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Clinical Characteristics

There are three clinical stages during the acute phase of noma: namely, pregangrenous, gangrenous, and healing. Prior to the development of gangrene, the child has symptoms of an ulcerating gingivitis with sore mouth and itching, swollen gums. Ulceration that is initially localized soon spreads to the adjacent cheek and bone, leading to tenderness and edema of the cheek and jaw and loosening of the teeth. The breath is foul and there is a constant salivation (which is so excessive that the condition has sometimes been referred to as water cancer). During this stage, and even after gangrene begins, the child usually shows few systemic symptoms. There is little, if any, fever or leukocytosis and the lesion itself causes little pain.

As gangrene ensues, the cheek or jaw area overlying the spreading ulceration becomes tense, swollen, and dark red. At this stage, gangrene will occur whether or not the child is receiving antibiotics. A black patch appears on the skin and the gangrenous area shows a well-defined line of demarcation with little or no extension beyond. As the necrotic area becomes secondarily infected, there is rapid deterioration in the child's general health. There is fluctuating fever, malaise, prostration, and tachycardia with rapid pulse. There is little or no correlation between the severity of the orofacial lesion and the degree of systemic manifestations. In older children and adults, systemic features are less commonly seen and are milder.

In the poorly nourished infant or child who goes untreated, the outcome is usually fatal, often with terminal bronchopneumonia and lung abscess from aspiration of necrotic tissue. However, with proper treatment with intravenous antibiotics, tissue debridement, and restoration of a reasonable state of nutrition, the afflicted child usually survives and progresses to the third stage, that of healing. After the necrotic slough has separated, usually within several days, the child's health improves rapidly. Red granulation tissue forms around the previously purulent margins of the cavity. Bone which has been exposed during the gangrenous process usually undergoes sequestration and is extruded within several weeks. The new epithelium extends across the granulating surfaces, and gaping margins draw closer as contracture occurs. The resulting deformity and increasing trismus, which in some patients may progress to ankylosis of the temporomandibular joints and lower jaw with inability to eat, are serious late consequences of cancrum oris and may require extensive reconstructive surgery. An average of seven operations per patient was reported by Durrani. Dribbling of saliva, difficulty in feeding and drinking, voice alteration, psychological disturbances, and social stigmatism further complicate the child's life, especially if plastic surgery is unavailable or unaffordable.

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Copyright: Palmer and Reeder
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