Oral manifestations and dental considerations of patients with hereditary hemorrhagic telangiectasia: a scoping review

Objective. We examined the range, nature, and extent of research conducted regarding the oral and dental implications of hereditary hemorrhagic telangiectasia (HHT) to identify gaps in the research and knowledge of the ﬁeld. Study Design. We performed a scoping review according to the Preferred Reporting Items for Systematic Reviews and Meta-Anal-yses Extension for Scoping Reviews and 2017 Guidance for the Conduct of Joanna Briggs Institute Scoping Reviews. We searched the MEDLINE and Web of Science databases for all full-text articles published in English from December 1946 to October 2022. Results. We identiﬁed 103 articles describing oral and dental considerations of patients with HHT, primarily case reports. Most reported oral telangiectasias of the tongue, lips, and palate. Many reported management of bleeding and the use or recommendation of prophylactic antibiotics before dental procedures. Conclusions. Oral telangiectasias are commonly found in patients with hereditary hemorrhagic telangiectasia, and dental professionals may be the ﬁrst to diagnose it in their patients. Early detection and diagnosis are important to prevent potentially fatal outcomes, and prophylactic antibiotics before procedures may be warranted. (Oral Surg Oral Med Oral Pathol Oral Radiol 2023;136:691 (cid:1) 702)

Hereditary hemorrhagic telangiectasia (HHT), also known as Mb Osler or Osler-Weber-Rendu syndrome, 1 is an autosomal-dominant inherited disorder with an approximate prevalence of 1 in 5,000 to 8,000 affected individuals in the population. 2,3Mutations in genes, most commonly endoglin or ACVR1, affect the transforming growth factor beta superfamily and cause aberrant formation of vascular endothelial cells, resulting in malformed vascular networks. 4The malformations of the vascular system range from large visceral arteriovenous malformations (AVMs) to minor mucocutaneous telangiectasias.Visceral arteriovenous malformations in HHT are characterized by a lack of capillaries intervening veins and arteries, causing right-to-left shunts. 1 Telangiectasias in HHT usually develop between the ages of 20 and 30 years and increase in incidence with age.Likewise, the development of AVMs is positively associated with increasing age.As age increases, AVM-related symptoms tend to increase in both severity and frequency, whereas severe symptoms tend to occur less frequently in younger patients. 5elangiectasias are malformed capillary beds in the oral and nasal cavities that blanch with pressure and refill promptly after the pressure is removed.Because telangiectasias are often superficial on the mucosal surface and prone to tear with minimal trauma, 6 recurrent epistaxis is the most common clinical presentation of HHT.The recommended treatments to minimize epistaxis severity in HHT are prophylactic use of nasal lubricants (White Vaseline or Nozoil), saline washing, and prophylactic medical treatment using peroral tranexamic acid.In the event of epistaxis, patients are advised to use self-management products, such as hemostatic gauzes or sponges, to stop the bleeding. 7If the patient cannot self-manage epistaxis, physicianaided use of different types of nasal packing, including topical vasoconstrictive agents such as lidocaine-Àadrenaline or topical tranexamic acid, may be warranted.If conservative management of recurrent epistaxis is ineffective, different types of laser treatments; 8 septodermoplasty; or surgical procedures, such as the Young procedure for epistaxis, may be recom-mended. 9In recent years, the use of bevacizumab (Avastin) has been suggested, but further controlled trials examining the effects of this potent medical agent are required. 10arger AVMs are mostly found in the lungs as pulmonary arteriovenous malformations (PAVMs); in the liver as hepatic arteriovenous malformations; or in the cerebral system, including the spinal cord, as cerebral arteriovenous malformations.Complications from shunting or bleeding may be sudden and fatal.Patients with PAVMs can develop brain abscesses or suffer from stroke because of septic emboli.For this reason, screening for PAVMs is recommended for all patients with confirmed HHT diagnosis, 11 for whom the incidence of PAVM is estimated to range from 24% 12 to 48.6%. 13Pulmonary arteriovenous malformations with a feeding vessel diameter >2 mm typically require embolization to prevent complications. 11Early diagnosis, screening, and treatment can reduce the serious sequelae associated with the disease. 14ntibiotic prophylaxis before surgical and dental procedures is recommended for patients with HHT who have PAVMs.This treatment aims to decrease the risk of paradoxical embolism and prevent bacteremia due to right-to-left shunting, which is believed to cause neurologic symptoms, such as cerebral abscess or stroke. 15Dental procedures, such as single tooth extraction, dental scaling, and endodontic treatment, have been reported to cause bacteremia, with anaerobic bacteria more commonly found than aerobic microorganisms. 16Non-invasive dental activities, such as tooth brushing, have also been shown to cause dental-associated bacteremia, 17 which may prompt consideration of the benefits of antibiotic prophylaxis for patients with daily bacteremia exposure.The microorganisms in brain abscesses can also be detected in the periodontal bacterial flora.However, it is difficult to determine the impact of a dental procedure, as it can take months for a brain abscess to present clinically.Further research regarding dental-associated bacteremia and the susceptibility of HHT patients with PAVMs to bacteremia is warranted. 11iagnosis of HHT requires presence of at least 3 of the following 4 Curaçao Diagnostic Criteria for HHT: (1) spontaneous and recurrent epistaxis; (2) multiple telangiectasias located on the lips, oral cavity, fingertips, and the mucosa of the nasal cavity and gastrointestinal tract; (3) AVMs in the lungs, liver, brain, and spinal cord; and (4) a family history of HHT, particularly having first-degree relative with HHT. 1 There is a need for a summary of research findings regarding the latest treatment modalities and expert opinions on this rare disease to aid the clinical practitioner in its diagnosis and treatment.To assist in this endeavor, we conducted a scoping review of the literature regarding oral and dental considerations in HHT.We chose to conduct a scoping review rather than a systematic review because of the small number of high-quality articles we identified in a preliminary search, which we attribute to the rarity of HHT.Using the guidelines of Munn et al., 18 we aimed to systematically map the previous research into the oral and dental considerations of patients with HHT to identify gaps in knowledge.Our research was guided by the following research question: What are the oral and dental considerations regarding and possible treatment strategies for patients with HHT?

