Patient guide — Download this guide
This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure.
RISKS OF CONSENT FOR TREATMENT
I also understand that whitening treatment results may vary or regress due to a variety of circumstances. Almost all natural teeth can benefit from whitening treatments and significant whitening can be achieved in most cases. Whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth. Teeth with multiple colorations, bands, or spots due to tetracycline use or fluorosis do not whiten as well, may need multiple treatments or and may not whiten at all. Teeth with many fillings, cavities may not lighten and are usually best treated with other non-bleaching alternatives. Provisionals or temporaries made from acrylics may become discolored after exposure to whitening treatment.
I understand that the results of my whitening treatment cannot be guaranteed
Teeth Sensitivity/Pain – During the first 24 hours after whitening treatment, some patients can experience some teeth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, teeth sensitivity or pain following a whitening treatment subsides within 24 hours, but in rare cases can persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed root surfaces, recently cracked teeth, micro-cracks, open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the teeth may find that those conditions increase or prolong teeth sensitivity or pain after whitening treatment.
Gum/Lip/Cheek Inflammation – Whitening may cause inflammation of your gums, lips or cheek margins. This is due to inadvertent exposure of a small area of those tissues to the whitening gel. The inflammation is usually temporary which will subside in a few days but may persist longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel.
Cavities or Leaking Fillings – Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone a root canal procedure. If any open cavities or fillings that are leaking and allowing gel to penetrate the teeth are present, significant pain could result. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings redone before undergoing the whitening treatment.
Cervical Abrasion/Erosion – These are conditions which affect the roots of the teeth when the gums recede and they are characterized by grooves, notches and/or depressions, that appear darker than the rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the enamel that covers the rest of the teeth. Even if these areas are not currently sensitive, they can allow the whitening gel to penetrate the teeth, causing sensitivity.
Root Resorption – This is a condition where the root of the teeth starts to dissolve either from the inside or outside. Although the cause of this is still uncertain, there is evidence that indicates the incidence of root resorption is higher in patients who have undergone root canals followed by whitening procedures.
Relapse – After the whitening treatment, it is natural for the teeth that underwent the treatment to regress somewhat in their shading after treatment. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents. The results of the whitening treatment are not intended to be permanent and secondary, repeat or take-home treatments may be needed for me to maintain the teeth shade I desire for my teeth.
The safety, efficacy, potential complications and risks of whitening treatment can be explained to me by my dentist and I understand that more information on this will be provided to me upon my request.
In signing this informed consent I am stating I have read this (or it has been read to me) and I fully understand it and the possible risks, complications and benefits that can result from the whitening treatment and that I agree to undergo the treatment as described by my dentist.
SIGNATURES
By signing this document in the space provided I indicate that I have read and understand the entire document and that I give my permission for whitening treatment to be performed on me.