What is Oral Hemangiomas?
Oral hemangiomas, or OHs, are non-harmful growths that form because of excess growth of the cells that line the inside of your blood vessels. These growths can usually be found in and around the mouth. While 60 to 70 percent of hemangiomas (clusters of extra blood vessels) occur in the areas of the head and neck, OHs are comparably rare. They typically involve the lips, tongue, inner cheek, and roof of the mouth. It has also been noted that they can form in the lower and upper jawbones (central hemangiomas) and within the muscles used for chewing (intramuscular hemangiomas).
People often use the terms “hemangioma” and “vascular malformation” interchangeably, which can lead to a lot of confusion. But “hemangiomas” are real tumors that are marked by the excessive growth and higher than normal replacement rates of the cells lining your blood vessels, while “vascular malformation” are localized abnormalities due to congenital mistakes in the formation of blood vessels with normal rates of cell replacement.
In doctor’s perspective, there can be two types of hemangiomas – infantile or congenital. Infantile hemangiomas (IHs) are growths appearing within the first couple of months of a child’s life and grow rather rapidly between 6 to 12 months of age, then this growth slows down. Most of them will disappear on their own between ages 6 and 9. On the other hand, congenital hemangiomas (CHs) are present at birth, they do not go through a phase of rapid growth, and they either shrink rapidly or not at all. Most hemangiomas will fully disappear, although 10%-20% may endure into adolescence or adulthood.
While there are treatments available including medications, physical procedures, and surgeries, there’s no one-size-fits-all treatment for OHs. This is mainly due to the potential complications. Treatment is usually not pursued unless the presence of the OH impedes normal oral function.
What Causes Oral Hemangiomas?
The exact reason why oral hemangiomas (OHs), also known as benign tumors in the mouth, occur isn’t completely known yet. However, it is believed that changing genes, blockages in the bloodstream, and hormones could all play a key role in their development.
One theory suggests that OHs might be caused by placental endothelial cells, which are cells that line the blood vessels in the placenta. These cells might get into the baby’s blood stream if there’s trauma or some other stress, acting like stem cells. It’s been noticed that procedures like chorionic villus sampling, a prenatal test, can increase the chance of babies getting hemangiomas.
Another theory is that genetic mutations, specifically spontaneous or inherited changes on chromosome 5q, could lead to nonstop blood vessel formation, which results in the formation of a hemangioma.
A third theory speculates that hemangiomas might form because nearby cells respond to low oxygen levels by producing two things: vascular endothelial growth factor (VEGF), which helps grow blood vessels, and glucose transporter 1 (GLUT1), which brings substances in and out of cells.
Surprisingly, none of the theories explain why hemangiomas occur more in females or why these tumors tend to be found primarily on the head and neck.
Risk Factors and Frequency for Oral Hemangiomas
Oral hemangiomas, which are types of tumors, occur in about 6.4% of infants. However, we don’t have much information about how often they happen in older age groups. These tumors are usually found on the underside of the tongue. This is different from oral vascular malformations, which often occur on the lips. Also, oral hemangiomas are seen three times more commonly in females than in males, and they are more prevalent in white babies.
- About 6.4% of infants have oral hemangiomas, but it’s unknown how common they are in older people.
- The tumors are typically found on the bottom of the tongue, while other similar conditions are primarily found on the lips.
- Oral hemangiomas are three times more likely in females than males.
- White babies are more commonly affected.
- Infants who are born prematurely, are part of a multiple birth (like twins or triplets), or have low birth weight (below 1 kilogram), or whose mothers are older, have a higher chance of developing oral hemangiomas.
Signs and Symptoms of Oral Hemangiomas
Hemangiomas, which are commonly found in the head and neck, are much rarer in the oral cavity. These oral hemangiomas often show up in the lips, tongue, inner cheek lining, and roof of the mouth. Changes may be noticed by patients or their parents over time as these lesions grow, stabilize, and possibly shrink. The most rapid growth often occurs in the first three to nine months of life, followed by stabilization around one year. Most of these growths then naturally shrink, with about 85% to 90% of them disappearing within the next four years.
Hemangiomas on the lower lip, however, do not disappear as quickly. Moreover, the behavior of one doesn’t predict how another might behave. Most oral hemangiomas are painless and cause no symptoms, being identified during routine checkups. But when located within the bone or muscles of the mouth, they can cause gum bleeding – either spontaneously or as a result of trauma, increased bleeding after dental work, or loosened teeth.
These growths are soft and squashable, and can vary greatly based on their location and depth. Superficial ones may have a noticeable red color and could be described as lobular, situated on the surface or having a stalk. Deeper ones are typically harder to see and may look like a soft blues or violet patch that is different from the surrounding tissue. The method, called “Diascopy”, in which a lesion is compressed to see if it goes pale, can be used to tell the difference between vascular lesions like hemangiomas (which become pale) and skin spots (which do not lose color). When the patient lowers their head or applies pressure to the abdomen, oral hemangiomas may become more noticeable and may darken in color.
