Cancrum oris

Cancrum oris is now rarely seen in the industrial world, but in many developing countries it is not uncommon. It is a gangrenous process of the mouth, which starts suddenly, rapidly involves the adjacent tissues of the face, quickly becomes well demarcated, and then spreads no further. It most often affects one or both sides of the jaw, and occasionally the front of the face (mouth, lips, nose, and chin). Fusiformis and Borrelia are largely responsible, but it is not contagious. It resembles Fournier's gangrene of the scrotum (23.30), and may be associated with simultaneous extraoral gangrenous lesions of the limbs, perineum, neck, chest, scalp, or ear, etc.

Although cancrum oris can occur at any age, you will see it most commonly in a malnourished child between 1 and 5, whose general health has been further weakened by some infectious disease, usually measles, but also malaria, gastroenteritis, typhoid, whooping cough, tuberculosis or leukaemia, etc. Sometimes, there is no antecedent infection.

The lesion starts inside a child's mouth, in association with acute ulcerative gingivitis, and then spreads to his lips and cheeks. The earliest stage, which is seldom seen, is a painful red or purplish-red spot, or indurated papule, on his alveolar margin, most often in his premolar or molar region. This lesion rapidly forms an ulcer, which exposes his underlying alveolar bone. If you see him at this stage, he has a sore mouth, a swollen, tender, painful lip or cheek, profuse salivation, and an extremely foul smell, with purulent discharge from his mouth or nose. Within the next 2 or 3 days, a bluish-black area of discoloration appears externally on his lips, or cheek. The gangrenous area is cone-shaped, so that much more tissue is destroyed inside his mouth, than his external wound might indicate. After separation of the slough, his exposed bone and teeth rapidly sequestrate.

Quite extensive superficial lesions can heal suprisingly well. But destruction of his deeper tissues, teeth and skeleton can produce such appalling disfigurement that you have to refer him for expert plastic surgery[md]if he is lucky. This may include: the correction of gross mutilation, ''dental anarchy', trismus (particularly difficult) and a salivary leak. You can however treat him during the acute stage, as described below. Untreated cancrum oris is almost always quickly fatal, due to the associated illness (measles, typhoid, diarrhoea etc.) or a complication, such as septicaemia or aspiration pneumonia. Secondary haemorrhage is most unusual. and cavernous sinus thrombosis (5.5) has never been reported.

Tempest MN, ''Cancrum oris'. British Journal of Surgery, 1966;53:11, 949[nd]69.[-3] Tempest MN, ''Cancrum Oris'. Tropical Doctor 1971;4:164[nd]169 Fig. 26-10 CANCRUM ORIS. A, cancrum oris in the acute stage, showing well-demarcated gangrene of the upper lip and adjacent cheek. B, a typical example of the gross facial mutilation that follows. After Michael Tempest with the kind permission of the editor of Tropical Doctor.

THE ACUTE STAGE OF CANCRUM ORIS Start emergency treatment immediately, and aim to build up the child's general resistance. If possible admit him. There is no need to isolate him. If admission is impractical, outpatient treatment is possible.

FEEDING AND ELECTROLYTES. You can usually correct his protein energy malnutrition, by feeding him by mouth. If his mouth is too sore, feed him through a nasogastric tube.

CORRECT HIS ANAEMIA; give him folic acid, iron, ascorbic acid, and the vitamin B complex, particularly nicotinic acid.

ANTIBIOTICS. Give him penicillin in large doses and metronidazole.

CARE FOR THE LESION by repeatedly irrigating it with saline. Chewing raw pineapple, or slices of orange, will help to clean his mouth. Pack cavities with gauze pads soaked in hypochlorite (''Eusol'), saline, or BIPP. Change these dressings often, and keep them moist by adding more solution to the outer layers. Avoid vaseline gauze (which acts like a foreign body), especially when it has been impregnated with antibiotics.

If he is fit enough for surgery, cut away any separating sloughs, and remove any loose teeth or sequestra. When quite large sequestra are ready to separate, you may be able to remove them under ketamine.

If he is too ill for surgery, allow the dead tissues to separate spontaneously. Sequestra occasionally drop out. More often, they have to be removed after 3 or 4 weeks, when his condition has improved enough for surgery to be safe.

CAUTION ! There is no place for radical surgery at this stage, except to control bleeding (rare).

REFER HIM FOR REPAIR at 3 to 6 months, before marked trismus develops. This will allow his scars to mature, his local tissues to become soft and pliable, and his health to improve. Meanwile, do your best for his nutrition, and for his oral hygiene.