Denture Consent Form

Patients Name:

Date of Birth:

Dentures are designed to assist with chewing and improve appearance of a person that is missing some or all of their teeth. The following types of dentures have been discussed:

A conventional denture - is placed in the mouth after all of the teeth have been removed and the extraction sites have healed. Usually 8-12 weeks after extraction.
An immediate denture – is placed at the time the teeth are extracted. Due to changes in the gums and bone following tooth extraction and healing, immediate dentures may require relining or replacement to fit properly.
A partial denture – is a removable appliance that replaces missing teeth and helps prevent remaining teeth from shifting.
An overdenture – a denture that is supported by remaining natural teeth or implants.

Option Chosen:

Risks and benefits associated with dentures

The stability and retention of dentures depends on many factors including the attachment and fit of the dentures to natural teeth, to implants, the amount and type of bone, gum tissue, and saliva.
Gum soreness or discomfort under the dentures may occur. It may take several visits before the dentures fit comfortably.
Facial and lip structures may not be supported perfectly.
Eating with the dentures will require practice. Start with soft foods, chew slowly, use both sides of the mouth at the same time to prevent the denture from tipping.
Pronouncing certain words may take practice. Practice by reading aloud. Sometimes the dentures may slip when laughing, coughing, or smiling. Reposition the denture by gently biting down and swallowing. If a speaking problem persists, contact the office.
Dentures require daily cleaning to remove food deposits and plaque. It is also essential to brush the tongue, gums, and palate with a soft bristled brush before wearing the denture.
Adjusting the denture at home may result in damage or irritation or breakage. Use of glue on a denture is not recommended. If the denture cracks, breaks, or chips, contact the office. If dentures are damaged from adjustments or glue at home, an additional fee may be required to repair or remake them.
Failure to wear dentures regularly may affect the fit of the dentures. Dentures may need to be relined or replaced following a period of non-use.
The edge of dentures usually rests on the gumline. Proper hygiene at home, a healthy diet, and regular professional cleanings are essential to help prevent these problems.

Risks of NO Treatment

Present complaints or conditions may worsen. Future repairs may be more difficult, not possible, or more costly.
Compromised esthetics.

Treatment Process

Please refer to denture appointment sheet.

My questions have been answered about the treatment and its alternatives. No guarantees regarding the success of the proposed treatment have been made.

I give my consent for the proposed treatment and have had the opportunity to ask questions. I do not consent to the proposed treatment and understand the potential consequences associated with this refusal.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signed:

Date Signed:

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