INTRODUCTION
The word ‘noma’ is derived from Greek, loosely translated as ‘the devouring of a pasture by a flock’ [1] credited for its first use by Dutch surgeon Cornelis van de Voorde in 1680 [2]. He described a rapidly spreading ulceration originating in wet soft tissues in children, ‘typical of the mouth’ [2]. Noma, or cancrum oris, is currently described as a rapidly progressing infection of the oral cavity, associated with a reported 90% mortality rate within weeks from onset if untreated [3]. Noma mostly affects young children who lack access to basic nutrition and healthcare (specifically childhood immunizations), although uncommon cases have been reported in immunocompromised adults [3]. Noma is preventable, and as living conditions in areas improve, noma is eradicated [3].Â
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Box 1: no caption available
Pathogenesis
The pathogenesis of noma is poorly understood and the microbiology is debated. A range of organisms have been identified in the oral flora of noma patients but none have been consistently present casting doubt on a specific organism's role in the development of the disease [4–9].
Epidemiology and staging
Currently, noma is most commonly reported in low and middle-income countries in Africa and Asia [10]. In 1998, the World Health Organization (WHO) estimated that 140 000 new cases of noma occur each year globally and that 770 000 patients were living with noma sequelae at that time [11]. For the purposes of case detection, the WHO has classified noma into stages; Stage 0: simple gingivitis; Stage 1: acute necrotizing gingivitis; Stage 2: edema; Stage 3: gangrene; Stage 4: scarring and Stage 5: sequelae [3] (Figs. 1 and 2). The aesthetic and functional sequelae of noma are compounded by the psychosocial impact of the disease due to the social isolation and shunning of survivors and their families, bullying, a lack of access to education, difficulties finding jobs, and limited marital prospects [12–16].
FIGURE 1: A 3-year old with WHO Stage 3 noma, note the defect of the lower lip and gum with the near-complete necrosis at the centre. Photo published with consent from caretaker of the child.
FIGURE 2: A 3-year old with WHO Stage 5 noma who has been left with a significant defect affecting the left eye and cheek. Photo published with consent from caretaker of the child.
NEGLECT OF NOMA RESEARCH
Noma has been reported in the scientific literature for centuries. Despite significant progress in scientific methods since these ancient reports, the literature on noma has predominantly been comprised of low level evidence such as case reports [10]. The focus of recent literature on noma (2019–2021) includes noma's distribution and risk factors [17–19], treatment [20–34], knowledge and beliefs about the disease [14,35–37] along with reviews of the literature and viewpoints [38–41]. Recent literature (2019–2021) has shown that noma cases are being reported from an increasingly diverse set of geographical locations outside of Africa including China [22,28], India [23], Vietnam, [24] and Indonesia [33] (Fig. 3). There have also been two landmark publications in 2022, one systematic review [42▪▪] and one case series from Lao [43▪▪] mirroring this wider distribution which dispels the prior claim that there is a so called ‘noma-belt’ in Africa. This increase in reporting could either indicate an increase in awareness about noma by treating physicians (who then write up case reports), or perhaps an increase in health seeking by patients to these physicians, or an increase in the publication of literature on noma. Whatever the reason, the increase in reporting of noma is assisting researchers to better understand the disease distribution; however, in order to further this understanding, robust primary studies on the distribution and burden of disease are needed.
FIGURE 3: Map of
noma cases reported from 2019 to 2021 (map made using Data Wrapper:
https://datawrapper.dwcdn.net/BY3TA/1/).
Gaps in knowledge
The neglect of noma in the research sector has led to several major gaps in knowledge about the disease including a lack of robust estimates of the global distribution and burden of disease; incomplete understanding of the true mortality rate and pathogenic cause(s) of noma; and limited understanding of factors that influence prognosis and the long-term outcomes after care (surgical and nonsurgical) [43▪▪,44–46].
TREATMENT OF NOMA
A comprehensive treatment package for noma addresses treatment of acute noma, treatment of secondary noma sequelae through surgery, and treatment of the psychosocial aspects of the disease (models of care are discussed in greater detail below).
Acute noma care
Treatment with antibiotics, conservative wound debridement, and nutritional support in the early, reversible stages of the disease can reduce the duration and severity of the acute phase and the extent of tissue damage, thus reducing mortality and morbidity of noma (Table 1) [3]. The current WHO guidelines for the management of the acute stages in clinical settings include: oral hygiene (mouthwash with chlorhexidine 0.2%, 10 ml), antibiotic treatment (amoxicillin and metronidazole), nutritional support (high protein diet), wound cleaning (compresses soaked in diluted hydrogen peroxide) and dressing (honey for local dressing and for antibacterial action and regeneration) [3].
