1
|
Khammissa RAG, Lemmer J, Feller L. Noma staging: a review. Trop Med Health 2022; 50:40. [PMID: 35698243 PMCID: PMC9195207 DOI: 10.1186/s41182-022-00431-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/03/2022] [Indexed: 11/10/2022] Open
Abstract
Noma is a bacterial, non-communicable, grossly destructive and disfiguring necrotising oro-facial disease. It is rare, but occurs most commonly in chronically malnourished children with other debilitating illnesses, in remote, poverty-stricken communities, mainly in sub-Saharan Africa, and much more rarely in central Latin America and in parts of Asia. In South Africa and in Zimbabwe, noma is observed, again rarely, in immunosuppressed HIV-seropositive subjects. The World Health Organization (WHO) has classified noma into five sequential stages: stage 1, acute necrotising ulcerative gingivitis; stage 2, oedema; stage 3, gangrene; stage 4, scarring; stage 5, sequela. In the opinion of the authors, this WHO classification requires fundamental re-appraisal. The purpose of this viewpoint article is to highlight the weaknesses of this classification, and to propose a simpler, more logical and practical evidence-based staging of noma, which if used should improve the quality and value of future epidemiological data about noma.
Collapse
Affiliation(s)
- Razia Abdool Gafaar Khammissa
- Department of Periodontics and Oral Medicine, School of Dentistry, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
| | - Johan Lemmer
- Department of Oral Medicine and Periodontology, University of the Witwatersrand, Johannesburg, South Africa
| | - Liviu Feller
- , 111 Portman Place, Fir Avenue, Bantry Bay, Cape Town, 8005, South Africa
| |
Collapse
|
2
|
Feller L, Lemmer J, Khammissa RAG. OUP accepted manuscript. Trans R Soc Trop Med Hyg 2022; 116:884-888. [PMID: 35576473 PMCID: PMC9526837 DOI: 10.1093/trstmh/trac043] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/02/2022] [Accepted: 04/13/2022] [Indexed: 12/03/2022] Open
Abstract
Noma is a debilitating orofacial necrotizing bacterial disease that disproportionately affects impoverished malnourished persons, particularly young children, the vast majority of whom live in tropical and subtropical areas in sub-Saharan Africa. It has a very high mortality rate; causes significant physical and psychological morbidity, stigmatization and social discrimination; could be prevented, controlled and indeed eliminated by common public health interventions; and is overlooked with regard to public health awareness, in-depth scientific research activities and allocation of funding for prevention, treatment and research. According to the WHO, noma comprises five sequential ‘stages’: (1) necrotizing gingivitis, (2) edema, (3) gangrene, (4) scarring and (5) sequelae. This WHO staging of noma is contentious, leading to diagnostic confusion with misestimation of the number of noma cases reported in epidemiological studies. We therefore suggest a simpler, more practical and scientifically valid two-stage classification comprising only (1) acute noma and (2) arrested noma. Noma meets all the WHO criteria for classification as a neglected tropical disease (NTD). Most survivors of noma live with gross physical disfigurement and disability, and with impaired psychosocial functioning, so they are very often stigmatized and unjustifiably discriminated against. Owing to the paucity of evidence-based epidemiological data on noma, the relatively low number of people affected worldwide, and its apparently limited geographic distribution, noma does not yet feature on the WHO's list of NTDs, or on any global health agenda, and thus has not become a health priority for global action. We strongly support the inclusion of noma within the WHO list of NTDs. Without doubt this will increase the awareness of noma among healthcare providers and promote the systematic international accumulation and recording of data about noma.
