Necrotizing stomatitis

Other names: NOMA, Cancrum Oris, Gangrenous Stomatitis

The word noma is derived from the Greek word ‘nomein’ that means ‘to devour’. It is rapidly progressive opportunistic infection which is caused primarily by Fusobacterium necrophorum, Fusobacterium nucleatum and Prevotella intermedia. Other reported organisms isolated from the Noma lesions include hemolytic Streptococci, Actinomyces spp., Peptostreptococcus micros, Veillonella parvula, Staphylococcus aureus, Corynebacterium pyogenes, Bacteroides fragilis, Bacillus cereus and Pseudomonas species.

The predisposing and/or 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.

Noma is considered to represent the ‘face of poverty’ because many of the risk factors that are associated with poverty. The World Health Organization (1998) has reported an estimated worldwide incidence of 140,000 cases per year.

Noma

Clinical features

Noma is usually seen in children between the age of 3 and 12 years mainly in the developing countries especially sub-Saharan Africa. 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.

Many authors believe that noma, occurs secondary to the extension of necrotizing ulcerative gingivitis. In the initial stages ulcerative areas from the gingiva extend to involve the adjacent soft tissues. Subsequently the necrotic areas spread both into deeper tissue planes and superficially. The overlying skin turns deep blue to black and eventually sloughs away. Extensive necrosis can lead to exposure of bone and osteomyelitis. Patient may present with pain, fever, malaise, foul odor and regional lymphadenopathy. The differential diagnosis for noma must include mucocutaneous leishmaniasis, lupus erythematosus, leprosy, agranulocytic ulcerations, injuries associated with physical trauma (including burns), syphilis, oral cancer and yaws.

Other variants of Noma

‘Noma neonatorum’ is characterized by gangrenous process of the nose, oral cavity, eyelids, and perineum usually seen in premature infants at births or within the first month of life. The causative organism for noma neonatorum is usually Pseudomonas. Noma pudendi is the term used for noma affecting the anogenital area and causing necrosis of the genitalia.

Complications and management

Extensive necrosis can cause premature loss of deciduous teeth, damage to the permanent tooth buds, sequestration of the jaws, trismus, and bony or fibrous ankylosis of the temporomandibular joint. Occasionally, infection from the oral cavity can extend to other parts of the body causing systemic complications such as toxemia, dehydration and bronchopneumonia. Untimely intervention can lead to death.

Local wound care along with restoration of the hydration, nutritional and electrolyte imbalance should be given adequate importance.

Penicillin along with metronidazole are the antibiotics of choice in the management of noma. However, clindamycin and gentamicin are the drugs of choice in the management of neonatal noma.

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