Epidemiological and biochemical studies of necrotizing ulcerative gingivitis and noma (cancrum oris) in Nigerian children

High burden of noma in the Gambella region of Ethiopia: a 12-year retrospective study on noma cases from the Facing Africa database

BACKGROUND

Noma, an infectious disease, mainly affects impoverished children. This study retrospectively assessed noma's prevalence in Ethiopia using data from the Facing Africa database and the 2022 United Nations Development Programme poverty index report.

METHODS

A thorough review of medical records spanning 2007 to 2019 identified a total of 235 noma cases. A standardized data extraction template was employed to systematically gather pertinent clinical and demographic data for subsequent analysis. Prevalence rates were calculated nationally and regionally for both the general population and children aged ≤10 y.

RESULTS

The analysis revealed estimated national prevalence rates of 0.65 per 100 000 individuals at risk and 1.9 per 100 000 children aged <10 y at risk. The Gambela region exhibited the highest prevalence rate (11.2 per 100 000), whereas the Benshangul Gumuz region had the lowest (0.25 per 100 000). Similar patterns were observed among children aged ≤10 y, with the Gambela and Benshangul Gumuz regions reporting rates of 32.9 and 0.74 per 100 000, respectively.

CONCLUSIONS

The study highlights noma's significant impact on children aged <10 y in Ethiopia, especially in the Gambella region. It offers crucial baseline data to assist public health professionals, policymakers and healthcare providers in formulating evidence-based strategies to combat noma and improve affected individuals' well-being.

Clinical Features, Etiopathogenesis, and Therapeutic Approaches of Acute Gingival Lesions: A Narrative Review

A bacterial infection is typically the source of gingivitis, a non-destructive condition that produces gum inflammation. Unlike chronic lesions, which have well-defined features and a gradual onset, acute lesions are unpleasant. Usually, the first symptoms are bleeding, swollen, and red gums. If gingivitis is not treated, it can lead to periodontitis, a more serious condition where the gums separate from the teeth. It seems that gingival disease-induced inflammation is a necessary condition for the breakdown of connective tissue attachment apical to the cementoenamel junction (CEJ). This may result in damage to the bone and soft tissue that support the teeth, leading to loosening and unstable teeth, and if the infection worsens, eventual tooth loss may occur. While one of the most prevalent inflammatory diseases in humans is plaque-induced gingivitis, there are several less common but frequently very significant non-plaque-induced gingival illnesses. Maintaining regular dental hygiene can help prevent gingivitis and make it reversible. Non-plaque-induced gingival lesions might be pathologic alterations restricted to gingival tissues, but they are also frequent signs of systemic disorders. Diagnosing patients with these lesions and creating treatment regimens for them must be the aim of the therapy.

Noma in the WHO's list of neglected tropical diseases: A review of its impact on undeveloped and developing tropical regions

Background

Noma is a neglected tropical disease and a global health concern.

Objectives

To elucidate the epidemiology, management, prevention, and public health implications of Noma.

Methods

PubMed, Scopus, and Web of Science, supplemented by Google Scholar and World Health Organization databases, were searched using keywords to gather both published and grey literature from 1970 to 2023 in English.

Results

Approximately 30,000-40,000 cases occur annually, with varying incidences across various African countries, such as Nigeria, Niger, and Chad. Incidence in Nigerian and Ethiopian states range from 0.6 to 3300 and 1.64 to 13.4 per 100,000 population, respectively. Mortality is approximately 8.5% in Niger. Risk factors include malnutrition, immunocompromised status, poor dental hygiene, inadequate sanitation, gingival lesions, low socioeconomic status, chronic and infectious diseases, low birth weight, high parity, diarrhoea, and fever. Diagnosis is primarily made based on clinical signs/symptoms and accordingly staging of disease is done. Stage I, II and II presents with acute necrotizing gingivitis, facial edema with halitosis, and necrotizing stomatitis, respectively. If the patient survives acute stages, the progress to Stage IV and Stage V manifests as trismus, difficulty in deglutition and phonation, and facial disfigurement, with increased severity in last stage. Treatment encompasses antibiotic therapy (amoxicillin, metronidazole, chlorhexidine, ampicillin, gentamicin), surgical interventions, wound management (honey dressing, ketamine), and nutritional support. Prevention strategies include oral hygiene, vaccination, health education, and community-based interventions.

Conclusion

Noma's recent inclusion in WHO list of neglected tropical diseases is a milestone in recognizing the importance of prevention and early intervention to globally enhance health outcomes.

Prevalence and associated risk factors for noma in Nigerian children: a systematic review and meta-analysis

OBJECTIVES

To determine the prevalence, case-fatality rate, and associated risk-factors of Noma in children in Nigeria.

METHODS

Search was conducted in PubMed, Google Scholar, and Cochrane Library databases. Data were extraction using a double-blind approach. Discrepancies were resolved by a third reviewer. Heterogeneity was evaluated using I2 statistics. Random-effects model was used for the meta-analysis and subgroup analysis was conducted. The study quality was evaluated using standard Critical-Appraisal-Checklist.

