Acute Gangrenous Stomatitis

Other names
Types
Causes
Symptoms and signs
Diagnostic tests
Non-pharmacological treatments (therapies and other care)
Drug treatments
Dietary molecular supplements
Drugs aimed at “immunity support / regenerative / stem-cell space”
Surgeries (what they are and why they’re done)
Preventions
When to see a doctor—right away
What to eat and what to avoid
FAQs

Acute gangrenous stomatitis is a very fast-moving infection that destroys the mouth and face. It usually begins as sore, bleeding gums, then the tissues of the cheek, lips, and jaw die and break down. Without quick care it can spread in days and be deadly. Doctors now call this disease noma. It mostly affects children living in extreme poverty with malnutrition, poor oral hygiene, and other illnesses that weaken the body. Noma is not considered contagious person-to-person; it is an “opportunistic” infection that takes hold when the body’s defenses are very low. World Health Organization+1

Acute gangrenous stomatitis—often called noma or cancrum oris—is a fast-moving, life-threatening infection that destroys the gums, cheeks, and jaw. It mostly affects young children living with severe malnutrition, poor oral hygiene, intercurrent infections (like measles or malaria), and extreme poverty. Without quick treatment, it can kill within days. Survivors often have severe facial scars and difficulty eating or speaking. World Health Organization+2PubMed Central+2

Noma emerges when a child’s body defenses are very low. Harmful mouth bacteria then invade gum tissue, cut off blood supply, and cause tissue death (gangrene). Triggers include malnutrition, dehydration, recent infections, and weak immunity (including HIV or blood cancers). Early care with nutrition, fluids, mouth cleaning, and antibiotics can halt the spread. World Health Organization+1

Other names

Noma, cancrum oris, gangrenous stomatitis, and necrotizing ulcerative stomatitis are names used for the same condition or closely related stages. Older articles may use the term “cancrum oris”; modern public health groups mainly say “noma.” World Health Organization+2PubMed Central+2

Types

The World Health Organization (WHO) groups noma into five sequential stages. This “staging” helps health workers recognize the disease early and act fast.

Stage 0 – Simple gingivitis
This is common gum inflammation: red, swollen, easy-to-bleed gums. At this point many children do not have noma, but poor oral hygiene, malnutrition, or illness can let it advance. Early cleaning, feeding, and treating mouth pain can keep it from worsening. World Health Organization
Stage 1 – Acute necrotizing gingivitis (ANG / ANUG)
The gum line becomes severely inflamed with painful ulcers and a “punched-out” look between teeth. Breath is foul, and chewing hurts. This is the warning stage when simple antibiotics, gentle oral care, fluids, and nutrition usually stop progression. World Health Organization
Stage 2 – Edema (swelling)
One cheek, lip, or the face swells quickly. Fever and weakness may rise. The swelling signals tissue injury under the skin and that gangrene may start if care is delayed. World Health Organization
Stage 3 – Gangrene
Cheek or lip skin dies, turns black, and breaks down. A hole can open from the mouth to the face. Pain may surprisingly lessen as nerves die, but this is the most dangerous stage with risk of sepsis and death. World Health Organization
Stage 4 – Scarring
If a child survives, the skin and mouth heal with thick scars. The jaw may lock (trismus). Eating, speaking, and smiling are hard. World Health Organization
Stage 5 – Sequelae (long-term effects)
Children often need staged reconstructive surgery and long rehabilitation to reopen the mouth, restore lips and cheeks, and improve feeding and speech. World Health Organization+1

Note: Several academic reviews support WHO’s five-stage approach, though some authors debate refinements. The five stages above are the current global reference. BioMed Central+1

Causes

Noma happens when many stresses stack together and the immune system collapses. Each item below is a short, plain explanation of a known or suspected driver.

