Noma staging: a review

Abstract

Noma is a bacterial, non-communicable, grossly destructive and disfiguring necrotising oro-facial disease. It is rare, but occurs most commonly in chronically malnourished children with other debilitating illnesses, in remote, poverty-stricken communities, mainly in sub-Saharan Africa, and much more rarely in central Latin America and in parts of Asia. In South Africa and in Zimbabwe, noma is observed, again rarely, in immunosuppressed HIV-seropositive subjects. The World Health Organization (WHO) has classified noma into five sequential stages: stage 1, acute necrotising ulcerative gingivitis; stage 2, oedema; stage 3, gangrene; stage 4, scarring; stage 5, sequela. In the opinion of the authors, this WHO classification requires fundamental re-appraisal. The purpose of this viewpoint article is to highlight the weaknesses of this classification, and to propose a simpler, more logical and practical evidence-based staging of noma, which if used should improve the quality and value of future epidemiological data about noma.

Keywords: Acute noma; Arrested noma; Necrotising gingivitis; Necrotising periodontitis; Necrotising stomatitis; Noma classification.

Fig. 1

Necrotising gingivitis adult HIV-seropositive subject: gingival marginal necrosis and truncation of interdental papillae

Fig. 2

Necrotising periodontitis adult seropositive subject: necrotic gingiva has separated; necrosis advancing into periodontium

Fig. 3

Necrotising stomatitis lower labial mucosa, following necrotising gingivitis: ‘contact’ spread: young HIV-seropositive male

Fig. 4

a, b Acute noma in malnourished impoverished juvenile: (b) and the arrested noma shortly after removal of the full-thickness necrotic buccal/facial tissue. Surgical reconstruction poses a major challenge.

Fig. 5

Arrested noma in a mature HIV-seropositive male, about 9 months after acute noma of cheek, before reconstructive surgery. The whitish material is food and tissue debris