What are the other Names for this Condition? (Also known as/Synonyms)

• Fusospirochetal Gangrene
• Gangrenous Stomatitis
• Noma

What is Cancrum Oris? (Definition/Background Information)

• Cancrum Oris is a severe and aggressive gangrenous process that affects young malnourished children (in poor and underdeveloped nations) with debilitating consequences. Cancrum Oris is also known as Noma, from the Greek word “nomē”, meaning to devour or feed
• The condition begins as small ulcer on the gums that rapidly spreads to involve other parts of the mouth including the teeth, jawbone, cheek, palate, and nose, resulting in widespread tissue necrosis and destruction
• Cancrum Oris can cause extensive facial disfigurement and severe complications, such as bone and pulmonary infections, and cachexia, which can result in fatalities. Often, complex facial reconstructive surgeries are necessary to recover basic functions such as eating, chewing, and speaking
• In many cases, children develop Cancrum Oris following a severe illness, such as measles or tuberculosis, during the recuperation phase. Their already weak body constitution combined with poor dental care, unhygienic surroundings, and low immunity levels, facilitate rapid infection spread
• The cause of Cancrum Oris is not clearly established, but the involvement of numerous pathogenic bacteria has been researched. In most children, the condition is observed to develop after the breastfeeding phase
• The treatment plan for Cancrum Oris involves wound cleaning and debridement, antibiotic administration, vitamin and mineral supplementation, including oxygen support, if necessary. Following this, plastic surgeries may be undertaken to correct facial tissue and bone defects
• The prognosis of the condition depends upon its severity and on the response to treatment. Nevertheless, in a vast majority of the affected children, Cancrum Oris is lethal

Who gets Cancrum Oris? (Age and Sex Distribution)

• Cancrum Oris is seen almost only in children (including neonates and infants). Around 80% of the children are below the age of 10 years, with a majority being between 2 and 6 years old
• It can affect both males and females
• No preference for any race or ethnic group is seen, although almost all cases are reported from among the economically poorest regions of the world such as parts of Africa (vast majority of cases), Asia, and South America

What are the Risk Factors for Cancrum Oris? (Predisposing Factors)

The risk factors associated with Cancrum Oris may include the following (below). In some cases, a combination of risk factors may be present.

• Extreme poverty
• Severe malnutrition and nutritional deficiency disorders (involving vitamins A and B, and mineral zinc)
• Conditions causing immunodeficiency; medications that lead to weak or suppressed immunity
• Infections that include measles, tuberculosis (TB), whooping cough, typhoid, and shigellosis
• Poor standards of living and overcrowding
• Unclean/unsafe water and poor environmental sanitation
• Living with domesticated or farm animals that are not maintained well
• Poor oral habits: This facilitates bacterial growth in the mouth thereby increasing the risk for developing periodontitis
• Early form of gum disease (or gingivitis), which is left untreated
• Cancers that include leukemia and lymphoma
• Smoking tobacco
• Dehydration

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Cancrum Oris? (Etiology)

• The exact cause of development of Cancrum Oris is presently unknown. It is almost exclusively seen against a background of severe malnourishment, particularly in those recovering from a systemic illness
• The condition is observed among malnourished children in underdeveloped regions, particularly after certain systemic diseases such as measles (primarily), tuberculosis, typhoid, and necrotizing ulcerative gingivitis (that affects the gums and teeth)
• Bacteria that have been described as being pathogenic in disease development include Fusobacterium necrophorum and Prevotella intermedia. These are known to work together with a variety of bacterial microorganisms to cause severe destruction including:
  • Abiotrophia spp.
  • Borrelia vincentii
  • Ochrobactrum anthropi
  • Porphyromonas gingivalis
  • Staphylococcus aureus
  • Stenotrophomonas maltophilia
  • Streptococcus spp.
  • Tannerella forsythia
  • Treponema denticola

It is important to note that predominantly the onset of Cancrum Oris is following the stoppage of breastfeeding in children.

What are the Signs and Symptoms of Cancrum Oris?

