NOMA: A Preventable "Scourge" of African Children

Abstract

Noma is a serious orofacial gangrene originating intraorally in the gingival-oral mucosa complex before spreading extraorally to produce a visibly destructive ulcer. Although cases of noma are now rarely reported in the developed countries, it is still prevalent among children in third world countries, notably in sub-Sahara Africa, where poverty, ignorance, malnutrition, and preventable childhood infections are still common. This review summarizes historical, epidemiological, management, and research updates on noma with suggestions for its prevention and ultimate global eradication. The global annual incidence remains high at about 140,000 cases, with a mortality rate exceeding 90% for untreated diseases. Where the patients survive, noma defects result in unsightly facial disfigurement, intense scarring, trismus, oral incompetence, and social alienation. Although the etiology has long been held to be infectious, a definitive causal role between microorganisms cited, and noma has been difficult to establish. The management of noma with active disease requires antibiotics followed by reconstructive surgery. Current research efforts are focused towards a comprehensive understanding of the epidemiology, and further elucidation of the microbiology and pathogenesis of noma.Although a formidable public health challenge, noma can be prevented with a potential for subsequent global eradication. To achieve both desirable goals, detection of early disease is crucial because these early lesions respond to conventional antibiotic treatments when instituted side by side with nutritional rehabilitation, and obviates the necessity for extensive surgical reconstruction often indicated in late stage disease. The eradication of noma in the developed world in the mid 20(th) century bears out the notion of a similar outcome following effective preventive strategies in Africa. A fundamental and necessary step towards attaining this goal is for the international community to adopt a perception of noma as an urgent global public health challenge. Research effort toward deciphering the microbiology, molecular events, and pathogenesis of noma also should intensify.

Keywords: Acute Ulcerative Gingivitis; Cancrum Oris; Noma; Preventable Disease; Sub-Sahara Africa; Surgical Management..

Fig. (1)

Acute necrotizing ulcerative gingivitis (ANUG) showing characteristic punched-out crater-like ulcers. (see also Fig. 2B).

Fig. (2)

Patients with measles (A and B). Measles (B; arrow) usually antedate ANUG. (B; arrow).

Fig. (3)

Necrotic (Arrow ) erythematous ulcer still confined to the alveolus and gingiva. This may represent the so-called “early noma” lesion.

Fig. (4)

Advanced noma lesions. A. Rapidly destructive and fulminating disease requiring lengthy antibiotic treatment prior to surgery. B. Arrested advanced disease requiring short course of antibiotics before surgical reconstruction (arrow indicates sequestrum formation (4A is adapted from Noma Project, Courtesy of Noma Children Hospital, Sokoto, Nigeria).