Cancrum Oris (Noma)

Synonyms: Noma (from Greek: to devour); Gangrenous stomatitis; Face of poverty (flourishes where poverty is rife)¹

Described in the mid-eighteenth century by Tourdes. It describes spontaneous necrosis of the soft and hard tissues of the oral cavity. Other oral problems are described in the related record Problems in the Mouth.

A disease of children - 80% of patients are less than 10 years old. Seen in developing countries especially poorest areas of Africa, some parts of Asia and South America.² WHO estimates that 100,000 people are affected per year - of which 80% are children in Africa.¹

Some cultures do not treat the disease as it is considered taboo. This results in a barrier to detection of the disorder and appropriate management.¹

The cause is unknown but it may develop secondary to acute necrotising fasciitis.

• Prior to necrosis:
  • Poor oral hygiene is nearly always present.
  • Excessive salivation
  • Malodour from the mouth
  • Grey discoloration
  • Gingival ulcer formation
• Followed by rapid, painless and extensive necrosis of oral cavity that can involve cheek, nose, palate and bones

In noma pudendi there is necrosis of the genitalia and in noma neonatorum mucocutaneous gangrene occurs during the neonatal period.³

• Swabs and culture for organisms - Borrelia vincentii and fusiform bacilli are commonly found as are anaerobes in rapidly progressing cases.⁴
• Facial X rays and CT scan to determine extent of involvement.

• Resuscitation - airway protection may be needed, fluid resuscitation to prevent dehydration.
• Antibiotics
• Enteral feeding
• Patients usually require wound debridement
• Later treatment requires plastic surgery with facial reconstruction and possible repair of temporomandibular joint.⁵

• Dehydration
• Sepsis
• Airway compromise
• Facial disfigurement
• Psychological stress

Clinical course varies with each case and there is a high morbidity and mortality rate. WHO estimates that 70 - 90% of cases die.^1,5