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Noma survivors need surgery to regain mouth, jaw functions —Dermatologist

A consultant physician and dermatologist at the Lagos State University Teaching Hospital, Ikeja, Dr. Folakemi Cole-Adeife, says many survivors of Noma disease will require plastic and maxillo-facial surgery to enable them to regain the functions of their mouth and jaw.

According to her, noma mostly affects children between the ages of one and six years, stressing that it mainly affects the mouth, nose and lips if not treated early.

Noma, also known as cancrum oris or gangrenous stomatitis, is a severe and aggressive gangrenous process (a condition wherein body tissues die due to infection or lack of blood supply) that affects the mouth, nose, and lips.

Cole-Adeife states that though the exact cause of the disease is not fully understood, it is known to mainly affect malnourished children living in poor communities with a high burden of other illnesses such as malaria, measles, tuberculosis, pneumonia and diarrhoea.

Speaking in an exclusive interview with PUNCH HealthWise, the dermatologist said noma is a dangerous and often fatal disease.

The physician explained, “Noma is a severe and aggressive condition that mainly occurs in sub-saharan African countries like Nigeria. It is also known as cancrum oris and is categorised as one of the Neglected Tropical Diseases.

“Here in Nigeria, though its incidence appears to be reducing, it is still seen all over the country in rural and impoverished communities, particularly in some parts of the northern regions.

“This is likely due to the civil unrest and large population of internally displaced persons in those regions as it is a disease that is strongly associated with poverty, poor hygiene and malnutrition.

“A recent study done by a group of researchers in a rural community in northwest Nigeria found the prevalence of noma to be about three percent in the children studied.

“Noma mostly affects children between the ages of one and six years. It mainly affects the mouth, nose and lips and if not treated early or aggressively enough, it can result in death or severe facial disfiguring as well as significant difficulties in breathing, eating and seeing.”

Giving further insight into the neglected disease, the physician said, “It usually begins as an ulcer or wound in the inner part of the mouth or the gums and rapidly spreads to other parts of the mouth, including the lips, tongue, cheeks and the nose.

“It can eventually cause extensive necrosis (destruction due to infection or lack of blood supply) of both soft tissue and bones in the face.

“The exact cause is not fully understood but it is known to mainly affect malnourished children living in poor communities with a high burden of other illnesses like malaria, measles, tuberculosis, pneumonia and diarrhoea.

“The risk factors for the disease are severe malnutrition, poor oral hygiene, lack of access to clean water, toilets and proper waste disposal and previous history of bacterial and viral infections.

“Thus, it is thought to be a disease driven by poor immune function. Also, certain bacteria species are frequently associated with noma like Fusobacterium and Prevotella species.”

“The clinical features of noma include swollen gums as well as mouth and lips ulcers which rapidly spread to form deep, foul smelling, discharging sores both inside and outside of the mouth.

“There may also be loss of teeth and severe deformities of the face. The colour of the inner oral cavity may also change from a pink to a greyish colour”, she said.

Dr. Cole-Adeife noted that noma is treated with the administration of systemic antibiotics, along with nutritional supplementation with protein, essential minerals and vitamins like folic acid, iron, vitamin B complex, and vitamin C.

She added, “Intravenous rehydration, electrolyte replacement and occasionally, blood transfusion, may also be required in severe cases.

“Many noma survivors often require plastic and maxillofacial surgery to reconstruct facial bones and help them to regain the function of mouth and jaw, in addition to removing damaged tissues.

“However, many cannot afford this and often live with stigmatisation due to significant facial deformities.”

According to the World Health Organisation, in the absence of any form of treatment, noma is fatal in 90 per cent of cases.

“Where noma is detected early, its progression can be rapidly halted, either through basic hygiene rules or with antibiotics. Such early detection helps to prevent suffering, disability and death,” WHO says.

A surgeon from India, Dr. Hafiz Muhammed, who is a member of team of Doctors Without Borders (Médecins Sans Frontières) that provided life-changing reconstructive surgery to noma patients in the northern part of the country while sharing his experience, had said he was surprised at the resilience of the patients after the surgery as they were all smiling as if nothing happened.

“More than anything else, what really astounded me was the resilience of our patients.

“Even with the disease, many would be up and about, smiling in the evening after their surgery, often making us wonder if it was the same patient who we had operated on that morning.

“Rarely would anyone complain of pain, which was remarkable and in stark contrast to the healthy and fit patients I regularly encounter in my daily practice back home.

“We treated over 27 patients and the large majority of them showed fair to excellent healing,” Muhammed had said.

He, however, observed that the awareness of the disease was very limited, and so were the treatment options.

According to him, noma is an overlooked but dangerous disease that can leave often young patients disfigured.

On ways of preventing the disease, Dr. Cole-Adeife, said noma could be prevented by ensuring that children eat adequate diet with protein and essential vitamins and minerals.

“Environmental and personal hygiene (particularly oral hygiene) awareness alongside poverty alleviation programs in at-risk populations and communities can also reduce the incidence of the deadly disease along with other NTDs and communicable diseases like malaria, diarrhoeal diseases and pneumonia.

“Improving access to clean water and sanitation in poor and rural communities which is one of the Sustainable development goals will also help to reduce noma disease”, the dermatologist said.


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