Title: Noma: A neglected oro-facial disease

Abstract

Noma is a non-communicable, destructive necrotizing orofacial disease affecting chronically malnourished children living in poverty-stricken communities in sub-Saharan Africa, and rarely in Latin America and Asia. In Southern Africa (South Africa and Zimbabwe), even though rare, noma affects immunosuppressed HIV-seropositive subjects. Noma is initiated by complex interactions between anaerobic microorganisms within dentogingival plaques in a background of severe malnutrition, impaired immunity, viral infections or states of debilitation. Noma starts in the mouth as necrotizing gingivitis, a simple bacterially induced infection that progresses to necrotizing periodontitis and then to necrotizing stomatitis. In the presence of predisposing factors, the intra-oral necrotizing process spreads quickly and aggressively causing gross destruction and disfigurement. If diagnosed in the early stages of necrotizing gingivitis, the devastating progression to noma can be avoided by simple and inexpensive antibiotics and toothbrushing. The World Health Organisation (WHO) has classified noma into five sequential stages: stage 1 – acute necrotizing ulcerative gingivitis; stage 2 – oedema; stage 3 – gangrene; stage 4 – scarring; stage 5 – sequela. In the opinion of the authors, this WHO classification requires fundamental re-appraisal. The purpose of this is to highlight the weaknesses of this classification, and to propose a simpler, more logical and practical evidence-based staging of noma, which if used should improve the quality and value of future epidemiological data about noma.