Noma (cancrum oris)

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.

[1]  R. Chandra.  1990 McCollum Award lecture. Nutrition and immunity: lessons from the past and new insights into the future. , 1991, The American journal of clinical nutrition.

[2]  L. Holdeman,et al.  The pathogenic anaerobic bacteria. , 1969 .

[3]  L. Hanson,et al.  Protective effect of breastfeeding against urinary tract infection , 2004, Acta paediatrica.

[4]  D. Bourgeois,et al.  Epidemiology of the incidence of oro-facial noma: a study of cases in Dakar, Senegal, 1981-1993. , 1999, The American journal of tropical medicine and hygiene.

[5]  C. Monteiro,et al.  The worldwide magnitude of protein-energy malnutrition: an overview from the WHO Global Database on Child Growth. , 1993, Bulletin of the World Health Organization.

[6]  W. Loesche,et al.  The bacteriology of acute necrotizing ulcerative gingivitis. , 1982, Journal of periodontology.

[7]  M. Chidzonga.  Noma (cancrum oris) in human immunodeficiency virus/acquired immune deficiency syndrome patients: report of eight cases. , 1996, Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons.

[8]  C. Enwonwu,et al.  Isolation of Fusobacterium necrophorum from cancrum oris (noma). , 1999, The American journal of tropical medicine and hygiene.

[9]  A. Williams,et al.  Nomalike lesion in a patient with chronic lymphocytic leukemia. Review of the literature and report of a case. , 1976, Oral surgery, oral medicine, and oral pathology.

[10]  H. Birkedal‐Hansen.  Role of cytokines and inflammatory mediators in tissue destruction. , 1993, Journal of periodontal research.

[11]  P. Berthold.  Noma: a forgotten disease. , 2003, Dental clinics of North America.

[12]  J. Pindborg,et al.  Occurrence of acute necrotizing gingivitis in South Indian children. , 1966, Journal of periodontology.

[13]  Marion C. Cohen.  Nutrition and Immunology: Principles and Practice , 2001 .

[14]  L. Allen.  Nutritional influences on linear growth: a general review. , 1994, European journal of clinical nutrition.

[15]  C. Enwonwu,et al.  Isolation of fusobacteria from the oral cavities of malnourished Nigerian children living in agricultural and herding villages. , 2008, Oral diseases.

[16]  J. S. Orr,et al.  CLAIMS FOR A DIATHERMY MACHINE , 1974 .

[17]  M. Elia,et al.  Chronic T Cell-Mediated Enteropathy in Rural West African Children: Relationship with Nutritional Status and Small Bowel Function , 2003, Pediatric Research.

[18]  C. Flaitz,et al.  Herpesviridae-associated persistent mucocutaneous ulcers in acquired immunodeficiency syndrome. A clinicopathologic study. , 1996, Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics.

[19]  F. Portaels,et al.  Mycobacterium ulcerans infection (Buruli ulcer): first reported patients in Togo , 1996, The British journal of dermatology.

[20]  J. Meis,et al.  Multiple brain abscesses and bacteremia in a child due toFusobacterium necrophorum , 1993, Infection.

[21]  P. Fraker.  Impact of nutritional status on immune integrity. , 2000 .

[22]  M. Mazariegos,et al.  The underprivileged, developing country child: environmental contamination and growth failure revisited. , 2009, Nutrition reviews.

[23]  M. Listgarten,et al.  The Distribution of Spirochetes in the Lesion of Acute Necrotizing Ulcerative Gingivitis: An Electron Microscopic and Statistical Survey , 1967 .

[24]  K. Ranganathan,et al.  Oral Lesions in HIV Infection in Developing Countries: an Overview , 2006, Advances in dental research.

[25]  Stéphane Hugonnet,et al.  Noma: an "infectious" disease of unknown aetiology. , 2003, The Lancet. Infectious diseases.

[26]  K. Marck.  A history of noma, the "Face of Poverty". , 2003, Plastic and reconstructive surgery.

[27]  D. W. Wang,et al.  Noma neonatorum: an unusual case of noma involving a full‐term neonate , 1992, Acta paediatrica.

[28]  C. Enwonwu,et al.  Pathogenesis of cancrum oris (noma): confounding interactions of malnutrition with infection. , 1999, The American journal of tropical medicine and hygiene.

[29]  H. Whittle,et al.  Severe ulcerative herpes of mouth and eye following measles. , 1979, Transactions of the Royal Society of Tropical Medicine and Hygiene.

