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Noma (cancrum oris)

Cyril O Enwonwu, ScD, PhD, MDS, BDS
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Elinor L Baron, MD, DTMH


Noma is a severe disfiguring gangrene of the mouth and face that begins as a gingival ulcer and spreads rapidly through the tissues of the mouth and face [1-5]. Unlike other infectious processes of the face, which may progress along anatomic spaces of the head and neck, noma can disrupt anatomic barriers and spread through muscle and bone [4]. The resulting gangrene may involve the maxilla, the mandible, and extend to the nose and infraorbital margins (picture 1). The word noma derives from the Greek "voun," meaning to devour, emphasizing the rapid progression of the disease [6,7].

Noma is categorized by the World Health Organization (WHO) as a necrotizing ulcerative stomatitis. Synonyms include cancrum oris and fusospirochetal gangrene. The name "cancrum oris" was introduced in Britain in the mid-17th century and is still in common usage in the United Kingdom [7,8]. According to an 1848 description, orofacial noma is a "gangrenous affection of the mouth, especially attacking children in whom the constitution is altered by bad hygiene and serious illness, especially from the eruptive fevers, beginning as an ulcer of the mucous membrane, with edema of the face, extending from within out, rapidly destroying the soft parts and the bone, and almost always quickly fatal" [9].

Mortality due to noma can be reduced with prompt, appropriate treatment. Noma is one of the most devastating and disfiguring human diseases worldwide and has been designated a health priority by the WHO [3,10-13].


Noma is a polymicrobial infection associated predominantly with anaerobic organisms [3,14]. Fusobacterium necrophorum has been observed most frequently in culture and appears to be an important organism for the development of noma [15-18]. Virulence factors of F. necrophorum include proteolytic enzymes and toxins capable of tissue destruction [18]. F. necrophorum also produces a growth stimulating factor for Prevotella intermedia, which facilitates lipid degradation.

Other microorganisms cultivated from noma lesions among Nigerian children are similar to those seen in adult periodontitis and are also capable of releasing enzymes that can degrade host tissues [19]. These include P. intermedia, alpha-hemolytic streptococci, Pseudomonas spp, Actinomyces spp, and Peptostreptococcus micros [3,15-18,20-22]. Spirochetes have also been observed at the advancing edge of active lesions with dark-field microscopy [15]. Molecular studies have demonstrated the complex diversity of microorganisms associated with noma, including 67 bacterial species, of which 25 have not yet been grown in vitro [23]. Herpes viruses have also been implicated, particularly herpes simplex virus and cytomegalovirus [1,21,24-26].

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Literature review current through: Nov 2017. | This topic last updated: Jun 15, 2016.
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