PERIODONTAL DISEASE Unfortunately, periodontal disease often occurs following

placement of fixed prostheses; 5 especially where the cavosurface margin is

placed subgingivally or the prosthesis is overcontoured. 29 Inflammation is more
severe with poorly fitting restorations (Fig. 32-12), but even "perfect" margins
have been associated with periodontitis. 31 At recall appointments, particular
attention is given to sulcular hemorrhage, furcation involvement, and calculus
formation as early signs of periodontal disease. Improperly contoured
restorations should be recontoured or replaced. OCCLUSAL DYSFUNCTION The
patient is examined for signs of occlusal dysfunction at each recall appointment
(Fig. 32-13). The patient should be asked about any noxious habits such as
bruxism. An examination of the occlusal surfaces may reveal abnormal wear
facets. In particular, the canines should be inspected because wear in this area
will soon lead to excursive interfering contacts on the posterior teeth. Abnormal
tooth mobility is investigated, as is muscle and joint pain. A standardized muscleand-joint palpation technique (see Chapter 1) is helpful. Articulated diagnostic
casts should be periodically remade (Fig. 32-14) and compared with previous
records so that any occlusal changes can be monitored and corrective treatment
initiated. A small number of patients may not have responded well to previous
occlusal treatment or may resume parafunctional activity some time after
completion of the active phase of treatment. Although resolving the underlying
etiology is preferable, a nightguard can occasionally be prescribed. Its design is
identical to the occlusal device described in Chapter 4 for treating neuromuscular
symptoms resulting from malocclusion. However, the device is only worn at
night. If the patient primarily clenches, the dentist should consider a slightly
flatter anterior ramp than is ordinarily incorporated in the conventional device.
PULP AND PERIAPICAL HEALTH At the recall appointment, the patient may
describe one or more episodes of pain during the previous months. This could
indicate the loss of vitality of an abutment tooth and should be investigated.
Appropriate corrective measures can then be taken. One advantage of partialcoverage restorations is that pulp health can be monitored with an electric pulp
tester (Fig. 32-15), although the vitality of any tooth with a complete crown can
still be assessed by thermal means. Correlating the histologic condition of a pulp
directly with the patient's response to pulp testing is difficult.32 Therefore, such
results should be combined with other clinical data that result from careful
patient history information and examination. Seeking the opinion of an
endodontist is often a good idea (Fig. 32-16). Radiographs provide useful
information about the presence of periapical pathosis. Teeth with fixed
restorations should be reviewed radiographically every few years. The use of a
standardized technique enables the dentist to make an objective comparison
with previous films. Although some studies have shown a high incidence of
periapical disease associated with fixed prostheses; 3,34 other studies have
shown a low incidence of this complication.28-35 ,36
EMERGENCY APPOINTMENTS Occasionally patients have an emergency between
routine recall visits. With carefully planned and executed treatment, however,
these should be rare (although problems can still develop even with the best
treatment). Patients should be taught to notice small changes in their oral health

and to report them without delay. For instance, the porcelain veneer of a metalceramic restoration may be shielded from further fracture when a small chip is
promptly rounded off and the occlusion adjusted immediately after it is first
noticed. Postponement of corrective treatment can be especially costly, requiring
a remake of a complex prosthesis that could have been saved with prompt
attention.
PAIN A patient presenting with pain should be asked about its location, character,
severity, timing, and onset. Factors that precipitate, relieve, or change the pain
should be investigated, and appropriate treatment measures should be initiated
(see Chapter 3). Although most oral pain is of pulpal origin, this should never be
assumed. A detailed investigation is always recommended. In difficult or
questionable situations, the diagnosis should be confirmed by an appropriate
specialist. If the patient has several endodontically treated teeth that have been
restored with posts-and-cores and fixed prostheses, the possibility of root
fracture should be considered, especially for teeth that were internally weakened
as a result of endodontic treatment in conjunction with oversized posts of less
than optimal length. If a fracture has occurred, the tooth is almost invariably lost,
which can significantly complicate follow-up treatment, especially if it involves an
abutment tooth for an FPD (Fig. 32-17).