Whats cancrum oris
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cancrum oris noma
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Cancrum Oris (Noma)
Cancrum oris, also known as noma or gangrenous stomatitis, is a rapidly progressive, polymicrobial gangrenous infection of the mouth and face. It represents the most severe end of the necrotizing periodontal disease spectrum.
Fig. 22.13 - Cancrum oris (S Das, Manual on Clinical Surgery)
Who Gets It?
- Primarily affects young, malnourished children in developing countries (sub-Saharan Africa, parts of Asia and South America)
- Also seen as a complication of measles and leukemia
- Predisposing factors: severe malnutrition, poor oral hygiene, immunocompromise (e.g., HIV), preceding illness (measles, TB)
Pathophysiology and Microbiology
The disease involves invasion of oral tissues by polymicrobial bacteria, predominantly:
- Fusobacterium necrophorum and Fusobacterium nucleatum
- Spirochetes (Treponema species)
- Prevotella intermedia and other anaerobes
It is considered the extreme end of a spectrum:
- Necrotizing gingivitis (ANUG / "trench mouth") - gingiva only
- Necrotizing periodontitis - extends to attachment apparatus
- Necrotizing stomatitis - spreads to surrounding oral mucosa
- Noma / cancrum oris - entire mouth and face involved, often fatal
Clinical Features
Early stage:
- Begins as an area of oedema and induration on the gums
- Small painful ulcers covered with yellow slough
- Gums swell, bleed easily; fetor oris (foul breath) is prominent
- Fever, anorexia, malaise, cervical lymphadenopathy
Advanced stage:
- The necrosis spreads rapidly from gums to the inner cheek, lips, and through to the external skin surface
- Produces a large area of full-thickness tissue loss - the characteristic feature
- Extremely painful; patient is very ill
- Can result in massive destruction of the face (cheeks, lips, nose, even jaw bones)
- Case fatality rate is high (70-90%) without treatment; survivors are left with severe disfigurement
Classification within Gangrene
In surgical pathology, cancrum oris is classified under moist/infective gangrene, alongside carbuncle and postoperative progressive gangrene - S Das, A Manual on Clinical Surgery.
Treatment
- Nutritional rehabilitation - addressing underlying malnutrition is essential
- Antibiotics - penicillin (covers Fusobacterium and spirochetes) + metronidazole (anaerobic cover); amoxicillin-clavulanate is an alternative
- Wound care - debridement of necrotic tissue, antiseptic mouth rinses
- Treat the precipitant - manage underlying measles, HIV, leukemia
- Reconstructive surgery - after the acute phase resolves, surgical reconstruction is needed for the severe facial defects (may require multiple procedures)
Key Points for Exams
| Feature | Detail |
|---|---|
| Synonym | Noma, gangrenous stomatitis, fusospirochetal gangrene |
| Age group | Young children (2-6 years most common) |
| Main predisposing factor | Malnutrition |
| Common precipitant | Measles |
| Key organisms | Fusobacterium, spirochetes |
| Pattern of spread | Gums → inner cheek → lips → external skin (full-thickness) |
| Mortality (untreated) | ~70-90% |
| Treatment | Nutrition + antibiotics (penicillin + metronidazole) + surgery |
Sources: S Das, A Manual on Clinical Surgery, 13th Ed.; Rosen's Emergency Medicine; Fitzpatrick's Dermatology; Park's Preventive & Social Medicine
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