Testing for Oral Hemangiomas
Hemangiomas are benign, non-cancerous growths that are generally found inside the mouth. You can usually identify them visually during a clinical examination without any need for detailed lab testing or advanced imagery. However, suppose you desire treatment. In that case, your doctor might suggest a color-doppler ultrasound – a fairly cost-effective and non-invasive procedure that uses sound waves to create images and doesn’t expose you to radiation. This type of ultrasound can provide detailed images of the shape, size and blood flow in and around the hemangioma.
If your doctor suspects that the hemangioma is within your bone or muscle, he or she might recommend a contrast-enhanced MRI scan. An MRI scan uses magnetic fields and radio waves to produce detailed images. In this case, it is considered a better choice than a CT scan, which uses X-rays to produce images.
Doctors typically avoid taking a biopsy of oral hemangiomas because doing so can cause significant bleeding. Yet, if your doctor suspects a malignant (cancerous) growth, a biopsy might be recommended. A biopsy is a procedure where a small sample of tissue is taken from the growth for further testing in a lab.
Treatment Options for Oral Hemangiomas
Oral hemangiomas, which are benign blood vessel growths in the mouth, usually don’t need treatment because they often reduce in size on their own over time. But in cases where they interfere with talking, swallowing, or breathing, or when they persist in teenagers or adults, treatment may be necessary. There are two main types of treatment: medication and surgery.
Medical treatment commonly involves a class of drugs known as beta-blockers, with propranolol being one of the most common examples. It’s not fully understood how these work in treating oral hemangiomas, but it’s believed they might cause local narrowing of blood vessels and trigger cell death in the cells lining the blood vessels. Patients usually notice improvements in the size and appearance of hemangiomas a few days after starting the treatment. However, it’s important to watch out for potential side effects of beta-blocker use, such as a slowed heart rate, low blood pressure, low blood sugar levels, and difficult or labored breathing.
Oral steroids, such as prednisone, are another treatment option for oral hemangiomas. However, they are less preferred than beta-blockers because they have a higher likelihood of causing unwanted side effects. If there is no noticeable change in the size or appearance of the hemangioma after two weeks of prednisone use, the treatment generally gets discontinued. While on steroid therapy, patients, particularly children, should also be monitored for an increase in blood pressure, persistently high blood sugar, mood changes, and slowed growth.
For patients whose hemangiomas don’t respond to either beta-blockers or steroids, a drug called interferon-alpha has been used with some success. However, this drug isn’t the first choice because it can cause multiple side effects, including a specific type of muscle stiffness and weakness known as spastic diplegia, reduction in white blood cells or platelets, and liver toxicity.
For cases where medication isn’t effective, or if the hemangioma is causing functional problems, surgery might be an option. Surgery provides a definitive solution, and it can be especially useful for smaller lesions located on the lips or inside of the cheeks. However, it wouldn’t be a preferred option for large lesions in the tongue as removing a significant part of the tissue might result in chronic difficulties with speech and swallowing.
An alternative to traditional surgery is sclerotherapy, where a medicinal substance, such as 3% sodium tetradecyl sulfate or ethanolamine oleate, is injected into one of the large blood vessels in the hemangioma. This causes damage to the cells lining the blood vessel and closure of the blood vessel lumen, helping to reduce the size of the hemangioma. So far, studies indicate that sclerotherapy is generally safe with minor side effects, although there’s still a risk of blood clots forming in the treated vessels.
What else can Oral Hemangiomas be?
When a doctor is trying to diagnose oral hemangiomas, which are noncancerous growths in the blood vessels, they also keep in mind a number of other similar conditions. These include:
- Vascular malformation (abnormal network of blood vessels)
- Vascular ectasia (dilation of blood vessels)
- Pyogenic granuloma (skin or gum growth)
- Granular cell myoblastoma (rare soft tissue tumor)
- Angiomyolipoma (a form of benign tumor)
- Angiosarcoma (type of cancer that forms in the lining of blood vessels)
- Hemangiosarcoma (malignant cancer that starts in cells lining the blood vessels)
- Kaposi’s sarcoma (a type of cancer arising from the cells lining lymph or blood vessels)
- Lymphangioma (a rare, benign tumor that occurs in areas where lymphatic vessels are present)
What to expect with Oral Hemangiomas
Oral hemangiomas, which are noncancerous growths, generally have a good outcome as only a small number (10% to 20%) need treatment. However, those located in the bone, particularly in the lower jaw, carry a greater risk. This is because they are associated with a higher chance of unexpected bleeding or bleeding after a procedure.
Possible Complications When Diagnosed with Oral Hemangiomas
The complications related to oral hemangiomas (OHs) largely depend on the size and location of the growth. Certain issues may arise as a result, such as:
- Ulceration (this is the most common complication)
- Bleeding
- Difficulty swallowing and poor growth
- Impaired speech
- Problems with breathing
Preventing Oral Hemangiomas
For most harmless skin growths, it’s important to reassure patients and their families that these are not cancerous and they often go away on their own over time. If the patient is prescribed medication to treat these growths, it is vital they are educated about the medication and regularly checked by their doctor to watch for any side effects. This way, any potential medication-related problems can be spotted and addressed promptly.