METHODS AND MATERIALS
We performed this scoping review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews 19 and 2017 Guidance for the Conduct of Joanna Briggs Institute Scoping Reviews. 20After a preliminary search of existing literature, we established and registered a protocol (DOI 10.17605/OSF.IO/PZTVM).Our search strategy was drafted by an experienced librarian at Uppsala University and refined by discussion (Supplementary Table S1).Due to the low prevalence of patients diagnosed with HHT, we anticipated identifying few, if any, randomized controlled trials examining the oral and dental considerations of patients with HHT.Therefore, we broadened the study design to include guidelines and case reports to review different aspects of oral and dental considerations in HHT.
To identify articles, we searched the MEDLINE and Web of Science databases for all articles published from December 1946 to October 2022 that met the inclusion criteria of being published in English and having full-text availability.We conducted our first search according to the Joanna Briggs Institute population/concept/context framework, defining the population as all human patients diagnosed with HHT; the concept as studies using any type of research design, including randomized control trials, cohort trials, casecontrol studies, cross-sectional studies, case reports, and opinion articles; and the context as having oral or dental relevance.As our search strategy included searching "all fields" in the database search engine, we retrieved several irrelevant articles that we excluded from our final sample.We did not alter our search strategy to compensate for these irrelevant articles to keep our search parameters sufficiently broad to retrieve all potentially relevant articles.
We exported the search results into EndNote and removed all duplicates.During the peer review process in June 2023, we updated the search parameters to include new literature published after October 13, 2022.After comparing the original and updated search results, we removed duplicates to ensure the final search records were accurate (Supplementary Table S2).One reviewer then evaluated the records to exclude unrelated articles and divided the articles into 5 groups that we considered data items: case reports, statements/guidelines/reviews, clinical manifestations, treatment modalities/clinical relevance, and other (Figure 1).Of the 513 articles we identified, we screened 409, for which 2 reviewers sequentially evaluated the titles, abstracts, and full text.We included case reports that contained the term "oral" even if oral considerations were not the article's main focus if the article addressed oral telangiectasis diagnosed according to the Curaçao Criteria.Finally, we carefully reviewed the full text of the selected articles and summarized them in tables.

