NOMA BEYOND BORDERS: A CASE LINKING PERIODONTAL DISEASE, SYSTEMIC INFLAMMATION, AND DIALYSIS VULNERABILITY

Noma, or necrotizing stomatitis, is a fulminant necrotizing disease that rapidly progresses from the oral cavity to the facial tissues. It is predominantly observed in developing countries, where malnutrition, poor sanitation, and infectious diseases are prevalent. In 2023, the World Health Organization (WHO) officially designated Noma as a neglected tropical disease (NTD). However, reports from developed countries remain exceedingly rare. We present a case of Noma in a patient undergoing maintenance hemodialysis for diabetic nephropathy, highlighting the potential for this disease to occur in immunocompromised individuals even in high-income settings. We also discuss the implications for oral hygiene management in dialysis patients.

The patient was a 52-year-old man who had been receiving maintenance hemodialysis since year X–6 due to diabetic nephropathy. In mid-April of year X, he developed discomfort on the left side of his tongue and hypersalivation, followed by fever, chills, tongue discoloration with a foul odor, and serosanguinous exudate. On admission, his vital signs were: blood pressure 114/76 mmHg, heart rate 106 bpm, body temperature 37.3°C, and SpO₂ 98% on room air. He was alert (JCS I-1). Oral examination revealed a large ulcer with serosanguinous discharge on the left lateral border of the tongue. Laboratory findings showed WBC 10.7 × 10⁹/L, hemoglobin 9.8 g/dL, albumin 2.4 g/dL, CRP 27.23 mg/dL, BUN 55.8 mg/dL, creatinine 9.28 mg/dL, and glycoalbumin 25.6%, indicating systemic inflammation, progressive anemia, renal dysfunction, hypoalbuminemia, and hyperglycemia.

This case underscores that Noma, although classically associated with extreme poverty and malnutrition in tropical regions, can also develop in patients with chronic comorbidities such as end-stage renal disease, diabetes mellitus, and immunosuppression in developed countries. The pathogenesis of Noma is thought to involve progression from periodontal disease to necrotizing gingivitis and ultimately to necrotizing stomatitis, with exacerbating factors including malnutrition, systemic infections, renal failure, diabetes, immunosuppressive states, and inadequate oral hygiene.

In patients undergoing dialysis, severe periodontal disease has been shown to correlate significantly with malnutrition, systemic inflammation, and atherosclerotic complications. Among these, the association between inflammation and malnutrition is particularly strong. Several studies suggest that treatment of periodontal disease may contribute to improvements in nutritional status and inflammatory markers in this population. Furthermore, multinational cohort studies have demonstrated that tooth loss and dental caries are associated with increased mortality risk in dialysis patients. Conversely, positive oral health behaviors—such as daily tooth brushing, use of dental floss and mouthwash, regular toothbrush replacement, and routine dental visits—have been linked to improved survival outcomes.

Taken together, these findings emphasize the importance of proactive oral health management in dialysis patients. Regular oral screening, promotion of dental care access, and continuous oral hygiene education may not only prevent severe oral infections such as Noma but also contribute to better systemic health and long-term prognosis in this vulnerable population.