Severe acute malnutrition – When protein and calories are too low, wounds do not heal and mouth bacteria invade deeper tissues; noma risk soars. World Health Organization+1
Chronic hunger/food insecurity – Ongoing lack of nutritious food keeps immunity weak for months, so a small gum ulcer can spiral. World Health Organization
Micronutrient deficiency (vitamins/minerals) – Lack of vitamins A, B-complex, C, zinc, and iron harms gum integrity and infection control. PubMed Central
Poor oral hygiene – Plaque and gum disease give harmful microbes a foothold; without brushing or cleaning, gum ulcers worsen. PubMed Central+1
Measles (recent or past) – Measles can suppress immunity for months, raising risk of severe mouth infections in undernourished children. BioMed Central
Other infections (malaria, TB, pneumonia, diarrhea) – These drain strength and nutrients, tipping the balance toward tissue death in the mouth. PubMed Central
HIV or other immune suppression – A weakened immune system struggles to control aggressive oral bacteria and necrotizing gum disease. PubMed Central
Extreme poverty – Crowding, unsafe water, limited clinics, and few toothbrushes create the conditions where noma thrives. World Health Organization
Unclean water and poor sanitation – Repeated diarrheal illness and poor mouth rinsing both increase risk. FDI World Dental Federation
Untreated necrotizing gingivitis/periodontitis – When these severe gum infections are not treated early, they can progress toward noma in vulnerable children. World Health Organization
Mucosal injury (cheek bites, sharp teeth) – Small injuries become entry points for aggressive microbes in malnourished children. PubMed Central
Tooth eruption pain leading to poor eating – Painful chewing during teething can reduce food intake further, deepening malnutrition. PubMed Central
Smoking exposure / indoor air pollution – Irritant smoke inflames the mouth and worsens infections, especially where cooking is indoors. (Inference supported by oral-health risk models in resource-limited settings.) PubMed Central
Seasonal “lean periods” – Pre-harvest hunger seasons cluster cases as diets collapse and infections rise. The Lancet
Lack of vaccines (especially measles) – Where vaccine coverage is low, post-measles immune weakness is common, feeding the cycle. BioMed Central
Weaning with very low-quality foods – Thin porridges without protein or micronutrients fail to protect gums and immunity. PubMed Central
Oral flora imbalance/dysbiosis – Studies show mixed bacterial communities in noma lesions; a single “cause bug” is unproven, but synergy is likely. The Open Dentistry Journal+1
Delayed care / far clinics – Families may live far from care, so early reversible stages are missed. BioMed Central
Social marginalization – Stigma and poverty can block help-seeking until gangrene appears. FDI World Dental Federation
Drought, conflict, or displacement – Emergencies cut food, water, and health access and have repeatedly preceded noma clusters. (Public health inference consistent with NTD reports.) The Lancet

Symptoms and signs

Bleeding, painful gums – The first visible change is sore, bleeding gums that hurt on brushing or eating. World Health Organization
“Punched-out” gum ulcers – Spaces between teeth look cratered; tissue appears grayish with a yellow film. World Health Organization
Foul breath (halitosis) – A strong, unpleasant odor comes from necrotic tissue and trapped food. World Health Organization
Facial swelling (one side) – Rapid, warm swelling of cheek or lip signals progression from gum disease to deep tissue injury. World Health Organization
Fever and general sickness – The body reacts to spreading infection with fever, fatigue, and loss of appetite. World Health Organization
Sudden mouth pain that may later lessen – Pain can drop as nerves die during gangrene, which is a dangerous sign. World Health Organization
Black discoloration of skin or mucosa – Dead tissue turns dark, then breaks down. World Health Organization
Open hole in the cheek or lip – Tissue sloughs off, leaving an opening from mouth to face. World Health Organization
Drooling and difficulty swallowing – Ulcers and swelling make swallowing hard and unsafe. World Health Organization
Difficulty chewing – Pain and loss of cheek support limit eating; weight loss worsens. World Health Organization
Trismus (jaw tightness) – Spasm or scarring reduces mouth opening. World Health Organization
Loose teeth / tooth loss – Bone and periodontal support are destroyed, so teeth loosen and fall. World Health Organization
Facial numbness or altered sensation – Nerve damage from necrosis may change feeling. World Health Organization
Weight loss and dehydration – Eating and drinking become difficult, deepening malnutrition. World Health Organization
Sepsis signs (fast pulse, confusion, cold extremities) – In advanced cases, bacteria enter the bloodstream and can be fatal. World Health Organization

Diagnostic tests

There is no single lab test that “proves” noma. Diagnosis is mainly clinical, supported by simple tests that check nutrition, infection, immunity, and complications. WHO emphasizes recognizing the stage and starting care urgently. World Health Organization

