Teeth Whitening is designed to lighten the color of your teeth. When done properly, the whitening will not harm your teeth or gums. Significant lightening can be achieved in the vast majority of cases, but the results cannot be guaranteed. Teeth whitening, like any other treatment, has some inherent risks and limitations. These are seldom serious enough to discourage you from having your teeth whitening, but should be considered in making a decision to have the treatment. Description of the procedure During the procedure, the whitening gel will be applied to my teeth and my teeth will be exposed to the bleaching agent for an average of three (3) fifteen minute sessions. During the entire treatment, a retractor will be placed in my mouth to keep it open and the soft tissues of my mouth (ie. lips, gums, cheeks, tongue) will be covered 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 treatment, the shade of my front teeth will be assessed and recorded. Just about anyone is a candidate for teeth whitening, but the following points should be noted: - Whitening will not change the color of fillings, crowns, dentures, veneers, or any other material (restorations) that is not enamel. If after bleaching a color difference results between your teeth and other restorations, these restorations may have to be replaced to match your new enamel color. Bleaching is only indicated for enamel.
- Whitening treatment is not recommended for pregnant or lactating women, and patients with known allergy or chemical sensitivity to peroxide or glycols.
- Whitening will likely not be successful if tartar buildup exists in your mouth. A cleaning is recommended to remove these deposits prior to bleaching.
- If you suffer from periodontal disease (bone loss around your teeth), and roots of your teeth are exposed, you’ll notice that these are darker than your enamel. Whitening will not change the color of your roots, only of enamel. It is likely that these areas may be more sensitive when exposed to whitening material.
- If you have tetracycline staining in your teeth, it is likely that you may need power bleaching for best results.
- It is recommended to have a thorough dental exam to evaluate for areas of decay and/or periodontal disease, and to treat these prior to whitening to maximize results and avoid complications and further advancement of disease.
I understand I may decide not to have the teeth whitening treatment at all. However, should I decide to undergo the treatment, I understand there are alternative treatments for whitening my teeth for which include: Whitening Toothpastes/Gels, Take-Home Whitening Kits (from dentists), and whitening strips I understand that the results of my bleaching treatment cannot be guaranteed. I understand that in-office whitening treatments are considered generally safe. I understand that although my dentist and dental hygienist have been trained in the proper use of the accelerated in-office whitening system, the treatment is not without risk. I understand that some of the potential complications of this treatment may include, but are not limited to: Tooth Sensitivity/Pain- During the first 24 hours after treatment, many patients can experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain following a bleaching treatment subsides after a few days, but it may persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed tooth surfaces and occlusal wear facets (severely worn teeth), damaged or missing enamel, cracked teeth, (micro-cracks), open cavities, leaking fillings, or other dental conditions increase or prolong tooth sensitivity or pain after bleaching 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 tissue were exposed to the gel. Dry/Chapped Lips- The treatment involves, 15 minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor. 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 cream. 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 and damage to the tooth could result. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings redone before undergoing in-office bleaching treatment. Cervical Abrasion/Erosion- These are conditions which affect the roots of the tooth when the gums recede and they are characterized by grooves, notches and/or 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 allow the whitening gel to penetrate the teeth, causing sensitivity, pain and possible damage to the nerve. I underststand that if my teeth have these conditions, I should not undergo the in-office bleaching treatment. Root Resorption- This condition where the root of the tooth starts to dissolve either from the inside or 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 bleaching treatment, it is natural for teeth that underwent the accelerated bleaching 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. Treatment usually involves wearing a take-home tray or repeating the accelerated in-office bleaching treatment. I understand that the results of the accelerated in- office bleaching treatment are not intended to be permanent and secondary, repeat or take-home treatments may be needed for me to maintain the tooth shade I desire for my teeth. I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 48 hours after treatment. These substances include: coffee, tea, colas, All tobacco products, mustard or ketchup, red wine, soy sauce, berry pie, red sauces. I understand that there are other substances that could discolor my teeth (typically anything that would stain clothing) which I should avoid during the first 48 hours after treatment. The safety, efficacy, potential complications and risks of bleaching treatment have be explained to me 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 accelerated in-office bleaching treatment, the list of complications in this form is incomplete. In signing this informed consent I am stating I have read this informed consent (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 I agree to undergo the treatment as described by xoxo, KaliCo LLC. By signing this document provided I indicate that I have read and understand the entire document and that I give my permission for the teeth whitening treatment to be performed on me. |