Collapse
Affiliation(s)
- Liviu Feller
- Department of periodontics and Oral Medicine, Corner Dr Savage and Steve Biko Road, Pretoria, 0001, South Africa
| | - Johan Lemmer
- Department of Oral Medicine and Periodontology, Faculty of Dentistry, University of the Witwatersrand, Johannesburg, South Africa
| | | |
Collapse
|
3
|
Farley E, Mehta U, Srour ML, Lenglet A. Noma (cancrum oris): A scoping literature review of a neglected disease (1843 to 2021). PLoS Negl Trop Dis 2021; 15:e0009844. [PMID: 34905547 PMCID: PMC8670680 DOI: 10.1371/journal.pntd.0009844] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022] Open
Abstract
Background Noma (cancrum oris) is an ancient but neglected and poorly understood preventable disease, afflicting the most disenfranchised populations in the world. It is a devastating and often fatal condition that requires urgent and intensive clinical and surgical care, often difficult to access as most cases of noma occur in resource-limited settings. We conducted a scoping review of the literature published on noma to understand the size and scope of available research on the disease and identify research gaps that need to be addressed to evolve our understanding of how to address this disease. Methods We searched 11 databases and collected primary peer reviewed articles on noma in all languages, the final search was conducted on 24th August 2021. The oldest manuscript identified was from 28th March 1843 and the most recently published manuscript was from 3rd June 2021. Search terms included cancrum oris and noma. Data was extracted using a standardised data extraction tool and key areas of interest were identified. The Preferred Reporting Items for Systemic review and Meta-Analyses requirements were followed. Results The review included 147 articles, the majority of the studies (n = 94, 64%) were case reports. Most manuscripts (n = 81, 55%) were published in the 2000s, 49 (33%) were from the 1900s and 17 (12%) from the 1800s. The main areas of interest identified were the history and epidemiology of the disease, noma’s clinical progression and aetiology, treatment regimens, mortality rates and the risk factors for the development of noma. Conclusions Noma has been reported in the literature for hundreds of years; however important gaps in our understanding of the disease remain. Future research should focus on determining the burden and distribution of disease; the true mortality rate, pathogenic cause(s) and the factors that influence prognosis and outcomes after treatment. Noma is a devastating and often fatal condition that mainly affects children in severely disenfranchised communities. Noma is preventable and requires urgent basic medical care in the early stages of disease. Once the disease reaches the last stage, sequelae, survivors require expert surgical care, usually difficult to access as most cases of noma occur in resource-limited settings. We conducted a scoping review of the literature published on noma to understand the size and scope of available research on the disease and to identify research priorities that will evolve our understanding of how to eradicate this disease. Our review showed that noma has been reported in the literature for hundreds of years; however several major gaps in knowledge still exist. There is appreciation among the small community of clinicians and researchers involved in noma care and research that these gaps in knowledge impact on the ability to develop and implement sound evidence-based policies and activities aimed at eradicating noma from communities that continue to be afflicted by this ancient disease. The main focus of future research should be to study the burden and distribution of disease; the true mortality rate, and the pathogenic cause(s) and the factors that influence prognosis and outcomes after treatment.
Collapse
Affiliation(s)
- Elise Farley
- Noma Children’s Hospital, Médecins Sans Frontières, Sokoto, Nigeria
- Nudibrink Research Consultancy, Cape Town, South Africa
- * E-mail:
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, Western Cape, South Africa
| | | | - Annick Lenglet
- Médecins Sans Frontières, Amsterdam, The Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands
| |
Collapse
|
4
|
Isah S, Amirtharajah M, Farley E, Semiyu Adetunji A, Samuel J, Oluyide B, Bil K, Shoaib M, Abubakar N, de Jong A, Pereboom M, Lenglet A, Sherlock M. Model of care, Noma Children's Hospital, northwest Nigeria. Trop Med Int Health 2021; 26:1088-1097. [PMID: 34080264 PMCID: PMC9292046 DOI: 10.1111/tmi.13630] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The Nigerian Ministry of Health has been offering care for noma patients for many years at the Noma Children’s Hospital (NCH) in Sokoto, northwest Nigeria, and Médecins Sans Frontières has supported these initiatives since 2014. The comprehensive model of care consists of four main components: acute care, care for noma sequelae, integrated hospital‐based services and community‐based services. The model of care is based on the limited evidence available for prevention and treatment of noma and follows WHO’s protocols for acute patients and best practice guidelines for the surgical treatment of noma survivors. The model is updated continually as new evidence becomes available, including evidence generated through the operational research studies performed at NCH. By describing the model of care, we wish to share the lessons learned with other actors working in the noma and neglected tropical disease sphere in the hope of guiding programme development.
