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Vincent and Ludwig angina: Two damaging oral infections

Carlson, Dorothy S. DEd, RN; Pfadt, Ellen PhD(c), RN

doi: 10.1097/01.NURSE.0000392916.76411.2f
Feature

Be prepared to intervene if your patient has one of these painful, potentially serious disorders.

Dorothy S. Carlson and Ellen Pfadt are associate professors of nursing at Edinboro University of Pennsylvania, Edinboro, Pa.

Figure. Vi

Figure. Vi

WHEN NURSES FIRST read the diagnoses Vincent angina and Ludwig angina, they may think of chest pain or anginal equivalent symptoms suggesting myocardial ischemia. True, angina pectoris is the most familiar type of angina. But angina, a Latin word for sharp, choking, or suffocating pain, also describes several disorders of the oral cavity caused by bacterial infections. Although similar, Vincent angina and Ludwig angina differ in location, clinical manifestations, and management. This article reviews both conditions and implications for nursing care.

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Vincent angina: Acute gingival infection

Known by various names, including acute necrotizing ulcerative gingivitis and trench mouth, Vincent angina is an acute bacterial infection of the gingiva caused by spirochetes, such as Borrelia vincentii, fusiform bacteria, or an overgrowth of normal oral flora. Predisposing factors include poor oral hygiene, advancing age, impaired nutritional status, smoking or chewing tobacco, immunosuppression, preexisting gingivitis, extreme stress, or lack of sleep.1–3 In this country, younger adults are most often affected, but in developing countries, it primarily occurs in children.4

Vincent angina typically has an abrupt onset, starting with a shallow ulcerated area of the gingival oral mucosa and interdental papillae. The tissue is erythematous and edematous, with a characteristic gray appearance.2,5 The ulcerated area may become deeper and irregular and spread to the oropharynx. Without treatment, the gingivae may become necrotic.

Initial signs and symptoms include halitosis; thick, increased oral secretions; bleeding gums; and localized cervical lymphadenopathy. The patient may complain of pharyngitis, otalgia, pain in the affected area, a foul taste in the mouth, and sometimes a choking sensation—hence the term "angina."

If the condition progresses, the periodontium may be destroyed. Possible systemic manifestations include fever, anorexia, weakness, and fatigue.2,5

Patients may be treated by a dentist or periodontist who performs thorough debridement under local anesthetic. The practitioner may prescribe oral antibiotics (usually penicillin or metronidazole for 7 to 10 days), antiseptic rinses, such as chlorhexidine gluconate, or a hydrogen peroxide mouthrinse to remove necrotic tissue.3,5

Other priorities include optimal pain management, adequate nutrition with a soft or bland diet, vitamin supplementation, and risk factor modification. Patients with severe infections may require I.V. antibiotics.1,3–5

Complications of untreated Vincent angina include spread of the infection beyond the gingiva to other facial tissue. Without proper debridement and antibiotic therapy, mortality may be as high as 70%.6 Tooth loss may also result from ineffective or delayed treatment.

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Nursing care for Vincent angina

The goals of nursing care are comfort and pain management, adequate nutrition, and patient education. Administer antibiotics and analgesics as prescribed, and assist with oral hygiene or provide mouth care every 2 to 4 hours with a soft toothbrush, toothette, or water pik. Don't use lemon-glycerin swabs, which dry and irritate tissue.

For the first few days of an acute episode, when brushing the teeth may be very painful, patients may prefer using oral rinses instead. Avoid alcohol-based mouthwashes, which irritate the gingivae. A warm saline rinse may be more comfortable for the patient and promote healing.6,7

Pain from Vincent angina can prevent a patient from consuming enough calories and fluids. Offer foods high in calories and protein, soft in texture, and lukewarm in temperature. Advise the patient to avoid extremely hot, spicy, or acidic foods that may further irritate or damage mucosa.

Note the patient's likes and dislikes to encourage adherence to the nutritional plan. Providing five to six small, frequent meals may be more appetizing than three larger meals. Monitor the patient's weight to estimate food consumption.

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Patient-teaching priorities

Assess patients with Vincent angina to identify the likely cause. Identifying and correcting predisposing factors is important to eradicate the infection and prevent a recurrence.

Educate patients about their condition, predisposing factors, and treatment, and include them in the decision-making process whenever possible. Patients and families who actively participate in care are more likely to achieve treatment goals and avoid future problems.

During nursing care, reinforce good oral hygiene, including flossing and brushing teeth after meals and before bedtime. Encourage regular visits to the dentist and hygienist. Reinforce the importance of taking antibiotics as prescribed.