Table 1 -
Description of each stage of
noma and treatment per stage based on the WHO guidelines
[3] (more information on other aspects of management can be found in the guidelines
[3])
| Stage |
Description |
Treatment |
| Stage 0: simple gingivitis |
Bleeding gums when touchedRed/purple gumsGum swelling |
Mouthwash with chlorhexidine 0.2%, 10 ml/3 times dailyMouthwash with betadine/2 times daily can be used for children aged 0–6 years: clean the inflamed area with a compressVitamin A supplements |
| Stage 1: acute necrotizing gingivitis |
Spontaneous bleeding of gumPainful ulceration of gumFetid breathExcessive salivation |
Amoxicillin PO 100 mg/ kg every 12 h for 14 days + metronidazole PO 15 mg/kg every 12 h for 14 daysMouthwash with chlorhexidine 0.2%, 10 ml/3 times daily •Aspirin or paracetamol • Use compresses soaked in hydrogen peroxide 20 volumes to clean the gum lesionsVitamin A supplements • Nutritional rehabilitation: high-energy, ready to use paste, 3 sachets/daily |
| Stage 2: oedema |
Rapid extension of gingival ulcerationFetid breathFacial swelling/oedemaPainful cheekHigh feverExcessive salivationMouth sorenessDifficulty eating/anorexiaLymphadenopathy |
Antibiotic treatment Option 1: Amoxicillin & clavulanic acid, 50 mg/kg intravenously every 6 h for 14 days + slow intravenous administration of gentamycin, 5 mg /kg every 24 h for 5–7 days + slow intravenous administration of metronidazole, 15 mg/kg every 12 h for 14 days Option 2: Ampicillin intravenously, 100 mg/ kg every 6 h for 14 days + slow intravenous administration of gentamycin, 5 mg/kg every 24 h for 5–7 days + slow intravenous administration of metronidazole, 15 mg/kg every 12 h for 14 daysMouthwash with Chlorhexidine 0,2%, 10 ml 3 times daily |
| Stage 3: gangrene |
Destruction of intraoral and soft and hard tissueLesion with blackened center and well demarcated perimeterSloughing with a hole in the face, often near cheeks or lipsDifficulty eatingRapid perforation of the cheekExposure of teeth and bonesTransition from wet to dry gangreneAnorexia and/or apathy |
Antibiotics, intravenous for 14 days, as in Stage 2 |
| Stage 4: scarring |
Trismus may occurSequestration of the teethExposure of boneScarring |
Antibiotics, intravenous for 14 days, as in Stage 2 |
| Stage 5: sequelae |
Disfigurement, Tooth lossTrismusFeeding and speech difficultiesSalivary leakTooth displacement and/or dental anarchyFusion of mandible and maxillaNasal regurgitation |
Surgical managementPhysiotherapyOccupational therapy |
Care for patients with sequelae
Those who survive the early stages will often have severe sequelae such as difficulty eating, vision loss, trismus, drooling, and dental anarchy [3,30,47]. Many survivors only receive complex surgical reconstruction to address these difficulties decades after the acute infection has resolved [30,43▪▪,44]. The most commonly used classification systems for noma surgical programs are the Montandon system which focuses classification on the area of the face implicated [48], the WHO noma classification system which classifies noma according to distinct stages of clinical progression [3] and the nose, outer lining, inner lining, trismus, upper lip, lower lip, particularities (NOITULP) grading tool which classifies noma cases based on the percentage loss of each anatomical unit [49]. Appropriate reconstructive surgery is performed to repair defects and restore esthetic form and function, utilizing local, regional, pedicled, and free flaps along with surgery of the craniofacial skeleton [23,24,28,29,33,48,50–53]. Surgical plans are formulated from a multidisciplinary group, with special consideration for airway management, postoperative care settings, and physical therapy needs.
