Teeth Whitening Informed Consent

Description of the Process

• Professional teeth whitening is designed to lighten the shade of my teeth using a hydrogen peroxide gel.  During the process, the whitening gel will be applied my teeth for 3, 15-20 minutes sessions (depending on my tolerance) for the initial whitening appointment, 2, 15-20 min session for the maintenance appointment, and 1 30 minute lower percentage session for the touch-up appointment. 

• During to process a cheek retractor will be placed in my mouth and the gums will be protected with a resin dam to minimize exposure to the gel.  Eye protection will be provided.  All protective items will be removed upon completion of the process.  If needed a desensitizing agent will be applied to the teeth and a Vitamin E oil mask will be applied to the soft tissue. 

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Risks of Treatment

• I understand that whitening treatment results vary from person to person based on the natural Shade Classification of the teeth and other existing conditions, resulting in some individuals achieving more whiter shades than others. 

• I understand the sustained whiteness of the teeth vary from person to person depending on diet, lifestyle habits, and natural tendencies of regression.   

• I understand that almost all natural teeth can achieve significant whitening.  

• I understand that whitening treatments are not intended to lighten artificial teeth, caps/ crowns, veneers, root surfaces, or fillings.  

• I understand some individuals experience tooth sensitivity as a side effect of the teeth whitening process.  Usually minimal or no discomfort is felt; but there is a rare chance that severe sensitivity may occur lasting 12-24 hours.  A combination of acetaminophen and ibuprofen regimen is recommended. 

• I understand recent or current dental orthodontia is contraindicated for teeth whitening.  Waiting 1-3 months after braces or Invisalign has been completed is recommended.  

• I understand teeth slowly regress in brightness over time due to diet, lifestyle, age, and other dental factors.  Repeat treatments are indicated to manage this.  

• I understand refraining from consuming substances that could discolor my teeth for the first 48 hours.  "If it could stain a white shirt, it could stain the teeth".

• I understand teeth professional teeth whitening is contraindicated if an allergy to RESIN or PEROXIDE is known.    

 

Things to avoid for the first 48 hours (or as long as possible):

• coffee, tea, dark colas, tobacco products, mustard, tomato based foods, blueberries, etc.  Since it is impossible to state every contraindicated item, this list is incomplete.  

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