Noma: Poverty and Oral Health Linked to Orofacial Gangrene

Margaret Scarlett, DMD; Cyril O. Enwonwu, ScD, PhD, MDS, BDS

Disclosures

June 29, 2011

Editor's Note

Poverty and oral health are inextricably linked and nowhere is this more evident than in the disfiguring oral-facial disease known as noma. Found primarily in children living in remote areas, often presenting after an acute illness like measles or malaria, the disease has a rapid and life-threatening course.

Cyril O. Enwonwu, ScD, PhD, MDS, BDS, is a global leader on the eradication of noma. Currently heading up Global Research Initiatives at the University of Maryland Dental School, Dr. Enwonwu has a PhD in nutritional biochemistry from Massachusetts Institute of Technology and dental degrees from Bristol University, UK.

Dr. Margaret Scarlett, Clinical Editor, Medscape Dentistry and Oral Health, spoke with Dr. Enwonwu on the topic of noma, its treatment and prevention, and the role of oral health professionals in collaboration with other healthcare professionals to eradicate the disease.

Medscape: Dr. Enwonwu, what is noma?

Cyril O. Enwonwu, ScD, PhD, MDS, BDS: Noma is the "forgotten disease of the poor," which presents clinically as gangrene of the mouth and neighboring facial structures. Often beginning as an oral ulcer, usually in the gingiva, lesions spread rapidly to become an acute necrotizing ulcerative stomatitis. Necrosis can extend to the maxilla, mandible, lips, cheeks, and, unlike other oral infections, to the facial soft tissues, including the chin and palate. The orbit and nose can also be affected by necrosis.

Noma is typically found in children who are chronically malnourished, or after an epidemic of measles, and is rarely seen in adults. However, adults with immuno-compromising conditions, such as HIV infection or AIDS, tuberculosis, or malaria, may also present with noma. Since the late 1990s, the World Health Organization (WHO) Oral Health Unit has called attention to this forgotten, devastating, and preventable disease of the oral cavity and face.

Figure 1. Child with noma.Photo provided courtesy of Dr. Cyril Enwonwu.

Medscape: What causes noma and how common it is?

Dr. Enwonwu: Noma is a polymicrobial infection caused by anaerobic organisms that produce enzymes, as well as pro-inflammatory mediators, that degrade the intracellular matrix. Acute necrotizing gingivitis is a risk factor for developing noma. It may start as a simple ulcer, and without nutritional support and antibiotics can rapidly progress.

Although fusobacteria have been implicated in this condition, numerous other anaerobes are present in the ulcer. Polymerase chain reaction (PCR), a molecular laboratory technique for identifying microorganisms, is not useful for identifying the key causative organism(s) because noma is an open wound that is often contaminated before the child presents for treatment. Generally, the lesion is sensitive to a broad range of antibiotics, including metronidazole, penicillin, and streptomycin.

Noma was common in North America in the early 1900s, in cities such as New York, and especially following epidemics of measles. By the 1940s, the widespread use of antibiotics, plus improved standards of living, had virtually eliminated noma in the United States. However, the last cases in the United States were reported in 1986 in Native American children who were suffering from severe combined immunodeficiency syndrome.

Now, noma is found in other parts of the world, including sub-Africa (particularly West Africa), the Indian subcontinent, the Caribbean, and Central and South America. Several cases have been reported in Laos.

Noma typically affects poor children who are 3-5 years old living in developing countries. Children with noma often have systemic comorbidities, such as leukemia, HIV/AIDS, diarrhea, malaria, or a recent case of measles. In general, children who were premature or of low birthweight are more susceptible to noma than children who were born at term and had normal birth weights.

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Video provided by National Institute of Dental and Craniofacial Research: "Science Knows No Country," with narration by Dr. David Barmes (deceased), former head of the Oral Health Unit, World Health Organization.

