Noma: Eradicating a Preventable Disease to Save Lives

Context

Noma (also known as cancrum oris) is a noncommunicable necrotising disease that typically occurs in young children living in extreme poverty.¹ Early intervention can prevent suffering, disability, and death. Starting as necrotising ulcerative gingivitis, noma progresses rapidly due to weakened host immunity, destroying the soft tissues and bones of the mouth and further progressing to perforate the tissues of the face. Within a few days, if undiagnosed, noma causes death for 90% of those affected and leaves life-changing facial disfigurement for the other 10%, including impairment in their ability to eat, speak, and participate socially. When noma is detected early, its progression can be halted through basic care, nutrition, oral hygiene, and antibiotics.

The global burden of disease of noma is hard to assess.² In 1998, the World Health Organization (WHO) estimated that up to 770,000 experience noma, with 140,000 new cases each year.² Noma occurs in low-income settings where oral health professionals are scarce, mostly in sub-Saharan Africa. Lack of health care in these areas, together with early death, stigma, and traditional beliefs associated with noma, mean that numerous cases remain undetected. Whilst its aetiology is unknown, risk factors include malnutrition, coinfections, vaccine-preventable diseases, poor oral hygiene, and poor living conditions, such as deficiencies in water, sanitation, and hygiene.¹

Scope

This policy statement provides an overview of noma, highlights risk factors, and identifies the important role that all health and social care professionals can have in identifying noma, raising awareness and caring for people affected by it, irrespective of where they live.

Definitions

Suspected new case of noma: Any child with a mouth ulcer and other warning signs such as malnutrition, poor hygiene, recent illness from measles, persistent diarrhoea, or malaria should be considered to potentially have noma.³

Confirmed new case of noma: Any gangrenous disease which starts as gingival ulcerations and spreads rapidly through the tissues of the mouth and face, destroying the soft and hard tissues.³

Principles

This policy statement aims to raise awareness of noma across health and social care professionals internationally, to promote and improve early identification and prompt delivery of life-saving treatment, and to highlight the lifetime of special oral health care required by survivors. Ultimately, noma is preventable through tackling the underpinning social inequality. This can best be achieved by working in partnership across governmental, nongovernmental, and academic domains.

Policy

Whilst noma does not exist in all geographic areas, FDI is inclusive and global, so this is a global call for action. FDI acknowledges that few oral health professionals work in those geographic areas of the world most affected by noma, so this issue requires a response across health and social care.

In collaboration with governmental, nongovernmental,and academic organizations

FDI advocates for the inclusion of oral health for all in the policies of governments around the world.

FDI supports research to improve and share understanding of the epidemiologic and aetiologic factors contributing to the onset of noma as well as its pathophysiologic mechanisms and ways to tackle the modifiable causes of noma.⁴

All health and social care professionals

FDI recommends that all health and social care professionals, particularly those working in areas where noma is prevalent, should:

• •Emphasise optimal oral hygiene and nutrition to help prevent the development of noma.
• •Raise awareness amongst the local population about noma, including its symptoms and stages, its risk factors, and that it is neither contagious nor associated with witchcraft.
• •Recognise that progression occurs within days, so early identification and prompt treatment are vital.
• •Be familiar with the WHO treatment guidelines.⁵

Providers of education and training for health and social care professionals

In areas where noma is endemic, FDI recommends that all health and social care professionals apprise themselves of education and training that:

• •Acknowledges their life-saving role in identifying noma early and caring for people affected by it.
• •Recognises the lifelong impact of noma.
• •Includes the basic principles of oral examination and recognition of the reversible (necrotising ulcerative gingivitis and oedema) and irreversible (gangrenous, scarring, and sequelae) stages of noma.⁵
• •Explains the risk factors and complex range of circumstances that lead to the progression from gingival inflammation to the gangrenous tissue destruction of noma.

Disclaimer

The information in this policy statement was based on the best scientific evidence available at the time. It may be interpreted to reflect prevailing cultural sensitivities and socioeconomic constraints.