RESULTS

Of the 1652 articles identified, 12 studies that met the inclusion criteria included 871 cases of Noma. Two studies had high-risk of bias and were excluded in the meta-analysis. Pooled prevalence of Noma was 2.95% (95%CI:2.19-3.71; Z = 7.60; p < 0.00001, I2:100.0). Case fatality was reported in one study. Sex-distribution had a male-to-female ratio of 1.1:1. Malnutrition (88.42%, 95%CI:52.84-124.00; I2:100.0), measles (40.60%; 95% CI:31.56-49.65; I2:100.0) and malaria (30.75%; 95% CI:30.06-31.45; I2:100.0) were the most notable associated risk-factors. Prevalence of Noma was non-significantly lower in southern (1.96%,95%CI:1.49-2.44;6 studies) than in northern (4.43%; 95%CI:-0.98-9.83; 4 studies) Nigeria. One study reported the prevalence of Noma in children younger than 5 years.

CONCLUSIONS

About every 3 in 100 children in Nigeria had Noma and the prevalence was non-significantly higher in northern than southern Nigeria. Malnutrition, measles, and malaria were major associated risk-factors. Case-fatality rate and prevalence based on different age-groups were inconclusive.

Acute Necrotizing Ulcerative Gingivitis: A Case Report

Compared to other conditions found in the necrotizing periodontal diseases group, acute necrotizing ulcerative gingivitis (ANUG) is a definite and specific disease. This illness has a long history that originates from the time of Hippocrates and is also referred to by several synonyms. ANUG occurs less commonly than other oral disorders, even though it is typically not rare. It starts suddenly, advances quickly, and finally results in significant loss of alveolar bone and soft tissue. Viral microorganisms and weakened host defenses have been linked to the etiology and pathophysiology of ANUG. In situations where there is psychological and physiological stress, the incidence of ANUG rises. In developed nations, the incidence of ANUG has declined and, in some cases, gone extinct due to the development of antibiotics and improved nutritional status. However, due to the persistently low nutritional status, the illness continues to be a frequently diagnosed clinical lesion in developing nations. This case report presents the case of a 24-year-old ANUG patient and the sequential treatment of this patient.

Noma is a facial disfiguring childhood disease: Insights from cases of Noma in Ethiopia

OBJECTIVES

Noma is a neglected infectious disease that causes severe destruction of facial tissues and poses a significant public health threat. The disease reportedly affects individuals with a debilitating health condition. This study aimed to identify the most vulnerable age group affected by Noma disease and assess the severity of tissue damage among Noma cases in Ethiopia.

METHODS

A cross-sectional study was conducted to determine the age group most susceptible to noma and assess the disease-associated severity of tissue damage. The research objectives were met by scrutinizing electronic medical records of noma cases treated in Addis Ababa, Ethiopia, from 2007 to 2019, obtained from the Facing Africa database. Data collection was carried out using a standardized survey form, while the severity of facial tissue damage was assessed using the NOIPTUS score.

RESULTS

Among 164 Noma cases with documented data on disease onset, 92.7 % occurred during childhood, with 92.1 % of those cases being children aged ten years and younger. Approximately 11.6 % of all noma cases had mild tissue damage, classified as NOITULP grade 1, while 26.2 % had an intermediate level of tissue damage, classified as NOITULP grade 2. Severe tissue damage (NOITULP grade 3) was present in 37.2 % of cases, while 25 % had very severe tissue damage (NOITULP grade 4).

CONCLUSIONS

The findings underscore the vulnerability of children, particularly those aged ten years and younger, to Noma disease, supporting the argument that Noma is a facial-disfiguring childhood disease. Targeted interventions and preventive measures during childhood can be vital in controlling Noma incidence.

Retrospective Characterization of Noma Cases Found Incidentally across Nigeria during Outreach Programs for Cleft Lip from 2011-2020

Reports of cases of noma in Nigeria remain scarce despite its known and devastating effects on victims. This report presents a retrospective cross-sectional study based on data regarding on patients with noma encountered incidentally during Oral Health Advocacy Initiative outreach on orofacial diseases across 34 states and the Federal Capital Territory in Nigeria over 10 years (2011-2020), which was aimed at contributing to an understanding of the epidemiology of noma in Nigeria. The data were collated and analyzed, and are presented in frequency distribution tables and charts. A total of 7,195 patients with noma were encountered. The northeastern region had the greatest number of patients (n = 1,785, 24.8%) whereas the southwestern region had the least (n = 196, 2.7%). When aggregated by state, Ondo State had the least number of patients (n = 31, 0.4%) whereas Kano State had the greatest (n = 623, 8.7%). Patient age ranged from 3 to 70 years, with a slight male preponderance (56.9%). This report highlights the fact that noma is prevalent in Nigeria but remains neglected, with extensive but preventable physical, emotional, and social debilitation and devastation of the victims across all age groups. There is a need for a more robust survey to determine the true burden of the disease. There is also an urgent need for collaboration between governments and nongovernmental organizations to institute appropriate interventions by way of public education and enlightenment, as well as case detection and early treatment to mitigate the devastating consequences of delayed or poorly managed cases.

