Noma (Water Crayfish)

Noma, also known as water canker or cheek burn, is a serious infectious disease of the cheek mucosa, which originates from bacteria in the oral mucosa and, if left untreated, spreads to the surrounding soft and bone tissue. Children in developing countries are primarily affected by noma, as there are environmental factors such as malnutrition, poor hygienic conditions and insufficiently treated infectious diseases that favor the development of noma.

Noma (Water Crayfish)

What is noma?

A noma is a severe form of progressive (advancing) inflammation of the buccal mucosa, which is caused by a bacterial infection by Borrelia and Fusobacteria. See etaizhou for What does NCL Mean.

Noma manifests itself in poor hygienic conditions and a generally poor state of health of those affected, which is why the disease usually occurs in children with a disturbed immune system as a result of infectious diseases or malnutrition in developing countries.

At the beginning, Noma is accompanied by ulcers of the oral mucosa, which spread as the disease progresses, decompose the body’s own tissue, damage the facial bones and thus the symptoms characteristic of Noma, such as foul-smelling bad breath, necrotic areas in the face and mucous membrane, pain and fever cause.

In addition, as a result of the increasing necrotic areas in the advanced stage, noma impairs the sensory organs and the speech apparatus.


Noma is caused by bacteria (borrelia, fusobacteria) that are normally harmless to the human organism and are typically found in the human mouth. If the immune system is weakened by poor hygienic conditions, infectious diseases such as measles, scarlet fever, rubella or meningitis and by malnutrition (mainly a lack of proteins, vitamins, electrolytes), the bacteria can build up in the oral mucosa, especially in children up to six years of age multiply, from where they spread to the surrounding tissues (skin, mucosa and facial bones) and cause noma.

Symptoms, Ailments & Signs

Noma (water cancer) is a serious disease of malnourished children in developing countries that, if left untreated, can result in death or facial disfigurement despite treatment. The disease starts with a small wound in the oral mucosa and leads to the death of large areas of tissue and bone parts in the face.

The children’s immune systems are very weak due to malnutrition. In addition, there are the catastrophic hygienic conditions in these countries. This can lead to this catastrophic infection with often otherwise fairly harmless bacteria. The disease often begins with bleeding gums and foul breath.

A small wound in the oral mucosa initially forms a red-bluish nodule, which quickly spreads to the cheeks and lips. There is swelling at the inflamed areas, with the affected area becoming hard and thick. Furthermore, pus forms with an increasingly unbearable odor. The patients also suffer from severe pain and fever.

At the site of the swelling, tissue necrosis occurs in a further stage. The dead tissue turns black. This area is surrounded by a white line, which acts as a boundary line to indicate the further progression of tissue decomposition. The general condition deteriorates drastically and is accompanied by diarrhea and fever. In the final stages of the disease, almost all parts of the face can be destroyed. Death occurs in untreated people from pneumonia, blood poisoning or bloody diarrhea.

Diagnosis & History

Noma is usually diagnosed on the basis of the characteristic symptoms and the corresponding accompanying circumstances such as a weakened immune system as a result of a previous infectious disease or malnutrition and poor hygienic conditions.

The typical symptoms of noma are ulcers in the oral mucosa, which cause foul breath and gradually spread to the soft and bony parts of the face, thus permanently affecting the sensory organs and the speech apparatus.

In the advanced stage, parts of the facial bones can be exposed and sepsis (blood poisoning) or pneumonia (aspiration pneumonia) can become life-threatening. In developing countries, noma takes a severe course in many cases, since there are often insufficient treatment options in these areas.

About 90 percent of children affected by noma die in these areas, although the prognosis is good if treatment is started early. In contrast, the survivors show severe facial disfigurement as a result of the disease with noma.


Noma (water cancer) always leads to fatal complications if left untreated. In the early stages of the disease there are still very good chances of recovery. However, if there is no change in diet with an adequate supply of proteins and vitamins at the beginning of the disease, the number of bacteria in the mouth area increases so much that the tissue there decomposes.

The final stage is characterized by fatal sepsis, further tissue breakdown around the mouth, pneumonia, or severe bloody diarrhea. Over 90 percent of children affected by noma do not survive the disease. Even after medical treatment, long-term consequences and complications can still occur. These consequences include a severely scarred face.

Sometimes even the tissues of the lips, cheeks, or eye sockets completely decompose. The face is then forever disfigured. The consequences of the disfigurement are particularly bad for those affected, because the scars and mutilations often lead to lifelong burdens and disabilities for the person. Those affected suffer the most from psychological problems.

They are often discriminated against because of their disfigurements, leading to loneliness and social isolation. In the affected families, the sick children are often rejected, leaving them completely neglected. They don’t show themselves in public, but live hidden. This excludes them from normal development.

When should you go to the doctor?