A) Physical examination

Full mouth and gum inspection – Clinician looks for necrotizing gingivitis (stage 1), swelling (stage 2), or visible gangrene (stage 3). This bedside exam is the core of diagnosis. World Health Organization
Facial skin and soft-tissue check – Palpation notes warmth, tenderness, crepitus, or black eschar; early detection can save tissue. World Health Organization
Jaw opening measurement (inter-incisor distance) – Limited opening suggests trismus and later scarring, guiding therapy and rehab needs. PubMed Central
Nutritional assessment (MUAC, weight-for-age) – Simple tape and scale identify malnutrition that must be corrected alongside antibiotics. World Health Organization
Hydration and sepsis screening – Vitals, capillary refill, and mental status guide urgent fluids and antibiotics to prevent death. World Health Organization

B) Manual / bedside tests

Oral pain and function tests (chew/swallow trials) – Small supervised sips and soft bites reveal aspiration risk and feeding support needs. World Health Organization
Odor assessment and wound probing (gentle) – Foul smell and undermined edges suggest anaerobic necrosis, helping stage the lesion. World Health Organization
Mouth opening improvement after warm compress/physio – Early simple therapy can show reversible muscle spasm vs. fixed scarring. PubMed Central

C) Laboratory and pathological tests

Complete blood count (CBC) – Looks for anemia, leukocytosis, or neutropenia; results influence antibiotics and nutrition plans. PubMed Central
C-reactive protein / ESR – High levels confirm active inflammation and help track response. PubMed Central
Electrolytes, glucose, and renal function – Guide safe refeeding, fluids, and medication dosing. World Health Organization
HIV testing (where appropriate) – Identifies immunosuppression; linkage to HIV care improves survival. PubMed Central
Measles immunity or recent infection review – History or serology may show post-measles immune vulnerability. BioMed Central
Wound swab for culture (selective) – Cultures often show mixed aerobes/anaerobes; no single “noma germ” is proven, but cultures can guide therapy in hospitals. The Open Dentistry Journal
Histology (rarely needed acutely) – If biopsied, tissue shows necrosis and mixed infection; used more in reconstruction planning than in emergency diagnosis. PubMed Central

D) Electrodiagnostic tests

ECG (electrocardiogram) – Severe sepsis, electrolyte shifts, and refeeding can affect the heart; ECG helps monitor safety during treatment. (Supportive care principle in severe infection.) World Health Organization
Nerve conduction/EMG (selected cases later) – Considered in long-term rehab if nerve injury is suspected around the face after healing. (Rehabilitation planning.) PubMed Central

E) Imaging tests

Plain facial X-ray – Quick, low-cost view for bone loss, sinus involvement, or foreign bodies; useful in low-resource centers. World Health Organization
CT scan of face/jaws (where available) – Defines bone destruction, abscesses, and surgical planning in survivors needing reconstruction. PubMed Central
MRI (selected hospitals) – Gives the best soft-tissue detail for complex reconstructions and to map scarring around muscles. PubMed Central

Non-pharmacological treatments (therapies and other care)

