Noma (disease)

Noma or cancrum oris is a rapidly progressive often gangrenous

Noma
infection of the mouth and face.[2]
Other cancrum oris, fusospirochetal
names gangrene, necrotizing ulcerative
stomatitis, stomatitis gangrenosa[1]
Contents
Signs and symptoms
Causes
Treatment
Prognosis
Society and culture
See also
References
A man afflicted with noma
Further reading
Specialty Gastroenterology
External links

Signs and symptoms

The mucous membranes of the mouth develop ulcers, and rapid, painless tissue
[3]
degeneration ensues, which can degrade tissues of the bones in the face.

Causes
Noma affects extremely impoverished and malnourished children in sub-Saharan
countries and other tropical regions; while some bacterial organisms are often found
in affected children, these same bacteria are widespread. The underlying causes for
[4][5]
this disease are primarily poverty and malnutrition.

Fusobacterium necrophorum and Prevotella intermedia are important bacterial

pathogens in this disease process, interacting with one or more other bacterial
organisms (such as Borrelia vincentii, Porphyromonas gingivalis, Tannerella
forsythia, Treponema denticola, Staphylococcus aureus, and certain species of
nonhemolytic Streptococcus).[6] Treatment of these organisms can help arrest the Noma (sketch from 1836)
infection, but does not restore already-missing or disfigured tissue.

It is often reported as a sequela toacute necrotising ulcerative gingivitis. Predisposing factors include:[7][8]

malnutrition (particularly A-and B-vitamins) or dehydration

poor hygiene, particularly oral
unsafe drinking water
proximity to unkempt livestock
recent illness
an immunodeficiency disease, including AIDS
measles
smoking
Treatment
Known in antiquity to such physicians as Hippocrates and Galen, noma was once reported around the world, including Europe and
the United States. With improvements in hygiene and nutrition, noma has disappeared from industrialized countries since the 20th
century, except during World War II when it was endemic to Auschwitz and Belsen concentration camps.[9] The disease and
treatments were studied by Berthold Epstein, a Czech physician and forced-labor prisoner who had recommended the study under
Josef Mengele's direction.[9]

The progression of the disease can be halted with the use of antibiotics and improved nutrition; however, its physical effects are
permanent and may require oral and maxillofacial surgery or reconstructive plastic surgery to repair. Reconstruction is usually very
[10]
challenging and should be delayed until full recovery (usually about one year following initial intervention).

Prognosis
The disease is associated with high morbidity and mortality[11] and affects mainly children in the poorest countries of Africa.
Children in Asia and some countries of South America are also highly affected. Most children who get the disease are between the
ages of two and six years old.[12] The WHO estimates that 500,000 people are affected, and that 140,000 new cases are reported each
year.[13] The mortality rate is approximately 90 percent.[1]

Society and culture

Children and other noma survivors in Africa are helped by a few international charitable organizations, such as Facing Africa, a UK
registered charity that helps affected Ethiopian, and Swiss charity Winds of Hope.[14] There is one dedicated noma hospital in
Nigeria, the Noma Children Hospital Sokoto, staffed by resident and visiting medical teams. In other countries, such as Ethiopia,
international charities work in collaboration with the local health care system to provide complex reconstructive surgery which can
give back facial functions such as eating, speaking and smiling. Teams of volunteer medics coming from abroad are often needed to
support the local capacity to address the most severe cases, which can be extremely challenging even for senior maxillofacial
surgeons.[15] On 10 June 2010 the work of such volunteer surgeons was featured in a UK BBC Two documentary presented by Ben
Fogle, Make Me a New Face: Hope for Africa's Hidden Children. Recently a case was reported from Nepal where the 19-year-old
girl received free surgical treatment in Chitwan Medical College, Bharatpur; the team of surgeons was led by Dr. Sushil Subedi, Oral
and Maxillofacial surgeon and the head of Department.[16][17]

