MPS Foundation
Estimated read time: 7 mins
Carcinoid syndrome represents a rare but significant challenge in dental practice, arising from neuroendocrine tumors that secrete vasoactive substances causing symptoms including flushing, diarrhea, and bronchospasm. The condition's most serious complication, carcinoid heart disease, involves plaque buildup on heart valves leading to dysfunction. For dental practitioners, the primary concern during treatment is the risk of triggering a carcinoid crisis – a life-threatening event characterised by severe haemodynamic instability, which is when the body can’t get enough blood flow.
Despite the potential severity of complications, there exists a significant gap in peer-reviewed literature regarding specific dental management protocols for these patients. This case report demonstrates that comprehensive dental care can be safely provided to patients with carcinoid syndrome through identifying risks and complications and seeking multidisciplinary collaboration.
Consent to publish this case has been obtained.
Patient background and medical history
A 64-year-old female presented to a community dental clinic with a referral from the endocrinology team for dental management. She had a complex medical history including carcinoid syndrome, carcinoid heart disease, and type II diabetes mellitus. Her oncological history revealed ovarian neuroendocrine tumors with hepatic metastases, and she had recently undergone prosthetic valve replacement due to carcinoid-induced cardiac complications. Importantly, she was not receiving active cancer treatment or anti-resorptive medications at the time of presentation.
Presenting complaints and clinical findings
The patient reported constant dental pain, difficulty with chewing and swallowing, and a sensation of loose teeth. Despite maintaining meticulous oral hygiene practices, her oral health had significantly deteriorated. Extra-oral examination revealed no abnormalities, and soft tissue examination was unremarkable. Intraorally, the patient had gross calculus deposits, predominantly lingual and posteriorly, but was fairly plaque-free. The LR8, LR7, and LL8 were grade III mobile, indicating severe periodontal disease. The LL6 was broken down coronally but caries free. Radiographic investigations, including an orthopantomogram and bitewing radiographs, confirmed the presence of periodontal disease.
Figure 1. Orthopantomogram showing existing dentition, including a number of coronal restorations and severity of periodontal disease.
Figure 2. Left and right horizontal bitewings showing existing dentition – note the generalised horizontal bone loss including furcation involvement.
The following diagnoses was made:
Generalised periodontitis, stage IV grade C, currently unstable, risk factors: Type II diabetes mellitus.
Lower left 6 heavily broken-down crown with furcation involvement.
Lower right 7 chronic periapical periodontitis.
Grade III mobility of the following teeth: Lower left 8, lower right 8, lower right 7.
Literature review
A systematic search of current literature (PubMed, MEDLINE, Cochrane Library, 2000-2024) revealed minimal peer-reviewed research specific to dental management in carcinoid syndrome. The absence of randomised controlled trials, cohort studies, and limited case reports necessitated reliance on clinical judgment and theoretical risk assessment.
Collaborative approach
Recognising the complexity of the case, we implemented a comprehensive multidisciplinary approach involving consultation with endocrinology, cardiology, and the patient's general practitioner. This helped us with tailoring the treatment to fit the health requirements of the patient.
The endocrinology team provided crucial guidance regarding anaesthetic safety, advising that Lidocaine 2% with Adrenaline (1:80,000) was appropriate for use in this low-risk patient and was unlikely to trigger a carcinoid crisis. Additionally, given the recent prosthetic valve replacement, cardiology consultation confirmed the necessity for infective endocarditis prophylaxis using Amoxicillin 3g oral powder sachets administered one hour prior to all invasive procedures, in accordance with NICE guidelines.
Emergency preparedness
Despite the assessed low risk of complications, the patient was closely monitored during all procedures, and the dental team had the relevant safety measures put into place such as a team briefing with the whole department prior to treatment to ensure swift management in case a medical emergency took place.
Urgent treatment
The patient was experiencing worsening pain and swelling from the lower right quadrant. To relieve her of this, the LR7 and LR8 were extracted under local anaesthetic and with antibiotic prophylaxis. The extractions were uneventful, but due to the patient’s complex medical history, it was decided to place a haemostatic agent in the socket post extraction to aid in blood clot formation. This site was reviewed in the next prevention appointment which revealed good healing of the area.
Preventive care
Preventive care was a cornerstone of the patient’s dental management. The patient was educated on the importance of maintaining good oral hygiene to prevent further dental complications and she was advised to use high fluoride toothpaste (5000ppm). Additionally, sodium fluoride varnish (2.26% NaF) was applied professionally to further reduce the risk of dental caries. The patient was also provided with dietary advice to reduce sugar intake and avoid cariogenic foods and drinks.
