Patient Name
First Last
Diagnosis:
Facts for Consideration:
- 1. A conventional denture (removable) is placed in the mouth after all of the teeth have been removed and the extraction sites have healed, usually six to eight weeks after extraction.
- 2. An immediate denture is placed at the time the teeth are extracted. To make this possible, measurements and models are taken during the preliminary visit. However, bones and gums can shrink over time, especially during the healing period in the first six months after extraction of teeth. When gums shrink, immediate dentures may require rebasing or relining to fit properly.
- 3. A partial denture is a removable appliance usually composed of framework, artificial teeth, and acrylic material. It fills in the spaces created by missing teeth and prevents other teeth from shifting.
- 4. An overdenture is a type of removable denture that is supported by a small number of remaining natural teeth or implants. Natural teeth must be prepared (reshaped) to fit the overdenture and provide stability and support for the denture.
Options chosen:
*
- I understand the stability and retention of the denture(s) depends on many factors, including the attachment and fit of the denture(s) to natural teeth, implants if any, the amount and type of bone, gum tissue, and saliva, as well as my ability in placing and removing the denture(s).
- When using natural teeth as support, I understand my dentist will anesthetize (numb) my teeth and the gum tissue around the teeth. The teeth acting as support will be filed down along the chewing surface and sides to make room for the denture(s).
- I understand that holding my mouth open during treatment may temporarily leave my jaw feeling stiff and sore and may make it difficult for me to open wide for several days. This can occasionally be an indication of a further problem. I must notify my dentist if this or other concerns arise.
- I understand there may be gum soreness or discomfort under the denture(s). This can be relieved by the dentist with adjustments and tissue treatment. It may take several appointments before the denture(s) fit comfortably.
- I understand the new denture(s) may feel awkward for a few weeks until I become accustomed to them, and the denture(s) may feel loose while my cheek muscles and tongue learn to keep them in place.
- I understand my dentist will make every attempt to create a natural appearance for the denture(s); however, it may not be possible for the denture(s) to support my lip and facial contours perfectly.
- I understand eating with the denture(s) will require practice. My dentist has recommended I start with soft foods cut into small pieces and chew slowly, using both sides of my mouth at the same time, to prevent the denture(s) from tipping. I understand I need to be cautious when eating chewy, hot, or hard foods (for example: apples, popcorn, raisins, candy).
- I understand that pronouncing certain words may take practice. I can do this by reading aloud and repeating troublesome words. Sometimes the denture(s) will slip when I laugh, cough, or smile. I can reposition the denture(s) by gently biting down and swallowing. If a speaking problem persists, I will call my dentist for consultation.
- Similar to natural teeth, I understand that my denture(s) require daily brushing to remove food deposits and plaque. My dentist has explained to me how best to care for my denture(s) and which products to use. I have to brush my gums, tongue, and palate with a soft bristled brush before wearing my denture(s). If I do not properly clean or care for my denture(s), they may stain, develop odor, and affect the way food tastes.
- I understand that any adjustments I make to my denture(s) can compromise the denture(s) and cause gum and cheek irritation and sores. If my denture(s) become loose, chip, crack, or break, I will contact my dentist immediately. Glue bought over-the-counter to repair a broken denture often contains harmful chemicals and should not be used on dentures. Adjusting my denture(s) on my own is not advised and may result in permanent changes to the denture(s) that affect their fit and function. This may also result in the need to remake the denture, which I understand will be at my own expense.
- I understand that I am required to keep regular care appointments with my dentist to maintain good oral health and ensure my denture(s) retain their proper fit and function.
- I understand that every reasonable effort will be made to ensure the success of my treatment.
Benefits of Dentures, Not Limited to the Following:*
- I understand that a reasonable aesthetic appearance may be achieved.
- With dentures, I understand my function and ability to eat will improve as opposed to being edentulous (without teeth).
Risks of Dentures, Not Limited to the Following:*
- I understand that there are potential problems such as: periodontal (gum) disease, porcelain fractures, occlusal (bite) changes, stains and color changes, gum recession, food impaction, decay, excessive wear due to grinding and bruxing, temporomandibular joint dysfunction (TMD), and others.
- I understand that dentures may have characteristics and potential problems, such as: odor, chipping, and wear; stability and retention problems; changes in facial and lip appearance; and adaptation of the tongue and lips for proper speech. Periodic relines may be required as gum and bone may change over time, oral sensations may change, and good oral hygiene is imperative.
- I understand poor fitting dentures can cause constant irritation over a long period and may contribute to the development of sores. Failure to wear my denture(s) over a long period of time may affect the fit of the denture(s). My denture(s) may need to be relined or replaced. If my denture(s) begin to feel loose or cause pronounced discomfort, I will contact my dentist.
- I understand a numb lip may occur from the pressure of the removable denture(s). This problem requires selective adjustment and in rare cases, a nerve might need surgical repositioning.
- I understand that the edge of the denture(s) usually rests on the gumline, which is in an area prone to gum irritation, infection, or decay. Proper hygiene at home, a healthy diet, and regular professional cleanings are some preventative measures essential to control these problems.
Consequences if no Treatment is Administered, Not Limited to the Following:*
- I understand that I can choose to do nothing and my present complaints will continue and may worsen. Subsequent choices for dentition repair may become more difficult, expensive, or not feasible.
- I understand if I do not replace missing teeth, I risk compromised aesthetics and possible drift of adjacent and/or opposing teeth into the space(s) with the resultant collapse of the arch integrity. This could also create or exacerbate a temporomandibular problem.
Treatment Process:
- I understand the following timeline represents an estimate of the treatment proposed by my dentist. It is important that I keep appointments within close succession of the estimated timeline, or I risk compromising the entire treatment plan.
Exam, shade, mold selection, and impression

Est. date completed
Mouth preparation, surgical adjustment

Est. date completed:
Multiple impressions, custom trays

Est. date completed:
Try-in wax adjustment

Est. date completed:
Adjustment and delivery

Est. date completed:
Alternatives to Dentures, Not Limited to the Following:*
- I understand that depending on the reason I am a candidate for dentures, alternatives may exist, including the use of dental implants to support the denture. I have asked my dentist about them and their respective expenses. My questions have been answered to my satisfaction regarding the procedures and their risks, benefits, and costs.
Alternatives discussed:
No guarantee or assurance has been given to me by anyone that the proposed treatment will cure or improve the condition(s) listed above. I have had my questions answered to my satisfaction.*
- I have been given the opportunity to ask questions and give my consent for the proposed treatment as described above.
- I refuse to give my consent for the proposed treatment(s) as described above and understand the potential consequences associated with this refusal.
Patient Signature*
Witness's Signature
Date*
MM slash DD slash YYYY
Dentist Signature
I attest that I have discussed the risks, benefits, consequences, and alternatives of dentures with the above-referenced patient, who has had the opportunity to ask questions, and I believe my patient understands what has been explained.
Date
MM slash DD slash YYYY

Dentures

INFORMED CONSENT DISCUSSION FOR DENTURE(S)