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Office of Keerthi Senthil DDS, MS

27700 Avenida Belleza, Cathedral City, CA - 92234, USA

760-318-4400

PATIENT CONSENT FORM FOR ALL-ON-X IMPLANT TREATMENT

Patient Information:

Last Name:
Middle Name:
First Name:
Date of Birth:
Phone:
Email:

I. INTRODUCTION

You are being advised to undergo an "All-on-X" implant-supported fixed restoration, a treatment involving the placement of multiple dental implants to support a full-arch prosthesis. This may include immediate or staged restorations.

This form outlines the nature, benefits, risks, alternatives, and aftercare instructions, including care for both temporary (acrylic hybrid) and final (zirconia) restorations.

Important Note: If you are not a candidate for immediate fixed restoration due to infections, lack of adequate bone, or other clinical considerations, you may be required to wear a removable prosthesis for a period of 4 to 6 months until the implants are sufficiently integrated and conditions allow for final restoration.

Patients with certain health conditions such as diabetes, smoking history, osteoporosis, autoimmune diseases, or other metabolic disorders are at higher risk for delayed healing, implant failure, infection, and complications. Strict medical management and adherence to post-operative instructions are critical for treatment success.


II. BENEFITS (PROS)

  • Improved Function: Enhanced chewing ability.
  • Aesthetic Enhancement: Natural, attractive smile.
  • Bone Preservation: Reduces future bone loss.
  • Immediate Results: Temporary teeth may be placed same day.
  • Comfort: No removable appliances.
  • Speech Improvement: Better enunciation.
  • Increased Confidence: Boosts self-esteem.

III. RISKS AND LIMITATIONS (CONS)

  • Implant Failure: 5-10% even with good conditions; higher in medically compromised patients.
    Initials:
  • Infection Risk: Potential infection at implant or surgical site.
    Initials:
  • Nerve Damage: Rare but possible numbness or tingling.
    Initials:
  • Bone Loss: Risk of bone loss over time.
    Initials:
  • Prosthesis Complications:
    • Chipping (acrylic):
      Initials:
    • Cracking (zirconia, rare but severe):
      Initials:
  • Speech Adaptation Period: Adjustment period required.
    Initials:
  • Maintenance Commitment: Essential for long-term success. Patients are required to attend hygiene maintenance appointments every 4 months for the first year, and every 6 months thereafter.
    Initials:
  • Higher Cost: Compared to removable dentures.
    Initials:

Patients with uncontrolled diabetes, smoking history, or systemic illnesses may have:

  • Higher rate of implant failure:
    Initials:
  • Prolonged healing times:
    Initials:
  • Increased risk of infections:
    Initials:
  • Potential need for additional procedures:
    Initials:

IV. DO'S AND DON'TS

A. Fixed Acrylic Hybrid Prosthesis

Do's

  • Use a water flosser daily.
  • Soft-bristle brush and non-abrasive toothpaste.
  • Visit dentist every 4 months for the first year, and every 6 months thereafter.
  • Wear nightguard if recommended.
  • Report fractures or looseness immediately.

Don'ts

  • Avoid hard foods (ice, nuts, hard candies).
  • Avoid sticky foods (caramel, gum).
  • No abrasive toothpaste.
  • Do not ignore minor fractures.

B. Zirconia Final Restoration

Do's

  • Use water flosser, superfloss, or interdental brushes.
  • Soft brushing daily.
  • Wear nightguard if necessary.
  • Attend hygiene maintenance visits as scheduled.

Don'ts

  • Avoid excessive biting forces (hard bones, shells).
  • Do not use metal picks at home.
  • Do not ignore looseness or discomfort.

V. LEGAL DISCLAIMER

I understand that while the clinical team will exercise their best professional efforts and judgment, treatment outcomes cannot be guaranteed. I accept that implant failure, prosthesis complications, the need for additional treatments, or other unforeseen circumstances may occur despite appropriate care.


VI. PATIENT ACKNOWLEDGEMENT

I acknowledge:

  • Full understanding of the procedure, benefits, risks, and limitations.
  • Importance of maintenance and compliance with aftercare.
  • Awareness of possible need for a removable prosthesis during healing.
  • Understanding that certain medical conditions may elevate risks.
  • Acceptance that no guarantees are made regarding final outcomes.

By signing below, I confirm that:

  • I have had an opportunity to ask questions.
  • All of my questions have been answered to my satisfaction.
  • I voluntarily consent to the All-on-X procedure and related treatments as explained.

Patient's Signature

Use your mouse cursor or the tip of your finger to sign above

Date:

Witness's Name:
Witness' Signature:

Use your mouse cursor or the tip of your finger to sign above

Date:

Post-Op Instructions Sheet

Care After Implant Placement:

  • Soft diet for 2 weeks.
  • Ice packs for swelling (20 min on, 20 min off).
  • Sleep with head elevated.
  • Rinse with prescribed mouthwash (do not swish vigorously).

Care for Temporary Acrylic Prosthesis:

  • Soft foods only first 3 months.
  • Clean gently with water flosser.
  • No biting directly into hard or crunchy foods.

Transition to Final Zirconia Restoration:

  • Maintain excellent hygiene.
  • Visit dentist every 4 months for the first year, then every 6 months.
  • Report any signs of fracture, mobility, or discomfort immediately.

Emergency Contact

Keerthi Senthil DDS MS

Phone: 760-318-4400

Email: drsenthil@smileguru.dentist


Thank you for entrusting us with your care.

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