Oral Hemangiomas

What Are Oral Hemangiomas?

Oral hemangiomas (OHs) can usually be called benign tumors that may develop because of endothelial cell proliferation in the oral cavity. These benign tumors are more frequent on the ventral surface of the tongue, in stark contrast to oral vascular malformations. Oral hemangiomas may commonly be discovered during routine dental examination owing to their tendency to bleed after dental procedures or present with spontaneous gingival bleeding. These lesions are more prevalent on the lips with a predisposition in whites with a 3:1 female-to-male predominance. These are particular incidents in:

• Infants who are born prematurely.

• Infants of twins or triplets.

• Infants who have low birth weight (less than 1 kg).

• Infants who are born to older mothers are all at a likely possibility to develop OHs.

An estimated 60 to 70 percent of hemangiomas occur in the head and neck region. Though comparatively rare in the oral cavity, these lesions involve the lips, tongue, buccal mucosa, and palate in the infants affected. Oral hemangiomas can also be observed in the mandible, maxilla, or intramuscularly within the masseter or other masticatory muscles. Clinically in cases of the intramuscular or even in central hemangiomas occurring in the jaw, gingival bleeding is a very common clinical feature accompanied often by root resorption bony expansion. The patients may present with tooth pain, swelling, or even tooth mobility, and the dentist may observe post-extraction bleeding severity in these individuals.

How Are Oral Hemangiomas Classified?

Clinically, hemangiomas can be classified as:

• Infantile hemangiomas.

• Juvenile hemangiomas.

• Congenital hemangiomas.

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Infantile Hemangiomas:

Infantile hemangiomas (IHs) usually form during the first 2 months of life. These lesions rapidly proliferate between 6 and 12 months of age. Then they undergo a characteristic period of slow involution. Most IHs will spontaneously fade away between 6 and 9 years of age.

Congenital Hemangiomas:

Congenital hemangiomas (CHs) are present at birth. The majority of hemangiomas will completely involute, with 10 to 20 % lesions that may persist into the early adolescence or puberty phase. These lesions do not exhibit a proliferative phase and can either involute or not undergo this phase at all.

What Is the Broadly Trusted Hypothesis of Oral Hemangioma?

The hypothesis commonly trusted by the research behind OH formation is that they are formed due to embolic placental endothelial cells. These cells enter the fetal circulation after a trauma or in response to a cellular stressor and function as stem cells. Studies also show that chorionic villus sampling during pregnancy increases the risk of hemangiomas in the infant though this theory remains elusive.

Another theory is that loss-of-functional mutations on chromosome 5q can trigger or create activation of angiogenesis phenomenon in the child, resulting in hemangioma formation.

A third and widely accepted hypothesis is that hemangiomas may be formed due to the up regulatory metabolism of vascular endothelial growth factor (VEGF) and glucose transporter 1 (GLUT1) production by the local cells in response to hypoxic stressors.

What Are the Clinical Features of Oral Hemangiomas?

1. OHs are painless, asymptomatic, soft, and compressible masses found mostly only upon routine clinical examination by the dentist.

2. These lesions can vary both depending on location and depth.

3. Superficial lesions show a prominent red hue and can be further clinically described as lobulated, sessile, or pedunculated appearance.

4. Deeper lesions, though more difficult to visualize, can appear to the dentist as a soft blue or violent discoloration clinically distinct from surrounding mucosa.

5. Diascopy employs the principle of blanching of an oral lesion following compression with a finger or glass slide.

6. In this physical examination, a maneuver is used to distinguish or differentiate between the vascular lesions (blanching) from purpura (non-blanching). This can be performed to confirm the diagnosis of OH by the dentist.

7. The physician or dentist can identify the same by applying pressure on the abdominal region or compressive force on the abdomen while lowering the head on which the OH may turn dark in appearance.

What Are the Differential Diagnosis of Oral Hemangiomas?

The dentist should differentiate between the below-given conditions that may poise similar characteristics to oral hemangiomas but can be ruled out during diagnostics by:

• MRI (magnetic resonance imaging).

• Doppler ultrasound.

• CT (computed tomography) scan.

The differential diagnosis of oral hemangiomas are:

• Angiomyolipoma.

• Vascular ectasia.

• Pyogenic granuloma.

• Vascular malformation.

• Granular cell myoblastoma.

• Lymphangioma.

• Hemangiosarcoma.

• Angiosarcoma.

• Kaposi's sarcoma.

How Are Oral Hemangiomas Diagnosed and Treated?

Treatment is mainly diagnostic that can be confirmed by the first-line imaging modality of color Doppler ultrasound. If an intraosseous or intrabony or intramuscular hemangioma is suspected by the physician, a contrast-enhanced MRI (magnetic resonance imaging) would be the imaging modality of choice. Doppler technique is not only cost-effective and non-invasive; it also helps to diagnose without the risk of radiation. It can accurately diagnose in a short time span and provides morphological characteristics. It is preferable to the conventional CT scan.

Most surgeons and physicians prefer steroid therapy and beta-blocker drugs depending upon the lesion's size, location, and extent. Patients, especially children and young infants, should be monitored during the course of steroid therapy (mainline treatment) for the development of:

• Persistent hyperglycemia.

• Hypertension.

• Growth retardation.

• Mood changes.

For patients with OHs resistant to beta-blockers and steroids, interferon-alpha has been studied but is generally not preferred or used judiciously due to the side effect of liver toxicity in excess doses.

Surgical resection remains the other mainline treatment for OH and may be preferred for smaller lesions located on the lips and buccal mucosa by the dental surgeon. Resection would not be preferred for lesions on the tongue as removal of tissue in the case of large lesions can result in chronic impairment of speech and swallowing. Sclerotherapy, in which a foreign agent (such as 3% sodium tetradecyl sulfate or ethanolamine oleate) is injected into one of the major vessels of an OH. It is an evolving treatment modality preferred by maxillofacial surgeons for these lesions that will obliterate the endothelium and cause shrinkage.

Conclusion:

Oral hemangiomas though benign in nature, are a source of oral discomfort. It needs prompt action by the maxillofacial surgeon or dentist to prevent further aggravation either by the required drug therapy, sclerotherapy, or surgical resection.