RESULTS
Using our search strategy and criteria, we identified 107 articles, case reports, observational studies, and statements/guidelines that we classified as case reports, statements/guidelines/reviews, clinical manifestations, treatment modalities/clinical relevance, and other.A total number of 77 case reports published between 1946 and 2023 qualified for inclusion.The majority described cases in adult patients, with only a few describing clinical manifestations in pediatric patients, and telangiectasias were most frequently reported in the oral cavity, lips, tongue, and palate.Of the 5 categories, case reports, shown in Table I, comprised the greatest number.Most case reports described the clinical manifestation of HHT but not any treatment strategies specifically of oral interest, although several provided possible treatment modalities.
Table II shows the studies describing the clinical manifestations of HHT in larger patient samples ranging from 6 to 268 patients.The 11 articles describe the number and the locations of telangiectasias, with several providing insight into the complications from bleeding from telangiectasias and 3 describing clinical manifestations in pediatric patients.Table III shows   22 PROST Telangiectasias on tongue and lips, fractured incisor caused by trauma, and hemorrhage on tongue managed by compression, maxillary denture, and caution at site of telangiectasia.Scopp et al. 23 OM Telangiectasias on tongue, buccal mucosa, hard and soft palate, and lips.Dental procedures performed without any complications.Durocher et al. 24 PROST Telangiectasias on tongue, lips, buccal mucosa, and palate.Upper denture had not caused palate lesions to hemorrhage.Oliver et al. 25 OM Telangiectasias on tongue, uvula, hard palate, and lips.Traiger et al. 26 OM Telangiectasia on gingiva, tongue, hard and soft palate, and lips.Smith et al. 27 OM 2 cases of telangiectasia on tongue.Hashimoto et al. 28 OM Telangiectasia on lips, tongue, and buccal mucosa.Donaldson et al. 29 PROST Telangiectasias on palate, lips, and tongue.Upper denture was not considered cause of bleeding.Austin et al. 30 PERIO Treatment of HHT with conservative and surgical periodontal therapy.Cos et al. 31 PED No signs of oral telangiectasia in a 13-y-old female.Olson et al. 32 PROST Telangiectasias on tongue, palate, and lips and on the masticatory gingiva mandibular ridge.Lower denture did not cause hemorrhage.Peery et al. 33 OM Telangiectasias on tongue and lips.Flint et al. 34 OM Telangiectasias on tongue and lips, with trauma against tongue causing bleeding and emergency admission to hospital.Reyes-M ujica et al. 35 PED Telangiectasias on tongue and floor of mouth in a 23-mo-old.Maruyama et al. 36 OM Telangiectasias on oral mucosa.Colver et al. 37 OMS Telangiectasias on palate and hemorrhage treated by excision and infrared coagulation.Ogino et al. 38 OM Telangiectasias on tongue.Takahama et al. 39 OM Telangiectasias on tongue and lips.Finkbeiner et al. 40 OMS Telangiectasias on gingiva, with bleeding lesion on marginal gingiva treated with laser.Ishikawa et al. 41 OM Telangiectasias on buccal mucosa.Edwards et al. 42 ENDO Telangiectasias on palate, tongue, and lips.Treatment of external cervical root resorption palate aspect of anterior maxillary teeth caused by telangiectasia.Yunoki et al. 43 OM Telangiectasias on tongue and lips.Haarmann et al. 44 OM Telangiectasias on palate, tongue, and gingiva.Kamal et al. 45 OM Telangiectasias on tongue and lips.Ragsdale et al. 46 OM Four cases of telangiectasias on oral mucosa and tongue.Fraga et al. 47 PED No signs of oral telangiectasias in a 5-y-old.Juares et al. 48M Telangiectasias on tongue, lower lip, and buccal mucosa.Lozano et al. 49 OMS Treatment of gingival overgrowth with electrical gingivectomy.Lee et al. 50M Telangiectasias on tongue.Santos et al. 51 OM Telangiectasias on tongue and lips.Stojanov et al. 52 OM Telangiectasias on tongue and lips treated by embolization of right lingual artery.Ishikawa et al. 41 OM Telangiectasias on floor of mouth.Cesareo et al. 53 OM Telangiectasias on oral cavity mucosa.Chang et al. 54 OM Telangiectasias on lips and tongue.Corre et al. 55 GP Telangiectasias on vestibule, brain abscess 1 wk after 10 teeth had been extracted, infection with Fusobacterium nucleatum and Staphylococcus epidermidis.Olitsky et al. 56 OM Telangiectasias on tongue and lips.Hopp et al. 57 OMS Telangiectasias on gingiva and larger AVM.Treatment of lesion on marginal gingiva by sclerotherapy.Mylona et al. 58 GP Telangiectasias on lips and cerebral abscess caused by infection with Enterococcus faecalis 10 d after dental procedure performed without antibiotic prophylaxis.Samol et al. 59 OM Telangiectasias on lips.Velthuis et al. 60 OM Telangiectasias on lips.Chadha et al. 61 OM No signs of mucocutaneous telangiectasia.Inocêncio et al. 62 OM Telangiectasia on lips.Kaminski et al. 63 OM Telangiectasia on tongue and lips.Boza et al. 64 OM Telangiectasia on oral mucosa and tongue.Chiu et al. 65 OM Telangiectasia on tongue.Komaki et al. 66 OM Telangiectasia on lips.Ahamed et al. 67 OMS Telangiectasias on hard palate and gingival and lingual mucosa.