Stigma and discrimination
The aesthetic and functional sequelae of noma are compounded by the psychological impacts of the disease, not only on the patient, but also on family members and caretakers. A 2020 Ethiopian study of 80 patients found that before surgery, 65% of survivors covered their face in public, 59% reported difficulty eating, 81% were unhappy with their appearance, and 71% experienced bullying [30]. These findings are mirrored in a Lao study (n = 50) whose respondents also mentioned not being able to get married due to the discrimination they faced because of noma [43▪▪]. Other studies have shown that noma survivors face stigmatization, excessive questions about their physical appearance [12–15], a lack of access to education, difficulties finding jobs, and limited marital prospects [12,16]. All of these factors contribute to the mental strain of survivors and their families [54,55]. For many survivors, this stigmatization is the leading reason for seeking care [31,51]. As such, treatment programs should encompass a mental health component [34]. This component should be paired with a concerted effort to sensitize communities by sharing information about noma in an attempt to decrease the stigma survivors’ face.
Normal anatomy not restored
Complete restoration of normal anatomy is not a realistic aim of noma surgery due to the widespread destruction of the orofacial tissues. As such, the goal of noma surgery is to improve function where possible and the quality of life of the survivor. Recent studies have shown that a range of methods are used to treat noma cases, and that although prenoma functionality is not often restored, surgical treatment does improve patients’ quality of life [20–34]. Specific improvements included decreased social isolation and improved functionality such as eating and speaking [31].
Recent literature has pointed to the need for a standardized noma patient reported outcome tool which can be used in a range of settings where noma surgery takes place [31,45]. This standardization would allow for comparison between study results in different locations. The collection of this data from a variety of noma care service providers would contribute to a better understanding of the lived experiences of noma survivors and their families.
Trismus – an unsolved problem
Trismus, caused by soft tissue and muscle contraction during healing from acute noma, is one of the most debilitating sequelae of noma. Trismus can lead to complications such as aspiration, malnutrition, poor oral hygiene, speech deficits, a compromised airway, and pain [29]. The goals of surgery for noma-related trismus include increasing the mouth opening to ensure the patient is able to eat, speak, and live with as little restriction of mouth opening as possible. Challenges with anaesthesia for noma survivors have been reported, particularly in patients with severe trismus, making the availability of fiberoptic intubation a necessity for performance of trismus release surgery [23,26,27,33].
Trismus surgery for noma is associated with high rates of recurrence, further exacerbated by a lack of access to continual physiotherapy [29,34]. Noma patients frequently live in remote locations with limited access to healthcare, and access to specialized physiotherapy is rare. Without this continued care, reoccurrence rates increase.
This point is highlighted in a recent study including 40 noma patients treated for trismus in Niger using distraction therapy. In this study, although the mean interincisal distance of 2.7 ± 0.5 cm obtained immediately after treatment was retained for the first 6 months, 3–5 years after treatment some signs of relapse were detected, and the average mouth opening decreased to 1.5 ± 1.9 cm [29]. This cohort of patients did not have access to physiotherapy [29]. As trismus is a common and severe sequelae of noma, a rigorous physiotherapy program for all patients with a restriction of mouth opening is important to include in any treatment plan.
Program integration
Noma patients are most frequently cared for by the ministries of health in their home countries. The WHO have developed guidelines for care [3] as well as a step-by-step guide to develop national action plans for noma prevention and control in priority countries [13]. The number of surgeons who have the required skill set to treat the sequelae of noma is very limited globally, and especially in noma-endemic countries. To fill this gap, nongovernmental organizations (NGO's) also provide care for noma patients. NGO's use different models to provide care. Some organizations transport patients to established hospitals (in the capitals/urban centres of the home countries of patients or internationally to a high-resource setting) where multistage treatment is provided (patients can spend months or years away from home). This treatment is often provided by medical teams who have been flown in to endemic countries [30,34]. These models of care have limitations: the COVID-19 pandemic and ensuing travel restrictions have exacerbated and highlighted these limitations as many surgical teams have been unable to travel to these locations, and as a result patients have not undergone the planned reconstructive surgery [56]. This points to the importance of moving away from a vertical, substitution approach (where a small sub-specialized international surgical team spends a short amount of time in a hospital providing only surgical treatment for noma). Instead, horizontal care models focussing on a sustainable approach that builds local surgical capacity and integrates surgical treatment with health promotion, education, preventive and curative services, and appropriate follow-up care are needed.
Cross-cutting initiatives
Recent research has indicated that integrated, cross cutting mechanisms can move past the ‘silo’ of surgical care to the prevention of disease, and, failing that, the early detection and treatment of survivors in the reversible stages of disease [45]. These initiatives can address more than one disease, strengthen reporting structures and upskill human resources in a cost-effective manner. They include improving surveillance of noma at a community level (current surveillance mechanisms are mainly hospital based), more robust health financing systems, and widespread healthcare worker training (including training for traditional healers) [25,35,36]. These components would improve early detection of patients and hopefully speed up access to life-saving treatment in the crucial early, reversible stages of infection.