A retrospective clinical, multi-center cross-sectional study to assess the severity and sequela of Noma/Cancrum oris in Ethiopia

Introduction

Noma is a disfiguring gangrenous disease of the orofacial tissue and predominantly affects malnourished children. The tissue gangrene or necrosis starts in the mouth and eventually spreads intra-orally with the destruction of soft and hard tissues. If not controlled, the natural course of the condition leads to a perforation through the skin of the face, creating a severe cosmetic and functional defect, which often affects the mid-facial structures. Furthermore, the course of the disease is fulminating, and without timely intervention, it is fatal.

Materials and methods

A retrospective clinical cross-sectional study was conducted to assess the sequela and severity of Noma in Ethiopia. Medical records of patients diagnosed with Noma were reviewed. The medical files were obtained from Yekatik 12 Hospital, Facing Africa, and the Harar project,—the three major Noma treatment centers in Ethiopia. The severity of facial tissue damage and the extent of mouth trismus (ankylosis) were examined based on the NOIPTUS score.

Results

A total of 163 medical records were reviewed. Of those, 52% (n = 85) and 48% (n = 78) have reported left-sided and right-sided facial defects, respectively. The facial defects ranged from minor to severe tissue damage. In other words, 42.3% (n = 69), 30.7% (n = 50), 19% (n = 31), and 8% (n = 13) have reported Grade-2 (25–50%), Grade-3 (50–75%), Grade-1 (0–25%), and Grade-4 (75–100%) tissue damages respectively. Cheek, upper lip, lower lip, nose, hard palate, maxilla, oral commissure, zygoma, infra-orbital region, mandible, and chin are oftentimes the major facial anatomic regions affected by the disease in the individuals identified in our review. Complete loss of upper lip, lower lip, and nose were also identified as a sequela of Noma.

Discussion

The mortality rate of Noma is reported to vary between 85% and 90%. The few survivors suffer from disfigurement and functional impairment affecting speech, breathing, mastication, and/or even leading to changes in vision. Often, the aesthetic damage becomes a source of stigma, leading to isolation from society, as well as one’s family. Similarly, our review found a high level of facial tissue damage and psychiatric morbidity.

Noma is orofacial gangrene that rapidly disintegrates the hard and soft tissue of the face. The mortality rate of Noma varies between 85–90%. The remaining 10–15% of Noma survivors permanently suffer from severe facial deformities. Noma is a widely neglected disease affecting poor people globally. Most cases of Noma are reported from the so-called Noma belt, located south of the Sahara and runs across Africa from Senegal to Ethiopia. Though Ethiopia is one of the countries in the Noma-belt region where people, particularly children, are significantly affected by the disease, the attention given to this devastating condition is remained to be very low. Therefore, we believe that assessing the severity and sequela of Noma in Ethiopia is crucially essential to lay bare the burden of the disease and increase the overall understanding of the condition among different stakeholders. We are also convinced that the study’s findings can serve as baseline data for further in-depth scientific investigations and preventive policy development.

Columella reconstruction using double nasolabial flap and costal cartilage: A case report

Total loss of columella causes significant aesthetic and functional deformities due to its important functions which provides assistance and extension to the nose pointer. Noma is described as one of the developed sources of total columellar loss, and is also contagious, with the ability to intensely damage facial tissues and immediate structures. However, the condition is predominantly suffered in Africa, with an estimation of 20 instances per 100,000 individuals. Furthermore, the reformation of a columellar disorder offers a complex process, due to the structural features of the location. A 24-year-old female patient with total columellar loss caused by Noma. We performed a two stage reconstruction. First, we used double nasolabial flaps to create a new columella. Second, we inserted costal cartilage and dermofat graft to support it. The double nasolabial flap demonstrated 100% survival. Both nasal airway and the final appearance showed functionally and cosmetically remarkable results. The nasolabial angle projected better than the preoperative measurement. The patient was satisfied. The patient was followed up until a year after surgery. The double nasolabial flaps combined with costal cartilage graft is one of the best surgical options to obtain astonishing columellar reconstruction.

Noma: Overview of a Neglected Disease and Human Rights Violation

Noma is an orofacial gangrene affecting malnourished children and mainly observed in tropical countries, particularly sub-Saharan Africa. Epidemiological data on noma are scarce, but a current estimate of the global incidence is 30,000-40,000 cases per year, with a mortality rate of approximately 85% and a burden of disease calculated to be a loss of 1-10 million disability-adjusted life years. The etiology of noma is multifactorial with malnutrition as an ever present factor, often in combination with concomitant diseases, such as measles, malaria, and human immunodeficiency virus (HIV), and poor oral hygiene. The pathogenesis is a fast-spreading, noncontagious gangrenous infection occurring in the face, often preceded by acute necrotizing gingivitis, and stomatitis. Rare microbiological studies suggest an opportunistic infection caused by an imbalance in normal intraoral microorganisms. Prevention lies in food security, measles vaccination, prevention of malaria and HIV, including the early detection and treatment of necrotizing gingivitis and stomatitis. Early treatment with antibiotics may prevent gangrene or reduce its extent. Late treatment consists of surgical rehabilitation, which is often complex. However, access to medical care is very limited for noma patients due to the extremely poor conditions in which they live that are frequently located in remote rural areas. The authors support the United Nations Human Rights Council Resolution 19/7 adopted on March 22, 2012 "The right to food," and advocate for the inclusion of noma on the list of neglected tropical diseases to encourage more medical and institutional attention for this often lethal or very mutilating infectious gangrene.

