Case #11

A 14-year-old female presented to a dental office for an initial examination and dental prophylaxis. During the exam, a large, reddish patch was noted on her lower lip.

Th 137040

By Joen Ianncci Haring

A 14-year-old female presented to a dental office for an initial examination and dental prophylaxis. During the exam, a large, reddish patch was noted on her lower lip.

History

The patient claimed that the red area on her lower lip had been present as long as she could remember. When questioned about any change in size or color, the patient stated that the area appeared to be getting larger and darker. When questioned about any symptoms associated with the area, the patient stated that the lesion was painless. The patient reported no history of trauma to the affected area.

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At the time of the dental appointment, the patient appeared to be in an overall good state of health with no significant past medical history. At the time of the dental visit, the patient was not taking any medications. The patient's last dental appointment was approximately one year earlier for a routine checkup.

Examinations

Physical examination of the head and neck region revealed no enlarged or palpable lymph nodes. The patient's vital signs were all found to be within normal limits. Extraoral examination revealed a red lesion on the vermilion of the lower lip. The lesion appeared flat and measured approximately 1.00 cm x 0.75 cm in diameter. The patch exhibited a smooth surface without ulceration or hemorrhage. When pressure was applied to the lesion, blanching occurred. Further examination of the oral soft tissues revealed no other lesions present.

Clinical diagnosis

Based on the clinical information presented, which one of the following is the likely diagnosis?

o hematoma
o vascular malformation
o varicosity
o ecchymosis
o purpura

Diagnosis

• vascular malformation

Discussion

For years, the terms hemangioma and vascular malformation have been used interchangeably as generic terms for vascular anomalies. Currently, the term hemangioma is used to describe a benign tumor that arises within the first eight weeks of life and is characterized by endothelial cell proliferation and rapid growth, followed by gradual involution. In contrast, the term vascular malformation refers to a structural anomaly of blood vessels without endothelial proliferation that is present at birth and persists throughout life. Vascular malformation may be categorized based upon the vessel involved (for example, capillary, venous, arterial).

Clinical features

The vascular malformation results from abnormal blood vessel development. It may consist of a mix of arteries, capillaries, and veins. Over time, the vascular malformation tends to grow as a patient grows, and may become darker in color or nodular due to vascular ectasia. The vascular malformation blanches with pressure. Common locations include the head and neck region.

An example of a vascular malformation is the port wine stain. Port wine stains are capillary malformations that occur in approximately 1 percent of newborns. Such lesions are most common on the face and follow the distribution of the trigeminal nerve. Port wine stains typically present as a reddish-purple flat lesions that grow with the patient. With age, these lesions tend to darken and become nodular.

Diagnosis

The clinical appearance, duration history, and blanching with pressure is highly suggestive for the vascular malformation. The vascular malformation may clinically resemble the hematoma, ecchymosis, purpura, or varicosity. All four of these lesions may be included in the differential diagnosis.

The hematoma is a large pool of extravasated blood that results from trauma. Extravasated blod refers to blood that has been forced out of blood vessels and into the surrounding soft tissue. The hematoma appears as a dark red or blue elevated mass that is tender to the touch and fades with time. It does not blanch with pressure because the blood is not located within a blood vessel.

The terms ecchymosis and purpura refer to bruises. These lesions represent extravasated blood that results from trauma. The ecchymosis and purpura appear as reddish-blue or purple flat lesions that may be tender to the touch and fade with time. These lesions do not blanch with pressure.

The varicosity is a dilated vein that is caused by the reduced elasticity of the venous wall as a result of aging. It appears as a red-blue or purple swelling that is fluctuant and blanches with pressure. The varicosity, unlike vascular malformations, is seen in older individuals and first appears late in life.

Treatment

The vascular malformation is a benign lesion that does not regress over time. If eradication is the goal, surgical intervention is required. The smaller, stable malformations located in areas that are not an esthetic concern may not require treatment. In contrast, the larger, non-esthetic lesions may be treated with a combination of sclerotherapy and surgical removal. Laser therapy may also be an effective method of treatment.

Joen Iannucci Haring, DDS, MS, is a professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.

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