If mouth and face infections, ulcers and other signs of serious illness develop, a doctor must be consulted. The doctor can diagnose noma and contribute to a speedy recovery through prompt treatment. Therefore, the first symptoms should already be clarified. Those who live in poor hygiene conditions or suffer from malnutrition are particularly susceptible to infection. HIV, AIDS and typhus patients as well as people with a disease of the immune system are also among the risk groups and should go to the family doctor with the symptoms mentioned.

If the symptoms appear after staying in one of the risk countries, a doctor must be consulted immediately. The same applies to advanced diseases that may have already spread to the internal organs. The nearest hospital must be visited immediately with skin bleeding, coughing up blood and severe gastrointestinal complaints. In addition to the family doctor, an internist or a dermatologist can be involved in the treatment of noma. Children should be presented to the pediatrician immediately if there are signs of noma infection.

Treatment & Therapy

In the case of noma, the therapeutic measures are determined by the stage of the disease and focus on containing and eliminating the infection, preventing recurrence (recurrence of the disease) and treating the accompanying symptoms. In the early stages (stage I) of an illness with noma, therapeutic measures aimed at eliminating malnutrition, above all through an additional supply of proteins, vitamins and electrolytes, and limiting the focus of infection by means of antiseptic mouthwashes with chlorhexidine and metronidazole are sufficient.

In the second stage of the disease, a swab is taken from the affected area to determine the specific strain of bacteria present and the antibiotic mix to be used for treatment, while mouthwashes are still used. In the later course of the noma (stage III), artificial nutrition is required in addition to antibiotic therapy to compensate for the lack of fluids and electrolytes.

If the noma progresses further so that the necrotic (dead) tissue is already detaching (stage IV), plastic reconstruction to restore the damaged facial areas as part of a surgical procedure is indicated. In developing countries, such surgical measures are often beyond the scope of medical care and the affected children have to live with facial scars and disfigurements for the rest of their lives, which makes additional psychological care for the children affected by noma necessary.

Outlook & Forecast

The prognosis of noma is unfavorable. Without comprehensive medical care, those affected face the risk of premature death. The risk group for the disease includes children with malnutrition, most of whom live in developing countries. If the attending physicians can save the child’s survival with drug therapy and special mouthwashes, long-term damage is almost inevitable.

The more advanced the disease is, the more difficult the future prospects are. The children suffer optical changes and attitudes in the facial area. Despite all efforts and early therapy, it cannot yet be ruled out that developing countries are unable to treat them. If it is possible to bring the patient to western regions, cosmetic surgical interventions can alleviate the optical abnormalities. The interventions are associated with a great deal of effort and the possibility of complications. As a result, only very few sufferers get them.

Due to the symptoms and optical peculiarities, the affected person is threatened with emotional and psychological conflicts. Stressful conditions can lead to psychological complications. These have a further negative impact on the quality of life and general well-being of those affected. If the course of the disease is very favorable, not only can the child survive, but there is also the prospect that only scars will remain on the face.


Noma can be prevented by adequate hygienic measures and comprehensive medical care. Accordingly, the disease could be avoided in developing countries by improving the living conditions and quality of children. In particular, minimizing undernourishment and malnutrition, improving hygienic conditions and early and comprehensive medical treatment of infectious diseases and appropriate vaccinations can contribute to a lower incidence of noma in developing countries.


The disease water cancer actually requires a minor medical therapy. However, this is not available in the distribution areas. The same applies to medical follow-up care. Therefore, two groups must be distinguished: those who die and those who survive. Up to 90 percent of patients are among the former.

The survivors of the cheek burn need follow-up care, but do not receive it due to the desolate medical care system. All that remains for them is a life of distortions and disadvantages. According to European standards, the water cancer leads to a long-term treatment in which the patient receives all the support.

The mutilated and disfigured face in particular requires medical attention. It can be restored with plastic reconstructions. This requires several interventions and numerous visits to the doctor. Routine checks are carried out until a satisfactory result is obtained. In addition to physical examinations, blood analyzes are also arranged.

Noma disease can recur. A close aftercare tries to prevent this in the distribution areas. Doctors tackle malnutrition, administer the missing vaccinations and teach basic hygiene standards. The patient or his parents are responsible for compliance with the latter.

You can do that yourself

In order to be able to treat noma (water cancer) effectively, the general condition of the patients – they are mostly children in developing countries – must stabilize. This includes regular meals with an increased protein content, vitamins and electrolytes as well as plenty of fluids, sufficient rest and protection from sunlight and/or insects.

The patient’s immune system must be built up so that it can deal with the Borrelia and bacteria that have triggered the disease. Hygiene in the environment is also extremely important. It must be possible for the patient to wash himself daily and also clean the affected areas and take care of the wounds. In the beginning, antiseptic mouthwashes are sufficient, but if the disease is already advanced, antibiotics must also be taken. The medication prescribed should be taken regularly and not stopped prematurely.

Once the infection has been overcome, scars can still disfigure the face. Depending on the culture, corrective operations are not always possible. Nevertheless, ways must be found for the patients to cope with their sometimes considerable disfigurements. Psychotherapeutic accompanying treatments or other assistance, such as those offered by various local aid organizations (see also, are best.