Acute periodontal lesions

This review provides updates on acute conditions affecting the periodontal tissues, including abscesses in the periodontium, necrotizing periodontal diseases and other acute conditions that cause gingival lesions with acute presentation, such as infectious processes not associated with oral bacterial biofilms, mucocutaneous disorders and traumatic and allergic lesions. A periodontal abscess is clinically important because it is a relatively frequent dental emergency, it can compromise the periodontal prognosis of the affected tooth and bacteria within the abscess can spread and cause infections in other body sites. Different types of abscesses have been identified, mainly classified by their etiology, and there are clear differences between those affecting a pre-existing periodontal pocket and those affecting healthy sites. Therapy for this acute condition consists of drainage and tissue debridement, while an evaluation of the need for systemic antimicrobial therapy will be made for each case, based on local and systemic factors. The definitive treatment of the pre-existing condition should be accomplished after the acute phase is controlled. Necrotizing periodontal diseases present three typical clinical features: papilla necrosis, gingival bleeding and pain. Although the prevalence of these diseases is not high, their importance is clear because they represent the most severe conditions associated with the dental biofilm, with very rapid tissue destruction. In addition to bacteria, the etiology of necrotizing periodontal disease includes numerous factors that alter the host response and predispose to these diseases, namely HIV infection, malnutrition, stress or tobacco smoking. The treatment consists of superficial debridement, careful mechanical oral hygiene, rinsing with chlorhexidine and daily re-evaluation. Systemic antimicrobials may be used adjunctively in severe cases or in nonresponding conditions, being the first option metronidazole. Once the acute disease is under control, definitive treatment should be provided, including appropriate therapy for the pre-existing gingivitis or periodontitis. Among other acute conditions affecting the periodontal tissues, but not caused by the microorganisms present in oral biofilms, infectious diseases, mucocutaneous diseases and traumatic or allergic lesions can be listed. In most cases, the gingival involvement is not severe; however, these conditions are common and may prompt an emergency dental visit. These conditions may have the appearance of an erythematous lesion, which is sometimes erosive. Erosive lesions may be the direct result of trauma or a consequence of the breaking of vesicles and bullae. A proper differential diagnosis is important for adequate management of the case.

[Noma]

Noma is a necrotizing ulcerative stomatitis known since Antiquity. It occurs mostly in poor countries, the Sahel countries being the most affected. Each year, several hundred thousand cases are reported. Noma affects especially malnourished children who are less than 6 years old and rarely adults with acquired immunodeficiency (HIV, cancer). Ulcerative lesion is occurring rapidly due to the production of endotoxins by bacteria from oral commensal, telluric and animal origin. Necrotic debridement leads to huge defects: loss of soft tissue (skin, nerves, vessels, eye), bone (maxilla, mandible) and teeth. Death occurs rapidly in a few weeks in 80 % of the cases. In case of survival, the consequences are functional, aesthetic, psychological and social. The goal of the treatment in the acute phase is the patient's survival and the fight against limited mouth opening. The management of the phase of sequela is an anaesthetic, surgical and physiotherapy challenge. Its purpose is the social reintegration of the patient.

Microarray analysis of microbiota of gingival lesions in noma patients

Noma (cancrum oris) is a gangrenous disease of unknown etiology affecting the maxillo-facial region of young children in extremely limited resource countries. In an attempt to better understand the microbiological events occurring during this disease, we used phylogenetic and low-density microarrays targeting the 16S rRNA gene to characterize the gingival flora of acute noma and acute necrotizing gingivitis (ANG) lesions, and compared them to healthy control subjects of the same geographical and social background. Our observations raise doubts about Fusobacterium necrophorum, a previously suspected causative agent of noma, as this species was not associated with noma lesions. Various oral pathogens were more abundant in noma lesions, notably Atopobium spp., Prevotella intermedia, Peptostreptococcus spp., Streptococcus pyogenes and Streptococcus anginosus. On the other hand, pathogens associated with periodontal diseases such as Aggregatibacter actinomycetemcomitans, Capnocytophaga spp., Porphyromonas spp. and Fusobacteriales were more abundant in healthy controls. Importantly, the overall loss of bacterial diversity observed in noma samples as well as its homology to that of ANG microbiota supports the hypothesis that ANG might be the immediate step preceding noma.

Risk factors for noma disease: a 6-year, prospective, matched case-control study in Niger

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.

The global burden of periodontal disease: towards integration with chronic disease prevention and control

