Tooth, Odontogenic Infection, Ludwig’s Angina
Tooth infections result from dental caries (cavities) and periodontal disease (gingivitis and periodontitis). Collectively, as they arise from the teeth, such infections are referred to as odontogenic.
Periapical tooth infections can extend and cause a variety of infectious complications:
Ludwig’s angina is a complication of an infected tooth and/or periodontal infection:
Rapidly progressive bilateral infection of the submandibular space leading to posterior displacement of the tongue with a choking (angina) sensation.Usually occurs in adults with infection of the mandibular teeth.Can occur after fracture of mandible or piercings of the frenulum or tongue.Other complications include: odontogenic sinusitis, cervical necrotizing fasciitis, cavernous sinus thrombosis, brain abscess Noma (also known as Cancrum oris) is a Variant in the malnourished manifest as severe necrotizing gingivitis
Most of the infections are polymicrobic; in general strict or facultative anaerobic bacteria predominate
Ludwig’s Angina: Surgical drainage and removal of necrotic tissue are essential!
Risk of airway compromise is increased 10x in the absence of surgical drainageRef.:Med Princ Pract 2018;27:362
Viridans group streptococci.
Peptostreptococci, Fusobacteria, Prevotella and Actinomyces.
In immunocompromised patients, worry about Staph. aureus and aerobic gram-negative bacteria.
Severe infection:Protect the airway
Immunocompetent: patient: Penicillin G 3 mU IV q6h + Metronidazole 500 mg IV q6h; add Vancomycin if gram-positive cocci in clusters on gram stain.
Vancomycin 1 gm IV q12h + Piperacillin-tazobactam 4.5 gm IV q6h.
Surgical debridement if abscess seen on CT scan or MRI.
Less severe infections:(Amoxicillin-clavulanate 875/125 mg po bid or 2000/125 mg bid) q12h.
Severe infections immunocompetent or immunocompromised:
Piperacillin-tazobactam 3.375 gm IV q6h or Meropenem 1 gm IV q8h.
Clindamycin 600 mg IV q6-8h