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 this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. My dentist has informed me that my teeth are discolored and could be treated by in-office whitening (also known as “bleaching") of my teeth.
Risks of Consent for Treatment
I understand that whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all-natural teeth structure can benefit from whitening treatments and significant whitening can be achieved in most cases. I understand that whitening is 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 receive better results than people with gray/bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches, or spots due to tetracycline use/fluorosis do not whiten as well, may need multiple treatments/may not whiten at all. I understand that Provisionals/temporaries made from acrylics may become discolored after exposure to whitening treatments.
I understand that whitening is not recommended for pregnant/lactating women, light sensitive individuals, patients receiving PUVA (psoralen + UVA radiation) or other photo chemo-therapeutic drugs/treatment, as well as patients with melanoma, diabetes, or heart conditions. I understand that the ZOOM/Laser light emits ultraviolet radiation (UVA) and that patients taking any drugs that increase photosensitivity should consult with their physician before undergoing any whitening treatment
I understand that the results of my Whitening treatment cannot be guaranteed.
I understand that in-office whitening treatments are considered generally safe by most dental professionals. I understand that although my dentist has been trained in the proper use of the whitening systems, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to:
- Tooth sensitivity/Pain: During the first 24 hours after whitening treatment, some patients can experience some tooth sensitivity/pain. the is normal and is usually mild, but it can be worse in susceptible Individuals. Normally sensitivity/pain subsides within 24 hours, but in rare cases can persist for longer periods of time. People with existing sensitivity, recession, exposed dentin, exposed tooth surfaces, recently cracked teeth, open cavities, leaking fillings, or other dental conditions that cause sensitivity/allow penetration of the gel into the tooth may find that those conditions increase/prolong sensitivity/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 ultraviolet light. The inflammation is usually temporary which will subside in a few days but may persist longer and may result in significant pain/discomfort, depending on the degree to which the soft tissues were exposed to the gel/ultraviolet light
- Dry/Chapped Lips: The whitening treatment involves three/four 15-minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor. This could result in dryness/chapping of the lips/cheek margins, which can be treated by application of lip balm, petroleum jelly or Vitamin E cream.
- Cavities/Leaking Fillings: Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone root canal treatment. If any open cavities/fillings that are leaking and allowing gel to penetrate to the present tooth, significant pain can result. I understand that if my teeth have these conditions, I should have my cavities filled/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/they are characterized by grooves, notches/depressions, that appear darker that 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 call allow the whitening gel to penetrate the teeth, causing sensitivity. I understand that if cervical abrasion/erosion exists on my teeth, these areas will be covered with the dental dam prior to my whitening treatment.
- Root Resorption: This is a condition where the root of the tooth starts to dissolve wither from the inside/outside. Although the cause of this is still uncertain, I understand that 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 whitening 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. Treatment may involve wearing a take-home whitening tray or repeating the whitening treatment. I understand that the results of the whitening treatment are not intended to be permanent and secondary, or repeat/take-home treatments may be needed to maintain the shade I desire for my teeth.
I understand that my dentist has evaluated whether I am a proper candidate for an in house whitening procedure. The dentist can explain the safety, efficiency, potential complications, and risks of whitening to me, and I understand that more information on this will be available upon my request. Since it is impossible to state every complication that may occur because of whitening, the list of complication on this form is incomplete.
In signing this consent form, I am stating I have read this informed consent (or it has been read to me) and I fully understand it and possible complications and benefits that can result from the whitening treatment and that I agree to undergo the treatment as described by the dentist.