A further innovative approach would be for epidemiological surveys to be incorporated into routine primary healthcare assessments, vaccine coverage surveys and malnutrition surveys. This inclusion would improve our understanding of the burden and distribution of noma. Such cross-cutting initiatives will need adoption from a range of stakeholders, a further reason to increase awareness about the disease.
RECOGNITION OF NOMA ON THE GLOBAL STAGE
The neglected nature of noma is clear. A 2020 paper argued that this neglect spreads to the detection of noma, prevention, treatment, research and policy on the disease [37]. This neglect can be officially recognized by the WHO by including noma on the list of neglected tropical diseases (NTD) [37,39,40]. There is a unified and concerted effort in support of this initiative from the ministries of health in endemic countries, the various nongovernmental organizations providing care for noma patients, human rights advocates and the noma research community. It is the hope that the addition of noma to the WHO NTD list will raise awareness about the disease and spark research interest, and attract funding for research, treatment and prevention.
In order to increase awareness about this disease, noma should be included in infectious disease and tropical medicine courses globally, as well as nursing, dentistry and medical training courses in endemic countries. Journals and conferences should encourage submissions on noma. This increase in awareness will hopefully lead to more research and a deeper understanding of this neglected disease.
CONCLUSION
This paper provides an overview of the most recent literature on noma. Since noma has largely been neglected in the research sphere, more robust research on the disease is needed. What is clear from the existing literature is that noma is entirely preventable, and its progression can be halted if patients are treated in the early stages of the disease. Treatment for survivors with the later stages of noma remains complex and requires significant human and financial resources. As such, prevention remains key.
Acknowledgements
The authors are grateful to all of the all of the authors who work on noma and add to the scant body of knowledge about this disease. Every study helps. Patient consent has been received forFigs. 1 and 2.
Financial support and sponsorship
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Conflicts of interest
There are no conflicts of interest. The views and opinions expressed in this article are those of the authors and do not necessarily reflect those of the institutions they are affiliated to.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
â–ª of special interest
▪▪ of outstanding interest
REFERENCES
1. Ritchie P. Observations on the inflammations of the mouth in children, with an illustrative case. Trans Edinburgh Obstet Soc 1871; 2:418–435.
2. Marck K.
Cancrum oris and
noma: Some etymological and historical remarks. Br J Plast Surg 2003; 56:524–527.
3. World Health Organization Regional Office for Africa. Information brochure for early detection and management of
noma. 2017. Available at:
https://apps.who.int/iris/handle/10665/254579.
4. Falkler W, Enwonwu C, Idigbe E. Isolation of fusobacterium necrophorium from
cancrum oris [
noma]. Am J Trop Med Hyg 1999; 60:150–156.
5. Falkler W, Enwonwu C, Idigbe E. Microbiological understandings and mysteries of
noma [
cancrum oris]. Oral Dis 1999; 5:150–155.
6. Enwonwu C, Falkler W, Idigbe E, et al. Pathogenesis of
cancrum oris [
noma]: confounding interactions of malnutrition with infection. Am J Trop Med Hyg 1999; 60:223–232.
7. Baratti-Mayer D, Gayet-Ageron A, Hugonnet S, et al. Risk factors for
noma disease: a 6-year, prospective, matched case-control study in Niger. Lancet Glob Heal 2013; 1:87–96.
8. Whiteson K, Lazarevic V, Tangomo-bento M, et al.
Noma affected children from Niger have distinct oral microbial communities based on high-throughput sequencing of 16S rRNA gene fragments. PLoS Negl Trop Dis 2014; 8:1–13.
9. Phillips R, Enwonwu C, Falkler W. Pro- versus anti-inflammatory cytokine profile in African children with acute oro-facial
noma [
cancrum oris,
noma]. Eur Cytokine Netw 2005; 16:70–77.
10. Farley E, Mehta U, Srour ML, Lenglet A.
Noma [
cancrum oris]: a scoping literature review of a neglected disease [1843 to 2021]. PLoS Negl Trop Dis 2021; 15:e0009844.
11. World Health Organization, OMS. World Health Report Life in the 21st century: a vision for all report of the director-general. 51st World Heal Assem. 1998;1–226. Available at:
https://www.who.int/whr/1998/en/whr98_en.pdf?ua=1.
12. Wali IM, Regmi K. People living with facial disfigurement after having had
noma disease: a systematic review of the literature. J Health Psychol 2016; 22:1243–1255.