[30]  M. Blössner,et al.  The World Health Organization Global Database on Child Growth and Malnutrition: methodology and applications. , 2003, International journal of epidemiology.

[31]  D. Adelekan.  Childhood nutrition and malnutrition in Nigeria. , 2003, Nutrition.

[32]  B. Lowe,et al.  Inflammatory mediators in children with protein-energy malnutrition. , 1997, The American journal of clinical nutrition.

[33]  K. Albertsson-Wikland,et al.  Long-Term Consequences of Early Linear Growth Retardation (Stunting) in Swedish Children , 2000, Pediatric Research.

[34]  W. Beisel.  Nutrition in pediatric HIV infection: setting the research agenda. Nutrition and immune function: overview. , 1996, The Journal of nutrition.

[35]  T. Skerry.  The effects of the inflammatory response on bone growth. , 1994, European journal of clinical nutrition.

[36]  S. Suominen,et al.  The use of the pedicled supraclavicular flap in noma reconstructive surgery. , 2006, Journal of Plastic, Reconstructive & Aesthetic Surgery.

[37]  F. Martinez,et al.  Exclusive breast-feeding for at least 4 months protects against otitis media. , 1993, Pediatrics.

[38]  O. Ransome-kuti.  Intra‐uterine Growth, Birthweights and Maturity of the African Newborn , 1985, Acta paediatrica Scandinavica. Supplement.

[39]  R. Busch,et al.  An estimation of the incidence of noma in north‐west Nigeria , 2003, Tropical medicine & international health : TM & IH.

[40]  C. Enwonwu,et al.  Inflammatory cytokine profile and circulating cortisol levels in malnourished children with necrotizing ulcerative gingivitis. , 2005, European cytokine network.

[41]  C. Enwonwu,et al.  Living conditions of children at risk for noma: Nigerian experience. , 2008, Oral diseases.

[42]  R. Pass,et al.  Epidemiology and transmission of cytomegalovirus. , 1985, The Journal of infectious diseases.

[43]  C. Karp.  Measles: immunosuppression, interleukin‐12. and complement receptors , 1999, Immunological reviews.

[44]  A. Ersbøll,et al.  Breast-feeding influences thymic size in late infancy , 1999, European Journal of Pediatrics.

[45]  J. Oliphant,et al.  Aetiological agents of necrobacillosis in captive wallabies. , 1984, Research in veterinary science.

[46]  C. Enwonwu.  Epidemiological and biochemical studies of necrotizing ulcerative gingivitis and noma (cancrum oris) in Nigerian children. , 1972, Archives of oral biology.

[47]  M. Beck.  The influence of antioxidant nutrients on viral infection. , 2009, Nutrition reviews.

[48]  J. Taiwo.  Oral hygiene status and necrotizing ulcerative gingivitis in Nigerian children. , 1993, Journal of periodontology.

[49]  M. Ota,et al.  The host response in malaria and depression of defence against tuberculosis , 1999 .

[50]  J. Kennedy,et al.  Resurfacing the nasomaxillary cavity for management of epistaxis in Osler-Rendu-Weber disease. , 2006, Journal of plastic, reconstructive & aesthetic surgery : JPRAS.

[51]  J. Slots,et al.  Human Herpesviridae in acute necrotizing ulcerative gingivitis in children in Nigeria. , 1997, Oral microbiology and immunology.

[52]  P. Lunn,et al.  Intestinal permeability, mucosal injury, and growth faltering in Gambian infants , 1991, The Lancet.

[53]  C. Enwonwu,et al.  Oro-facial gangrene (noma/cancrum oris): pathogenetic mechanisms. , 2000, Critical reviews in oral biology and medicine : an official publication of the American Association of Oral Biologists.

[54]  C. Enwonwu,et al.  Nutrition and oral health in Africa. , 2004, International dental journal.

[55]  F. Bitar,et al.  Necrotising infection of the orofacial tissues in neonates (noma neonatorum). Case report. , 1998, Scandinavian journal of plastic and reconstructive surgery and hand surgery.

[56]  D M Bourgeois,et al.  The World Health Organization initiative on noma. , 2008, Oral diseases.

[57]  E. Asamoah-odei,et al.  HIV prevalence and trends in sub-Saharan Africa: no decline and large subregional differences , 2004, The Lancet.