Chronic diseases are accelerating globally, advancing across all regions and pervading all socioeconomic classes. Unhealthy diet and poor nutrition, physical inactivity, tobacco use, excessive use of alcohol and psychosocial stress are the most important risk factors. Periodontal disease is a component of the global burden of chronic disease, and chronic disease and periodontal disease have the same essential risk factors. In addition, severe periodontal disease is related to poor oral hygiene and to poor general health (e.g. the presence of diabetes mellitus and other systemic diseases). The present report highlights the global burden of periodontal disease: the ultimate burden of periodontal disease (tooth loss), as well as signs of periodontal disease, are described from World Health Organization (WHO) epidemiological data. High prevalence rates of complete tooth loss are found in upper middle-income countries, whereas the tooth-loss rates, at the time of writing, are modest for low-income countries. In high-income countries somewhat lower rates for edentulism are found when compared with upper middle-income countries. Around the world, social inequality in tooth loss is profound within countries. The Community Periodontal Index was introduced by the WHO in 1987 for countries to produce periodontal health profiles and to assist countries in the planning and evaluation of intervention programs. Globally, gingival bleeding is the most prevalent sign of disease, whereas the presence of deep periodontal pockets (≥6 mm) varies from 10% to 15% in adult populations. Intercountry and intracountry variations are found in the prevalence of periodontal disease, and these variations relate to socio-environmental conditions, behavioral risk factors, general health status of people (e.g. diabetes and HIV status) and oral health systems. National public health initiatives for the control and prevention of periodontal disease should include oral health promotion and integrated disease-prevention strategies based on common risk-factor approaches. Capacity building of oral health systems must consider the establishment of a financially fair service in periodontal care. Health systems research is needed for the evaluation of population-oriented oral health programs.

Bacterial diversity in oral samples of children in niger with acute noma, acute necrotizing gingivitis, and healthy controls

BACKGROUND

Noma is a gangrenous disease that leads to severe disfigurement of the face with high morbidity and mortality, but its etiology remains unknown. Young children in developing countries are almost exclusively affected. The purpose of the study was to record and compare bacterial diversity in oral samples from children with or without acute noma or acute necrotizing gingivitis from a defined geographical region in Niger by culture-independent molecular methods.

METHODS AND PRINCIPAL FINDINGS

Gingival samples from 23 healthy children, nine children with acute necrotizing gingivitis, and 23 children with acute noma (both healthy and diseased oral sites) were amplified using "universal" PCR primers for the 16 S rRNA gene and pooled according to category (noma, healthy, or acute necrotizing gingivitis), gender, and site status (diseased or control site). Seven libraries were generated. A total of 1237 partial 16 S rRNA sequences representing 339 bacterial species or phylotypes at a 98-99% identity level were obtained. Analysis of bacterial composition and frequency showed that diseased (noma or acute necrotizing gingivitis) and healthy site bacterial communities are composed of similar bacteria, but differ in the prevalence of a limited group of phylotypes. Large increases in counts of Prevotella intermedia and members of the Peptostreptococcus genus are associated with disease. In contrast, no clear-cut differences were found between noma and non-noma libraries.

CONCLUSIONS

Similarities between acute necrotizing gingivitis and noma samples support the hypothesis that the disease could evolve from acute necrotizing gingivitis in certain children for reasons still to be elucidated. This study revealed oral microbiological patterns associated with noma and acute necrotizing gingivitis, but no evidence was found for a specific infection-triggering agent.

NOMA: A Preventable "Scourge" of African Children

Noma is a serious orofacial gangrene originating intraorally in the gingival-oral mucosa complex before spreading extraorally to produce a visibly destructive ulcer. Although cases of noma are now rarely reported in the developed countries, it is still prevalent among children in third world countries, notably in sub-Sahara Africa, where poverty, ignorance, malnutrition, and preventable childhood infections are still common. This review summarizes historical, epidemiological, management, and research updates on noma with suggestions for its prevention and ultimate global eradication. The global annual incidence remains high at about 140,000 cases, with a mortality rate exceeding 90% for untreated diseases. Where the patients survive, noma defects result in unsightly facial disfigurement, intense scarring, trismus, oral incompetence, and social alienation. Although the etiology has long been held to be infectious, a definitive causal role between microorganisms cited, and noma has been difficult to establish. The management of noma with active disease requires antibiotics followed by reconstructive surgery. Current research efforts are focused towards a comprehensive understanding of the epidemiology, and further elucidation of the microbiology and pathogenesis of noma.Although a formidable public health challenge, noma can be prevented with a potential for subsequent global eradication. To achieve both desirable goals, detection of early disease is crucial because these early lesions respond to conventional antibiotic treatments when instituted side by side with nutritional rehabilitation, and obviates the necessity for extensive surgical reconstruction often indicated in late stage disease. The eradication of noma in the developed world in the mid 20(th) century bears out the notion of a similar outcome following effective preventive strategies in Africa. A fundamental and necessary step towards attaining this goal is for the international community to adopt a perception of noma as an urgent global public health challenge. Research effort toward deciphering the microbiology, molecular events, and pathogenesis of noma also should intensify.

Visor flap for total upper and lower lip reconstruction: a case report

Introduction

Noma, aptly named the 'face of poverty', is a scourge with a mortality rate of up to 90% that affects some 140,000 people each year, predominantly children in the sub-Saharan 'noma belt'. Survivors of the acute attack suffer severe facial disfigurement from loss of facial tissue and scarring. Surgical reconstruction of noma defects is a major challenge, especially in Africa, where the majority of cases occur.

Case presentation

We report the case of a 40-year-old Somali man who presented with severe facial disfigurement, including total absence of both upper and lower lips. After a failed initial reconstruction, a combination of platysma flaps and a left deltopectoral flap provided mucosal lining, while a scalp visor flap served to recreate upper and lower lips, the beard and moustache.

