Introduction

Noma, also known as cancrum oris, is a devastating, non-communicable disease that affects small children, particularly in some of the world's most impoverished regions. Historically, noma was once prevalent in North America and Europe, but economic development and public health improvements have drastically reduced its occurrence in these regions. Unfortunately, today it remains a major health problem in developing areas, particularly in sub-Saharan Africa. Noma primarily targets neglected populations, and in countries like Ethiopia, the disease is most common in the Amhara regional state. Despite its significant impact, noma has not yet been officially recognized as a neglected tropical disease (NTD) by the World Health Organization (WHO), despite fulfilling the criteria for this designation. Due to this lack of recognition, noma is often referred to as a "neglected-neglected tropical disease."

This horrific disease is a violation of human rights, affecting children who already face extreme poverty and social marginalization. The United Nations Human Rights Council Advisory Committee has described noma as the "face of poverty," embodying the most severe violations of children's rights. Approximately 140,000 children are affected annually, and without treatment, the disease has a staggering 80-90% mortality rate. For those who survive, around 770,000 people worldwide are living with the physical and psychological consequences of noma.

Noma begins in the gums and rapidly destroys both soft and hard tissues of the face. While the precise cause is unknown, it is believed to arise from microorganisms that are part of the normal oral flora. Left untreated, it can lead to severe disfigurement, long-term health complications, and death. The disease progresses through five stages: acute necrotizing ulcerative gingivitis (ANUG), edema, gangrene, scarring, and sequelae. Early diagnosis is critical, as prompt treatment can prevent the disease's progression. However, untreated noma is almost always fatal, with profound physical, psychological, and social consequences for survivors.

Malnutrition: A Major Driver of Noma

Malnutrition is one of the leading risk factors for noma, and in many cases, the disease is considered a direct consequence of extreme poverty. The link between malnutrition and noma is so well-established that the disease has earned the nickname "the face of poverty." Malnutrition weakens the immune system and creates an environment in which the disease can thrive, making it a major contributor to noma's spread in impoverished communities.

Malnutrition can take many forms, but in the context of noma, undernutrition is particularly important. Undernutrition occurs when a person does not consume enough nutrients to meet their body's needs. This can lead to depletion of fatty tissue, muscle atrophy, and weakened immunity, leaving children vulnerable to infections like noma. Undernutrition is commonly diagnosed by looking at a person's weight in relation to their age, height, and body composition, with key markers being underweight, stunting (low height for age), and wasting (low weight for height).

Noma primarily affects malnourished children, especially those who suffer from protein-energy malnutrition (PEM), a condition caused by a lack of essential proteins and calories. Protein-energy malnutrition compromises the body's ability to fight infections, making it easier for diseases like noma to take hold. Studies have found that children with PEM often have reduced levels of immunoglobulin A (IgA), an antibody that is crucial for protecting the mucosal surfaces of the mouth. Without sufficient IgA, the mucosal integrity of the mouth deteriorates, making it easier for the normal oral flora to invade and cause infections that lead to noma.

Fig. 1 A diagrammatic view of how malnutrition jeopardizes noma and vice versa (Gezimu W., et al. 2022).

In addition to weakening the immune system, malnutrition can lead to deficiencies in vital vitamins that are essential for maintaining the health of the oral mucosa. Vitamins A, C, and B-complex, in particular, play key roles in protecting the body from infections. A deficiency in vitamin C can cause bleeding gums, delayed wound healing, and weakened collagen, all of which can create an environment conducive to bacterial invasion. Similarly, vitamin A deficiency can lead to the breakdown of epithelial tissues, which can contribute to the development of noma. Many children affected by noma are also found to have vitamin B deficiencies, which can cause issues such as cracked lips, sore tongues, and inflamed gums.

The relationship between malnutrition and noma is not one-sided. While malnutrition increases the risk of developing noma, the disease itself can exacerbate malnutrition. Children with noma often face difficulties eating due to the lesions and damage in their mouths, which can make it even harder for them to get the nutrition they need. This creates a vicious cycle, where malnutrition leads to noma, and noma worsens malnutrition. Breaking this cycle requires addressing both the disease and the underlying nutritional deficits that contribute to its development.

Poor Oral Hygiene: An Overlooked Factor

While malnutrition is a well-known risk factor for noma, poor oral hygiene is another major contributor that often goes unaddressed. Oral hygiene plays a fundamental role in maintaining overall health, but in many developing countries, especially in impoverished areas, access to basic oral care is limited. Poor oral hygiene can exacerbate noma by creating an environment in which harmful bacteria can thrive and infect the oral tissues.

In children with poor oral hygiene, the presence of debris, plaque, and bacteria on the teeth and gums can contribute to the development of infections that lead to noma. Studies have found that children from low-income families are particularly vulnerable to poor oral hygiene due to a lack of access to proper dental care and hygiene products. In regions where noma is endemic, children with poor oral hygiene are often at greater risk of developing severe forms of the disease.

Evidence from Nigeria, where noma is relatively common, shows that children with poor oral hygiene are more likely to experience more severe cases of the disease. Similarly, studies in Ethiopia have found that poor oral hygiene is often diagnosed in noma survivors. In these cases, poor oral hygiene not only contributed to the development of the disease but also made treatment more difficult, as infections surrounding the affected areas hindered recovery.

The prevention of noma, therefore, requires a focus on improving oral hygiene in at-risk populations. Caregivers must ensure that children receive proper oral care from an early age, and public health programs should incorporate oral hygiene education into their efforts to prevent and treat noma. In regions where noma is prevalent, healthcare workers should be trained to assess the oral health of children as part of routine check-ups, and efforts to promote good oral hygiene should be strengthened.

Addressing Noma: A Call for Action

Noma is a preventable disease, yet it continues to affect thousands of children each year in some of the world's poorest regions. Addressing the root causes of noma—malnutrition and poor oral hygiene—is essential to reducing its incidence and improving outcomes for those affected. Nutritional supplementation should be prioritized in both clinical and community settings, particularly in areas where noma is prevalent. In addition, oral hygiene programs should be implemented to educate caregivers and healthcare workers about the importance of maintaining oral health in children.

While noma has not yet been recognized as a neglected tropical disease by the WHO, there is a growing need for global attention to be directed toward this devastating illness. By recognizing noma as an NTD, international organizations and governments can allocate more resources to its prevention and treatment, ultimately reducing the disease's burden on vulnerable populations.

The battle against noma is not just a medical one-it is also a fight against poverty, inequality, and neglect. By addressing the social determinants of health that contribute to the disease, we can work towards a future where no child has to suffer from this preventable illness.

Conclusion

Noma is a disease of poverty, neglect, and injustice. Its impact on children in developing regions, particularly in sub-Saharan Africa, is profound, leaving survivors with physical disfigurements, psychological trauma, and social stigmatization. While malnutrition and poor oral hygiene are the primary drivers of noma, addressing these risk factors through improved nutrition and oral care can significantly reduce the disease's impact.

As the global health community continues to work towards reducing the burden of neglected tropical diseases, it is crucial that noma is recognized as a priority. By investing in preventive measures, such as nutritional support and oral hygiene education, we can begin to break the cycle of poverty and disease that sustains Noma's existence. In doing so, we will not only save lives but also uphold the basic human rights of children living in some of the world's most impoverished regions.