Oro-Facial Gangrene (Noma/Cancrum Oris): Pathogenetic Mechanisms

Abstract

Cancrum oris (Noma) is a devastating infectious disease which destroys the soft and hard tissues of the oral and para-oral structures. The dehumanizing oro-facial gangrenous lesion affects predominantly children ages 2 to 16 years, particularly in sub-Saharan Africa, where the estimated frequency in some communities varies from I to 7 cases per 1000 population. The risk factors are poverty, malnutrition, poor oral hygiene, residential proximity to livestock in unsanitary environments, and infectious diseases, particularly measles and those due to the herpesviridae. Infections and malnutrition impair the immune system, and this is the common denominator for the occurrence of noma. Acute necrotizing gingivitis (ANG) and oral herpetic ulcers are considered the antecedent lesions, and ongoing studies suggest that the rapid progression of these precursor lesions to noma requires infection by a consortium of micro-organisms, with Fusobacterium necrophorum (Fn) and Prevotella intermedia (Pi) as the suspected key players. Additional to production of a growth-stimulating factor for Pi, Fn displays a classic endotoxin, a dermonecrotic toxin, a cytoplasmic toxin, and a hemolysin. Without appropriate treatment, the mortality rate from noma is 70-90%. Survivors suffer the two-fold afflictions of oro-facial mutilation and functional impairment, which require a time-consuming, financially prohibitive surgical reconstruction.

Pseudomonas sepsis with Noma: An association?

“…[3] Fusobacterium necrophorum and Prevotella intermedia are the suspected causative organisms. [2] [3], [8] Children at risk for Noma have been seen to have low plasma concentrations of zinc, retinol, ascorbate, and essential amino acids with increased plasma and saliva levels of free cortisol.…”

“…[3], [6] The risk factors for Noma include poverty, malnutrition, immunosuppression (including HIV infection), poor oral hygiene, unsanitary environment, leukemia, and infectious diseases caused by measles and herpesviridae. [2], [3],[6], [7] It is usually seen in children between the ages of 3 and 12 years mainly in the developing countries especially sub-Saharan Africa. [3], [6] WHO (1998) estimated a worldwide incidence of 1 40 000 cases per year with prevalence of 7 70 000 people living with Noma sequelae (in 1997).…”

“…[1] Noma or cancrum oris is a devastating childhood infectious disease, which destroys the soft and hard tissues of the oral and paraoral structures by causing oro-facial gangrenous lesions. [2], [3] We report here a case of Noma in child with Pseudomonal sepsis. Such an association has not yet been reported in older children.…”

A Study on Biofilm Formation in Relation to Oral Hygiene Status Related to Tooth Brushing Practice

“…Many surveys in different part of the world have found brushing to be the best way to maintain oral health [15] . Enwonwu in 2000, found that poor oral hygiene is one of the main cause of Noma [16] . The study showed that the frequency of the tooth brushing of the respondent increased, the severity of dental plaque decreased, but this relation was not statistically significant (p>0.05) ( Table-3).…”

Bacterial Diseases: Humans vs Microorganisms

“…Also referred to as "cancrum oris‖ is described 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 edema of the face, extending from within out, rapidly destroying the soft parts and the bone, and almost always quickly fatal.‖ [24] The mucous membrane becomes inflamed and develops an ulcer. The infection then spreads to the skin causing necrosis of the lips and cheeks.…”