Case management for comprehensive dental care and patient management in vulnerable populations

Ola A. Farrag

Cheng Li

Farrag, Ola A., Li, Chengbei
Faculty / Advisor: Sheridan, Olivia
University of Pennsylvania School of Dental Medicine, Department of Preventive and Restorative Sciences


Many patients present for dental care with the lowest expectations for alleviating pain and restoring function based on their cultural background and previous dental experience. Vulnerable individuals and populations require additional consideration when receiving dental care due to their past experiences, trauma and limited language skills 1 This poster will explore the treatment planning and treatment considerations for one such patient, as well as emphasize the role of educated dental professionals sensitive to the needs of torture survivors in allowing thorough communication to provide comprehensive oral health treatment with the highest level of standard of care and without the risk of retraumatization. Patient Background: ME presents to Penn Dental Medicine in September 2020 with a chief complaint of “I have pain in my lower left tooth.” ME immigrated to the US from Iran in 2015 with his family and was seen at Penn Dental in 2016. However, ME was discouraged by the initial treatment plan rendered that involved implants and ceased continuation of care. His existing dental work included multiple adhesive restorations, fixed dental prostheses, and root canal treatments that were completed in Iran, many of which had recurrent decay or designed below the standard of care. ME’s goals for treatment were to control pain and to regain posterior support for mastication, with very little aesthetic requests or concerns. His case took well over the entire course of the clinical year. Challenges in his treatment included establishing mutual understanding of the complexities of his case, especially in restoring and replacing defective restorations--in terms of both design and integrity--which brought him no pain or discomfort at the time of treatment.


Findings/Diagnosis/Treatment planning ME presented as partially dentate with generalized chronic moderate periodontitis, caries of dentin, pain on his lower left side, and existing cantilever FDPs on #11(R)-12(P)-13(R), #19(R)-20(R)-21(P)-22(P), and #28(P)-29(R)-30(R)-31(P). ME’s initial diagnoses included multiple existing restorations were failing with poor marginal seal, recurrent decay under existing FDPs, and a PAP on #21. Sequential plan of action involved removing current FDPs with recurrent decay, assessing restorability of abutments, consulting endodontics for #21 PAP, and consulting prosthodontics for maxillary and mandibular PRDP design. A definitive treatment plan was developed based on evidence-based predictability and longevity of treatment and outcomes involving FDP #7-12, maxillary PRDP, RCT #21, decoronation #31 to preserve ridge, and PRDP with survey crowns on #21,22 and 28.


Clinical steps: Remove existing FDPs to assess restorability of #12, #21, #28, #31.  #31 was deemed unrestorable, the decision was made to decoronate the tooth in order to preserve ridge height for future PRDP  NS-RCT #21 in Endo to address PAP and pain. ME presented with 8mm facial pocketing and was determined to have endo only lesion. Maxillary PRDP design: Due to the location of the remaining five maxillary teeth, a 6-unit FDP was planned in order to evenly distribute stresses on the remaining dentition during function, wrought wire clasps on #7 and #12 to allow for flexibility and relieve stress during function on abutment teeth. Discussion with the patient regarding aesthetic compromise in return for better success of prosthesis; ME very receptive to having some metal showing while smiling if it improved long term prognosis of PRDP  Mandibular PRDP design: #21, #22, #28 deemed restorable after removing existing FDPs. Core build-up for #21 and refined preps of 3 abutment teeth for survey crowns. PRDP with bilateral distal extension and lingual plate due to limited lingual vestibule depth. Decoronation of #31 to preserve ridge height.  Interim partials were fabricated and adjusted to receive FDP retainers tooth by tooth as modifications were added to the existing FDPs.  Challenges and Patient Management:  The main challenge was communicating to our patient the necessity of each phase of treatment rendered for him. Due to differences in language, culture, and expectations, multiple conversations were had to encourage our patient to follow through with full mouth rehabilitation. It took some time to reach a mutual understanding of how extensive his treatment was going to be in terms of duration and complexity. For example, our patient was satisfied with our provisionals and was wary of having to remove it for final impression; there was also difficulty communicating the need to decoronate his failing crown on #31 in order to preserve his ridge, especially given that the tooth was in no discomfort or pain. Repetition, patience on both parties, altering the way we explained the treatment sequence, and using different modalities of explanation all contributed to building patient-provider trust during this treatment process. Another particularly difficult challenge we faced was in obtaining a long duration of anesthesia during treatment. Our patient was expressing dissatisfaction with how quickly anesthesia dissipated, which translated to decreased morale and motivation to continue full mouth rehabilitation. A solution that we developed involved fabricating interim maxillary and mandibular partial dentures for the duration of ME’s FDP process. After having a tangible model of what we strived for at the end of treatment, our patient regained his motivation and desire to continue treatment. Upon delivering his 6-unit FDP, our patient’s trust in our treatment process and confidence in himself flourished even more; after seeing the difference between the provisional and final prosthesis of his anterior 6-unit splinted FDP, ME was more than pleased with the aesthetics of his new restoration.


Vulnerable populations have a harder time advocating for themselves and what they deserve. Care for patients like ME requires more meaningful discussion, thought, and rhetoric in order to get a better understanding of the intention and desire the patient really wants, which can change over time as they gain more trust in their providers. Our role as dental caregivers is to not only cater towards the initial chief complaint of the patient but to also develop a meaningful relationship in order to pave the way for a deeper channel of open communication; oftentimes that means advocating for what the patient truly deserves on their behalf while respecting the patient’s autonomy. We must be able to create a balance that maximizes the benefit to patients of vulnerable populations.