Urgent stabilization (ABC, fluids, electrolytes)
Purpose: Prevent shock and organ failure.
Mechanism: Rehydration restores blood flow to tissues; correcting salts supports cell function. WHO | Regional Office for Africa
Aggressive nutrition (high-energy, high-protein feeds)
Purpose: Reverse starvation; help wounds heal.
Mechanism: Calories and protein rebuild tissues and immune cells. WHO | Regional Office for Africa
Vitamin A repletion
Purpose: Support immunity and epithelial healing.
Mechanism: Vitamin A improves mucosal integrity and immune responses. WHO | Regional Office for Africa
Treat co-infections (measles, malaria, TB, HIV) and fever control
Purpose: Reduce whole-body stress that worsens mouth necrosis.
Mechanism: Removing infectious triggers lowers inflammatory burden. WHO | Regional Office for Africa
Daily gentle oral hygiene
Purpose: Reduce germ load in the mouth.
Mechanism: Soft swabbing with clean water/saline removes dead debris and plaque. PubMed Central
Antimicrobial mouth rinses (chlorhexidine 0.12%)
Purpose: Lower bacterial counts on ulcers/margins.
Mechanism: Chlorhexidine disrupts bacterial membranes during rinsing. (Prescription mouthwash for gingivitis; used off-label as adjunct in acute care.) FDA Access Data+2FDA Access Data+2
Debridement of necrotic tissue (conservative in acute phase)
Purpose: Remove dead tissue that fuels infection.
Mechanism: Careful bedside debridement improves oxygenation and antibiotic penetration. BMJ Global Health
Pain management (non-opioids, local care)
Purpose: Enable eating, cleaning, and sleep.
Mechanism: Reduces sympathetic stress that impairs healing. PubMed Central
Wound dressings (e.g., moist saline, clean honey where protocols allow)
Purpose: Protect wound; support granulation.
Mechanism: Moist, clean environment favors tissue growth and decreases bacterial growth. PubMed Central
Physiotherapy for trismus (after acute pain/infection improves)
Purpose: Preserve mouth opening.
Mechanism: Gentle stretching prevents scarring-related lockjaw. PubMed Central
Feeding support (cup/spoon, nasogastric if needed)
Purpose: Ensure adequate intake despite mouth pain.
Mechanism: Bypasses painful chewing; stabilizes nutrition. WHO | Regional Office for Africa
Psychosocial support and caregiver training
Purpose: Reduce fear, support adherence at home.
Mechanism: Coaching improves hygiene, feeding, and follow-up. PubMed Central
Anemia correction (iron, folate once infection controlled)
Purpose: Improve oxygen delivery; immunity.
Mechanism: Restores red cell production and tissue oxygenation. WHO | Regional Office for Africa
Safe water and sanitation at bedside
Purpose: Lower reinfection risk.
Mechanism: Reduces exposure to pathogens during care/feeding. PubMed Central
Oral health education
Purpose: Prevent recurrence and new lesions.
Mechanism: Daily cleaning and simpler diets lower plaque/necrosis risk. PubMed Central
Early referral to surgical team (planning phase)
Purpose: Prepare for reconstructive needs after stabilization.
Mechanism: Timing surgery after infection resolution reduces complications. BMJ Global Health
Thermal regulation (keep warm, avoid hypothermia)
Purpose: Reduce metabolic stress in malnourished children.
Mechanism: Conserves energy and improves immune function. PubMed Central
Micronutrient repletion (zinc, B-complex as part of nutrition plans)
Purpose: Support wound healing and immunity.
Mechanism: Cofactors for collagen, cell division, and immune enzymes. WHO | Regional Office for Africa
Careful mouth opening under supervision
Purpose: Prevent fibrous ankylosis.
Mechanism: Gentle exercises maintain muscle length and joint mobility. PubMed Central
Close follow-up after discharge
Purpose: Catch relapse or scarring early.
Mechanism: Reinforces nutrition, hygiene, and rehabilitation. PubMed Central

Drug treatments

No single regimen is proven superior; early broad anaerobic and oral flora coverage is standard, alongside nutrition and local care. BMJ Global Health