The signs and symptoms associated with Cancrum Oris may include the following:

During the initial stages:

• Poor oral hygiene and dental care
• Presence of ulcerous sores on the gums and inside the mouth: The initial presentation is a red/purplish papule that is painful, which ulcerates and spreads quickly to involve other mucosal surfaces
• Foul-smelling mouth
• Change in oral cavity discoloration (greyish mouth)
• Excessive drooling from the mouth in children
• Severe malnourishment
• Fever that relapses

During the later stages:

• Gangrenous stomatitis: Oral mucosal membranes are rapidly affected and destroyed (tissue degeneration and death)
• Bone loss and exposed jawbone may occur
• Difficult to eat, drink or speak
• Physical deformity of the oral cavity is observed
• The infection spreads to involve the entire cheek, roof of the mouth, nose, and skull bones
• The cheek and chin may perforate at various places, to reveal the inner mouth parts or facial structures. At this stage, the condition is generally painless

How is Cancrum Oris Diagnosed?

The diagnostic tests for Cancrum Oris may involve the following:

• An oral specialist (dental professional) will examine the symptoms and perform a physical exam on the mouth
• A thorough analysis of the individual’s medical history and recent illnesses is performed
• X-rays of the jaw, head, and neck area can be taken to detect the extent of bony involvement
• An MRI scan or CT scan of the head and neck region can be used to detect the extent of damage to the jaw, head, and neck
• Culture studies through oral swabs to detect causative bacteria
• Tests to determine any underlying illness causing poor immune system
• Oral tissue biopsy, if necessary

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Cancrum Oris?

The possible complications associated with Cancrum Oris include:

• Permanent and irreversible injury to the face and dental cavity (including to the supporting structures, jawbone, etc.)
• Severe facial disfigurement and psychological trauma
• Septicemia, or infection of the bloodstream
• Poor feeding or oral food intake further worsens malnourishment
• Breathing difficulties
• Increased susceptibility to other infections/diseases

The condition is life-threatening and fatal in many cases.

How is Cancrum Oris Treated?

The treatment of Cancrum Oris may involve a multidisciplinary team comprising of various healthcare experts. The treatment process may involve:

• Administration of systemic antibiotics
• Wound care that involves medical cleaning of wound and debridement/removal of necrotic tissue
• Protection of airways including resuscitation, when necessary
• Enteral feeding: Addressing nutritional imbalances and dehydration through hydration, intravenous electrolytes, vitamin and nutritional supplementation
• Facial repair and reconstruction (plastic) surgery, which may be extensive
• Surgery to correct the temporomandibular joint (TMJ)
• Undertaking treatment for underlying (immune-suppressing) conditions

How can Cancrum Oris be Prevented?

Currently, the best approach to prevent the formation of Cancrum Oris is to promote increasing awareness of the condition among the impoverished, educate people on the importance of hygiene, sanitation, and clean drinking water, establish goals to reduce poverty in the region, address malnourishment and nutritional deficiencies among children, provide adequate prenatal and postnatal care for both mother and child, and encourage ‘exclusive’ breastfeeding in children up to age 6-9 months.

The following considerations may also be made:

• Good oral hygiene, which can be achieved by brushing and flossing teeth daily
• Using recommended oral rinses and antiseptic mouthwashes
• Stopping smoking or chewing tobacco and substance abuse
• Create an awareness of the importance of oral health in children, from an early age
• Parents and caregivers are asked to periodically  check the mouth of children for detecting any early signs of gum disease or other dental health issues
• Controlling diabetes through lifestyle changes
• Have a well-balanced diet to avoid any nutritional imbalances
• Early and prompt treatment of mild gum disease or any dental health conditions
• Regular immunization in children, per approved healthcare recommendations
• Suitably treating any underlying conditions including cancer

What is the Prognosis of Cancrum Oris? (Outcomes/Resolutions)

• The prognosis of Cancrum Oris is dependent upon the severity of the signs and symptoms and associated complications, along-with the severity of the underlying illness
• However, typically, the prognosis is poor and high rates of mortality are observed (between 70-90%). Most deaths occur from severe atrophy and wasting syndrome (cachexia), lung infections such as pneumonia, and bone infection (or osteomyelitis)

Additional and relevant useful information for Cancrum Oris:

Please visit our Dental Health Center for more physician-approved health information:

https://www.dovemed.com/healthy-living/dental-health/