Elsevier

The Lancet

Volume 368, Issue 9530, 8–14 July 2006, Pages 147-156
The Lancet

Seminar
Noma (cancrum oris)

https://doi.org/10.1016/S0140-6736(06)69004-1Get rights and content

Summary

Noma is an opportunistic infection promoted by extreme poverty. It evolves rapidly from a gingival inflammation to grotesque orofacial gangrene. It occurs worldwide, but is most common in sub-Saharan Africa. The peak incidence of acute noma is at ages 1–4 years, coinciding with the period of linear growth retardation in deprived children. Noma is a scourge in communities with poor environmental sanitation. It results from complex interactions between malnutrition, infections, and compromised immunity. Diseases that commonly precede noma include measles, malaria, severe diarrhoea, and necrotising ulcerative gingivitis. The acute stage responds readily to antibiotic treatment. The sequelae after healing include variable functional and aesthetic impairments, which require reconstructive surgery. Noma can be prevented through promotion of national awareness of the disease, poverty reduction, improved nutrition, promotion of exclusive breastfeeding in the first 3–6 months of life, optimum prenatal care, and timely immunisations against the common childhood diseases.

Section snippets

Global burden of noma

Noma was not always restricted to tropical or African countries.2, 10 It was common in Europe until the end of the 19th century.1, 2 Noma disappeared from more developed countries in the 20th century, except for cases reported in the concentration camps of Bergen-Belsen and Auschwitz18, 19 and, more recently, in association with intense immunosuppressive therapy,20 in patients with HIV infection or AIDS,8, 9 as well as in native American children with severe combined immunodeficiency syndrome.21

Clinical presentation, progression, and sequelae

Many patients with acute noma present with a range of features reflecting pre-existing, debilitating health conditions. They include fever (temperature 38·3–40·5°C), tachycardia, high respiratory rate, and anorexia. The medical history generally shows recurrent fevers, diarrhoea, and infections with parasites (eg, malaria) and viruses (eg, measles, herpes) in the recent past.1, 2, 3, 5 Severe anaemia, with haemoglobin concentrations as low as 50–60 g/L, white-blood-cell counts of 20–30×109 per

Orofacial features

The orofacial lesion can occur unilaterally or bilaterally, but it is unilateral in many cases. Descriptions of the initial stages are inconsistent because the disease is generally well established before the victim seeks medical help.1, 2, 16 The early features include soreness of the mouth, pronounced halitosis, foetid taste, tenderness of the lip or cheek, cervical lymphadenopathy, a foul-smelling purulent oral discharge, and a blue-black discolouration of the skin in the affected area.1, 3,

Differential diagnosis of noma

The disorder known as noma neonatorum affects newborn and preterm infants and clinically resembles noma in children.47, 48, 49 The necrotic lesion, generally in the oronasal region, develops during the first month of life; in most cases, there is evidence of infection with Pseudomonas aeruginosa, Escherichia coli, klebsiella, or staphylococci.47, 48 Except for one case in a preterm baby in the USA,50 virtually all the reported cases have been in infants born in India, China, Lebanon, or Israel.

Microbiology

The earliest bacteriological studies of noma were described by Weaver and Tunnicliff in 1907.57 An important major microscopic observation is the presence of large numbers of fusiform bacilli and spirochaetes.1, 16, 57 Hicken and Eldredge58 suggested that a symbiotic association of fusiform bacilli with a non-haemolytic streptococcus and Staphylococcus aureus was needed to produce noma. Emslie40 observed that these organisms were predominant in smears from patients with acute noma but also

Risk factors for noma

Noma has not been reported in healthy, privileged African children.13, 22 Poverty is the key risk factor in Africa2, 3, 22 and elsewhere.43, 44 A retrospective study of 173 cases at a hospital in Nigeria showed that 98% were from very poor homes with a mean of seven children per family.76 The global dimensions of poverty and its health implications, particularly malnutrition, are well documented.77 Chronic malnutrition is a major predisposing factor in all countries reporting noma.2, 3, 13, 16

Treatment of acute noma

The key points of management during the acute phase of noma (panel 1) are prompt admission to hospital, correction of dehydration and electrolyte imbalance, nutritional rehabilitation to correct energy deficit and deficiencies of proteins and micronutrients, treatment with antibiotics, daily dressing of the lesion with gauze soaked in oral antiseptic, and treatment of associated systemic diseases.2, 16, 86 Some researchers16 recommend the use of a broad-spectrum antibiotic, whereas others86

Prevention and early detection of noma

Noma is encountered mainly in underprivileged, illiterate, remote communities. It becomes established very rapidly, leaving patients little time to seek medical assistance. Parents, and even many health personnel, know little about the disease. Information campaigns are therefore needed at national, regional, and village levels. All health personnel, including physicians and dentists, should routinely screen at-risk children for early signs of noma (panel 2), and suspected cases should be

Proposed pathogenesis of noma

There is a three-way relation between malnutrition, immune dysfunctions in the host, and increased susceptibility to infections.91, 92, 93, 94, 95 As shown in figure 8 under the broad umbrella of poverty, this relation tends to be synergistic91, 94 and results in impaired oral mucosal immunity. In African communities at risk of noma, the adverse consequences of IUGR, which include impaired development of immune function, especially cell-mediated immunity,96, 97 become apparent in early

Search strategy and selection criteria

We did a comprehensive search of scientific publications including databases OLD MEDLINE via OVID (1951–65), MEDLINE via PubMed (1950–2005), and ISI web of science. The search terms used were “noma”, “cancrum oris”, “oral gangrene”, “orofacial necrosis”, “necrotiz[s]ing ulcerative gingivitis”, and “noma, malnutrition AND oral health”, “noma AND measles”, “noma AND viral infections”, and “noma AND HIV/AIDS”. Many published reports on noma were also identified through searches of COE's

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