Clinical decision framework for sublingual hematoma: literature-based retrospective analysis with machine learning

Sublingual hematoma is a rare but life-threatening condition with heterogeneous etiologies that complicate emergency decision-making. This study compared clinical characteristics and management outcomes between implant-induced sublingual hematoma (ISH) and spontaneous sublingual hematoma (SSH), and developed an etiology-guided treatment algorithm through integrated statistical and machine-learning analyses. A systematic literature search through January 2025 identified 77 studies comprising 85 cases (ISH, n = 33; SSH, n = 52). Clinical variables were compared statistically, and random forest and decision tree models were applied to identify determinants of treatment and prognosis. SSH was strongly associated with cardiovascular comorbidities and anticoagulant therapy (84.6% vs 12.1%; p < 0.001), whereas ISH required surgical intervention more often (54.5% vs 13.5%; p < 0.001), with shorter hospital stays (5.3 ± 3.9 vs 10.5 ± 9.8 days). Machine learning identified symptom-to-treatment time and surgical parameters as major predictors for ISH management, while warfarin use and respiratory distress determined SSH severity. These findings indicate that sublingual hematoma requires prompt, etiology-specific management: immediate surgical hemostasis for implant-induced cases and correction of coagulopathy with airway vigilance for spontaneous cases. The proposed framework provides preliminary data-informed guidance for managing this rare but critical condition.