Collapse
Affiliation(s)
| | | | - Elise Farley
- Noma Children's Hospital, Sokoto, Nigeria.,Médecins Sans Frontières, Sokoto, Nigeria
| | | | - Joseph Samuel
- Noma Children's Hospital, Sokoto, Nigeria.,Médecins Sans Frontières, Sokoto, Nigeria
| | | | - Karla Bil
- Médecins Sans Frontières, Amsterdam, Netherlands
| | | | - Nura Abubakar
- Noma Children's Hospital, Sokoto, Nigeria.,Médecins Sans Frontières, Sokoto, Nigeria
| | | | | | - Annick Lenglet
- Médecins Sans Frontières, Amsterdam, Netherlands.,Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | |
Collapse
|
5
|
Traore H, Sogodogo E, Coulibaly A, Toure A, Thiocary S, Sidibé M, Timbiné L, Sangaré A, Traoré B, Ouedraogo J, Sogodogo D, Kouriba B. Case report: a rare case of NOMA (cancrum oris) in a Malian woman. New Microbes New Infect 2021; 42:100907. [PMID: 34188939 PMCID: PMC8219893 DOI: 10.1016/j.nmni.2021.100907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 11/05/2022] Open
Abstract
Noma or cancrum oris is a multi-bacterial and opportunistic infection that destroys soft tissue, as well as muscle and bone, and can be fatal. We present a rare case of Noma in a 32-year-old Malian woman, from whom we isolated an Escherichia coli extended-spectrum beta-lactamase.
Collapse
Affiliation(s)
- H. Traore
- Centre National d’Odonto-Stomatologie (CNOS), Bamako, Mali
| | - E. Sogodogo
- Centre d'infectiologie Charles-Mérieux (CICM), Bamako, Mali
| | - A. Coulibaly
- Centre National d’Odonto-Stomatologie (CNOS), Bamako, Mali
| | - A. Toure
- Centre National d’Odonto-Stomatologie (CNOS), Bamako, Mali
| | - S. Thiocary
- Centre National d’Odonto-Stomatologie (CNOS), Bamako, Mali
| | - M.D. Sidibé
- Centre National d’Odonto-Stomatologie (CNOS), Bamako, Mali
| | - L.G. Timbiné
- Centre d'infectiologie Charles-Mérieux (CICM), Bamako, Mali
| | - A.K. Sangaré
- Centre d'infectiologie Charles-Mérieux (CICM), Bamako, Mali
| | - B.Y. Traoré
- Centre d'infectiologie Charles-Mérieux (CICM), Bamako, Mali
| | - J. Ouedraogo
- Centre d'infectiologie Charles-Mérieux (CICM), Bamako, Mali
| | - D. Sogodogo
- Centre Hospitalier Mère-enfant - Le Luxembourg, Bamako, Mali
| | - B. Kouriba
- Centre d'infectiologie Charles-Mérieux (CICM), Bamako, Mali
| |
Collapse
|
6
|
Abstract
Abstract
We present a case of a necrotising disease of the orofacial tissues, the so-called noma, in a female patient with AIDS in a stage of severe immune deficiency. To our knowledge, this is the first time a case like that has been reported in Bulgaria. The patient received an antibiotic course of treatment with a triple combination to good effect on the inflammatory process, and began also HAART. Within 3 weeks, the patient’s general condition improved. However, despite the treatment, a demarcation line was formed, and a defect on the lower lip occurred. Noma is a manifestation of severe immune deficiency with lasting adverse consequences for the patient: severe deformation of the maxilo-facial region and functional impairment (i.e. difficulties eating and speaking, and salivary leak).
Collapse
|
7
|
Feller L, Khammissa RAG, Altini M, Lemmer J. Noma (cancrum oris): An unresolved global challenge. Periodontol 2000 2019; 80:189-199. [PMID: 31090145 PMCID: PMC7328761 DOI: 10.1111/prd.12275] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Noma (canrum oris) is a mutilating necrotizing disease of uncertain etiology, but it is accepted that it is caused primarily by a polybacterial infection with secondary ischemia. The consequent necrotizing fasciitis, myonecrosis, and osteonecrosis results in destruction of facial structures with severe functional impairment and disfigurement. It most frequently affects children, particularly in sub‐Saharan Africa, who are malnourished or debilitated by systemic conditions including but not limited to malaria, measles, and tuberculosis; and less frequently debilitated HIV‐seropositive subjects. In the vast majority of cases, in susceptible subjects, noma is preceded by necrotizing stomatitis. However, it has been reported, albeit rarely, that noma can arise without any preceding oral lesions being observed. Noma is not recurrent and is not transmissible.
