Background

Oral hemangiomas (OHs) are growths that are not dangerous. Too many endothelial cells grow and cause them. They mainly happen in and around the mouth area. Most hemangiomas (60-70%) are found in the head and neck. But OHs are rare. They mostly affect parts like lips, cheeks, tongue, and palate. They can also appear in jaw bones (central hemangiomas). And they can be in chewing muscles (intramuscular hemangiomas). The words “hemangioma” and “vascular malformation” were used interchangeably. This caused confusion. But in 1982, Mulliken and Glowacki classified them differently. “Hemangiomas” are true growths with high endothelial cell turnover. “Vascular malformations” are localized defects from vascular issues. They have normal cell turnover rates. 

Epidemiology

Oral hemangiomas usually appear in babies and young kids. They form within a couple weeks or months after birth. Many hemangiomas shrink over time. Some studies suggest more girls than boys get them, but this isn’t always true. Around 6.4% of newborns have oral hemangiomas. Data’s limited for older kids and adults. Oral hemangiomas occur more often on the underside of the tongue than vascular malformations, which happen more on the lips. Oral hemangiomas affect 3 times more girls than boys. They’re more common in white people. If a baby’s premature, a twin/triplet, underweight (under 1 kg), or the mom’s older, risk increases. 

Anatomy

Pathophysiology

The abnormal growth of blood vessels in oral hemangiomas results from rapid endothelial cell reproduction. This leads to clusters forming inside the mouth. No one knows the exact reason, but genes and hormones may play a role. Studies show genes like VEGF help start and grow these tumors. Endothelial cells multiply faster in oral hemangiomas, causing rapid infant growth. Most appear shortly after birth, stop growing, then shrink over time. During shrinkage, endothelial cells die, reducing blood flow and tumor size. Oral hemangiomas develop from a complex mix of genetic, hormonal, and environmental factors interacting. 

Etiology

The start of oral hemangiomas involves many things working together. We know genes play a part. If someone in your family had hemangiomas, you may get them too. Hormones are important as well, especially for babies whose mothers were older. Hemangiomas grow more in these babies. A protein called VEGF helps make abnormal blood vessels grow in hemangiomas. Most oral hemangiomas appear in infancy. But their growth patterns and how they go away on their own show that other things like our environment affect them too. So, oral hemangiomas start because of genes, hormones, and environmental factors all working together to make abnormal blood vessels grow. 

Genetics

Prognostic Factors

For most people with oral hemangiomas, the outlook is good. They usually go away on their own without causing any problems. 

Clinical History

Often, oral hemangiomas are noticed when parents or caregivers spot red or bluish discolorations on a baby’s lips, tongue, buccal mucosa, or palate. Most become visible within weeks or months after birth. Important details include the patient’s family history, premature birth, multiple births, and maternal factors during pregnancy. These growths tend to appear soon after delivery, with the proliferative phase peaking around six months. Each phase’s duration varies; proliferative lasts months, plateau months to years, and involution years. Early childhood usually sees complete resolution, though changes may persist.  

Physical Examination

Oral hemangiomas are reddish or bluish spots on the mouth’s lining. Their texture ranges from smooth to lumpy, based on their depth. Their size varies, and location matters – lips, tongue, cheeks, and roof of mouth are common spots. Raised patches are superficial, while deeper ones can be felt with fingers. Problems like sores, bleeding, or crusting can happen if injured. These growths move around and change consistency over time. Depending on their size and placement, they may impact talking, eating, or alter lip shape. Increased blood flow or pulsing may be visible. Examining helps determine stage – actively growing, stable, or shrinking. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

• Angiosarcoma  
• Vascular ectasia  
• Vascular malformation  
• Lymphangioma  
• Pyogenic granuloma  

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Medical Therapy:  

• Beta-blockers like propranolol work by narrowing blood vessels and destroying cells lining the blood vessel walls. They form the main treatment. But you need to watch for bradycardia and low blood pressure side effects. 
• Prednisone and other oral steroids aren’t the first choice due to side effects. But they may be an option if beta-blockers can’t be used. Monitor for issues like high blood pressure and high blood sugar. 
•  As a last resort for cases resistant to beta-blockers and steroids, interferon-alpha has been studied. However, its use is limited by  potential side effects like muscle stiffness, low white blood cell and platelet counts, and liver damage. 

Surgical Resection:   

For tiny growths found inside cheeks or lips, surgically removing them is an ideal option. But big growths on the tongue mean doctors try to avoid surgery. That’s because taking them out could permanently affect how you speak and swallow. 

Sclerotherapy:   

Injecting special chemicals into vessels supplying blood to the growth is a new treatment called sclerotherapy. By entering major vessels and causing damage, the chemicals trigger vessel scarring and closure. This method works well but has risks like blood clots that travel elsewhere. When           deciding treatment, doctors consider growth size, location, your overall health, and risk factors for each option. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Administration of pharmaceutical agent

Role of Beta-blockers  

 Beta-blockers, especially propranolol, fight oral hemangiomas (OHs). The exact way isn’t fully known, but may restrict blood flow locally and trigger cell death in vessel walls. Patients start taking 2-3 milligrams per kilogram daily, split into three doses. In 1-2 days, hemangiomas often look better. Checking for slow heart rate, low blood pressure, low blood sugar, and breathing troubles is vital during the up to 6-month treatment. Regular check-ups ensure propranolol safety and effectiveness against OHs. 

Role of Corticosteroids  

Steroids taken orally sometimes are used to treat oral hemangiomas (OHs). However, they aren’t favored because of potential side effects. Prednisone is the most studied oral steroid for OHs, given up to four months. But if no progress after two weeks, stop prednisone. Closely monitor patients,            especially kids, for high blood pressure, mood swings, excess blood sugar, and stunted growth. For treatment-resistant OHs, interferon-alpha showed some success but isn’t preferred due to risks like paralysis, low blood cell counts, liver damage. If medicines fail or function impaired, doctors may suggest procedures or surgery. 

Surgical Intervention  

Removing oral hemangiomas surgically works well for smaller lip and cheek lesions. But extensive tongue growths can’t be surgically removed, as speech and swallowing may suffer. Sclerotherapy is a new treatment approach. It injects foreign substances like sodium tetradecyl sulfate or      ethanolamine oleate into vessels feeding the growth. This damages inner linings and blocks the lumen. Studies show sclerotherapy’s promise, with good results and few side effects reported. Still, there are worries about clot risks from embolization. More research is needed on sclerotherapy’s efficacy and safety for managing oral hemangiomas. 

Medication

Future Trends

Media Gallary

References