DISCUSSION
As shown in Tables I and II, diagnosis of HHT associated with multiple telangiectasias, often in the oral cavity and lips, has been well documented in case reports and cohort studies with larger patient samples.In this scoping review of 107 articles, we retrieved 65 that had been published since 2010, indicating an escalation in this field of research.Most articles are case reports and observational studies, and we retrieved no randomized controlled trials from the databases, possibly due to the low prevalence of HHT.We identified no articles describing HHT-related orofacial pain, orthodontic treatment, dentofacial orthopedics, or cariology.In the following sections, we describe our findings regarding the dental and oral considerations and management of patients with HHT according to dental specialty.

General practice dentistry
Most patients with HHT present with telangiectasias in the mucosa, gingiva, palate, tongue, and/or lips.As dental visits typically occur regularly and most patients with HHT first present with telangiectasias in the oral  69 2015 OM Telangiectasia on tongue and lips and brain abscess, with no mention of dental procedure.Holden et al. 70 2016 OM No signs of mucocutaneous telangiectasia.Kiyeng et al. 71 2016 OM Telangiectasias on tongue and hard palate.Lonarcevic et al. 72 2016 OM Telangiectasias on tongue, lips, and oral mucosa.Muthu et al. 73 2016 OM Telangiectasias on lips.Dissanayake et al. 74 2017 OM Telangiectasias on oral mucosa.Khaitan et al. 75 2017 OM Telangiectasias on tongue, hard palate, and lips.Jackowska et al. 76 2018 OM Telangiectasias on tongue and lips.Latos et al. 77 2018 OM Telangiectasias on oral mucosa.Mill an-Cayetano et al. 78 2018 OM Telangiectasias on tongue and lips.Ejiri et al. 79 2019 OM Telangiectasias on tongue.Jan et al. 80 2019 OM Telangiectasias on tongue and palate.Mangkorntongsakul 81 2019 OM Telangiectasias on tongue and lips.Tokoro et al. 82 2019 OM Telangiectasias on tongue and oral mucosa.Leonida et al. 83 2019 OMS Telangiectasias on tongue, palate, and lip of undiagnosed HHT.Hospital admission after tooth extraction and implant surgery.Treatment with implant in region 36 and antibiotic prophylaxis.Leung et al. 84 2019 PED Telangiectasias on tongue and floor of mouth in a 6-mo-old.Bowers et al. 85 2020 OMS Telangiectasias on tongue, floor of mouth, and hard palate.Treatment with KTP laser coblation and bevacizumab injection.Callejas-Moraga et al. 86
cavity, dental professionals have a unique opportunity to be the first clinicians to diagnose HHT.Upon finding telangiectasias in the oral cavity, they can ask their patients if they experience recurrent epistaxis and have a familial history of HHT to confirm the diagnosis and then refer them to a specialist for further treatment.An important finding is that HHT patients with previous or known PAVMs should be given antibiotic prophylaxis before dental procedures.Shovlin et al. 11 and Boother et al. 119 have attempted to link dental procedures to the formation of brain abscesses, but the correlation is difficult to study due to ethical considerations and the often months-long duration of brain abscess development.Bacteremia can be caused by an everyday event, such as tooth brushing, or a large event, such as in 2 case reports that each described dental procedures involving 10 extractions having been conducted 1 week before the development of brain abscesses. 55,58Brain abscesses may have also developed after dental procedures in several case reports that did not state whether a dental procedure had been performed or what the status of dental hygiene had been before the development of a brain abscess. 69To minimize the risk of dental bacteremia and the need for Review article and presentation of patients with HHT who all had intra oral lesions, mainly on the lips and tongue.Recommended that dental professionals prevent injury of mucosal telangiectasia by removing sharp or abraded teeth.Folz et al. 98 2004 Clinical report OM 70 Found telangiectasias in the oral cavity and observed that the number of sites affected increased with age.Of 70 patients, 13 had experienced hemorrhage from the oral cavity, most of which could be stopped by the patient.Geisthoff et al. 99 2006 Observational study OM 11 Investigated lesions of the buccal mucosa with contact endoscopy to describe and monitor oral lesions.Giordano et al. 100 103 2018 Observational study OM 20 Examined 14 patients with telangiectasia on the oral mucosa, tongue, and lips.
Gonzalez et al. 104 2019 Retrospective cohort study PED 90  In pediatric patients found cutaneous telangiectasia (73%) was more common than oral (27%).Observed adolescents aged 10 to 18 y have a higher incidence of oral telangiectasia than children aged 0 to 9 y.Reported 1 case in the cohort had experienced a hemorrhagic event involving extra nasal telangiectasia (lip) that required no treatment.Only 21 of 90 patients with multiple telangiectasias had them on the locations in the Curaçao Criteria.Matti et al. 105 2021 Observational study PED 70 Found pediatric patients with HHT more often have nasal telangiectasias than oral and skin telangiectasias and that 13 of 90 patients had 3 or more telangiectasias on the skin and/or oral cavity.Hyldahl et al. 106 2022 Observational study OM 34 Found 16 of 18 patients with HHT1 but only 9 of 15 patients with HHT2 had telangiectasias on the tongue.Found 14 of 18 patients with HHT1 but only 8 of 15 patients with HHT had oral mucosal telangiectasias.The differences between the HH1 and HH2 patients were significant.Regarding sites, 47.1% reported bleeding from the gums, 20.6% from the lips, 14.7% from the tongue, and 14.7% from the palate.McDonald et al. 107  dental procedures, patients with HHT should receive support, recommendations, and information about dental hygiene. 114In accordance, one of the latest recommendations of the European Reference Network for Rare Diseases is that all patients with PAVM and HHT receive a written recommendation of antibiotic prophylaxis before dental procedures. 114