Collapse
Affiliation(s)
- Liviu Feller
- Department of Periodontology and Oral Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Razia A G Khammissa
- Department of Periodontology and Oral Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Mario Altini
- Division of Anatomical Pathology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Johan Lemmer
- Department of Periodontology and Oral Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| |
Collapse
|
8
|
Lee YJ, Kim YJ, Won CH, Chang SE, Lee MW, Choi JH. Nomalike Necrotizing Stomatitis in a Child with Crohn's Disease. Pediatr Dermatol 2017; 34:e275-e276. [PMID: 28783211 DOI: 10.1111/pde.13212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Noma is an opportunistic infection characterized by devastating gangrenous stomatitis leading to severe tissue destruction that predominantly affects malnourished children in sub-Saharan Africa. Only a few cases have been reported in immunocompromised patients from developed countries. We present an unusual case of nomalike necrotizing stomatitis in a previously healthy child with Crohn's disease in Korea.
Collapse
Affiliation(s)
- Ye Jin Lee
- Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Young Jae Kim
- Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Chong Hyun Won
- Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Sung Eun Chang
- Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Mi Woo Lee
- Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Jee Ho Choi
- Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| |
Collapse
|
9
|
Weledji EP, Njong S. Cancrum Oris (Noma): The Role of Nutrition in Management. J Am Coll Clin Wound Spec 2016; 7:50-52. [PMID: 28053869 DOI: 10.1016/j.jccw.2016.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Cancrum oris (noma) is caused by the spirochete Borrelia vincenti in association with anaerobic bacteria, commonly a member of the fusobacteria. The disease occurs in deprived and undernourished individuals with poor hygiene. We present a case of clinically diagnosed cancrum oris in a 2-year old child in sub-saharan Africa that was conservatively managed by wound care and hyperalimentation. As the underlying factor and cause of mortality from noma is the immune depression of malnutrition, the role of active nutrition or hyperalimentation in the management of noma is extremely important.
Collapse
Affiliation(s)
| | - Sylvia Njong
- Department of Surgery, Faculty of Health Sciences, University of Buea, Cameroon
| |
Collapse
|
10
|
Indurkar MS, Sethi R. An unusual case of osteonecrosis of the jaw associated with dengue fever and periodontitis. Aust Dent J 2016; 61:113-119. [DOI: 10.1111/adj.12308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2015] [Indexed: 11/27/2022]
Affiliation(s)
- MS Indurkar
- Department of Periodontology; Government Dental College and Hospital; Aurangabad India
| | - R Sethi
- Department of Periodontology; Government Dental College and Hospital; Aurangabad India
| |
Collapse
|
11
|
Ashok N, Tarakji B, Darwish S, Rodrigues JC, Altamimi MA. A Review on Noma: A Recent Update. Glob J Health Sci 2015; 8:53-9. [PMID: 26573028 PMCID: PMC4873589 DOI: 10.5539/gjhs.v8n4p53] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 06/09/2015] [Indexed: 11/16/2022] Open
Abstract
Noma is a gangrenous infection primarily affecting under developed countries. The aim of this paper was to review all recent articles on noma from January 2003 to August 2014 and briefly update the latest information related to the topic. A literature search was done on PUBMED using the keywords “noma / cancrum oris”. Noma is commonly seen in malnourished children. There has been an increased incidence of noma in HIV patients. Apart from these, noma has also been reported in association with cyclic neutropenia, herpetic stomatitis, leukemia, Down's syndrome and Burkett's disease. Treatment of acute noma includes transfusion of blood and intravenous fluids, administration of antibiotics, putting the patient on a high protein diet and debridement of necrotic areas. Surgical phase is usually initiated 6 to 18 months after a period of quiescence. Although, the mortality rate associated with noma has reduced significantly with the advent of modern generation antibiotics, the functional, cosmetic and psychological challenges associated with the destruction of soft or hard tissues still remains a huge challenge. Adequate steps must be implemented by the government or medical professionals to prevent the disease and provide an early intervention.
