Severe cellulitis involving the floor of the mouth, caused by dental disease, and high risk of mortality. It could be prevented if good oral hygiene and early detection for treatment properly.

06/02/2020 15:01

In Vietnamese expression said : Teeth and hair are important parts of the body, meaning  it’s  not only known as a beauty, also health issue we have to care.


In 4th Feb, 2020 Viet Duc Hospital has received and treated surgically on emergency one particular patient related to oral issue. It was elderly female patient, Tran Thi M., 76, address at Nghia Tan Nghia Hung, Nam Dinh. The patients’ relatives have shared that patient had toothache in two weeks, tried to manage it at home because she did not want to be caring in the hospital when the Chinese Lunar new year was coming up closely. However with no relief, continuous high fever, swollen face, difficulty swallowing and speaking due to stiff jaw so the family takes her into emergency at Nam Dinh Hospital firstly, then moved National Hospital of Odonto- Stomatology and VietDuc hospital last one. Upon arrival, the patient was quickly examined, blood tested and underwent x ray examination. The diagnosis of severe cellulitis involving the floor of the mouth, caused by dental disease was confirmed and she was operated on for emergency.


Operations proceed smoothly with the large incision performed under the jaw and  hundred ml of bad smell odor pus drained, commonly in the oral cavity, spreading to the neck and nearly extending to mediastinum. After the operation, the patient is stable, alert with the endotracheal tube for airway management, no fever. The  drainage for continuous irrigation system over the abscess, combining high doses of spectrum antibiotics and resuscitation. The skin is open and expecting to close after 7 to 10 days.

The patient after operation

Big abscess located under the left jaw and extended to neck areas

According to Associate Professor. Nguyen Duc Chinh, head of the Department of Septic Surgery and Wound Care, also head of the surgical team, said: Severe cellulites of mouth spreading the floor area is acute infectious disease, potential lethal. In severe cases, patients can die quickly due to sepsis, especially due to a compromised airway by pressure of abscess to the throat and tongue, even push tracheal to the opposite side, therefore the patient can not swallow nor breathe.


The disease was first described by German physician Wilhelm Frederick von Ludwig in 1836 to later disease called severe cellulites involving mouth floor – Ludwig angina. End of 19th century, early 20th century, the mortality rate was very high because of not understanding disease well, lack of knowledge of dental hygiene and no antibiotics.


Disease characterized by widespread necrosis, not limited to the mouth floor. Infections due to combination of both aerobic bacteria and anaerobic caused  severe condition and poor prognosis. Most of the infections from the large lower teeth spread in the mouth floor. Apart from dental causes, diffuse inflammatory mouth floor also by acute inflammation of the submandibular salivary gland abscess, necrosis of the lymph nodes around neck…


Manifestations: In the early days of high fever patients is 39 – 40 degree Celsius then appeared shocked infection, urine less, patient so painful and nervous, difficulty breathing, and swallowing with very bad odor breath. Blood tests showed higher leukocyte especially Polymorphonuclear leukocytes, and disorder of liver and kidney functions. Blood cultures may be positive in case of sepsis.


Clinical examination: Swelling under the jaw to the floor on one side mouth then rapidly spread to the opposite side. It can spread down from the neck to the chest. Pear-shaped face, red skin, some may find a bit scratchy signs subcutaneous (due to gas gangrene). Half open month posture (mouth can not open or shut up), tongue us pushed up and dropped off the mouth causing difficulty breathing, swallowing and speaking. High secretion of saliva with bad smell also happened. Check in the mouth can see the cause of death marrow teeth, inflammation around the teeth..


Treatment: Systemic high-dose spectrum antibiotics to control infection; steroidal drug could be used; fluid resuscitation and ventilation by endotracheal tube or tracheotomy on emergency.


Surgical treatment: Large incision to open abscess and to drain pus as soon as possible. Incision could be from the angle jaw side to angle jaw side in a horseshoe  sharp in order to communicate all the abscess and removal of necrosis, then put the drainages for continuous irrigation with saline serum. The causes of infection will be checked and treated later.

Abscess descending to neck and chest areas

Incision to drain pus .


Ass. Prof. Nguyen Duc Chinh said that in addition to oral hygiene, treatment of mouth diseases for the prevention of disease. If the patients see signs of disease as above mentioned, they should soon go to the qualified medical facilities to be cared, absolutely not self-medication because is dangerous to life. Recently Viet Duc Hospital has treated successfully many case of Ludwig angina most of the teeth cause with good results. However, there are some deaths due to the patient came to hospital too late in shocked unconscious caused by toxic infection although surgery and the resuscitation could not save lives.


Nguyễn Đức Chính, BV HN Việt Đức



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