Conclusion

The scalp visor flap offers a simple but extremely versatile tool for use in midfacial reconstruction, especially in the male, providing neo-lip tissue, a moustache and a beard. This is the first report of a simultaneous total upper and lower lip reconstruction using a scalp visor flap, in the English literature. We also emphasize on a process of transfer of skills to enable local surgeons to effectively manage the challenge that noma presents.

Noma (cancrum oris)

Noma is an opportunistic infection promoted by extreme poverty. It evolves rapidly from a gingival inflammation to grotesque orofacial gangrene. It occurs worldwide, but is most common in sub-Saharan Africa. The peak incidence of acute noma is at ages 1-4 years, coinciding with the period of linear growth retardation in deprived children. Noma is a scourge in communities with poor environmental sanitation. It results from complex interactions between malnutrition, infections, and compromised immunity. Diseases that commonly precede noma include measles, malaria, severe diarrhoea, and necrotising ulcerative gingivitis. The acute stage responds readily to antibiotic treatment. The sequelae after healing include variable functional and aesthetic impairments, which require reconstructive surgery. Noma can be prevented through promotion of national awareness of the disease, poverty reduction, improved nutrition, promotion of exclusive breastfeeding in the first 3-6 months of life, optimum prenatal care, and timely immunisations against the common childhood diseases.

Enfermedad periodontal necrosante: una manifestación de trastornos sistémicos

Necrotizing periodontal disease (NPD) is an infection characterized by gingival necrosis presenting as "punched-out" papillae, with gingival bleeding, and pain. Prevotella intermedia and spirochetes have been associated with the gingival lesions. Predisposing factors may include emotional stress, immunosuppression, especially secondary to human immunodeficiency virus (HIV) infection, cigarette smoking, poor diet and pre-existing gingivitis. During the last few years, diagnosis of NPD has became more important not only because of its contribution to the appearance of clinical attachment loss and gingival sequelae, but also because it has been revealed as a marker for immune deterioration in HIV-seropositive patients.

Temporal relationship between the occurrence of fresh noma and the timing of linear growth retardation in Nigerian children

BACKGROUND

Fresh noma (cancrum oris) occurs predominantly in children <4 years of age. The key risk factors are poverty, malnutrition and infections. Evolution from an intraoral inflammation to a grotesque oro-facial gangrene is very rapid.

OBJECTIVE

We assessed potential relationship between the occurrence of fresh noma and linear growth retardation (LGR) which is prevalent in deprived Third World infants/children between ages 3 and 30 months. LGR is attributed to malnutrition and chronic immunostimulation by environmental antigens.

DESIGN

Anthropometric evaluation of children (n = 91) with fresh noma, ages 0-8 years, in relation to US National Center for Health Statistics Reference values was carried out. Age-matched noma-free, poor village children (n = 151) from similar communities as noma cases, and elite urban children (n = 132) served as control groups. Heights and weights were measured and the height for age (HAZ), weight for age (WAZ) and weight for height (WHZ) scores calculated as indices of stunting, underweight and wasting respectively. Serum level of interleukin (IL)-18, a multifunctional cytokine, was also measured.

RESULTS

In the age groups 0-4 and 4-8 years, the percentages of noma children <-2.0SD were 91% and 67% respectively. The corresponding values for the village children were 37% and 24% and significantly different (P < 0.001) from the noma group. Only 7% of the elite children aged 4-8 years were stunted. Low body weight and wasting were prominent features of village and noma groups, but more marked in the latter. Associated with noma was a profound increase (P < 0.001) in IL-18 in comparison with urban controls, and a 34% non-statistically significant increase relative to the village control group. Among other functions, IL-18 induces several pro-inflammatory cytokines and the matrix metalloproteinases, influences long bone growth, and consequently may be relevant to growth retardation seen in poor village children and noma victims.

CONCLUSION

These results suggest that occurrence of fresh noma was probably programmed very early in life by malnutrition and chronic infections resulting from replacement of breast milk with contaminated, inferior substitutes. Although not investigated, we speculate that children with fresh noma might also be victims of intrauterine growth retardation as noma is most prevalent during the infantile phase of child growth which starts at mid-gestation and tails off at 4 years.

Serum vitamin C-periodontal relationship in community-dwelling elderly Japanese

OBJECTIVE

To determine the relationship between serum vitamin C and periodontitis as estimated by clinical attachment loss (CAL) in community-dwelling elderly Japanese.

MATERIAL AND METHODS

This analysis was confined to 413 Niigata citizens aged 70 years in whom the data for serum vitamin C and CAL were available. High-pressure liquid chromatography method was used to ascertain the serum vitamin C levels while CAL was assessed on six sites of all teeth present including third molars by means of pressure-sensitive probes. Other variables included gender, smoking, toothbrushing frequency, number of teeth present and random blood sugar levels.

RESULTS

Serum vitamin C concentration was inversely related to CAL (r=-0.23, p<0.00005) at bivariate level. Multiple linear regression analysis showed that CAL was 4% greater in subjects with lower serum vitamin C levels than in subjects with higher serum vitamin C levels notwithstanding smoking, diabetes, oral hygiene, gender or number of teeth present.

CONCLUSION

The findings suggested that serum vitamin C might have relatively weak but a statistically significant relationship with periodontitis in this elderly population.