Collapse
|
12
|
Zushi Y, Noguchi K, Moridera K, Takaoka K, Kishimoto H. Osteonecrosis of the jaw in an AIDS patient: a case report. AIDS Res Ther 2015; 12:13. [PMID: 25932039 PMCID: PMC4415315 DOI: 10.1186/s12981-015-0049-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 02/24/2015] [Indexed: 11/29/2022] Open
Abstract
We report a rare case of osteonecrosis of the jaw following necrotizing gingivitis in a Japanese AIDS patient. Intraoral examination showed exposed necrotic bone in the left mandible and spontaneous loss of teeth. This patient was successfully treated with highly active anti-retroviral therapy combined with minimally invasive surgical procedures to remove the osteonecrosis of the jaw.
Collapse
|
13
|
van Niekerk C, Khammissa RA, Altini M, Lemmer J, Feller L. Noma and cervicofacial necrotizing fasciitis: clinicopathological differentiation and an illustrative case report of noma. AIDS Res Hum Retroviruses 2014; 30:213-6. [PMID: 24304357 DOI: 10.1089/aid.2013.0259] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Noma predominantly affects malnourished young children. The pathogenesis of noma is complex and multifactorial, involving interaction between local polybacterial infection on the one hand, and malnutrition, immunosuppression, or systemic bacterial or viral infections on the other hand. Noma is considered to be an opportunistic disease, but the immediate cause is uncertain. Immunosuppression associated with a high HIV load may be an important risk factor in South Africa. Cervicofacial necrotizing fasciitis, on the other hand, occurs mainly in adults. It is frequently a consequence of an odontogenic infection and is characterized by an irregular pattern of rapidly spreading necrosis of fascia, muscle, and skin. We present an unusual case of noma in a 32-year-old malnourished HIV-seropositive female with AIDS in whom, within a period of 3 days, the initial intraoral necrotizing process spread rapidly and caused circular full thickness perforating destruction of the lower lip. Prompt diagnosis and treatment brought about control of the active disease and limited the extension of the established noma and of progression of the disease at other affected oral sites.
Collapse
Affiliation(s)
- Charles van Niekerk
- Department of Maxillofacial and Oral Surgery, University of Limpopo, Medunsa Campus, Pretoria, South Africa
| | - Razia A.G. Khammissa
- Department of Periodontology and Oral Medicine, University of Limpopo, Medunsa Campus, Pretoria, South Africa
| | - Mario Altini
- Division of Anatomical Pathology, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
| | - Johan Lemmer
- Department of Periodontology and Oral Medicine, University of Limpopo, Medunsa Campus, Pretoria, South Africa
| | - Liviu Feller
- Department of Periodontology and Oral Medicine, University of Limpopo, Medunsa Campus, Pretoria, South Africa
| |
Collapse
|
14
|
Feller L, Altini M, Chandran R, Khammissa RAG, Masipa JN, Mohamed A, Lemmer J. Noma (cancrum oris) in the South African context. J Oral Pathol Med 2013; 43:1-6. [PMID: 23647162 DOI: 10.1111/jop.12079] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2013] [Indexed: 11/29/2022]
Abstract
Noma (cancrum oris) is a destructive necrotising disease affecting orofacial tissues predominantly of malnourished young children. It is characterised by a rapid acute onset which usually starts in the mouth, spreads intra-orally destroying soft tissue and bone and progresses to perforate the facial skin, causing disfigurement. Polybacterial anaerobic infection is critical too, but is not alone sufficient for the initiation of noma. Cofactors, first and foremost malnutrition, but also systemic viral and bacterial infections are crucial to the development of noma. A patient with necrotising stomatitis or noma must be admitted to hospital for antibiotic treatment, fluid and electrolytes as well as nutritional supplementation and general supportive treatment. The epidemiology of noma in the South African population is unknown, and the clinicopathological features are poorly characterised. Although worldwide there is no evidence that HIV infection is a strong risk factor for noma, HIV infection may play a substantial role in the pathogenesis of noma in South Africa.
Collapse
Affiliation(s)
- L Feller
- Department of Periodontology and Oral Medicine, University of Limpopo, Medunsa, South Africa
| | | | | | | | | | | | | |
Collapse
|