[58]  B. Eley,et al.  Characterization of protease activities in Capnocytophaga spp., Porphyromonas gingivalis, Prevotella spp., Treponema denticola and Actinobacillus actinomycetemcomitans. , 1997, Oral microbiology and immunology.

[59]  F. Spijkervet,et al.  [Noma: 'the face of poverty']. , 2001, Nederlands tijdschrift voor tandheelkunde.

[60]  A. Fasola,et al.  Cancrum oris (noma): Level of education and occupation of parents of affected children in Nigeria. , 2000, Odonto-stomatologie tropicale = Tropical dental journal.

[61]  J Karlberg,et al.  Linear growth retardation in relation to the three phases of growth. , 1994, European journal of clinical nutrition.

[62]  N. Solomons.  Environmental contamination and chronic inflammation influence human growth potential. , 2003, The Journal of nutrition.

[63]  J. Slots,et al.  The occurrence of Actinobacillus actinomycetemcomitans, Bacteroides gingivalis and Bacteroides intermedius in destructive periodontal disease in adults. , 1986, Journal of clinical periodontology.

[64]  C. Enwonwu.  Noma (orofacial gangrene) , 2005, International journal of dermatology.

[65]  A. Prentice,et al.  Improved thymic function in exclusively breastfed infants is associated with higher interleukin 7 concentrations in their mothers' breast milk. , 2004, The American journal of clinical nutrition.

[66]  C. Shiboski,et al.  Prevalence and classification of HIV-associated oral lesions. , 2002, Oral diseases.

[67]  D. Morley.  Severe measles in the tropics. I. , 1969, British medical journal.

[68]  G. Jovic,et al.  Cancrum Oris: Management, Incidence, and Implications of Human Immunodeficiency Virus in Zambia , 1998, Plastic and reconstructive surgery.

[69]  E. Malberger.  Acute infectious oral necrosis among young children in the Gambia, West-Africa. , 1967, Journal of periodontal research.

[70]  C. Enwonwu,et al.  Microbiological understandings and mysteries of noma (cancrum oris). , 2008, Oral diseases.

[71]  J. Woods,et al.  Noma: a review. , 1996, Annals of plastic surgery.

[72]  S. Ghosal,et al.  NOMA NEONATORUM: ITS ÆTIOPATHOGENESIS , 1978, The Lancet.

[73]  S. Kimaro,et al.  Gangrenous stomatitis (cancrum oris): clinical features, etiologic factors, and complications. , 1997, Quintessence International.

[74]  H. Löe,et al.  The role of local factors in the etiology of periodontal diseases. , 1993, Periodontology 2000.

[75]  M. Peña,et al.  Malnutrition and poverty. , 2003, Annual review of nutrition.

[76]  D. Jelliffe.  Infective gangrene of the mouth (cancrum oris). , 1952, Pediatrics.

[77]  C. Enwonwu,et al.  Noma (cancrum oris): questions and answers. , 2008, Oral diseases.

[78]  C. Enwonwu.  Noma--the ulcer of extreme poverty. , 2006, The New England journal of medicine.

[79]  A. Davies-Adetugbo.  Promotion of breast feeding in the community: impact of health education programme in rural communities in Nigeria. , 1996, Journal of diarrhoeal diseases research.

[80]  D. Montandon,et al.  The Surgical Treatment of Noma , 1991, Plastic and reconstructive surgery.

[81]  B. Mogilner,et al.  Noma in a Full-term Neonate , 1985, Clinical pediatrics.

[82]  M. Chidzonga,et al.  HIV/AIDS orofacial lesions in 156 Zimbabwean patients at referral oral and maxillofacial surgical clinics. , 2003, Oral diseases.

[83]  K. D. de Cock,et al.  Clinical spectrum of human immunodeficiency virus disease in children in a west African city. Project RETRO-CI. , 1996, The Pediatric infectious disease journal.

[84]  Macdonald Jb.  On the Pathogenesis of Mixed Anaerobic Infections of Mucous Membranes: Charles Tomes Lecture delivered at the Royal College of Surgeons of England on 20th July 1962. , 1962 .

[85]  Moshe Amitai,et al.  Neonatal Noma , 1993, American Journal of Perinatology.

[86]  C. Enwonwu.  Noma: a neglected scourge of children in sub-Saharan Africa. , 1995, Bulletin of the World Health Organization.

[87]  B. Pittet,et al.  Clinical Experience in the Treatment of Noma Sequelae , 2001, The Journal of craniofacial surgery.

