A severe variant called noma (gangrenous stomatitis) can cause full-thickness tissue destruction (sometimes involving the lips or cheek), typically in a debilitated patient. It begins as a gingival, buccal, or palatal (midline lethal granuloma) ulcer that becomes necrotic and spreads rapidly. Tissue sloughing may occur.
Noma is a rapidly progressive, polymicrobial, opportunistic infection that occurs during periods of compromised immune function. Fusobacterium necrophorum and Prevotella intermedia are thought to be key players in the process and interact with one or more other bacterial organisms (such as Borrelia vincentii, Porphyromonas gingivalis, Tannerella forsynthesis, Treponema denticola, Staphylococcus aureus, and nonhemolytic Streptococcus spp).
The reported predisposing factors include:
- Malnutrition or dehydration
- Poor oral hygiene
- Poor sanitation
- Unsafe drinking water
- Proximity to unkempt livestock
- Recent illness
- An immunodeficiency disorder, including AIDS
Noma was observed in Nazi concentration camps in World War II, and was studied by Nazi physician Josef Mengele. In many cases a recent debilitating illness, usually measles and sometimes herpes simplex, varicella (chicken pox), scarlet fever, malaria, tuberculosis, gastroenteritis or bronchopneumonia, precedes the appearance of noma as well as cancers such as leukemia. In many instances the infection begins as necrotizing ulcerative gingivitis (NUG). Early presentation is unclear as noma is often well progressed at initial presentation.
Noma, unlike most infections, is able to spread through anatomic barriers such as muscle
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