Noma: causes, symptoms, diagnosis, treatment

Nomoma (cancrum oris) is a disease in which necrotic tissue causes extensive defects in the soft and bony tissues of the orofacial region, a kind of moist gangrene that currently occurs only in underdeveloped and developing countries.

Usually there are only a few cases of noma, but sometimes with worsening social conditions, after severe infectious diseases, the number of diseases increases. So, in the early 20-ies of the last century due to the plight of the Russian population (intervention, civil war, crop failure, famine) in some areas (Perm, Astrakhan and others), the number of noma cases has increased significantly. With the number, the mucous membrane of the oral cavity is primarily affected most often. Dentists identify the patient with ulcer-necrotic gingivitis, acquired for one reason or another a malignant form of flow. Currently, ulcerative necrotic gingivitis can be considered a disease-predecessor noma.

Most children are mainly sick at the age of 2 to 15 years. According to AI Makarenko (1933), IM Sobol (1936), ATPulatov (1956), and others, noma usually develops in weakened children who are depleted during or after infectious diseases such as measles , whooping cough, dysentery, scarlet fever, diphtheria, pneumonia, typhus, leishmaniasis, influenza, etc. In adults, it is much less common, in spite of the fact that adults are much more likely to get ulcerative necrotic gingivitis.

The reason for noma. In view of the above conditions and risk factors, most authors associate it with an infectious onset. So, with the number were allocated various bacteria, spirochetes, cocci, mushrooms, anaerobes.

According to some authors, V. Perfringens plays an important role in the etiology of the noma, which causes the development of local necrotic processes. However, most authors believe that with the number there is an association of fusospirochetoznoy microbiota (symbiosis of Plaut - Vincent). Some authors attach aetiological importance to such factors as the special enzymatic action of saliva and avitaminosis. Currently, other microorganisms and viruses, such as Prevotella intermtdia, Fusobacterium spirochetae, hemolytic streptococcus, and viruses from the Herpes family are expected to act. The contagiousness of the noma remains in question, despite the fact that there are observations of diseases of a noma in one family or in one hearth. Nevertheless, the occurrence of the noma should not be associated with a specific pathogen, but mainly with adverse domestic, social, sanitary conditions, the consequences of infectious diseases that dramatically reduce the immunobiological resistance of the organism, with avitaminosis and other risk factors.

Pathological anatomy and clinical course. When the number is most often affected by the mucous membrane of the mouth, develops a severe form of gangrenous stomatitis (gingivitis, periodontitis) with rapid, during the first 3-5 days, the spread of the necrotic process in breadth and depth. As a result, significant areas of affected tissues are destroyed and fall off. Nome may also appear on the auricle, neck, genitalia, in the anus region, etc. Beginning, as a rule, on the distal part of the alveolar process in the form of ulcerative necrotic gingivitis, the nose can quickly spread to the lips, cheeks and nose. Within a few days all the bone tissue in the cheek area can be fully exposed due to the destruction of soft tissues.

The disease begins with the appearance of a bluish-red bubble on the skin or mucous membrane, and then the spots are dark blue, the skin around which acquires a waxy color with a pearly hue - the so-called waxy zone. The tissues surrounding this zone acquire the appearance of vitreous edema, are dense to the touch and quickly undergo necrotic decomposition, producing an unpleasant putrefactive odor. Affected areas with the number are painless (similarity with leprosy), bleeding is almost absent. The area of the lesion from the oral cavity rapidly increases, the cervical areas of the teeth are necrotic, and the teeth are loosened and dropped (super-mild form of periodontitis). In the most severe cases, the process passes to the tongue, the sky, the lip and the opposite side. The gangrenous process also extends to the skin of the face, affecting the entire cheek, the pyramid of the nose, and can spread to the orbit and, like creeping, not knowing the obstruction of the ulcer, spread to the eyeball and the bony formations of the maxilla. AI Makarenko (1961) describes the process of destruction of the nome of the facial region.

Disintegration of tissues progresses, the formed cheek defect increases, jaws, teeth, tongue are exposed; marked release of putrefactive exudate, abundant salivation.

The general condition of the patient is severe, due to severe intoxication. Patients are usually indifferent to the surrounding, often marked by the confusion of consciousness, body temperature - such as continua, reaches 39-40 ° C.

The ingestion of products of putrid decay of tissues causes gastrointestinal disorders, aspiration leads to the occurrence of pulmonary complications (pneumonia, gangrene of the lung). However, the noma can also be benign. In benign course, the process may be limited to ulceration of the mucous membrane of the oral cavity or the formation of a defect in the cheek and nose of a larger or smaller size, followed by scarring. However, the process of cleansing the wound surface and scarring the wound proceeds slowly, reminiscent of a similar process with damage by ionizing radiation. Deep defects are formed on the site of the dead tissues. Scars after nome disfigure the face, cause the emergence of the contracture of the temporomandibular joint. These organic defects are subsequently, as far as possible, eliminated by plastic surgery.

In malignant course, the necrotic process quickly progresses and leads to rapid death of the patient. Due to complications and concomitant diseases, the lethality is now from 70 to 90%.

Diagnosis of noma in the process is not difficult. In some cases, in young children in the initial period of the nome, which affected the oral mucosa, the disease remains unnoticed and is found only by unusual putrid smell from the mouth. Differential diagnosis is difficult in the initial stage of the disease. In the opinion of G.M. Babiyak (2004), the clinical picture in this period of the nose is so worn out (especially in recent years) that it is possible to distinguish it from many other nomophilic diseases only because of the absence of a specific vitreous edema around the focus of inflammation in the latter.

Treatment of the nome is carried out in the hospital with certain measures of anti-infection protection of medical staff and other patients, taking into account the age, prevalence of the local process and the severity of the general condition of the patient.

It includes the appointment of broad-spectrum antibiotics, taking into account the type of microbiota and its sensitivity to the treatment used. Much attention should be paid to the local necrotic process, the timely removal of necrotic tissues, the use of proteolytic enzymes, local antiseptics and a careful toilet of the affected anatomical formations. Simultaneously prescribe drugs that strengthen immunity, the general condition of the body, vitamins. Carry out detoxification therapy up to plasmapheresis and UFO- or laser-autohemotherapy. Symptomatic treatment - according to indications.

Prophylaxis of the nome is hygienic care of the oral cavity in children with infectious diseases, especially those accompanied by exhaustion, conduction of general strengthening and immunocorrective treatment.

[1], [2], [3]