Informed Consent for Teeth Whitening

This form explains the risks, benefits, consequences, and alternatives to Teeth Whitening; A procedure that is designed to lighten the color of your teeth. The form also obtains the patient's consent to perform the treatment.

Informed Consent for Teeth Whitening

Whitening is a procedure that is designed to lighten the color of your teeth. When done by a licensed professional and completed properly, whitening should not harm your teeth or gums.  Significant lightening can be achieved in the majority of cases, but particular RESULTS CANNOT BE GUARANTEED.  Whitening, like any other procedure, has some inherent risks and limitations.  Although these risks are seldom serious enough to discourage one from having his or her teeth whitened, they should be considered in making a decision whether to have the procedure performed. There are many variables that can affect the outcome of the procedure, such as the type of discoloration that affects your teeth, the degree to which you follow the instructions, and the overall condition of your teeth.

Who are the best candidates for whitening?

Almost anyone is a candidate for whitening. Experience shows that people with dark yellow or yellowish brown teeth sometimes achieve better whitening results than those with gray or bluish-gray teeth.  Multi-colored teeth, especially if stained due to tetracycline, do not whiten as well.  In addition, teeth with many fillings, cavities, chips, etc., are usually best treated with bonding, porcelain veneers, or porcelain crowns.

In-Office Whitening

This process can be done in one visit but may require two or more visits depending on how your teeth respond to the treatment.  Each appointment should take between one and one & one-half hours. Due to the strong whitening gel used in this procedure, either a resin or a rubber shield will be used to protect your gums.  Once the gums are protected, the gel is applied to the tooth surface. In-office whitening can also be done to lighten a tooth that has had a root canal.  In this case, the tooth is whitened both from the inside and the outside. 

The advantages of in-office whitening are that we can do a lot of the work for you and you spend less overall time whitening your teeth.  The disadvantages include some of the normal inconvenience associated with any dental treatment such as having to keep your mouth open for the duration of the procedure and the possibility of increased costs as compared to take-home whitening.

Take-Home Whitening

This process involves wearing a custom-made whitening tray that looks like a thin, transparent night guard. You fill the tray with a professional whitening gel.  You then need to wear the gel filled tray every night over a period of time that generally extends from 2-4 weeks.  We will check your whitening progress as necessary during the period you are using the whitening gel.

The advantages of take-home whitening include convenience and possibly less cost. The disadvantages include the inconvenience of wearing the whitening trays and the time that it takes to complete treatment. If you choose home whitening, it is very effective but only if you conscientiously wear the trays as recommended.

Tooth Sensitivity

During the first 24 hours following whitening, many patients experience sensitivity.  This sensitivity is usually mild unless your teeth are normally sensitive.  With in-office whitening, this sensitivity will usually subside within 1-2 days.  With take-home whitening, it may be necessary to reduce the number of hours you wear the trays or stop using it for a short time to resolve the sensitivity. We will provide a desensitizing solution to reduce this sensitivity.

However, if your teeth are normally sensitive, whitening may make your teeth much more sensitive for an extended period of time.  Under these circumstances, you may choose to delay whitening until we are able to complete desensitization procedures.  If your teeth are sensitive following the whitening procedure, a mild analgesic such as Tylenol or Advil will usually be effective to make you more comfortable until your teeth return to normal.

Gum Irritation

Whitening may cause temporary inflammation of your gums.  With In-office whitening, this can be the result of a very small amount of gel leaking under the gum protection.  A burning sensation in your gums may also occur.  This is a minor problem and will subside within a few days.

With take-home whitening, irritation can result from using the whitening tray too many hours when you first start whitening or using the tray too many hours in a row without a break.  It may be necessary for you to reduce the number of hours you are wearing the tray or stop using it for a short time to resolve these gum problems.  The tray may also overlap your gums, allowing the gel to contact your gums for an extended period.  This problem can be resolved by returning to the office so that we can trim the tray to a position slightly short of your gums.

Leaking Fillings or Cavities

Most whitening is indicated for the outside of the teeth (unless you already had a root canal).  However, if you have any fillings that are leaking and the gel gets into the inside of the teeth, damage to the nerves of the tooth could result.  In this case, the fillings need to be redone prior to the whitening. All cavities should also be filled before whitening.

Cervical Abrasion/Erosion

These conditions affect the roots of the teeth when gums recede.  They are the grooves, notches, or depressions where the teeth meet the gums that generally look darker than the rest of the teeth.  They look darker because there is no enamel in these areas.  Even if these areas are not sensitive, the whitening gel can potentially penetrate the teeth and damage the nerves.  These areas should not be whitened and should be filled after the whitening is complete.

Root Resorption

This is a condition where the root of a tooth starts to dissolve either from the inside or outside.  Although the cause of resorption has not been determined, studies have shown that its incidence is higher in teeth that have had a root canal and are then whitened. 

Effects on Fillings

Even though open cavities should be filled or badly leaking fillings should be refilled prior to whitening, take-home whitening can cause tooth-colored fillings to become softer and may make them more susceptible to staining.  Therefore, you should be prepared to have any fillings in your front teeth replaced after whitening.  In addition, since whitening will normally lighten teeth, but not fillings, you may need to have your fillings replaced so that they will match your newly whitened teeth.

Whitening Level

There is no reliable way to predict how light your teeth will whiten.  With in-office whitening, one or two treatments is usually necessary to significantly whiten your teeth.  With take-home whitening, two to four weeks of wearing the tray daily for the prescribed number of hours will give you much lighter teeth.  We do not recommend home whitening longer than four weeks unless you have severe tetracycline staining.

Relapse

Once whitening is complete, there may be a gradual relapse back to the original color.  To prevent this relapse, you may choose to wear your take-home whitening tray periodically.

[x] I consent to the teeth whitening treatment as described above.

x_______________________________                    Date:____________________________

Please Sign Here (Patient)

[x] I attest that I have discussed the risks, benefits, consequences, and alternatives to this treatment with the patient who had the opportunity to ask questions, and I believe my patient understands what has been explained

x_______________________________                    Date:____________________________

Please Sign Here (Dentist) 

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