Introduction
Infantile oral hemangioma, or simply oral HEM, refers to vascular tumors that can appear in infants or early childhood. While these growths are common, require management if they persist or become extensive. This article discusses the significance, classification, clinical features, predisposing risk factors during or after pregnancy that may make infants more susceptible to HEM, and the management strategies employed by oral surgeons and physicians.
What Is Infantile Oral Hemangioma?
Oral infantile hemangiomas, also known as vascular tumors, are benign growths that occur in children. These growths can appear either at birth or during infancy, with a higher incidence in female infants. According to the American Academy of Pediatric Dentistry (AAPD), lesions can present as masses or tumor-like conditions affecting the oral soft and hard tissues in children and young adolescents, the majority of these lesions are mucosal. Hemangiomas (HEM) fall within this category of intra-oral mucosal lesions, with a global incidence exceeding 9 percent according to epidemiological studies. These vascular tumors are recognized as the most prevalent form of benign lesions in children. Oral vascular tumors are a wide range of anomalies that can result from congenital or neonatal conditions affecting vascular structures. The term hemangioma (HEM) is used by oral surgeons to describe these localized benign vascular growths, originating from mesenchymal tissues, and often becoming evident very early in infancy or childhood.
What Is the Classification and Differential Diagnosis of Vascular Lesions in Pediatric Patients?
The pediatric vascular lesions can be categorized into two main groups:
- Hemangiomas: These can further be divided into proliferating and involuting types.
- Vascular Malformations.
This pediatric classification was refined in 1996 by the International Society for the Study of Vascular Anomalies (ISSVA), leading to the following categories
- Vascular Origin Tumors: This includes conditions like infantile and congenital hemangiomas, and pyogenic granulomas, among others.
- Vascular Malformations.
An accurate diagnosis of any oral lesion in pediatric patients, whether it presents in early childhood or infancy is important. This is essential to differentiate these lesions from various other oral conditions and anomalies, such as developmental disturbances, orofacial anomalies, and reactive and inflammatory lesions of the oral cavity caused by various factors like bacteria, viruses, fungi, or congenital neoplastic tumors. Any intraoral soft tissue swelling should not be dismissed as a simple inflammatory lesion but should undergo analysis by a multidisciplinary specialized team. They can provide a confirmative diagnosis, often aided by advanced two-dimensional or three-dimensional imaging of intraoral lesions in infants or children, for the best possible care and management.
What Are the Clinical Features and Predisposing Factors of Hemangiomas (HEM)?
Hemangiomas are the most prevalent benign tumors seen in both infants and children. Approximately 80 % of these tumors present as solitary lesions, which can be found either in the deeper or more superficial regions of the oral cavity. While the occurrence of HEM in infants, especially girls, is higher in areas like the lips, oral mucosa, and tongue, these lesions can be seen on the palate, near the salivary glands, or even within the mandibular or lower jawbone. These lesions manifest as well-defined, dark red growths with a firm texture, often isolated within specific locations.
When examined, they may feel rubbery to the touch by dentists or oral surgeons. They account for nearly 30 % of all benign tumors observed within the oral cavity in the pediatric age group. HEM can also be observed on the skin of the head, face, or neck, with an estimated incidence ranging from 3 to 10 percent in children under one year of age. This condition exhibits a specific predisposition or risk factor linked to infants born to individuals during or after pregnancy. These risk factors are associated with an increased likelihood of developing hemangioma (HEM):
- Preterm or premature low-birth-weight infants (weighing less than 2.2 pounds).
- Infants with decreased gestational age.
- Twin infants.
- Multiple gestation pregnancies.
- Gestational hypertension.
- Preeclampsia predisposition during pregnancy.
- Complications like placenta previa.
- Chorionic villus sampling of the fetus.
- Antenatal vaginal bleeding, among others.
Medical research into this condition reveals that approximately 50 to 80 percent of HEM cases in children linked to these predisposing factors will typically resolve on their own by the age of 5 years, especially within the oral cavity. This is attributed to the fact that endothelial cell proliferation, responsible for tumor growth, tends to subside by this age.
How to Manage Hemangioma Lesions in Infants?
Oral hemangiomas are commonly benign vascular tumors that often resolve on their own, typically not requiring invasive treatments. But, in cases where the lesions persist, cause discomfort in the infant, or become particularly large, recent advancements in treatment options have offered safer and proven therapeutic approaches. These include:
- Systemic Corticosteroid Therapy: This treatment involves the use of corticosteroids either systemically or through intralesional injections. Injected corticosteroids are frequently employed, especially for HEM lesions with the potential for rapid growth, particularly within the first year of life.
- Other Effective Agents: Promising and efficacious agents such as beta-adrenergic blockers, Polidocanol, oral Propranolol, and Bleomycin, among others, have been introduced in pediatric practice and show promise in managing HEM.
- Surgical Excision: While considered a last resort, surgical excision becomes a viable option for large HEMs, especially when they cause significant oral discomfort, particularly during activities like sucking. Surgical removal of the HEM lesion can be recommended by a pediatric surgeon or dentist, particularly for lesions located in critical areas like the infant's lower lip, upper lip, vermilion border, or even within the parotid gland region.
Conclusion
Vascular tumor-like lesions in infants may be relatively rare, but their clinical importance in pediatrics is important. Practitioners must possess a deep understanding of these conditions, including their characteristic features, diagnostic methods, and the spectrum of surgical and non-surgical management options available for oral hemangiomas (HEM). In pediatric dentistry, non-surgical therapies are often preferred as the primary treatment due to their non-invasive nature and effectiveness. The medical care of young patients with HEM requires a multidisciplinary healthcare team, comprising pediatric dentists, oral surgeons, dermatologists, and other specialists, which is to ensure accurate diagnosis, comprehensive management, and the best possible outcomes for these children.
