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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.
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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
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Jin HB, Yang JY, Kim KS, Kim SH, Choe J, Chung JH. Staged lower lip reconstruction following gangrenous stomatitis in an immunosuppressed patient. Arch Craniofac Surg 2018; 19:222-226. [PMID: 30282435 PMCID: PMC6177670 DOI: 10.7181/acfs.2018.01928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/06/2018] [Indexed: 11/21/2022] Open
Abstract
A 70-year-old male with a history of diabetes mellitus, hypertension, and coronary stent insertion visited our hospital 7 days after biting his lower lip. Swelling and inflammation had worsened despite debridement and antibiotic treatment. On the 8th hospital day, fungal infection with Candida albicans and superimposed bacterial infection with Klebsiella pneumoniae were found on tissue culture. Extensive necrosis resulted in a defect of approximately 3/4 of the entire lower lip and a full-layer skin defect from the vermilion to the gingivobuccal sulcus at the right corner of the mouth. To correct drooling, incomplete lip sealing, and trismus, staged reconstruction was performed with consideration of cosmetic and functional features. The treatment process using staged reconstruction and antifungal treatment for an extensive lower lip defect caused by fungal stomatitis is described.
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Affiliation(s)
- Han Byeol Jin
- Department of Plastic and Reconstructive Surgery, Myongji Hospital, Goyang, Korea
| | - Jeong Yeol Yang
- Department of Plastic and Reconstructive Surgery, Myongji Hospital, Goyang, Korea
| | - Kyung Sik Kim
- Department of Plastic and Reconstructive Surgery, Myongji Hospital, Goyang, Korea
| | - Seung Hong Kim
- Department of Plastic and Reconstructive Surgery, Myongji Hospital, Goyang, Korea
| | - Joon Choe
- Department of Plastic and Reconstructive Surgery, Myongji Hospital, Goyang, Korea
| | - Jee Hyeok Chung
- Department of Plastic and Reconstructive Surgery, Myongji Hospital, Goyang, Korea
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Baratti-Mayer D, Gayet-Ageron A, Hugonnet S, François P, Pittet-Cuenod B, Huyghe A, Bornand JE, Gervaix A, Montandon D, Schrenzel J, Mombelli A, Pittet D. Risk factors for noma disease: a 6-year, prospective, matched case-control study in Niger. LANCET GLOBAL HEALTH 2013; 1:e87-e96. [PMID: 25104163 DOI: 10.1016/s2214-109x(13)70015-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Noma is a poorly studied disease that leads to severe facial tissue destruction in children in developing countries, but the cause remains unknown. We aimed to identify the epidemiological and microbiological risk factors associated with noma disease. METHODS We did a prospective, matched, case-control study in Niger between Aug 1, 2001, and Oct 31, 2006, in children younger than 12 years to assess risk factors for acute noma. All acute noma cases were included and four controls for each case were matched by age and home village. Epidemiological and clinical data were obtained at study inclusion. We undertook matched-paired analyses with conditional logistic regression models. FINDINGS We included 82 cases and 327 controls. Independent risk factors associated with noma were: severe stunting (odds ratio [OR] 4·87, 95% CI 2·35-10·09) or wasting (2·45, 1·25-4·83); a high number of previous pregnancies in the mother (1·16, 1·04-1·31); the presence of respiratory disease, diarrhoea, or fever in the past 3 months (2·70, 1·35-5·40); and the absence of chickens at home (1·90, 0·93-3·88). After inclusion of microbiological data, a reduced proportion of Fusobacterium (4·63, 1·61-13·35), Capnocytophaga (3·69, 1·48-9·17), Neisseria (3·24, 1·10-9·55), and Spirochaeta in the mouth (7·77, 2·12-28·42), and an increased proportion of Prevotella (2·53, 1·07-5·98), were associated with noma. We identified no specific single bacterial or viral pathogen in cases. INTERPRETATION Noma is associated with indicators of severe poverty and altered oral microbiota. The predominance of specific bacterial commensals is indicative of a modification of the oral microbiota associated with reduced bacterial diversity. FUNDING Gertrude Hirzel Foundation.
