Especially small children refuse nutrition because of pain once they get sick. Many starve. But even at this point, Noma could still be controlled with antibiotics, improved nutrition and vitamins.
Very few families in developing countries know the telltale signs of the disease. The necessary medication is usually not available, either. Reaching a nursing station also takes too long. Parents have to carry their children through extreme heat in the desert to get to the stations.
As a result, the third phase of the disease in most cases is not prevented. The disturbed blood supply causes the affected tissue to fall off the facial bones. The bone itself dissolves in many cases. A black discoloring in the face is visible for the next two to three days.