Denture Delivery/Adjustment Procedure Note

Date: [Date of service]

Clinician: [Name and credentials]

Encounter Type: [Delivery / Adjustment / Delivery + Adjustment]

Prosthesis: [Complete Denture / RPD / Overdenture / Other]; [Maxillary / Mandibular / Both]; [Conventional / Immediate / Interim] (Include only applicable descriptors)

Framework Material: [Cobalt-chromium / Titanium / Flexible / Other] (Include for RPD only)

Implant-Assisted: [Yes / No] (If yes, specify attachment type)

Lab Case #: [Lab case number] (Optional; include when available)

(Include only sections and details relevant to the selected encounter type. For Delivery + Adjustment, document both delivery and adjustment elements.)

Chief Complaint / Reason for Visit

[Stated reason for visit] (For adjustment visits, include brief direct quote if it clarifies location or functional limitation. For delivery visits, a simple purpose statement suffices.)

Interval History

• [Medical/dental updates since last visit] (Conditions, medications, allergies. State "No changes" explicitly if unchanged.)
• [Prosthesis wear pattern] (Hours per day, night wear habits) (Include for adjustment visits)
• [Hygiene practices] (Cleaning method, adhesive use) (Include for adjustment visits)
• [Symptom description] (Specific anatomic location, severity, triggers such as insertion, chewing, or speaking) (Include for adjustment visits)
• [Consent discussion] (If material risk discussion occurred regarding adjustment vs. reline vs. remake, document discussion and patient decision)

Examination Findings

(Document findings supporting clinical rationale for adjustments. Omit extraoral/TMJ findings unless relevant to complaint.)

Intraoral/Soft Tissue

• [Mucosal condition under denture-bearing areas] (Erythema, ulcerations with size and location, inflammation, or other pathology) (Required for adjustment visits; recommended at delivery)
• [Ridge anatomy and saliva characteristics] (Include if affecting fit or retention)

Prosthesis Evaluation

• [Fit] (Seating complete/incomplete; pressure areas)
• [Retention] [Good / Fair / Poor]
• [Stability] [Stable / Rocking present] (If rocking, note direction)
• [Border extension] (Over- or under-extended areas with specific anatomic locations)
• [Pressure-indicating medium findings] (Include if used)
• [RPD framework assessment] (Framework integrity, clasp condition, rest seating, connector fit) (Include for RPD)

Occlusion

• [Centric contacts] [Even bilateral contacts / Prematurities present] (Specify teeth or regions if prematurities)
• [Bilateral balance] [Present / Absent] (If assessed)
• [Excursive interferences] (Direction and location if present)
• [Vertical dimension] (Include only if symptomatic and observed)

Phonetics/Esthetics

(Include only when assessed or when driving patient concern)

• [Phonetics] (Speech issues noted)
• [Esthetics] (Lip support, midline, tooth display, patient satisfaction)

Procedure

Summary: [One-line summary of procedures performed]

(Specify targets, locations, and outcomes. Avoid vague phrases like "adjusted as needed." If specific locations cannot be determined, document limitation and what was verified afterward.)

Delivery Verification

(Include for delivery encounters)

• [Insertion and seating] (Full seating confirmed; initial pressure areas noted)
• [Initial retention and stability assessment]
• [Initial occlusal verification] (Centric and excursions)

Fit Adjustments

• [Method used] (e.g., pressure-indicating paste)
• [Problem areas identified] (Arch, surface, region)
• [Adjustments performed] (Intaglio relief location and extent)
• [Post-adjustment result] (Findings after re-check)

Border/Flange Adjustments

• [Areas trimmed] (Specific border/flange with anatomic location)
• [Indication] (Overextension, frenum impingement, muscle interference)
• [Outcome after functional movement re-check]

Occlusal Adjustments

• [Articulating paper used] (Type/thickness if noted)
• [Premature contacts corrected] (Teeth/regions)
• [Verification] (Even bilateral contacts confirmed; excursions verified)
• [Clinical remount] (If performed: new record taken, articulator adjustment, intraoral verification)

RPD-Specific Adjustments

(Include for RPD encounters)

• [Clasp adjustments] (Teeth involved, goal, method)
• [Rest seat adjustments] (Location and reason)
• [Framework seating corrections] (Areas relieved or refit)

Finishing

• [Polishing] (Adjusted areas polished; sharp edges eliminated)
• [Insertion/removal confirmed] (Patient able to insert and remove without excessive force) (Include for RPD)

Patient Tolerance

• [Tolerance] [Tolerated well / Tolerated with difficulty]
• [Complications] (If any: event, response, outcome)
• [Anesthesia] (If local or topical used: agent, site, amount)

Patient Education

• [Wear schedule] (Daytime wear with nightly removal for conventional dentures; specific instructions per surgical protocol for immediate dentures)
• [Expected adaptation] (Transient soreness, increased salivation, speech changes are normal initially)
• [Warning signs reviewed] (Return for persistent ulceration, inability to wear prosthesis, worsening pain, signs of infection)
• [Diet guidance] (Soft foods initially, small bites, bilateral chewing, avoid sticky/hard foods)
• [Hygiene instructions] (Daily cleaning with appropriate brush/cleanser, store moist when out, clean oral tissues; for RPD: clean remaining natural teeth; avoid self-adjustment or OTC repair materials)
• [Adhesive or soft liner guidance] (If discussed or placed: instructions and reassessment timing)
• [Comprehension verified] [Demonstrated insertion/removal / Verbalized key instructions] (Do not document understanding without observed basis)

Assessment

[Problem-oriented clinical summary] (Use clear language: post-delivery adaptation expected, traumatic ulceration due to overextension, occlusal prematurities, poor retention with suspected cause, need for reline/remake evaluation. If uncertain, use "concern for" or "consistent with.")

Plan

• [Follow-up] [24-hour / 1 week / 2 weeks / PRN] for [reason: sore spot reassessment / occlusion re-check / liner follow-up / routine]
• [Expectation set] (Additional adjustments may be needed, especially early after delivery)
• [Escalation plan] (If indicated: reline/remake evaluation, prosthodontics referral)
• [Prescriptions] (Drug, dose, quantity, instructions) (If applicable)
• [Referrals] (Specialty and reason) (If applicable)
• [Barriers to follow-up] (If patient declines or cannot schedule: document barrier and recommended timeframe)