Before necrosis the following are common presentations [7]:

• Poor oral hygiene
• Excessive salivation
• Malodour from the mouth
• Grey discoloration
• Gingival ulcer formation

These are followed by rapid, painless and extensive necrosis of the oral cavity which should involve the cheek, nose and palate bones. There may be necrosis of the genitalia and mucocutaneous gangrene may be seen during the neonatal period.

• Gangrene

  The many historical synonyms for this disease together with other historical data indicate that orofacial gangrene in children was a common affection in Europe in previous centuries. [ncbi.nlm.nih.gov]

  Noma (cancrum oris, gangrenous stomatitis) is a severe gangrenous disease of orofacial tissues seen in malnourished children. [symptoma.com]

• Fever

  The child had experienced occasional cough and fever and also had erupting tooth buds. These tooth buds had been seen as the cause of the cough and fever by the traditional herbalist; hence, they were extracted. [ncbi.nlm.nih.gov]

• Ecthyma

  Our case is consistent with previous descriptions of noma neonatorum; however, we question the distinction between noma neonatorum and a neonatal presentation of ecthyma gangrenosum. [ncbi.nlm.nih.gov]

• Screaming

  Evolution's engine is the grinding of predatory teeth upon the screaming, living flesh and bones of prey.… If evolution be true, my faith has rougher seas to sail. I don't agree with this man, but we could have a wonderful argument. [stephenjaygould.org]

Diagnosis is reliant on swabs and cultures for organisms [8]. The result often shows Borrielia vincentii and fusiform bacilli. In rapidly progressing cases, anaerobes may be detected.
To determine the extent of the condition, facial x-rays and CT scans can be used.

• Streptococcus Bovis

  Streptococcus bovis type II and E coli were isolated from the noma and Streptococcus bovis, Bacteroides fragilis, and Bacteroides asacharolyticus from the peritoneal fluid. [ncbi.nlm.nih.gov]

Treatment involves the following [9]:

• Fluid resuscitation
• Antibiotics
• Enteral feeding
• Wound debridement

The last stage of treatment in some cases is plastic surgery which involves facial reconstruction and the possible repair of temporomandibular joint.

The clinical course for each case varies a great deal and the mortality and morbidity rate is high as 70-90% of cases die [6]. It remains to be seen if this high mortality is as a result of clinical manifestations or as a result of poor or inaccurate diagnosis.

Fusobacterium necrophorum and Prevotella intermedia are believed to play a role in the development of this disease [2]. The interactions that bring about the disease remain unclear but it is believed to develop following acute necrotising fasciitis.

The following are risk factors documented for the condition [3]:

• Poverty
• Malnourishment
• Immunosuppression
• Poor oral hygiene
• Poor sanitation
• Living too close to domestic and unkempt animals
• Leukaemia
• Measles
• Typhoid
• Tuberculosis
• Bacillary dysentery

The condition is a disease of children as 80% of cases are seen in patients less than 10 years old [4]. It is common in developing countries, most especially in the poorest areas of Africa, parts of Asia and parts of South America. A total of 100,000 people are affected per year by this condition.

Noma refers to a severe disfiguring gangrene of the face and mouth which first starts as gingival ulcer before it spreads rapidly through the tissues in the mouth and face [5]. Unlike what is obtainable with other facially infectious processes, noma can disrupt anatomic barriers by spreading through the bone and muscle instead of progressing along anatomic spaces of the head and neck. The gangrene that results may involve the maxilla and the mandible and also extend to the infra-orbital margins as well as the nose.

The main preventive measures include proper nutrition, cleanliness as well as sanitation [10].

This condition refers to the spontaneous necrosis of both the soft and hard tissues in the oral cavity [1]. The condition was first described in the mid-eighteenth century by Tourdes. It is a rapidly progressive and polymicrobial infection that is found when the immune system is compromised.

Noma is a type of disease which destroys the mucous membranes of the mouth as well as other tissues. It is seen mostly in malnourished children in parts of the world known for uncleanliness and living closely with animals.

The main cause is unknown however it I believed to be as a result of bacteria known as fusospirochetal organisms. The disorder is most potent when the child has had illnesses such as measles, scarlett fever, tuberculosis, cancer and other forms of immunocompression.

Treatment is often with the aid of antibiotics but the chance of survival is often very poor most of the time.

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2. Evrard L, Laroque G, Glineur R, Daelemans P. Noma: clinical and evolutive aspect. Acta Stomatol Belg 1996; 93:17.
3. Tempest MN. Cancrum oris. Br J Surg 1966; 53:949.
4. Marck KW. A history of noma, the "Face of Poverty". Plast Reconstr Surg 2003; 111:1702.
5. Boot A. Observationes Medicae de Affectibus Omissis. London: Thomas Newcomb, 1649.
6. Tourdes J. Du noma ou du sphacele de la bouche chez les enfants. Thesis. Strasbourg, 1848.
7. Baratti-Mayer D, Pittet B, Montandon D, et al. Noma: an "infectious" disease of unknown aetiology. Lancet Infect Dis 2003; 3:419.
8. Van Damme, PA. Essay noma. Lancet 2006; 368:561.
9. Leclercq MH. Can dentistry tackle inequality? The challenge of noma. Fdi world 1999; 2:9.
10. Bourgeois DM, Leclercq MH. The World Health Organization initiative on noma. Oral Dis 1999; 5:172.