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Ludwig angina: Acute and dangerous

A potentially life-threatening bacterial infection, Ludwig angina is a bilateral, aggressive, and rapidly spreading cellulitis of the sublingual and submaxillary spaces. Cellulitis is an inflammation of subcutaneous tissue that can spread to adjacent structures and deeper tissues.2,8,9

The infection begins in the floor of the mouth, most commonly related to the second or third mandibular molars, and rapidly spreads to sublingual and submandibular structures. Typically polymicrobial, Ludwig angina can be caused by normal oral cavity flora: Staphylococci, Streptococci, Bacteroides, and Fusobacterium.9,10

Most cases of Ludwig angina originate with a dental infection.8 Common contributing factors include poor oral hygiene, dental extraction, gingival infection, oral injury, lingual frenulum piercing-associated infections, and immunocompromised states.10

Often occurring in young adults, this disease has an abrupt onset and progresses rapidly to adjacent structures. Signs and symptoms include submandibular erythema, induration, and edema; fever; chills; malaise; stomatodynia (mouth pain), hoarseness; drooling; and dysphagia. The patient may report neck pain or stiffness, inability to close the mouth, otalgia, and fatigue. The patient may have a muffled voice or be unable to speak.8,9

Computed tomography is the imaging study of choice for diagnosing Ludwig angina.9 The provider may also order a Gram stain, culture, and sensitivity if a needle aspiration is performed, along with a complete blood cell count and differential, and blood cultures.

Interventions for Ludwig angina initially include airway management (which may include emergency tracheostomy), I.V. antibiotics, and pain management. A maxillofacial surgery or dental consultation may also be indicated for evacuation of abscess.10

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Beware airway obstruction

Ludwig angina can be fatal, but with prompt recognition and treatment, mortality has markedly decreased. The most serious complication is airway compromise. Prepare the patient for immediate intubation or tracheostomy, as indicated.2,9 If the airway may be compromised, fiberoptic intubation via the nasal route is recommended. Blind oral or nasotracheal intubation is considered unsafe in patients with advanced Ludwig angina because of the risk of severe laryngospasm, bleeding, and abscess rupture.8,10 Other possible complications are sepsis leading to septic shock and mediastinitis (rare).9

As with Vincent angina, preventing Ludwig angina starts with good oral and dental hygiene, regular dental checkups, and early treatment of mouth or tooth infections.

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Nursing care for Ludwig angina

Monitor the patient closely for airway compromise and other life-threatening complications. Ensuring that the patient has an open airway and is eupneic is the priority nursing goal. Frequently assess respirations, SpO2, breath sounds, and accessory muscle use. Immediately notify the healthcare provider of any abnormalities.

For patients with severe airway obstruction who have a tracheostomy tube, continue all of the above assessments and take measures to prevent tube obstruction. Help the patient cough and deep-breathe, humidify the oxygen source, and suction if needed. Prevent tracheostomy tube dislodgment by adequately securing the tube.

Evaluate and document the extent and progression of the cellulitis, administer antibiotics as prescribed, and monitor patient response to treatment. Pain management should include both pharmacologic and nonpharmacologic interventions, including administering prescribed analgesics, distraction, imagery, and maintaining a quiet environment.

After surgical intervention or drain placement, monitor the color, amount, and consistency of exudate. Maintain sterile technique for all nursing interventions involving the surgical area, including wound irrigation and packing, if prescribed.

Educate the patient about good oral hygiene, adherence to a preventive dental maintenance plan, early recognition of signs and symptoms indicating a problem requiring medical attention, and continuing prescribed treatment for its duration.

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Early recognition is the key

Knowledge about Vincent angina and Ludwig angina can help all nurses in clinical practice recognize these potentially serious oral infections, collaborate in care management, and provide patients with education to prevent future occurrences.

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REFERENCES

1. Black JM, Hawks JH. Medical-Surgical Nursing: Clinical Management for Positive Outcomes. 8th ed. St. Louis, MO: Saunders Elsevier; 2009.
2. Osborn KS, Wraa CE, Watson A. Medical-Surgical Nursing: Preparation for Practice. Upper Saddle River, NJ: Pearson-Prentice Hall; 2010.
3. Wilder RS, Moretti AJ. Gingivitis and peridontitis in adults: classification and dental treatment. UpToDate. 2010 .
4. Mayo Clinic. Trench mouth .
5. Trench mouth. MedlinePlus .
6. Stephen JM. Gingivitis. Emedicine. 2010 .
7. Lewis SL, Heitkemper MM, Dirksen SR, et al. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 7th ed. St. Louis, MO: Mosby Elsevier; 2007.
8. Ludwig's angina. MedlinePlus .
9. Chow AW. Submandibular space infections (Ludwig's angina). UpToDate. 2010 .
10. ENT emergencies: Ludwig's angina. Medscape .
© 2011 Lippincott Williams & Wilkins, Inc.