Context

Noma (also known as cancrum oris) is a noncommunicable necrotizing disease that typically occurs in young children living in extreme poverty.¹ Early intervention can prevent suffering, disability and death. Starting as necrotizing 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% 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 up to 770,000 suffer from noma (its prevalence) 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 healthcare in these areas, together with early death, stigma and traditional beliefs associated with noma, mean numerous cases   remain undetected. While 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 as a potential noma case.³

Confirmed new case of noma: Any person with a 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, non-governmental 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, non-governmental 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 epidemiological and aetiological factors contributing to the onset of noma, as well as its pathophysiological mechanisms and ways to tackle the modifiable causes of noma.⁵

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 among 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 is vital;
• be familiar with the WHO treatment guidelines.⁴

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 sequalae) stages of noma;⁴
• explains the risk factors and complex range of circumstances that lead to the progression from gingival inflammation to the gangrenous tissue destruction of noma. 

Keywords

noma, oral tissue, infection

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 socio-economic constraints.

References

1. WHO, Draft Global Strategy on Oral Health, 2022 Available at:  https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_10Add1-en.pdf Accessed 31 July 2022
2. Galli A, Brugger C, Fürst T, et al. Prevalence, incidence, and reported global distribution of noma: a systematic literature review. The Lancet Infectious Diseases 2022.
3. WHO. Standard Case Definitions, 2022. Noma: training of health workers at national and district levels on skin-NTDs. Available at: https://openwho.org/courses/NTDs-noma. Accessed 31 July 2022.
4. WHO. NOMA is a severe disease It is treatable if detected and managed early! https://www.afro.who.int/sites/default/files/2017-07/Information_brochure_EN.pdf
5. Farley E, Ariti C, Amirtharajah M, et al. (2021). Noma, a neglected disease: A viewpoint article. PLoSNeglTrop Dis 15(6):e0009437. https://doi.org/10.1371/journal.pntd.0009437. 18

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