Content Warning: The following article contains images and descriptions of Noma disease that are graphic and may be distressing to some readers.
Noma, also known as cancrum oris, is a gangrenous infection that leads to the rapid destruction of tissue in the face, particularly the mouth and cheeks. It primarily afflicts young children, typically between the ages of two and six, in communities grappling with extreme poverty. The disease progresses with startling speed, causing severe disfigurement and functional impairment in those who survive. While it begins inside the mouth, its effects quickly become visible externally.
The Visual Progression of Noma
The initial stage of Noma often goes unnoticed, beginning inside the mouth as a lesion on the gums, a condition known as acute necrotizing gingivitis. While there are no external facial signs, this stage is characterized by severe gum inflammation, fever, foul-smelling breath, and pain in the mouth.
Within a few days, the infection enters its acute phase, marked by visible facial swelling, or edema. A hard, often dark-colored patch may form on the outside of the cheek or lip, corresponding to the internal ulceration. The swelling can be extensive, affecting the lips, cheeks, and sometimes the area around the eyes, signaling that the infection is spreading through the soft tissues of the face.
The most destructive stage follows with alarming speed, often within days of the initial swelling. Gangrene sets in, and the hardened patch of skin breaks down as the infection consumes the soft tissue and bone of the cheek, jaw, and nose. This process results in a large, open wound on the face, exposing the teeth and jawbone and leading to severe facial disfigurement.
For those who survive the acute infection, the disease enters a scarring phase. The large wound eventually begins to heal, but it leaves behind dense, tight scar tissue. This scarring can lock the jaw, making it difficult or impossible to eat or speak, and can also impair breathing, swallowing, and vision.
Underlying Risk Factors
Noma is not contagious; it is an opportunistic infection that flourishes when the body’s defenses are severely weakened. The primary catalyst for the disease is extreme poverty and the conditions that accompany it. It is so strongly linked to destitution that it is often called “the face of poverty.”
Severe malnutrition is a universal precursor to Noma, as a diet deficient in protein and essential vitamins compromises the immune system. This weakened state is often exacerbated by recent or concurrent illnesses. Diseases like measles, malaria, HIV, or even severe diarrhea can further suppress a child’s immunity, allowing the bacteria associated with Noma to thrive.
These risk factors converge most intensely in specific parts of the world. The vast majority of cases occur in sub-Saharan Africa, in a region often referred to as the “Noma Belt.” Cases have also been documented in Asia and Latin America. The common thread in these locations is a lack of access to adequate nutrition, clean water, sanitation, and basic healthcare.
Treatment and Reconstruction
The progression of Noma can be stopped if detected in its earliest stages. When the disease is confined to the gums as acute necrotizing gingivitis, a course of antibiotics, improved oral hygiene, and nutritional support can halt the infection. This early intervention prevents tissue destruction and allows for complete healing. Nutritional rehabilitation with a high-protein diet and vitamin supplements is a part of bolstering the child’s immune system.
For survivors left with severe facial disfigurement, the journey toward recovery involves highly specialized medical care. Reconstructive surgery is necessary and is not a single procedure but often a series of complex operations performed over several years. The primary goals of surgery are to restore function and improve appearance. Surgeons work to rebuild destroyed bone and tissue, often using grafts from other parts of the body.
These surgical interventions aim to release the scar tissue that may have locked the jaw, a condition known as trismus, allowing the survivor to eat and speak again. The reconstruction also focuses on closing the hole in the face, rebuilding the nose or lips, and restoring a more normal facial structure. Beyond the physical repairs, these surgeries help survivors reintegrate into their communities, reducing the social stigma and isolation they often face.