See also
Necrotizing fasciitis

References
1. Marck KW (April 2003)."A history of noma, the "Face of Poverty" " (https://www.ncbi.nlm.nih.gov/pubmed?term=126
55218). Plastic and Reconstructive Surgery. 111 (5): 1702–7. doi:10.1097/01.PRS.0000055445.84307.3C(https://do
i.org/10.1097%2F01.PRS.0000055445.84307.3C) . PMID 12655218 (https://www.ncbi.nlm.nih.gov/pubmed/1265521
8).
2. Enwonwu CO, Falkler WA, Phillips RS (July 2006). "Noma (cancrum oris)".Lancet. 368 (9530): 147–56.
doi:10.1016/S0140-6736(06)69004-1(https://doi.org/10.1016%2FS0140-6736%2806%2969004-1) . PMID 16829299
(https://www.ncbi.nlm.nih.gov/pubmed/16829299).
3. "AllRefer Health - Noma (Cancrum Oris, Gangrenous Stomatitis)"(https://web.archive.org/web/20070528130856/htt
p://health.allrefer.com/health/noma-info.html). Archived from the original (http://health.allrefer.com/health/noma-info.h
tml) on 2007-05-28. Retrieved 2007-07-12.
 4. Srour ML, Marck K, Baratti-Mayer D (February 2017)."Noma: Overview of a Neglected Disease and Human Rights
Violation" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5303022). The American Journal of Tropical Medicine and
Hygiene. 96 (2): 268–274. doi:10.4269/ajtmh.16-0718(https://doi.org/10.4269%2Fajtmh.16-0718). PMC 5303022 (ht
tps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5303022). PMID 28093536 (https://www.ncbi.nlm.nih.gov/pubmed/2809
3536).
5. Enwonwu CO, Falkler WA, Phillips RS (July 2006). "Noma (cancrum oris)".Lancet. 368 (9530): 147–56.
doi:10.1016/S0140-6736(06)69004-1(https://doi.org/10.1016%2FS0140-6736%2806%2969004-1) . PMID 16829299
(https://www.ncbi.nlm.nih.gov/pubmed/16829299).
6. Neville, Brad. Oral and Maxillofacial Pathology(3rd ed.). Saunders Book Company. pp. 062008. 5.11.
7. Enwonwu CO (January 2006). "Noma--the ulcer of extreme poverty".The New England Journal of Medicine. 354 (3):
221–4. doi:10.1056/NEJMp058193(https://doi.org/10.1056%2FNEJMp058193). PMID 16421362 (https://www.ncbi.n
lm.nih.gov/pubmed/16421362).
8. Enwonwu CO, Falkler WA, Phillips RS (July 2006). "Noma (cancrum oris)".Lancet. 368 (9530): 147–56.
doi:10.1016/S0140-6736(06)69004-1(https://doi.org/10.1016%2FS0140-6736%2806%2969004-1) . PMID 16829299
(https://www.ncbi.nlm.nih.gov/pubmed/16829299).
9. Lifton RJ (1986). The Nazi Doctors: Medical Killing and Psychological Genocide
. Basic Books. p. 361. ISBN 978-0-
465-04905-9.
10. Neville, Brad. Oral and Maxillofacial Pathology, 3rd Ed. Saunders Book Company, 062008. 5.11.2
11. Barmes DE, Enwonwu CO, Leclercq MH, Bourgeois D, Falkler W A (1997). "The need for action against oro-facial
gangrene (noma)". Trop Med Int Health. 2 (12): 1111–1114. doi:10.1046/j.1365-3156.1997.d01-220.x(https://doi.org/
10.1046%2Fj.1365-3156.1997.d01-220.x).
12. "The European Noma-Network"(http://www.noma-project.de/htmlversion/indexhtml.html). Retrieved 2007-07-12.
13. Bourgeois DM, Leclercq MH (1999). "The W orld Health Organization initiative on noma".Oral Dis. 5 (2): 172–174.
doi:10.1111/j.1601-0825.1999.tb00085.x(https://doi.org/10.1111%2Fj.1601-0825.1999.tb00085.x) .
14. Fondation Winds of Hope(http://www.windsofhope.org/?lang=en)
15. Medical care (http://projectharar.co.uk/medical_care.html)at Project Harar
16. "Make Me a New Face: Hope for Africa's Hidden Children"(http://www.bbc.co.uk/programmes/b00sqlrg). BBC. June
2010. Retrieved January 13, 2016.
17. Fogle, Ben (July 6, 2010)."Ben's Documentary on Noma - BBC2"(http://www.benfogle.com/585). BenFogle.com.
Retrieved January 13, 2010.

Further reading
Tonna JE, Lewin MR, Mensh B (December 2010). Franco-Paredes C (ed.)."A case and review of noma". PLoS
Neglected Tropical Diseases. 4 (12): e869. doi:10.1371/journal.pntd.0000869. PMC 3006140. PMID 21200428.
Boss K, Marck K (2006).The Surgical Treatment of Noma (in Dutch). Alphen aan den Rijn : Belvédère/Mediadact.
ISBN 978-90-71736-31-5.

External links
Classification ICD-9-CM: 528.1 · D
MeSH: D009625
External MedlinePlus:
resources 001342

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