At-home teeth whitening information/informed consent

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Patient name:(Required)

General Information

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.

Candidates for Teeth Whitening

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.
  • Do not attempt to bleach crowns, veneers, or any other restoration, as this will not work and possibly damage them. Bleaching is only indicated for enamel.
  • Whitening is not recommended for patients that are pregnant, trying to get pregnant or breastfeeding.
  • Whitening will likely not be successful if tartar buildup exists in your mouth. A cleaning is highly 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.

Home Teeth Whitening

This process, which can be done anywhere and anytime, involves wearing a custom-made bleaching tray (looks like a thin, transparent night guard) filled with a mild bleaching agent. You must wear the gel filled tray from 2 to 6 hours per day or night or according to the directions of your instruction by the clinician, for one to two weeks. The advantage of home whitening is that you perform this treatment when it is convenient for you. The disadvantage to home whitening is that the success of the treatment is entirely based on your commitment to wearing the whitening tray for the period prescribed.

Potential Problems

  • Tooth Sensitivity: During whitening, some patients experience transient sensitivity. This sensitivity is usually mild if your teeth are not normally sensitive. It may be necessary to reduce the number of hours you are wearing the bleaching tray or stop using it for a short time to resolve the sensitivity. If your teeth are normally sensitive, whitening may make your teeth more sensitive for an extended period of time. Under these circumstances, you may choose to delay the whitening process until we are able to complete desensitizing procedures. 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: This is the result of using the trays for too many hours when you first start whitening. It may be necessary for you to reduce the number of hours you are wearing the tray or stop using them for a short time to resolve these gum problems.
  • Effect on Fillings: Be aware that tooth colored filling will not whiten and mismatched shading may happen. Same thing applies to any other restoration in your mouth (crowns, veneers, dentures, inlays, onlays, etc). You may need to replace these restorations so that they will match your newly whitened teeth.

Completion of Treatment

  • Level of whitening: There is no reliable way to predict how light your teeth will whiten. Type of staining, tooth anatomy and periodontal/carious condition vary from person to person, thus affecting bleaching results.
  • Relapse: Following the completion of whitening, pigment found in food and drinks will restain your teeth after some time. This is commonly called ‘bleaching relapse’. With home whitening, you may choose to wear your trays once every few months to keep relapse from occurring.

I have read and understand the procedure. This information has been explained to me and I have had the opportunity to ask questions. I consent to this take home treatment and take full responsibility for the outcome of the results.

Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.

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