Oral Medicine
Diagnosis of HHT is associated with multiple telangiectasias often found in the oral cavity and lips, as is well documented in both the case reports and cohort studies of larger patient samples shown in Tables I and II.The telangiectasias often need no treatment if asymptomatic, and diagnosis for HHT can be confirmed if the patient meets 3 of the four 4 Curaçao Criteria.

Oral and maxillofacial surgery
Several case reports describe the use of the same management of telangiectasias on the tongue that cause bleeding and of nasal telangiectasias that cause bleeding, primarily the use of self-management measures.
When patients needed medical intervention, several cases were treated by laser ablation, 37,40,[116][117][118] several cases by laser ablation in combination with Avastin, 67- 85 and 1 case by sclerotherapy. 57One article described the management of gingival overgrowth associated with HHT using an electrotome, 49 and 1 article described the treatment of a large AVM on the tongue by embolization. 52Most studies describe the treatment of bleeding oral telangiectasias in 1 case or several cases, but none provided recommendations for treating oral telangiectasias.One article recommended using a dental night guard to prevent occlusive trauma against oral telangiectasias and thereby minimize the risk of bleeding, 117 and several recommended restoration of fractured or carious teeth. 22,97One article described treatment in 1 patient with HHT by immediately replacing an extracted first molar in the lower left jaw with an implant using a post-extractive, 1-stage technique. 83The patient also received antibiotics 3 days prior and 3 days after the intervention and did not experience any septic events, but no follow-up on the implant was reported. 83

ENDODONTICS
One article described an interesting case of external root resorptions caused by telangiectasias in the hard palate near the frontal incisors that were treated endodontically by root-canal treatment and crown lengthening. 42However, this was the only case described in the literature.

Periodontology
In one Danish study with clinical examination of and complementary questionnaire regarding the bleeding  15 2008 Opinion Recommended that patients with PAVM and HHT receive antibiotic prophylaxis before dental procedures.Olitsky et al. 110 2010 Key recommendations for practice Recommended that all patients with history of PAVM be informed about and receive antibiotic prophylaxis before dental procedures if at risk of bacteremia and other infections.Shovlin et al. 111 2014 Clinical review Recommended antibiotic prophylaxis for patients with PAVM before dental procedures and that patients maintain meticulous oral hygiene.patterns of 34 patients with HHT, almost half reported experiencing bleeding from the gums. 106However, the authors did not indicate whether this bleeding was from telangiectasias or caused by plaque-induced gingival bleeding.One case report of 2 patients described initial periodontal treatment with oral instruction and information, plaque control, and quadrant-wise scaling, followed by uneventful periodontal surgical procedures. 30As no unusual bleeding occurred, the bleeding that did occur could be correlated to the degree of periodontal inflammation.