[88]  C. Enwonwu,et al.  Metabolic effects of acute measles in chronically malnourished Nigerian children. , 2004, The Journal of nutritional biochemistry.

[89]  D. Montandon,et al.  Noma ou Cancrum oris : aspects étiopathogéniques et nosologiques , 1995 .

[90]  A. D. De Schepper,et al.  Three cases of Fusobacterium necrophorum septicemia. , 1993, European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology.

[91]  C. Enwonwu,et al.  Editorial: The need for action against oro‐facial gangrene (noma) , 1997, Tropical medicine & international health : TM & IH.

[92]  M. Levin,et al.  Noma in children with severe combined immunodeficiency. , 1986, The Journal of pediatrics.

[93]  D. Jelliffe.  Infectious oral necrosis. , 1985, Community Dentistry and Oral Epidemiology.

[94]  N. Hicken,et al.  ACUTE MYELOGENOUS LEUKEMIA COMPLICATED BY NOMA AND ACUTE STREPTOCOCCIC DERMATITIS , 1935 .

[95]  J. Alverdy,et al.  The Effect of Glucocorticoid Administration on Bacterial Translocation: Evidence for an Acquired Mucosal Immunodeficient State , 1991, Annals of surgery.

[96]  M. Kabue,et al.  Cancrum oris in HIV infected children in Lesotho: report of two cases. , 2004, East African medical journal.

[97]  A. Turner,et al.  Susceptibility of wallabies to Fusobacterium necrophorum , 1986, Veterinary Record.

[98]  S. Bickler,et al.  Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia. , 2000, Bulletin of the World Health Organization.

[99]  A. Hyder,et al.  Malnutrition as an underlying cause of childhood deaths associated with infectious diseases in developing countries. , 2000, Bulletin of the World Health Organization.

[100]  A. Freeman,et al.  Is noma neonatorum a presentation of ecthyma gangrenosum in the newborn? , 2002, The Pediatric infectious disease journal.

[101]  K. Albertsson-Wikland,et al.  Children Born Small-for-Gestational Age: Postnatal Growth and Hormonal Status , 1998, Hormone Research in Paediatrics.

[102]  L. Adelsberger.  Medical observations in Auschwitz concentration camp. , 1946, Lancet.

[103]  C. Sabiston.  A review and proposal for the etiology of acute necrotizing gingivitis. , 1986, Journal of clinical periodontology.

[104]  A. Inglis,et al.  Noma and noma neonatorum. , 1990, Ear, nose, & throat journal.

[105]  K. Marck,et al.  Noma: the Sokoto approach , 1998, European Journal of Plastic Surgery.

[106]  C. Enwonwu,et al.  Pro- versus anti-inflammatory cytokine profile in African children with acute oro-facial noma (cancrum oris, noma). , 2005, European cytokine network.

[107]  F. Dewhirst,et al.  Prevalent Bacterial Species and Novel Phylotypes in Advanced Noma Lesions , 2002, Journal of Clinical Microbiology.

[108]  J. Harvey.  Noma neonatorum: Its aetiopathogenesis , 1979 .

[109]  R. Glineur,et al.  Noma: clinical and evolutive aspect. , 1996, Acta stomatologica Belgica.

[110]  M. Rouabhia,et al.  Interleukin-18 and Gamma Interferon Production by Oral Epithelial Cells in Response to Exposure to Candida albicans or Lipopolysaccharide Stimulation , 2002, Infection and Immunity.

[111]  M. Clerici,et al.  A TH1-->TH2 switch is a critical step in the etiology of HIV infection. , 1993, Immunology today.

[112]  A. Ferguson.  Prolonged impairment of cellular immunity in children with intrauterine growth retardation. , 1978, The Journal of pediatrics.

[113]  S. Gharbia,et al.  Characterization of Prevotella intermedia and Prevotella nigrescens isolates from periodontic and endodontic infections. , 1994, Journal of periodontology.

[114]  P. Papapanou,et al.  Cytokine Responses of Oral Epithelial Cells to Porphyromonas gingivalis Infection , 2000, Journal of dental research.

[115]  A M Prentice,et al.  Prenatal or early postnatal events predict infectious deaths in young adulthood in rural Africa. , 1999, International journal of epidemiology.

[116]  C. Enwonwu,et al.  Temporal relationship between the occurrence of fresh noma and the timing of linear growth retardation in Nigerian children , 2005, Tropical medicine & international health : TM & IH.