TEETH WHITENING INFORMATION & CONSENT FORM
Teeth whitening is designed to lighten the color of your teeth. Significant lightening can be achieved in the vast majority of cases, but the results cannot be guaranteed. When done properly, the whitening will not harm your teeth or gums. However, like any other treatment, it has some inherent risks and limitations. These are seldom serious enough to discourage you from having your teeth whitened, but should be considered when deciding to have the treatment.
Candidates for Teeth Whitening
Just about anyone is a candidate for teeth whitening. However, the following cases should be considered:
People with dark yellow or yellow‐brown teeth tend to whiten better than people with gray or bluish‐gray
Multi‐colored teeth, especially if due to tetracycline, do not whiten very well.
People with significant periodontal disease are not good candidates
If you are pregnant, obtain permission from your doctor before trying the whitening procedure.
People with minimal discoloration, (teeth that are already very white) may not see a substantial degree
Teeth with many fillings, cavities, chips, etc., are usually best treated by bonding, porcelain veneers or
porcelain crowns. Any current restoration you have, such as, fillings, porcelain crowns, onlays and inlays cannot be whitened.
Types of Teeth Whitening
IN-OFFICE WHITENING ‐ This process can be done in one visit or may require multiple visits depending on how your teeth respond to the whitening gel. Each appointment takes approximately 60 minutes.
4. Potential Problems
• TOOTH SENSITIVITY ‐ During the first 24 hours following whitening, some patients experience transient sensitivity. This sensitive is usually mild if your teeth are not normally sensitive. With power whitening, this sensitivity will usually subside in 1‐2 days. .
However, if your teeth are normally sensitive, whitening may make your teeth more sensitive for an extended period of time. Under these circumstances, we advise the use of a sensitive toothpaste one week prior to and after whitening.
• GUM IRRITATION ‐ This is the result of a small amount of solution leaking under the gum protection. A burning sensation on your gums may also occur. This should resolve by itself between a few hours to a few days. You may also experience burning and /or swelling of the lips.
• EFFECT ON FILLINGS ‐ Tooth colored fillings will not whiten. If the filling matches your current color, whitening will result in mis‐matched shades with your natural teeth. You may need to have your fillings replaced to match you newly whitening teeth.
5. Completion of Treatment
LEVEL OF LIGHTENING – There is no totally reliable way to predict how light your teeth will whiten. One session usually significantly whitens your teeth. Some patients require an additional session.
RELAPSE ‐ Following completion of whitening, pigments found in food and drinks will re‐stain your teeth, commonly called whitening relapse. You may use daily whitening toothpaste.
I have read the information provided and understand the whitening procedure. The staff at tHAIRapy SALON & EXTENSION STUDIO has explained this procedure to me and all my questions, if any, were answered. I consent to this treatment.