Pediatric dentistry
The incidence and number of telangiectasias generally increase with age, but they can occur in children with HHT, 100,104 with several articles describing cases of young children with oral telangiectasias. 35,47,84However, as younger patients typically do not have multiple telangiectasias on the locations specified in the Curaçao Criteria, they may not meet 3 of 4 of the criteria necessary for the diagnosis of HHT. 104One study found that children more often present with nasal telangiectasias rather than oral or skin telangiectasias. 105In the findings of 1 study, whether children have problems with hemorrhage from the oral cavity that need hospital treatment is not reported. 104

Prosthodontics
In treating edentulous patients, several articles describe the importance of ensuring that dentures do not interfere with or cause traumatic pressure on oral telangiectasias on the gingival ridges or in the vestibulum.None reported observing any hemorrhage linked to the traumatic wear of dentures in the upper or lower jaw. 22,24,29,32

CONCLUSIONS
In this scoping review of 103 articles describing oral and dental considerations regarding HHT in the literature, we highlighted the limited research in this area and the gaps in knowledge resulting thereof.As most studies we identified are case reports, there is a clear need for higher-quality studies examining larger samples to establish a more reliable evidence base to guide practitioners in clinical decision-making.Indeed, the fact that most of the articles we included are case reports, which can be attributed to the low prevalence of patients diagnosed with HHT and the limited number of articles describing oral considerations, was a limitation of this study.Nevertheless, the case reports we included provide insight into what should be the focus of future research.Another limitation was the exclusion of several case reports that might have been of interest, due to being published in another language than English.Given the limited amount of literature available on dental and oral considerations in HHT, the fact that 32 case reports were excluded out of the total number of 109 identified case reports, shown in Figure .1, may have led us to miss relevant considerations and could have created a bias in our findings.Despite these limitations and the fact that we cannot offer clinical recommendations based on our findings, our study highlights the importance of dental professionals remaining aware of the signs of HHT, particularly oral telangiectasias, as they might be the first to diagnose HHT in their patients.Future research should focus on describing the extent of oral pathology that needs treatment in patients with HHT, providing further evidence of the need for antibiotic prophylaxis before dental procedures, and describing the dental status of patients with a diagnosis of HHT.

FUNDING
The study was financed by grants from the Swedish state under ALF (Agreement on Medical Education and Clinical Research), an agreement between the Swedish government and the county councils, and by ALFÀRegion Uppsala (Regionalt ALFÀavtal Uppsala).

Authors
Year Article type No. patients Oral or dental relevance Milton et al. 120 1993 Case report/ treatment 3 Buccal epithelial autografts were used in 3 patients when conventional therapies were not sufficient to manage the severity of epitaxies with promising results.Further research is warranted with a larger patient sample.Steinbach et al. 121 2012 Observational study 54 Found that the gustatory and olfactory function of patients with HHT is reduced but that although patients had a reduced ability to smell and detect odors, they did not have reduced taste sensitivity compared to healthy subjects.Hvelplund et al. 122 2012 Retrospective cohort study 171 According to the European Reference Network on Rare Multisystemic Vascular Diseases., all patients should receive written advice on antibiotic prophylaxis before dental procedures.In Denmark, online 32% of patients received written advice, although 75% were thoroughly informed.Geisthoff et al. 123 2023 -Described nationwide HHT awareness campaign for dental professionals.After a case report was published in the journal of the German dental association, which reached almost 77,000 readers, 5 patients were identified and referred by dentists.

Fig. 1 .
Fig. 1.Flow diagram of article selection process according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews

Table I .
Case reports included in the scoping review Authors Year Main field Clinical presentation and treatment strategies Peluse et al. 21OM Telangiectasia on hard palate, gingiva, oral mucosa, floor of mouth, and lips and gingival hemorrhage from telangiectasia.Syrop et al.

Table I .
68ntinuedAuthorsYear Main field Clinical presentation and treatment strategies Barbosa et al.682015 OM Telangiectasias on lips, gums, palate, and oral and nasal mucosa.Dittus et al.

Table II .
Articles describing clinical manifestations included in the scoping review

Table III .
Articles describing statements, guidelines, and reviews included in the scoping review

Table IV .
Articles describing treatment modalities/clinical relevance included in the scoping review GP, general practitioner; HHT, hereditary hemorrhagic telangiectasia; PAVM, arteriovenous malformation; OMS, oral and maxillofacial surgery; PED, pediatric dentistry.