Children born to mothers who have active malaria during pregnancy may be susceptible to noma. Therefore, these mothers should be treated with antimalarial drugs. In addition, pregnant women with other infections, such as bacterial vaginosis, cytomegalovirus, and Chlamydia trachomatis, may have children who are at risk for noma. Noma has been reported in the children of women who have these infections.

Medscape: How is noma treated?

Dr. Enwonwu: Treatment is aimed at symptomatic control of infection. Generally, noma occurs following a case of measles, diarrhea, and malaria.

Figure 2. Surgical repair of noma (following resolution of initial infection). Provided courtesy of Chris Lawrence, Facing Africa, Seend, Wiltshire England, www.facingafrica.org

Figure 3. Postoperative surgical repair of adolescent after noma. Provided courtesy of Chris Lawrence, Facing Africa, Seend, Wiltshire England, www.facingafrica.org

The following steps should be considered:

  • Stabilize the patient, and consider hydration and nutritional support;

  • Administer appropriate antibiotics;

  • Clean and dress the wound, minimizing wound trauma; perform as little surgical intervention as necessary; and

  • Wait for 1-2 years before initiating any reconstructive surgery.

Medscape: Why should dentists/dental health professionals be aware of noma? Is it likely to be encountered in the dental clinic?

Dr. Enwonwu: Every year, WHO estimates, more than 100,000 cases of noma occur worldwide, and only 10% survive. Dentists on medical/dental missions, dentists who volunteer in refugee centers, or dentists who treat populations of refugees may see presentations of noma, especially among children. Cases have been reported in rural areas in Mexico, Columbia, Peru, rarely in Jamaica, as well as portions of West Africa, particularly Burkina Faso, Senegal, Gambia, Malawi, Nigeria, and Niger. Although no cases have been reported in the United States since 1986, clinicians outside of cities should be aware of this disease. Should a case be suspected or confirmed in one location, clinicians should be alerted that many more cases are likely to follow, especially in remote areas where healthcare is not easily accessed.

Noma is more common in poor rural rather than urban areas, and in migratory workers who live in proximity to domestic animals or in areas with poor sanitation, inadequate water supplies, persistent malnutrition, and/or compromised water supplies. If noma is suspected, rapid initiation of treatment is recommended because of the fulminant course of disease. Without prompt treatment, more than 75% of patients will die.

A key concern with noma is that some individuals may die without seeking medical care, as a result of local taboos or stigma associated with the acute stages of noma, which prevent early presentation for appropriate care. An estimated 9 out of 10 persons with noma will survive if treated promptly.

Medscape: What are best practices for dentists in caring for patients with noma?

Dr. Enwonwu: Once these anaerobic organisms are present in the susceptible host, destruction of tissue is rapid, so prompt treatment is essential. Once the patient is past the acute stage, dentists must work with an interdisciplinary care system and this requires teamwork. The dentist must develop a treatment plan for steps to restore both function and esthetics after initial stabilization with the pediatrician, nurses, primary care provider, surgeon, or other health provider for optimal patient care. Standard infection control practices are needed to provide care. Generally person-to-person transmission of noma (eg, from one sibling to another) does not occur.

Medscape: What is your role in prevention of noma?

Dr. Enwonwu: I have advised the WHO Oral Health Unit and its Regional Office for Africa and the Pan-American Health Organization on noma. Our strategy has been to promote antimalarials for pregnant and lactating women and to bring awareness of this devastating disease to dentists and stomatologists. Little attention has been focused on the elimination of noma.

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Video provided by National Institute of Dental and Craniofacial Research: "Science Knows No Country."

An emphasis on effective oral hygiene, clean water, and oral rehydration therapy, if necessary, in cases of dehydration from diarrhea, are excellent preventive strategies. Animals should be separated from living quarters in rural areas. In addition, standard immunizations for vaccine-preventable diseases, such as measles, mumps, and rubella, should be considered for all children. The treatment of infected pregnant and lactating women with antimalarials or standard tuberculosis therapy is another key preventive strategy.

Medscape: Thank you for providing this information to Medscape.

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