Noma: a possible reappraisal in western countries
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1
Polytechnical University of Marche, Department of Clinical Specialistic and Dental Sciences, Italy
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2
University of Foggia, Department of Clinical and Experimental Medicine, Italy
Aim. Noma refers to a gangrenous disease that destroys soft and hard tissues of oral and perioral structures. This lesion mostly affects children under 16 years of age in sub-Saharan Africa, whose the overall health is compromised by malnutrition, poor oral hygiene, and other diseases. In developed countries, sporadic cases of Noma occur in HIV-infected patients as an oral opportunistic lesion. In this work we reported 3 cases of Noma referred to Complex Operating Unit of Odontostomatology, involving HIV-negative Caucasian women in Italy.
Materials and Methods. We present 3 cases of Noma occurred in HIV-negative immunocompetent Caucasian women in different clinical conditions. All the patients showed some degree of malnutrition and poor oral health status. Case 1 refers to a 75-year-old woman with a 2.5x2 cm non-bleeding painful ulcer in the mucosa of the cheek from 3 days, which prevented her from feeding properly. Case 2 refers to a 43-year-old woman with type 2 Diabetes Mellitus (DM) and a 3x2 cm non-bleeding painful ulcer in the mucosa of the cheek from 4 days with spontaneous skin drainage. Case 3 refers to a 36-year-old woman a 3.5x3 cm bleeding painful ulcer in the mucosa of the cheek from 5 days, accompanied by weight loss. In each case, 2 biopsy samples were taken from the ulcer borders and processed for histological analysis, bacterial isolation, and susceptibility testing to antibiotic agents.
Results. In all cases, non-specific gram-negative cocci were found by microbiological tests, while the presence of Candida spp. could indicate a possible superinfection. All the patients showed some degree of malnutrition; moreover, all cases reported showed poor oral health status. A careful nutritional assessment was performed in the Case 1 due to advanced age and clinical condition, showing a BMI of 22. Moreover, low serum albumin levels and mild iron-deficiency anemia were found. Case 2 was affected by type 2 DM; this is the second case reported in literature. People with DM are more susceptible to developing oral health problems, and periodontal disease is the sixth major complication of diabetes. It is therefore possible that diabetes-related immune dysfunction creates the conditions for development of Noma. Case 3 refers to a woman weakened by untreated gastroenteritis, leaving the patient in a debilitated state. The presence of multiple micronutrient deficiencies cannot be excluded, although no specific analyses were conducted. It can be assumed that the patient health status, combined with the poor oral hygiene, led to development of Noma. Antibiotic and antifungal therapy was combined with the use of nasogastric nutrition, oral hygiene measures and wound healing treatment. Case 1 required intravenous antibiotic therapy with cephalosporins, while in the other cases we chose an antibiotic association that was the most effective against suspected pathogens, combined with an antifungal agent to prevent superinfection. All patients showed prompt recovery with local wound care and systemic drug therapy. Initial surgical treatment was avoided; however, in 2 cases reconstructive surgery became necessary.
Discussion. Noma is classically described as a gangrenous disease, although there is no evidence that the damage was the direct result of ischemia; instead, it is likely that necrosis develops later. The multiphase pathogenesis of this disease makes difficult to determine the bacterial species primarily responsible for Noma, although P. intermedia and F. necrophorum are suspected to play a key role. After nasogastric nutrition our patient showed rapid improvement of general conditions, suggesting that malnutrition could lead to Noma not only in developing countries but also in developed nations. However, further studies are necessary to investigate the role of malnutrition and other risk factors in the pathogenesis of Noma in HIV-negative adult patients.
Keywords:
Noma,
Cancrum oris,
Oral Ulcer,
immunocompetent adult,
Diabet Mellitus Type 2
Conference:
5th National and 1st International Symposium of Italian Society of Oral Pathology and Medicine., Ancona, Italy, 19 Oct - 20 Oct, 2018.
Presentation Type:
Poster Presentation
Topic:
Oral Diseases
Citation:
Pirani
F,
Mascitti
M,
Ciavarella
D,
Caponio
V,
Procaccini
M and
Santarelli
A
(2019). Noma: a possible reappraisal in western countries.
Front. Physiol.
Conference Abstract:
5th National and 1st International Symposium of Italian Society of Oral Pathology and Medicine..
doi: 10.3389/conf.fphys.2019.27.00024
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Received:
24 Oct 2018;
Published Online:
09 Dec 2019.
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Correspondence:
Dr. Marco Mascitti, Polytechnical University of Marche, Department of Clinical Specialistic and Dental Sciences, Ancona, Marche, 60121, Italy, marcomascitti86@hotmail.it