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 muscle-and-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 partial-coverage 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 ,36EMERGENCY 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 metal-ceramic 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).