INTRODUCTION
I have been informed that my teeth could be treated by an on-site whitening (also known as “bleaching”). 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.
DESCRIPTION OF THE PROCEDURE
On-site tooth whitening is a procedure designed to lighten the color of my teeth using a 38% hydrogen peroxide gel to produce maximum whitening results in the shortest possible time. Hydrogen peroxide has been used since 1913 as an antiseptic rinse and extensively used since 1986 to whiten teeth. During the procedure, the whitening gel will be applied to my teeth and my teeth will be exposed to the gel. During the entire treatment, a plastic retractor will be placed in my mouth to help keep it open and the soft tissues of my mouth (i.e., my lips and gums) will be protected to ensure they are not exposed to the gel. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper front teeth will be assessed and recorded.
ALTERNATIVE TREATMENTS
I understand I may decide not to have the whitening treatment at all. However, should I decide to undergo the treatment, I understand there are alternative treatments for whitening my teeth. These treatments include: Whitening Toothpastes/Gels, Other In-office Whitening Treatments, Take-Home Whitening Kits, Porcelain Crowns, Veneers or Composites.
RISKS OF CONSENT FOR TREATMENT
I understand that:
• existing issues should be treated before undergoing a whitening procedure.
• results will vary or regress due to a variety of circumstances. TREATMENT IS NOT A GUARANTEE OF SUCCESS.
• whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials, and these types of restorations may need to be replaced at my expense to match my newly whitened teeth.
• if there are many restorations that show in my smile this may be a contraindication for whitening treatment.
• darkly stained yellow or yellow-brown teeth frequently achieve better results than gray or bluish-gray teeth.
• teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, may whiten unevenly, may require additional whitening, or may not whiten at all.
• previous orthodontic treatments may cause teeth to whiten unevenly if any resin from the treatment was not properly removed from the teeth, either due to residual resin remaining on the teeth or overpolishing upon removal.
• teeth with many fillings or cavities may not lighten and are usually best treated with other non-whitening alternatives.
• minimally discolored teeth (teeth that are already very white) may not see a substantial degree of whitening.
• it is recommended that those currently treated for a serious illness or disorder (e.g. immune compromised, AIDS, etc) should consult a medical doctor before whitening.
• whitening treatment is not recommended for pregnant or lactating women.
I understand that the results of my whitening treatment cannot be guaranteed.
I understand that on-site whitening treatments are considered generally safe by most dental
professionals.
I understand that whitening treatments are 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 following whitening treatment, some patients can experience transient tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain subsides within one to two days but in rare cases can persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession exposing root surfaces, exposed dentin, untreated caries, cracked teeth, abfractions, oral tissue injury, open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow higher penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after a whitening treatment. A mild analgesic such as Tylenol or Advil is usually effective until tooth sensitivity returns to normal. Placement of a fluoride varnish desensitizing agent is recommended at the end of treatment to reduce the risk of transient tooth sensitivity.
Gum/Lip/Cheek Inflammation/Burn – The whitening procedure may cause or result in (i) inflammation of your gums, lips or cheek margins due to exposure of a small area of those tissues to the whitening gel, or (ii) a chemical burn due to whitening gel coming in contact with soft tissue. The inflammation or burn is usually temporary and will subside and resolve by itself 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.
Dry/Chapped Lips – The whitening treatment involves up to three, 20-minute sessions during which the mouth is
kept open continuously for the entire treatment by a plastic retractor which covers the lips. This could result in dryness or chapping of the lips or cheek margins, which can be treated by application of lip balm, petroleum jelly or Vitamin E oil.
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 tooth 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 a 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. I understand that if cervical abrasion/erosion exists on my teeth, these areas will be avoided during the whitening treatment as best as reasonably possible.
Relapse – After the whitening treatment, it is natural for the teeth to regress somewhat in their shading. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents found in food and drinks. I understand that the results of the treatment are not intended to be permanent and that secondary, repeat, or take-home treatments may be needed to maintain the tooth shade desired.
The safety, efficacy, potential complications and risks of treatment can be explained by the dental professional and I understand that more information on this will be provided to me upon my request. Since it is impossible to state every complication that may occur as a result of a whitening treatment, the list of complications in this form is incomplete. The basic procedures of on-site whitening treatment and the advantages and disadvantages, risks and known possible complications of alternative treatments have been explained to me and all of my questions have been answered to my satisfaction.