Periodontal therapy
The patient underwent non-surgical periodontal therapy to manage her advanced periodontal disease. The use of shorter appointment times and tailored oral hygiene instructions, including the modified Bass technique with a small-headed soft toothbrush, was implemented to improve her oral hygiene practices. Moreover, the use of interdental TePe brushes was encouraged to aid with her normal tooth brushing regime. Her periodontal condition was monitored every four months, including a full periodontal assessment and any sub-gingival professional mechanical plaque removal (PMPR) on sites indicated.
Restorative care
Restorative care was carried out, such as the extraction of the LL8 under local anaesthetic as it was grade III mobile and giving the patient discomfort when eating. In accordance with the ‘Avoidance of Doubt: provision of phased treatment’ guidance by NHS England. Once her oral hygiene was stabilised, the plan was to place a definitive restoration over the LL6 with the provision of upper and lower acrylic dentures.
Follow-up and maintenance
The patient was placed on a four month recall to monitor her oral health and ensure the effectiveness of the treatments provided. The patient was encouraged to maintain her oral hygiene routine and attend regular dental check-ups to prevent further complications. Reasonable adjustments were made to allow the patient to attend, such as shorter appointments mid-afternoon.
As the primary clinician managing this complex case from initial assessment through to completion, I found myself navigating uncharted territory where guidelines were virtually non-existent. It meant that every decision required careful consideration of potential risks versus benefits, drawing from fragmented expert opinions and medical literature.
I engaged with the patient’s endocrinology team, cardiologists, and also her GP to understand her complex medical history and current status. I found that clear, proactive communication with these specialists not only informed my clinical decisions, but provided reassurance that we were collectively prioritising patient safety. I also informed my own dental team regarding the condition, what a carcinoid crisis would look like, and how we can manage this patient whenever they were booked in.
Throughout the treatment process, I aimed for a patient-centred holistic approach. Given the complexity of her condition and the potential risks involved, I ensured she was fully informed regarding the proposed treatment plan, the rationale behind our modified approaches, and the precautions we were taking. I explained why we were prescribing antibiotics prophylactically, and how our team was working together to ensure her safety. This transparent communication approach helped build trust and reduce anxiety, which was particularly important given that stress could potentially trigger complications.
Personally, this case challenged me to expand my clinical perspective beyond traditional dental boundaries and reinforced the importance of collaborative, holistic care in managing complex medical conditions. It also made me realise the importance of prevention and aiming to stabilise the patient’s oral health by tailoring advice to their individual needs. This experience has given me more confidence in liaising with other health-care professionals, establishing a thorough medical history and carrying out treatment safely and effectively.
I hope this case highlights the need for general dentists to be aware of the potential complications associated with carcinoid syndrome and carcinoid heart disease. By being aware, these patients can be referred to the community dental services promptly to be seen by a special care dentist for either advice on management or for treatment.
Future research should focus on developing standardised risk assessment tools, treatment protocols, and emergency management guidelines for dental care in patients with carcinoid syndrome and related conditions. The establishment of clear guidance would improve patient safety and provide practitioners with confidence in managing these complex cases.
Finally, I would like to thank The MPS Foundation for providing me with the opportunity to share this interesting case and my management in hopes to illustrate that patient safety can always be prioritised through effective risk management and collaboration with medical and dental colleagues.
About the author Mohammed Junayed Uddin Hamza, Joint Dental Foundation and Core Trainee, Yorkshire and Humber Region Rotherham Community Dental Service, Kimberworth Park Dental Practice.
References
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https://www.rdhmag.com/patientcare/radiology/article/16408871/dental-considerations-of-ne uroendocrine-tumors-and-carcinoidcancer-really
Dangol, R.K. and Henricus, M.M. (2022). Carcinoid Heart Disease. New England Journal of Medicine, 386(21). doi:https://doi.org/10.1056/nejmicm2118205.
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NeuroEndocrine Cancer Australia. (2024). NeuroEndocrine Cancer Australia. [online] Available at: https://neuroendocrine.org.au/treatments/carcinoid-crisis-and-anaesthesia/
NHS England (2021). Avoidance of doubt: Provision of phased treatments.
NICE (2008). Overview | Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures | Guidance | NICE. [online] Nice.org.uk. Available at: https://www.nice.org.uk/Guidance/cg64.
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