13. World Health Organisation [WHO]. A step-by-step guide to develop national action plans for
noma prevention and control in priority countries. 2020. Available at:
https://www.afro.who.int/publications/step-step-guide-develop-national-action-plans-noma-prevention-and-control-priority.
14. Farley E, Lenglet A, Abubakar A, et al. Language and beliefs in relation to
noma: a qualitative study, northwest Nigeria. PLoS Negl Trop Dis 2020; 14:1–15.
15. Feller L, Altini M, Chandran R, et al.
Noma [
cancrum oris] in the South African context. J Oral Pathol Med 2014; 43:1–6.
16. Human Rights Council Advisory Committee. Study of the Human Rights Council Advisory Committee on severe malnutrition and childhood diseases with children affected by
noma as an example, including annexed. Human rights principles and guidelines to improve the protection of children at risk or affected by malnutrition, specifically at risk of or affected by
noma. UN Doc. A/HRC/19/73. 24 February 2012. Available at:
https://documents-dds-ny.un.org/doc/UNDOC/GEN/G12/102/15/PDF/G1210215.pdf?OpenElement.
17. Bello SA, Adeoye JA, Oketade I, Akadiri OA. Estimated incidence and prevalence of
noma in north central Nigeria, 2010–2018: a retrospective study. PLoS Negl Trop Dis 2019; 13:2010–2018.
18. Farley E, Oyemakinde MJ, Schuurmans J, et al. The prevalence of
noma in northwest Nigeria. BMJ Glob Heal 2020; 5:1–15.
19. Adeniyi S, Awosan K. Pattern of
noma [
cancrum oris] and its risk factors in northwestern Nigeria: a hospital-based retrospective study. Ann Afr Med 2019; 18:17–22.
20. Baniulyte G, Mcallister P, Shafi A, et al. Atypical orofacial necrosis of unknown aetiology: a case report with features similar to
noma. Int J Oral Maxillofac Pathol 2019; 10:1–3.
21. Bouassalo KM, Mossi EK, Padaro E, et al. Chronic lymphocytic leukemia revealed by a rare complication:
noma. First description from Togo. J Oral Med Oral Surg 2019; 25:31.
22. Xu L, Wei W, Ge X, et al.
Noma in a boy with septic shock: a case report. BMC Pediatr 2019; 19:1–5.
23. Ghorui T, Ray A. Release of extra articular ankylosis of jaws as a sequelae of
cancrum oris with extensive gingival myasis in a scoliosis patient: a rare case report. Indian J Otolaryngol Head Neck Surg 2019; 71 (s1):734–736.
24. Long N, Phong H, Truong D, et al. Rehabilitation of severe maxillary
noma defect with zygomatic implants: a case report. J Implant Adv Clin Dent 2019; 11:16–23.
25. Farley E, Muhammad H, Lenglet A, et al. ‘I treat it but I don’t know what this disease is’: a qualitative study on
noma [
cancrum oris] and traditional healing in northwest Nigeria. Int Health 2019; 12:28–35.
26. Sund GC, Muvunyi P, Harling MJ. Airway management through a facial defect resulting from
noma [orofacial gangrene]: a case report. A&A Pract 2020; 14:e01319.
27. Braun U, Wiese KG, Merten HA, Timmermann A. Anaesthetic care for
noma [
cancrum oris] – the disease, the airway and how to provide anaesthetic care without a clinical safety infrastructure. Trends Anaesth Crit Care 2020; 31:16–20.
28. Ding X, Wang QQ, Zhou Y, Xu JC. Case report: Malignant transformation of
noma: repair by forearm flap. Am J Trop Med Hyg 2020; 103:1697–1699.
29. Holle J, Kubiena H, Issa OH. Distraction therapy to correct trismus following
noma. J Craniofac Surg 2020; 31:488–491.
30. Rickart AJ, Rodgers W, Mizen K, et al. Facing Africa: describing
noma in Ethiopia. Am J Trop Med Hyg 2020; 103:613–618.
31. Farley E, Amirtharajah M, Winters R, et al. Outcomes at 18 mo of 37
noma [
cancrum oris] cases surgically treated at the
Noma Children's Hospital, Sokoto, Nigeria. Trans R Soc Trop Med Hyg 2020; 0:1–8.
32. Traore H, Sogodogo E, Coulibaly A, et al. Case report: a rare case of
NOMA [
cancrum oris] in a Malian woman. New Microbes New Infect 2021; 42 (Cicm):100907.