Metronidazole (IV/PO) — anaerobic coverage
Class: Nitroimidazole. Typical adult IV: 15 mg/kg loading, then 7.5 mg/kg q6h; pediatric doses per weight. Use/time: Start immediately for suspected anaerobic infection. Purpose: Kill obligate anaerobes common in necrotic mouth wounds. Mechanism: DNA strand breaks in anaerobic bacteria. Key side effects: Nausea, metallic taste; avoid alcohol; rare neurotoxicity. FDA Access Data+2FDA Access Data+2
Penicillin G (benzathine/procaine forms or aqueous IV in hospital) — streptococci, oral anaerobe synergy
Class: β-lactam. Use/time: Pair with metronidazole early in acute phase. Purpose: Hit susceptible streptococci and other oral flora. Mechanism: Inhibits cell wall synthesis. Side effects: Allergy, rash, rare anaphylaxis. (Formulation/label examples shown.) FDA Access Data+1
Ampicillin–sulbactam (IV)
Class: β-lactam/β-lactamase inhibitor. Use: Single-agent alternative covering many oral anaerobes. Purpose: Broad empiric therapy when IV access and monitoring are available. Side effects: GI upset, hypersensitivity. FDA Access Data+1
Amoxicillin–clavulanate (PO/IV where available)
Class: β-lactam/β-lactamase inhibitor. Use: Step-down or initial therapy when oral route is possible and child can swallow. Purpose: Covers mixed oral flora including β-lactamase producers. Side effects: Diarrhea, rash; dose by mg/kg. FDA Access Data+1
Clindamycin (IV/PO)
Class: Lincosamide (strong anaerobic coverage). Use: Penicillin allergy or add-on if osteomyelitis/necrotizing infection suspected. Purpose: Suppress anaerobes and some streptococci; good tissue penetration. Side effects: Diarrhea, C. difficile risk. FDA Access Data+1
Ceftriaxone (IV/IM)
Class: 3rd-gen cephalosporin. Use: Add for severe sepsis or gram-negative coverage with metronidazole. Purpose: Broad systemic coverage while awaiting culture (if feasible). Side effects: Biliary sludge, diarrhea, injection-site pain. FDA Access Data+1
Gentamicin (IV)
Class: Aminoglycoside. Use: Add in severe sepsis per some protocols (often with β-lactam ± metronidazole). Purpose: Potent gram-negative coverage. Side effects: Nephrotoxicity, ototoxicity—dose by weight and monitor. FDA Access Data
Chlorhexidine 0.12% oral rinse (adjunct, topical)
Class: Antiseptic. Use: Daily gentle rinsing when the child can cooperate. Purpose: Reduce bacterial burden at wound margins. Side effects: Tooth staining, taste changes. (Indicated for gingivitis; used as off-label adjunct in noma.) FDA Access Data+1
Doxycycline (PO; older children/adults)
Class: Tetracycline. Use: Alternative in mixed infections when susceptible and age-appropriate. Purpose: Broad coverage; anti-collagenase properties may help tissues. Side effects: Photosensitivity, tooth discoloration in young children—avoid in <8 yrs. FDA Access Data+1
Paracetamol/acetaminophen (PO/IV) for pain/fever control
Class: Analgesic/antipyretic. Use: Improve comfort, feeding. Side effects: Hepatotoxicity if overdosed; dose by weight. (Label example shown.) FDA Access Data

(Further antibiotics are chosen by local susceptibility, access, and comorbidities. Evidence comparing exact regimens is limited; early broad coverage with nutrition and hygiene is the consistent theme.) BMJ Global Health

Dietary molecular supplements

Use supplements only as part of medically supervised nutrition; they do not replace antibiotics or wound care.

Vitamin A — helps immune function and mucosal healing; give per age-appropriate protocols to reverse deficiency common in noma settings. WHO | Regional Office for Africa
Zinc — supports epithelial repair and immune enzymes; helpful in malnourished children. WHO | Regional Office for Africa
B-complex (including folate, B12 where deficient) — supports red blood cell and tissue repair in anemic, malnourished patients. WHO | Regional Office for Africa
Iron (after infection starts improving) — corrects iron-deficiency anemia; improves oxygen delivery; avoid during acute sepsis if unsafe. WHO | Regional Office for Africa
Protein supplements (milk/peanut-based ready-to-use foods) — provide concentrated amino acids for wound healing. WHO | Regional Office for Africa
Calorie-dense lipids (therapeutic foods) — restore energy stores and weight. WHO | Regional Office for Africa
Vitamin C — collagen formation and antioxidant support in healing wounds. WHO | Regional Office for Africa
Vitamin D — immune modulation and bone health during rehabilitation. PubMed Central
Electrolyte solutions (oral rehydration salts) — correct dehydration that worsens tissue perfusion. WHO | Regional Office for Africa
Multivitamin/mineral as a bundle — pragmatic coverage when individual labs are unavailable. WHO | Regional Office for Africa

Drugs aimed at “immunity support / regenerative / stem-cell space”

There are no approved stem-cell drugs for noma. Care focuses on reversing malnutrition and infection so the immune system can recover naturally.
Safe, practical “immune support” is nutrition, vitamin A, zinc, and infection control, as above. Experimental regenerative strategies are surgical (tissue flaps/bone grafts), not pharmaceuticals. BMJ Global Health

Evidence-based immune support: vitamin A, zinc, protein-energy rehabilitation, and antimicrobial control of infection. Avoid unproven “immune boosters.” WHO | Regional Office for Africa

Surgeries (what they are and why they’re done)

