Sir, a 25-year-old male attended a Tier 2 primary care MOS service referred for extraction of the 36 molar under IV sedation. The referral stated the patient was suffering pain and had had multiple courses of antibiotics for repeated swellings. There was nothing of clinical importance in the medical history. A periapical radiograph was included (Fig. 1).

Fig. 1
figure 1

Pre-operative periapical radiograph of the lower left first molar included in referral. Deep secondary caries and associated periapical pathology noted

Full size image

A large swelling was visible under his chin and he reported a three-day history of worsening swelling with increased pain and difficulty swallowing. Examination revealed a bilateral submental and submandibular enlargement which was firm, tender and warm to touch. Mouth opening was limited to less than one finger. A degree of hoarseness was noted in the voice but he was able to complete full sentences. Baseline observations were unremarkable. Due to the presence of red-flag signs a provisional diagnosis of Ludwig's angina was reached and a prompt referral to the local OMFS unit arranged. The patient was blue-lighted to resuscitation. He underwent emergency surgery involving incision and drainage with extraction of the infected 36 under GA. Post-operatively he remained in hospital for several days due to significant swelling and active extra-oral drains. Fortunately, escalation to intensive care was avoided.

True Ludwig's angina is uncommon. It is named after German physician Karl Friedrich Wilhelm von Ludwig, who first described it in 1836. The word angina is derived from the Latin word for choke (angere).1 Sepsis is not uncommon with large swellings caused by a nidus of infection and can quickly result in multiple organ failure especially in those with underlying health conditions that cause immunosuppresion such as diabetes. This case serves to remind clinicians of the signs and symptoms when assessing and managing dental abscesses. It is crucial to consider these signs and symptoms especially in this COVID-19 pandemic where remote consultations and prescribing have become more commonplace. Providing a safety net for patients will reduce the risk of serious complications and this can be done by discussing the red flags and the actions to take:

  • Significant trismus

  • Bilateral submental and submandibular swelling

  • Muffled (hot potato) voice

  • Fever

  • Firm/raised floor of mouth

  • Limited/altered tongue mobility

  • Difficulty swallowing or drooling.

These signs can indicate a significantly worsening swelling requiring emergency management.