Noma (disease)

Noma, also known as cancrum oris, is a rapidly progressive and destructive gangrenous disease affecting the face and mouth. It primarily affects malnourished children, particularly those living in conditions of extreme poverty, with poor oral hygiene, and compromised immune systems often following debilitating illnesses like measles, malaria, or severe bacterial infections.

The disease typically begins as a gingivitis or a small ulcer on the gums (often near the roots of the teeth), which rapidly progresses to necrotizing ulcerative gingivitis (NUG) and then spreads to the surrounding soft tissues and bone of the face. This necrosis can lead to severe disfigurement, functional impairment (difficulty eating, speaking), and even death if left untreated.

Etiology and Risk Factors:

While the exact cause of noma is not fully understood, it is generally considered to be a polymicrobial infection involving a synergistic combination of bacteria, including Fusobacterium necrophorum and Prevotella intermedia. These bacteria are opportunistic pathogens that take advantage of weakened immune systems and poor oral hygiene.

Major risk factors include:

• Malnutrition: Protein-energy malnutrition and vitamin deficiencies weaken the immune system.
• Poor Oral Hygiene: Lack of access to proper dental care and oral hygiene practices allows bacteria to proliferate.
• Compromised Immunity: Underlying conditions like HIV/AIDS, measles, malaria, and other infections impair the immune response.
• Poverty and Unsanitary Conditions: Living in poverty increases exposure to unsanitary conditions and infections.

Symptoms:

The progression of noma typically involves the following stages:

1. Gingivitis/Ulcer: A small ulcer develops on the gums.
2. Noma Floridum: Rapid spread of necrosis to surrounding tissues, characterized by swelling, edema, and a foul odor.
3. Sequestrum Formation: Dead tissue separates from healthy tissue, forming a sequestrum.
4. Scarring and Disfigurement: Once the infection is halted, severe scarring and disfigurement may remain.

Diagnosis:

Diagnosis is primarily clinical, based on the characteristic appearance of the lesions and the rapid progression of the disease. Laboratory tests may be used to identify the specific bacteria involved.

Treatment:

Treatment involves a multi-faceted approach:

• Antibiotics: Broad-spectrum antibiotics are crucial to control the bacterial infection.
• Nutritional Rehabilitation: Addressing malnutrition is essential to strengthen the immune system.
• Wound Care: Local wound care involves debridement of necrotic tissue and meticulous oral hygiene.
• Surgical Reconstruction: Surgical procedures may be necessary to reconstruct the face and improve function after the infection is controlled.
• Pain Management: Analgesics are used to manage pain.

Prevention:

Prevention is key to reducing the incidence of noma. Effective strategies include:

• Improving Nutrition: Addressing malnutrition through fortified foods and supplements.
• Promoting Oral Hygiene: Educating communities on proper oral hygiene practices.
• Vaccination: Immunizing children against preventable diseases like measles.
• Early Treatment of Infections: Promptly treating other infections that can weaken the immune system.
• Improving Socioeconomic Conditions: Addressing poverty and improving access to healthcare and sanitation.

Prognosis:

The prognosis depends on the stage of the disease at diagnosis and the availability of treatment. Early intervention with antibiotics and nutritional support can significantly improve outcomes. Without treatment, noma can be fatal in up to 70-90% of cases. Even with successful treatment, significant facial disfigurement and functional impairment can remain, requiring extensive reconstructive surgery.