Conservative debridement (acute phase) — remove dead tissue to limit bacterial spread and prepare clean wound bed. BMJ Global Health
Sequestrectomy / debridement of necrotic bone — treat jawbone involvement and reduce chronic infection risk. PubMed Central
Release of trismus and scar bands — restore mouth opening for eating and hygiene. PubMed Central
Local/regional flap reconstruction (e.g., nasolabial, forehead flaps) — replace missing cheek/lip tissue and restore function/appearance once infection and nutrition are stable. PubMed Central
Bone grafting/osteotomy with staged reconstruction — correct severe jaw defects and occlusion problems in sequelae phase. PubMed Central

Preventions

Good nutrition for mothers and children to avoid severe malnutrition. World Health Organization
Measles vaccination and prompt malaria treatment to reduce immune stressors. World Health Organization
Daily tooth/gum cleaning with a soft brush or clean cloth. PubMed Central
Safe water and sanitation to lower oral/enteric pathogen exposure. PubMed Central
Early dental care for gum ulcers or mouth pain. PubMed Central
Prompt treatment of diarrhea, pneumonia, and fever. World Health Organization
Vitamin A programs in high-risk areas. WHO | Regional Office for Africa
De-worming and anemia control as part of child health packages. WHO | Regional Office for Africa
Avoid tobacco smoke/irritants around children (irritates mucosa, weakens health). PubMed Central
Community awareness so caregivers seek help at the first sign of gum swelling or foul mouth odor. PubMed Central

When to see a doctor—right away

Any child with sudden gum swelling, bleeding, mouth pain, bad breath, fever, or a dark/grey patch on the gums or cheek—seek care the same day. Early antibiotics and nutrition can be lifesaving. World Health Organization

What to eat and what to avoid

Eat: soft, energy-dense foods (fortified porridges, milk- or peanut-based therapeutic foods), eggs, lentils/beans, fruits/vegetables rich in vitamin A (mango, papaya, leafy greens), and plenty of safe fluids. These provide protein, vitamins, and fluids needed for healing. WHO | Regional Office for Africa
Avoid (temporarily): hard or spicy foods that hurt ulcers; sugary drinks and junk snacks that promote plaque; alcohol or smoking exposure in the home. These irritate wounds and increase bacterial growth. PubMed Central

FAQs

1) Is noma contagious?
Not like measles or flu. It is an opportunistic infection that strikes when nutrition and immunity are very poor. World Health Organization

2) Can noma be cured if found early?
Yes. With nutrition, hygiene, and antibiotics, most early cases improve quickly and avoid severe destruction. World Health Organization+1

3) Which antibiotic is “best”?
There is no single proven best regimen; early anaerobic coverage (e.g., metronidazole plus a β-lactam) is widely recommended, adjusted to local practice and allergies. BMJ Global Health+1

4) Why add metronidazole?
It targets anaerobic bacteria common in dead tissue. FDA Access Data

5) Why use penicillin or amoxicillin-clavulanate?
They cover streptococci and other oral flora; clavulanate helps when bacteria make β-lactamase. FDA Access Data

6) Is clindamycin an option?
Yes—good anaerobic coverage; often used if penicillin allergic or with bone involvement. FDA Access Data

7) Do mouthwashes help?
Chlorhexidine 0.12% can reduce bacterial load as an adjunct to cleaning and systemic therapy. FDA Access Data

8) Do vitamins replace antibiotics?
No. Vitamins and food support healing but do not replace antibiotics or debridement. WHO | Regional Office for Africa

9) Can noma affect adults?
Mainly children, but immunocompromised adults can be affected. World Health Organization

10) Is surgery always needed?
Not in early disease. Surgery is for severe tissue loss or scars after infection settles. BMJ Global Health

11) How fast can noma spread?
In days without care; that is why same-day treatment matters. World Health Organization

12) Are there vaccines against noma?
No. Prevention uses nutrition, vaccination against measles, hygiene, and early illness care. World Health Organization

13) Can children with noma eat by mouth?
Yes—soft, high-energy foods; use NG feeds if mouth opening is limited. WHO | Regional Office for Africa

14) Will teeth be lost?
Sometimes. Gum and bone damage can loosen teeth; dental/surgical follow-up is needed. PubMed Central

15) What is the single most important action?
Start treatment immediately: nutrition + hygiene + broad anaerobic antibiotic coverage. World Health Organization+1

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