Introduction
Noma, also commonly known as cancrum oris, is a gangrenous orofacial infection with rapid, widespread destruction and facial disfigurement that manifests within a span of a few days or months. It specifically impacts severely malnourished children in lower or middle-socioeconomic countries. Read the article to know the cause of high mortality rates, the clinical sequelae, and the oro-systemic management of this deadly disease.
Why Is Noma Disease Globally Neglected?
Noma was first reported as the earliest disease in medical history, tracing back to the time of Hippocrates around 460 to 370 BC. Despite the major developments in health and medical research, noma remains poorly understood and is known to be a neglected disease worldwide. This is because of major gaps in public awareness, a lack of knowledge in lower socioeconomic countries, lack of understanding of the complex systemic etiology of this disease.
Given the remoteness of the patients who are affected in the rural areas, usually in lower and middle socioeconomic countries, and the apparently high mortality rate, the nature of the lesion is difficult to interpret. It requires comprehensive medical attention by professionals as it is a severe gangrenous form that affects the orofacial cavity.
What Are the Symptoms of Noma?
The reported mortality rate for untreated patients of noma is 90 % within a few weeks once the disease has onset with the initial symptoms. The patients who survive the initial stage of noma still may have to face many functional challenges like difficulty eating and speaking because of the oral and facial debilitation. This fatal infection initially targets the oral soft tissue structures or the mucous membranes such as the tongue, lips, cheek mucosa, jaw bone, and teeth, or hard structures later on. The lesions start as an ulcer of the oral soft tissues and when left untreated will involve an extensive area of the oral cavity and resulting in the breaching of the oral immune defense devastatingly.
Who Are at Risk for Noma?
Noma usually affects children who are prone to malnutrition and systemic disease, especially between two to five years of age. However, case reports suggest children are affected for up to 16 years of age as well. There are numerous case reports from the populations hailing from low-income settings in Africa and Asia. The World Health Organization (WHO) estimates nearly that 140,000 cases of noma occur annually impacting children.
What Are the Risk Factors of Noma?
The main risk factors for noma are
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Chronic malnutrition.
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No access to basic healthcare facilities like health checkups, pediatric facilities, or immunizations.
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Children with comorbidities like measles and human immunodeficiency virus (HIV).
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Lack of oral hygiene awareness in public health care systems in the affected populations especially in low and socioeconomic countries, and lack of oral diagnosis in these regions because of a dearth of healthcare professionals.
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Poor sanitation can lead to the spread of communicable diseases and systemic disease development.
What Is the Clinical Sequelae of Noma?
The sequence of clinical events that lead to noma formation is quite rapid and of acute nature and even possible that before the patient notices the nature of the infection, their life would be at potential risk of increased mortality.
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Necrotizing Gingivitis - The first step in this chain of poly-bacterial infection is the occurrence of necrotizing gingivitis. This condition is characterized by severe bleeding, marginal necrosis, and pain in the gums. Regional lymphadenopathy (swelling or enlargement of single or multiple lymph nodes) can also be observed.
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Ulcerated Necrotizing Gingivitis or Necrotizing Periodontitis - When necrotizing gingivitis condition is left untreated, it progresses a step further to untreated or ulcerated necrotizing gingivitis or necrotizing periodontitis. This condition is characterized by extensive gum ulceration and bone destruction in the affected jaws, particularly in immuno‐suppressed, malnourished, and debilitated individuals. This condition may progress at a very acute pace eventually extending beyond the mucogingival junction and leading to necrotizing stomatitis.
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Necrotizing Stomatitis - In this stage the affected gum tissues become very friable, and swollen, and appear with a characteristic blue‐gray color to the skin. The oral tissue is rather sloughed and it leaves a full circular defect that goes by the name medically termed " noma ".
How Is Noma Managed?
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It is important to address the underlying systemic conditions that favor the growth and replication of microorganisms in the patient's orofacial cavity. Timely recognition and elimination of this rampant and acute infection can be life-saving. The address of the etiology of the disease like malnutrition, immune suppression, or debilitation should be made a priority by the physician. Subjects with noma should be treated on an emergency basis and public healthcare facilities should ensure urgent admission to the hospital, immediate intravenous broad-spectrum antibiotic therapy, fluid, and electrolyte supplementation along with nutritional supplementation. This condition hence calls for a comprehensive medical care team.
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Early diagnosis and timely antibiotic treatment for patients suffering from any of the intra‐oral necrotizing conditions that may eventually progress to noma can prolong the patient's life span considerably.
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Surgical Management: An extensive reconstructive surgery should be performed by an oral and maxillofacial surgeon to retain the function and esthetics of patients who suffer the physical and mental trauma associated with severe facial disfigurement. An oral surgeon will then eliminate the local factors that favor infection like professional plaque control, control of gingival inflammation, and thorough antibiotic therapy to destroy the oral commensals.
Conclusion
The survivors of noma are those who are diagnosed on time and treated by the medical emergency team without any delay. As these patients may experience severe functional impairment, and psycho‐social consequences because of facial disfigurement, it is important that public health measures and qualified medical professionals must reach out to them and also educate the rural or underdeveloped areas of global populations to detect, diagnose and get timely treatment for noma.
