Academic journal article Bulletin of the World Health Organization

Noma: A Neglected Scourge of Children in Sub-Saharan Africa

Academic journal article Bulletin of the World Health Organization

Noma: A Neglected Scourge of Children in Sub-Saharan Africa

Article excerpt

Introduction

Noma (from the Greek nomen, "to devour") is a severe gangrene of the soft and hard tissues of the mouth, face, and neighbouring areas. This disease, also known as "cancrum oris", was described by Tourdes in 1848 as a "gangrenous affection of the mouth, especially attacking children in whom the constitution is altered by bad hygiene and serious illness, especially from the eruptive fevers, beginning as an ulcer of the mucous membrane with oedema of the face, extending from within out, rapidly destroying the soft parts and the bone, and almost always quickly fatal..." (1). This description is still very accurate today, except for the markedly reduced mortality rate resulting from the timely administration of appropriate antibiotic therapy. Survivors of the disease may exhibit facial mutilation, impaired growth of the facial skeleton, nasal regurgitation of food, leakage of saliva, defective speech, and chewing difficulties. Reconstructive surgery of the resulting deformity is very costly, and the results are often less than satisfactory in terms of improvement in the patient's quality of life.

Noma was well known in Europe and North America some centuries ago (1), but today is virtually nonexistent in developed countries. In marked contrast, the disease is still frequently seen in developing countries, especially in sub-Saharan Africa, where it occurs almost exclusively among poor children, usually aged 3-10 years (1-7). More ominous are recent data from WHO that suggest an escalating increase in the incidence of noma in developing countries, particularly in several famine-stricken parts of Africa (M.H. Leclercq, personal communication, 1994). In November 1992, WHO underscored the urgency of the situation by initiating a global information campaign on noma. Also in 1992, the WHO/Federation Dentaire Internationale (FDI) Joint Working Group on International Collaboration for Oral Health Research identified the disease as a major problem that would most benefit from shared international research, resources, and expertise (8). This view was reaffirmed on World Health Day 1994 (M.H. Leclercq, personal communication, 1994).

Some workers hold that noma begins as a purplish-red spot or indurated papule on the alveolar margin, most frequently in the premolar-molar region (1). The papule breaks down into an ulcer, which then extends to the labiogingival fold and onto the mucosal surfaces of the cheeks and lips (1, 2, 4, 9). Other workers maintain that noma of the face (cancrum oris) always starts as acute necrotizing gingivitis (ANG), a severe, painful form of gingivitis characterized by bleeding and necrosis of the interproximal papillae (4-6, 9). The early features of cancrum oris include soreness of the mouth, a swollen, tender, painful lip or cheek, a foul-smelling purulent discharge, and a bluish-black discoloration of the skin in the affected area (1, 2). The gangrene, once started, establishes itself rapidly, often in a matter of days, but remains remarkably well demarcated. Following separation of the soft tissue slough, sequestration of the exposed bone and teeth occurs rapidly.

In developing countries, noma is a neglected health problem that robs many children, particularly in Africa, of their future. In this review, widely held views on the cause of noma are reappraised in the light of recent observations. Also, a readily testable hypothesis is proposed, which suggests that in the presence of certain specific microorganisms any oral mucosal ulcer, and not only ANG, is potentially capable of evolving into cancrum oris in a malnourished, Bimmunosuppressed child

Risk factors for noma

An important risk indicator for noma in African children is poverty (1, 9). The known risk factors associated with an increased probability of the disease developing in a given individual include malnutrition (particularly protein-energy malnutrition and vitamin A deficiency), poor oral hygiene, and a state of debilitation, often resulting from malaria, measles, and other childhood diseases prevalent in the tropics (1, 2, 6, 10, 11). …

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