. The signs are bilateral (meaning both sides) lower facial swelling around the

lower jaw and upper neck. This is because the infection has spread to involve the Submandibular, Sublingual and Submental

spaces of the face.

Swelling of the Submandibular space, while externally is concerning the true danger lies in the fact that the swelling has also

spread inwardly - compromising, or in effect narrowing the airway. Dysphagia (difficulty swallowing), Odynophagia (pain during

swallowing) are symptoms that are typically seen and demand immediate attention.

The Sublingual and Submental spaces are anterior (beneath the middle and chin areas of the lower jaw) to the Submandibular

space. Swelling in these areas can often push the floor of the mouth, including the tongue upwards and backwards - further

compromising the airway.

Localisation of infection to thesublingual spaceis accompanied by swelling of structures in the floor of the mouth as well as thetongue being pushed upwards and backwards.

[5]

Spread of infection tosubmaxillary spaceis usually accompanied by signs of cellulitis rather than those of an abscess.

Submental and submandibular regions are swollen and tender.

Additional symptoms include malaise,fever,dysphagia(difficulty swallowing), odynophagia (pain during swallowing)[5]

and, in

severe cases,stridoror difficulty breathing. There may also be varying degrees oftrismus. Swelling of the submandibular and/or

sublingual space is imminent.

Treatment

Treatment involves appropriate antibiotic medications, monitoring and protection of the airway in severe cases, and, where

appropriate, urgent maxillo-facialsurgeryand/ordentalconsultation to incise and drain the collections.The antibiotic of choice is

from Penicillin group.

Incision and drainage of the abscess may be either intraoral or external. An intraoral incision and drainage procedure is

indicated if the infection is localized to the sublingual space. External incision and drainage is performed if infection involves the

submaxillary space.[5]
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A nasotracheal tube is sometimes warranted for ventilation if the tissues of the mouth make insertion of an oral airway difficult or

impossible.

In cases where the patency of the airway is compromised, skilled airway management is mandatory. This entails management

of the airway according to the American Society of Anesthesiologists' Difficult Airway Algorithm and necessitates fiberoptic

intubation.

Alveolar osteitis

Alveolar osteitis. Note exposed bone as marked by the arrow.

Alveolar osteitis or, colloquially, a dry socket, is a complication of wound healing followingextraction of a tooth. The

term alveolarrefers to the alveolus, which is the part of the jawbone that surrounds the teeth; osteitis means simply "bone

inflammation". It is known as "dry socket" as after the clot is lost, the socket has a dry appearance because of exposed bone.

The blood clot helps in stopping the bleeding and lays framework for new tissues to develop there but in case of dry socket, the

clot is dislodged and the bone is exposed. This bare bone is exposed to bacteria in the saliva and the food which the patient

consumes and the bone becomes infected and painful.

Signs and symptoms

Alveolar osteitis usually occurs 35 days after tooth extraction and causes severe throbbing and radiating pain which is difficult

to localize. Alveolar osteitis is characterized bydetritus, grayishslough, severe pain and foul odor.[1][2][3]

The foul odor, in

particular, is a result of the disintegration of the blood clot byputrefactionrather than by orderly resorption. If a probe is gentlypassed in the tooth extraction socket, then bare bone is encountered which is very sensitive.

[1]

Cause
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Alveolar osteitis, "dry socket" type. Note exposed bone, as marked by arrow.

Multiple types ofalveolar osteitis can result from disturbances in the healing process. The type that is commonly referred to as

"dry socket" is one in which the disturbance is from the time a blood clot forms immediately after tooth extraction to the initiation

of healing in the 45 day period after extraction occurs. The healing tissue that is supposed to replace the blood clot, known

asgranulation tissue, may fail to grow or be disrupted after beginning to grow, leading to the well known symptoms of alveolar

osteitis.[1]

Wound healing is a complex process and can be positively and negatively affected by many factors.[4]

Alveolar osteitis is the

most common healing disturbance of extraction sockets.[1]

Suppurative osteitis results when the disturbance of extraction socket wound healing occurs later, during the third stage of

healing from day 14 to 16 after extraction, and is a manifestation of the disruption ofconnective tissuedevelopment. This form

usually results from aninfectionand exhibits apurulent discharge(pus) from the extraction socket.[1]

Disruption of the extraction socket during an even later stage of healing might result in necrotizing osteitis in which

encapsulated shards of bone (bony sequestrae) will be noted alongside inflammatory cells.[1]

Prevention

True alveolar osteitis, as opposed to simple postoperative pain, occurs in only about 13% of extractions.[5]

No one knows for

certain how or why dry sockets develop followingdental extractionbut certain factors are associated with increased risk. One of

these factors is the complexity of the extraction.Smokingmay be a contributing factor, possibly due to the decreased amount of

oxygen available in the healing tissues. It is advisable to avoid smoking for at least 48 hours following tooth extraction to reduce

the risk of developing dry socket.

Women are generally at higher risk than men of developing alveolar osteitis, becauseestrogenslows down healing. Dentists

recommend that their female patients have extractions performed during the last week of their menstrual cycle, when estrogen

levels are lowest, to minimize chances of developing alveolar osteitis.[6]

Treatment

The pain from alveolar osteitis usually lasts for 2472 hours. There is no real treatment for alveolar osteitis; it is aself-

limitingcondition that will improve and disappear with time, but certain interventions can significantly decrease pain during an

episode of alveolar osteitis. These interventions usually consist of a gentle rinsing of the inflamed socket followed by the direct

placement within the socket of some type of sedative dressing, which soothes the inflamed bone for a period of time and
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promotes tissue growth. This is usually done without anesthesia.[7]

The active ingredients in these sedative dressings usually

include substances like,zinc oxide,eugenol, andoil of cloves. It is usually necessary to have this done for two or three

consecutive days, although occasionally it can take longer. Because true alveolar osteitis pain is so intense,

additionalanalgesicsare sometimes prescribed.
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Documents

Ludwig Angina Dry Socket