British Journal of Oral and Maxillofacial Surgery (2004) 42, 267—269

SHORT COMMUNICATION

Cancrum oris

Anil George Behanan*, Ajith Auluck, Keerti Latha Pai

Department of Oral and Maxillofacial surgery, College of Dental Surgery,Manipal Academy of Higher Education, Manipal-576 104, Karnataka, India

Accepted 13 February 2004

KEYWORDSGangrenous stomatitis;Noma;Extraoral ulcer

Summary A malnourished 9-year-old boy presented with an infection in the buccalspace that developed into cancrum oris during the course of treatment.© 2004 The British Association of Oral and Maxillofacial Surgeons. Published by ElsevierLtd. All rights reserved.

Introduction

Cancrum oris is also known as noma or gangrenousstomatitis.Over the years, the mortality has declined from

80 to 90% to current 8—10%1 as a result of antibi-otics. The disease occurs mainly in children in areaswhere poverty is life and hygiene is poor.

Case report

A 9-year-old boy presented with a 4 cm × 6 cmtender swelling on the right cheek. It had started3 weeks previously and there was no history oftrauma.The skin over the swelling was tense and

glossy and there were encrustations at the an-gle of mouth.. There was infra-orbital cellulitisand pus was discharging from angle of mouth.(Fig. 1).The right submandibular lymph nodes were en-

larged and tender. There was at that time no foulodour or signs of necrosis.

*Corresponding author. Tel.: +91-820-2574133;fax: +91-820-2571966.

E-mail addresses: agbehanan@rediffmail.com,agbehanan@yahoo.co.in (A.G. Behanan).

Inside the mouth there was a 2 cm ulcer on theright cheek that extended backwards from the cor-ner of mouth.The boys growth was stunted, he was malnour-

ished and had intermittent fever of 39 ◦C. Therewere signs of chronic lung disease.An orthopantomogram showed no bony changes.On the first day, we incised and drained the

swelling by an intraoral approach and patient wasgiven amoxicillin 500mg three times daily andmetronidazole 400mg twice a day. On the 7th dayskin over the right cheek began to show signs ofnecrosis with crater-like erosions (Fig. 2). We di-agnosed gangrenous stomatitis secondary to theinfection of buccal space and the antibiotic regi-men was changed. We gave injections of penicillin10,000 IU 6 hourly, gentamicin 30mg intravenouslyevery 12 h and vancomycin 125mg intravenouslyevery 6 h. We also gave metronidazole 200mg andciprofloxacin 500mg three times a day. We gave theboy a high protein diet and vitamin supplements.Laboratory investigations included a haemoglobin

concentration of 6.0 g/dl and a packed cell volumeof 21.3. Bleeding tests were within the referenceranges and ELISA for HIV showed no infection.Culture of pus showed that the organisms was

sensitive to gentamicin and ciprofloxacin. Fluores-cence microscopy showed no acid fast organisms.The lesions were kept clean by repeated irri-

gation with saline and hydrogen peroxide. Ribbon

0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjoms.2004.02.018

268 A.G. Behanan et al.

Figure 1 Buccal space infection.

Figure 2 Established cancrum oris.

Figure 3 Healing phase of cancrum oris.

gauzes soaked in Eusol Solution (Edinburgh univer-sal solution of lime) and boric acid were appliedand dressing changed twice a day. The sloughs wereremoved. After 20 days of dressings and antibioticsthe lesion had healed without further complica-tions (Fig. 3).

Discussion

Gangrenous stomatitis involves orofacial struc-tures and has been classified into three types–—labiomental, buccal and labiomaxillary.2 Thereis a strong correlation between gangrenous stom-atitis and debilitating conditions, such as malnu-trition, dehydration, blood dyscrasias and chronicinfectious diseases.3

The early features of cancrum oris include pain, aswollen tender painful lip or cheek, a foul-smellingpurulent discharge and a bluish-black discolorationof the skin in the affected area.3 The bacterialtoxins and enzymes produced by non-haemolyticstreptococcus, Staphylococcus aureus, Bacteroidessaccharolyticus, Fusobacterium necrophorum, andother anaerobic micro-organisms damage the vas-cular network resulting in bluish-black orocuta-neous ulceration.

Cancrum oris 269

The major causes of death are dehydration, bron-chopneumonia from aspiration, toxaemia and com-plications arising from the underlying debilitatingdisease.3 Recurrence is extremely rare.Even with appropriate antibiotics aggressive de-

bridement and repeated removal of sloughs are es-sential. In some cases the end result is extensivetissue necrosis resulting in large orocutaneous fis-tulas that require a pedicled flap harvested fromdistant site to close the defect.4

References

1. Tempest MN. Cancrum oris. Br J Surg 1966;53:949—69.2. Stassen LFA. Cancrum oris is an adult Caucasian female. Br

J Oral Maxillofac Surg 1989;27:417—22.3. Enweon WU. Epidemiological and biochemical studies of

necrotizing ulcerative gingivitis and noma (cancrum oris) inNigerian children. Arch Oral Biol 1972;17:1357—71.

4. Adekeye EO, Ord RA. Cancrum oris. Principles of manage-ment and reconstructive surgery. J Maxillofac Surg 1983;11:160—70.