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Affiliation(s)
- Denise Baratti-Mayer
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Angèle Gayet-Ageron
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Division of Clinical Epidemiology, Department of Community Health and Medicine, University of Geneva Hospitals, Geneva, Switzerland; Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals, Geneva, Switzerland
| | - Stéphane Hugonnet
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals, Geneva, Switzerland; Department of Pandemic and Epidemic Diseases, World Health Organization, Geneva, Switzerland
| | - Patrice François
- Genomic Research Laboratory and Clinical Microbiology Laboratory, University of Geneva Hospitals, Geneva, Switzerland
| | - Brigitte Pittet-Cuenod
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Antoine Huyghe
- Genomic Research Laboratory and Clinical Microbiology Laboratory, University of Geneva Hospitals, Geneva, Switzerland; University of Geneva, Sciences III, Department of Plant Biology, Microbiology Unit, Geneva, Switzerland
| | - Jacques-Etienne Bornand
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Central Laboratory of Virology, University of Geneva Hospitals, Geneva, Switzerland
| | - Alain Gervaix
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Department of Paediatrics, University of Geneva Hospitals, Geneva, Switzerland
| | - Denys Montandon
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Jacques Schrenzel
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Genomic Research Laboratory and Clinical Microbiology Laboratory, University of Geneva Hospitals, Geneva, Switzerland
| | - Andrea Mombelli
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Department of Periodontology and Oral Pathophysiology, School of Dental Medicine, University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Didier Pittet
- GESNOMA, Division of Plastic and Reconstructive Surgery, University of Geneva Hospitals, Geneva, Switzerland; Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals, Geneva, Switzerland.
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VIH et noma au Burkina Faso. ACTA ACUST UNITED AC 2012; 113:433-6. [DOI: 10.1016/j.stomax.2012.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Revised: 10/26/2011] [Accepted: 07/06/2012] [Indexed: 11/19/2022]
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Challacombe S, Chidzonga M, Glick M, Hodgson T, Magalhães M, Shiboski C, Owotade F, Ranganathan R, Naidoo S. Global Oral Health Inequalities. Adv Dent Res 2011; 23:227-36. [DOI: 10.1177/0022034511402081] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Four oral mucosal infections were identified as Global Oral Health Priorities: (a) HIV and associated viral, bacterial, and fungal infections; (b) tuberculosis; (c) NOMA; and (d) sexually transmitted diseases. Huge global inequalities exist in all four. HIV-associated infections constitute the major challenge. Oral manifestations of AIDS can be specifically diagnostic, indicating a significant role for dentists within health teams. The World Workshops in Oral Health & Disease in AIDS have identified a research program, elements of which are being implemented. Data on oral mucosal involvement in tuberculosis, syphilis, and gonorrhea are incomplete in developed countries and virtually non-existent in low- and middle-income countries, indicating the need for further epidemiological studies. Oral manifestations of tuberculosis and sexually transmitted diseases are largely associated with general health, so action programs should be integrated with agencies treating the systemic diseases. NOMA is very much in the oral health domain. It is a preventable disease associated with malnutrition and unidentified bacterial factors. Prevalence is probably grossly overestimated at present; but nevertheless it constitutes a challenge to the profession, especially in the NOMA belt. Current treatment is surgical, but plans for its eradication should be achievable. The global oral health community, especially the IADR, has a major role to play.
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Affiliation(s)
- S. Challacombe
- Oral Medicine, King’s College London Dental Institute, Central Office, Floor 18, Guys Tower, Guys Hospital, London SE1 9RT, UK
| | - M. Chidzonga
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - M. Glick
- University of Buffalo, Buffalo; NY, USA
| | - T. Hodgson
- Eastman Dental Hospital UCLH NHS Foundation Trust and UCL Eastman Dental Institute, UK
| | | | - C. Shiboski
- University of California at San Francisco, USA
| | - F. Owotade
- College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | | | - S. Naidoo
- University of the Western Cape, Cape Town, South Africa
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Chiandussi S, Luzzati R, Tirelli G, Di Lenarda R, Biasotto M. Cancrum oris in developed countries. Aging Clin Exp Res 2009; 21:475-7. [PMID: 20154519 DOI: 10.1007/bf03327447] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Cancrum oris (or noma) is a rapidly progressive disease characterized by destructive necrosis of oral tissues and underlying bone. It is part of a multistage condition and may represent the outcome of untreated necrotizing stomatitis. Necrotising stomatitis and cancrum oris predominantly affect children in developing countries, especially in Africa. Only few cases have been reported in developed countries, and were associated with debilitating diseases and disorders of the immune system. We report a case of noma in an elderly immunosuppressed Italian patient in whom necrosis caused an external buccal communication. This case stresses the importance of an early identification and prompt management of the necrotic condition, in order to avoid diffusion of the destructive process within the oro-facial tissues.