33. Putri IL, Agustina W, Hutagalung MR. Columella reconstruction using double nasolabial flap and costal cartilage: a case report. Ann Med Surg 2021; 64:102213.
34. Shafi’u I, Amirtharajah M, Farley E, et al. Model of care,
Noma Children's Hospital, northwest Nigeria. Trop Med Int Heal 2021; 26:1–10.
35. Brattström-Stolt L, Funk T, Sié A, et al.
Noma-knowledge and practice competence among primary healthcare workers: a cross-sectional study in Burkina Faso. Int Health 2019; 11:290–296.
36. Baratti-Mayer D, Daou MB, Gayet-Ageron A, et al. Sociodemographic characteristics of traditional healers and their knowledge of
noma: a descriptive survey in three regions of Mali. Int J Environ Res Public Health 2019; 16:1–11.
37. Caulfield A, Alfvén T. Improving prevention, recognition and treatment of
noma. Bull World Health Organ 2020; 98:365–366.
38. Feller L, Khammissa RAG, Altini M, Lemmer J.
Noma [
cancrum oris]: an unresolved global challenge. Periodontology 2019; 80:189–199.
39. Srour LM, Baratti-Mayer D. Why is
noma a neglected-
neglected tropical disease? PLoS Negl Trop Dis 2020; 14:1–4.
40. Farley E, Ariti C, Amirtharajah M, et al.
Noma, a neglected disease: a viewpoint article. PLoS Negl Trop Dis 2021; 15:1–5.
41. Speiser S, Langridge B, Birkl MM, et al. Update on
Noma: systematic review on classification, outcomes and follow-up of patients undergoing reconstructive surgery after
Noma disease. BMJ Open 2021; 11:e046303.
42▪▪. Galli A, Brugger C, FĂ¼rst T,
et al. Review: Prevalence, incidence, and reported global distribution of
noma: a systematic literature review. 2022. Available at:
www.thelancet.com/ [cited 2022 May 11]
43▪▪. Srour ML, Farley E, Mpinga EK. Lao
Noma survivors: a case series, 2002–2020. Am J Trop Med Hyg 2022; 106:1269–1274.
44. Shaye D, Rabbels J, Adetunji AS, et al. Evaluation of the
noma disease burden within the
noma Bel. JAMA Facial Plast Surg 2018; 20:332–333.
45. University of Cape Town, Farley E.
Noma in northwest Nigeria: a neglected disease in neglected populations. 2020.
46. Baratti-Mayer D, Pittet B, Montandon D, et al.
Noma: an ‘infectious’ disease of unknown aetiology. Lancet Infect Dis 2003; 3:419–431.
47. Ashok N, Tarakji B, Darwish S, et al. A review on
noma: a recent update. Glob J Health Sci 2016; 8:53–59.
48. Ruegg E, Baratti-Mayer D, Jaquinet A, et al. The surgical management of extra-articular ankylosis in
noma patients. Int J Oral Maxillofac Surg 2018; 47:1527–1533.
49. Marck K.
Noma: the Sokoto approach. Eur J Plast Surg 1998; 21:277–280.
50. Hartman E, Van Damme P, Sauter H, Suominen S. The use of the pedicled supraclavicular flap in
noma reconstructive surgery. J Plast Reconstr Aesthetic Surg 2006; 59:337–342.
51. Shaye D, Winters R, Rabbels J, et al.
Noma surgery. Laryngoscope 2019; 129:96–99.
52. Saleh D, Fourie L, Mizen K. Reconstruction of complex oro-facial defects using the myocutaneous sub-mental artery flap. J Cranio-Maxillofacial Surg 2014; 42:668–673.
53. Bello S. Gillies fan flap for the reconstruction of an upper lip defect caused by
noma: case presentation. Clin Cosmet Investig Dent 2012; 4:17–20.
54. Liverpool School of Tropical Medicine, Lafferty N. Changing the face of Africa. Estimating the burden of
noma in rural Ethiopia and identifying options for prevention and improvement in its diagnosis and management. 2012.
55. Yunusa M, Obembe A. Prevalence of psychiatric morbidity and its associated factors among patients facially disfigured by
cancrum oris in Nigeria a controlled study. Niger J Med 2012; 21:277–281.
56. Samuel J. The huge impact of COVID-19 on
noma patients in Nigeria. Royal Society of Tropical Medicine & Hygiene. 2021. Available at:
https://rstmh.org/news-blog/blogs/the-huge-impact-of-covid-19-on-noma-patients-in-nigeria.