Oral health in Nigeria

Most oral health surveys in Nigeria have been sporadic and based on convenience samples. Periodontal disease with deep pocketing occurs in Nigerians at an early age, the prevalence being 15-58% in those aged above 15 years. Caries experience has been reported to vary between very low and low in most studies, but is moderate in some urban communities. Although mean DMFT is below 4 in most communities, the restorative index is extremely low, most carious teeth remaining unrestored. The higher caries prevalence in second than first permanent molars that has been reported is most likely due to a change from traditional to Western-type diet. Other oral health problems include malocclusion, truamatised teeth, dental fluorosis, and oral tumours. The scanty oral health services available in the country are mainly in urban areas. There is, therefore, a need to develop sustainable strategies for national preventive and therapeutic oral health services in Nigeria.

Cancrum oris

A malnourished 9-year-old boy presented with an infection in the buccal space that developed into cancrum oris during the course of treatment.

Necrotizing ulcerative gingival lesions and clinical attachment loss

This paper describes the association between the occurrence of necrotizing ulcerative gingival lesions and clinical attachment loss using multivariable logistic regression methods and data originating in an epidemiological study conducted among a random sample of adolescents (n = 9203). Results show that the presence of necrotizing ulcerative gingival lesions is strongly associated with the occurrence of clinical attachment loss, whether defined as the presence of clinical attachment loss > or= 1 mm in at least two teeth or as the presence of clinical attachment loss > or = 3 mm in at least one tooth. This contribution of necrotizing ulcerative gingival lesions appeared to occur independently of the contribution from known common risk factors. Our findings suggest that there are causes of necrotizing ulcerative gingival lesions, yet to be identified, which have a substantial impact on the occurrence of clinical attachment loss.

Position paper: periodontal diseases of children and adolescents

Children and adolescents are subject to several periodontal diseases. Although there is a much lower prevalence of destructive periodontal diseases in children than in adults, children can develop severe forms of periodontitis. In some cases, this destructive disease is a manifestation of a known underlying systemic disease. In other young patients, the underlying cause for increased susceptibility and early onset of disease is unknown. These diseases are often familial, suggesting a genetic predisposition for aggressive disease. Current modalities for managing periodontal diseases of children and adolescents may include antibiotic therapy in combination with non-surgical and/or surgical therapy. Since early diagnosis ensures the greatest chance for successful treatment, it is important that children receive a periodontal examination as part of their routine dental visits.

Gingival crevice microbiota from Chinese patients with gingivitis or necrotizing ulcerative gingivitis

The objective of this study was to quantitatively compare the bacterial population structure in plaque from the gingival margin of two groups of 21 Chinese patients with gingivitis or necrotizing ulcerative gingivitis (NUG). Subjects were recruited in four dental clinics in Eastern China. Samples were quantitatively assessed by immunofluorescence and fluorescent in situ hybridization for taxa known to be associated with periodontal diseases. The analyses showed that the fusiform taxa (Fusobacterium nucleatum/Fusobacterium periodonticum, Leptotrichia buccalis, Tannerella forsythensis, and Capnocytophaga sp.), Campylobacter rectus, Prevotella intermedia, Prevotella nigrescens, Selenomonas sputigena, and treponemes were present in both groups with high prevalence. Porphyromonas gingivalis and Actinomyces gerencseriae were much more prevalent in the NUG group. Quantitatively, most taxa, including P. gingivalis, F. nucleatum and the treponemes, accounted, on average, for < 3% of the total bacterial cell number. Only P. intermedia/P. nigrescens, P. gingivalis, S. sputigena, A. gerencseriae, and the sum of all monitored suspected periodontal pathogens were significantly increased in the NUG group. The present study demonstrates for both groups a highly diverse plaque composition and suggests that, etiologically, the overall concentration and the concerted effects of the entire group of opportunistic pathogens thriving in NUG-associated plaque are of prime importance.

Noma: a forgotten disease

According to recent reports from the WHO, noma (or cancrum oris), a hideous, ancient disease primarily affecting children living in poverty in parts of sub-Saharan Africa, is increasing. Noma often starts as an ulcer on the oral mucosa or as ANG and commonly after a bout of measles or other disease. It quickly develops into a massive necrosis, moving from the inside outward, often involving major portions of the face. Early treatment with antibiotics, rehydration, correction of electrolytic imbalances, and administering nutritional supplements will halt the disease. The high mortality rate, however, indicates that many children are not given care or brought for care in time. Surviving victims often display severe facial deformities that demand extensive reconstructive surgery. Current research has elucidated parts of the pathogenesis of noma. The WHO started the international Action Network Against Noma in 1992, with its official launch on the World Health Day in 1994: a five-point action plan was presented and current work follows that plan.

Noma: an "infectious" disease of unknown aetiology

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.