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Casanas B, Pothiawala S, Sinnott JT. An Elderly Man With Noma Orofacial Gangrene. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2009. [DOI: 10.1097/ipc.0b013e318187e135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
A malnourished 9-year-old boy presented with an infection in the buccal space that developed into cancrum oris during the course of treatment.
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Affiliation(s)
- Anil George Behanan
- Department of Oral and Maxillofacial surgery, College of Dental Surgery, Manipal Academy of Higher Education, Manipal-576 104, Karnataka, India.
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Baratti-Mayer D, Pittet B, Montandon D, Bolivar I, Bornand JE, Hugonnet S, Jaquinet A, Schrenzel J, Pittet D. Noma: an "infectious" disease of unknown aetiology. THE LANCET. INFECTIOUS DISEASES 2003; 3:419-31. [PMID: 12837347 DOI: 10.1016/s1473-3099(03)00670-4] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Noma (cancrum oris) is a devastating gangrenous disease that leads to severe tissue destruction in the face and is associated with high morbidity and mortality. It is seen almost exclusively in young children living in remote areas of less developed countries, particularly in Africa. The exact prevalence of the disease is unknown, but a conservative estimate is that 770000 people are currently affected by noma sequelae. The cause remains unknown, but a combination of several elements of a plausible aetiology has been identified: malnutrition, a compromised immune system, poor oral hygiene and a lesion of the gingival mucosal barrier, and an unidentified bacterial factor acting as a trigger for the disease. This review discusses the epidemiology, clinical features, current understanding of the pathophysiology, and treatment of the acute phase and sequelae requiring reconstructive surgery. Noma may be preventable if recognised at an early stage. Further research is needed to identify more exactly the causative agents.
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Nath S, Jovic G. Cancrum oris: management, incidence, and implications of human immunodeficiency virus in Zambia. Plast Reconstr Surg 1998; 102:350-7. [PMID: 9703069 DOI: 10.1097/00006534-199808000-00008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The University Teaching Hospital is situated in the Zambian capital, Lusaka. In a 15-year period (1979 to 1993), 81 child patients with cancrum oris were admitted to the pediatric plastic surgery unit. There were 29 boys and 52 girls, of whom 58 were below 3 years of age. The majority of them were from certain provinces where the population is comparatively much lower than in other provinces of Zambia. The dietary habits in cancrum orisprone provinces are quite different than those of other provinces of Zambia. Of 81 patients, 3 refused surgery, 11 died during early medical treatment, and 12 died following early minor surgery. A total of 55 patients had reconstructive surgery by one of the authors (Nath). Problems encountered during management, such as anesthesia, trismus, and choice of appropriate flaps, are discussed in this paper. The implication of human immunodeficiency virus is also addressed.
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Affiliation(s)
- S Nath
- Department of Surgery, School of Medicine, University Teaching Hospital, Lusaka, Zambia
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Chidzonga MM. Noma (cancrum oris) in human immunodeficiency virus/acquired immune deficiency syndrome patients: report of eight cases. J Oral Maxillofac Surg 1996; 54:1056-60. [PMID: 8811814 DOI: 10.1016/s0278-2391(96)90159-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE This article describes the clinical features and management of noma (cancrum oris) in HIV/AIDS patients. PATIENTS AND METHODS Eight HIV/AIDS patients were studied. Clinical presentation was different in all of the cases. Conservative debridement under local anesthesia with an antibiotic was performed. RESULTS Satisfactory resolution of the acute phase of this dangerous infection was achieved. CONCLUSION Minimal but thorough debridement of necrotic tissue along with lavage with povidone-iodine is effective in controlling this infective process. However, long-term sequelae of noma are not possible because of the underlying HIV infection from which the patients inevitably soon succumbs.
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Affiliation(s)
- M M Chidzonga
- Department of Surgery, Medical School, University of Zimbabwe, Harrare, Zimbabwe
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Affiliation(s)
- T J Barrios
- Department of OMFS, Jersey City Medical Center, NJ 07304, USA
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