A history of noma, the "Face of Poverty"

Noma (necrotizing ulcerative stomatitis, stomatitis gangrenosa, or cancrum oris) is a devastating orofacial gangrene that occurs mainly among children. The disease has a global yearly incidence of 140,000 cases and a mortality rate of approximately 90 percent. Patients who survive noma generally suffer from its sequelae, including serious facial disfigurement, trismus, oral incontinence, and speech problems. The medical history of noma indicates that the disease was already known in classical and medieval civilizations in Europe. In the sixteenth and seventeenth centuries, Dutch chirurgeons clearly described noma as a clinical entity and realized that the popular name "water canker" was not sufficient, because this quickly spreading ulceration in the faces of children was different from "cancer." In the eighteenth century, awareness that noma is related to poverty, malnutrition, and preceding diseases such as measles increased in northwestern Europe. In the first half of the nineteenth century, extensive surgical procedures were described for the treatment of the sequelae of noma. At the end of that century, noma gradually disappeared in the Western world because of economic progress, which gave the poorest in society the opportunity to feed their children sufficiently. Only in the twentieth century were effective drugs (sulfonamides and penicillin) against noma developed, as well as adequate surgical treatment for the sequelae of noma. These modes of treatment remain inaccessible for the many present-day victims of noma because of their extreme poverty. The only truly effective approach to the problem of noma throughout the world is prevention, namely, combating the extreme poverty with measures that lead to economic progress. In the meantime, medical doctors in the Western world should not forget their own history and ignore this global health problem; rather, they should face "the face of poverty" with the eyes of mercy and concern suited to their profession.

Epidemiology of necrotizing ulcerative gingival lesions in adolescents

OBJECTIVE AND BACKGROUND

Relatively little is known about the epidemiology of necrotizing ulcerative gingival lesions (NUG) in adolescent populations. Most studies have comprised special target groups, such as military recruits, HIV patients, or severely malnourished subjects.

METHODS

A multistage random cluster sampling scheme was used to obtain a sample of 9203 students aged 12-21 years from 98 of a total of 618 high schools in Santiago, Chile. Students were given a clinical oral examination and questionnaire information was obtained on smoking and oral hygiene habits, dental attendance patterns, and diabetic status. The diagnostic criteria for NUG were the presence of necrosis and ulceration of at least one interproximal papillae.

RESULTS

The estimated prevalence of NUG was 6.7% (95% CI = [6.2; 7.3]). A multivariable logistic regression analysis showed that last seeing a dentist more than 1 year ago (OR = 1.60), or never (OR = 1.93), and reporting diabetes (OR = 2.12) showed a significant positive association with the presence of NUG; whereas neither gender nor smoking were important predictors. Students aged 18-21 years were more, albeit statistically insignificantly, likely to have NUG than were younger students (OR = 1.40).

CONCLUSIONS

Our observation that reporting to be diabetic was positively associated with the presence of NUG is interesting, as diabetes has never been addressed as a possible risk factor. As the association between diabetes and periodontitis in adults is thought to relate to impaired function of neutrophils, microangiopathy, and impaired wound healing this finding suggests a significant role of the host response also for the occurrence of NUG.

Oral fungal and bacterial infections in HIV-infected individuals: an overview in Africa

Oral opportunistic infections developing secondary to human immunodeficiency virus (HIV) infection have been reported from the early days of the epidemic and have been classified by both the EC-Clearinghouse and the World Health Organisation (WHO). Among the fungal infections, oral candidiasis, presenting in African HIV-infected patients has been sporadically documented. We review the literature with respect to candidal carriage, oral candidiasis prevalence and the predictive value of oral candidiasis for a diagnosis of underlying HIV disease in African HIV-infected patients. The use of oral candidiasis as a marker of disease progression, the species of yeasts isolated from the oral cavity in Africa and the resistance of the yeasts to antifungal agents and treatment regimens are discussed. Orofacial lesions as manifestations of the systemic mycoses are rarely seen in isolation and few cases are reported in the literature from Africa. In spite of the high incidence of noma, tuberculosis, chronic osteomyelitis and syphilis in Africa, surprisingly there have been very few reported cases of the oral manifestations of these diseases in HIV-positive individuals. Orofacial disease in HIV-infected patients is associated with marked morbidity, which is compounded by malnutrition. The authors indicate specific research areas, initially directed at the most effective management strategies, which would complete data in this important area.

Oro-facial gangrene (noma/cancrum oris): pathogenetic mechanisms

Cancrum oris (Noma) is a devastating infectious disease which destroys the soft and hard tissues of the oral and para-oral structures. The dehumanizing oro-facial gangrenous lesion affects predominantly children ages 2 to 16 years, particularly in sub-Saharan Africa, where the estimated frequency in some communities varies from 1 to 7 cases per 1000 population. The risk factors are poverty, malnutrition, poor oral hygiene, residential proximity to livestock in unsanitary environments, and infectious diseases, particularly measles and those due to the herpesviridae. Infections and malnutrition impair the immune system, and this is the common denominator for the occurrence of noma. Acute necrotizing gingivitis (ANG) and oral herpetic ulcers are considered the antecedent lesions, and ongoing studies suggest that the rapid progression of these precursor lesions to noma requires infection by a consortium of micro-organisms, with Fusobacterium necrophorum (Fn) and Prevotella intermedia (Pi) as the suspected key players. Additional to production of a growth-stimulating factor for Pi, Fn displays a classic endotoxin, a dermonecrotic toxin, a cytoplasmic toxin, and a hemolysin. Without appropriate treatment, the mortality rate from noma is 70-90%. Survivors suffer the two-fold afflictions of oro-facial mutilation and functional impairment, which require a time-consuming, financially prohibitive surgical reconstruction.