Teeth Whitening Informational Consent Form
General Information:

Teeth whitening is designed to lighten the colour of your teeth. Significant whitening 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 side-effects, risks and limitations. These are rare and seldom serious, but should be considered when deciding to have the treatment.

1. Candidates for Teeth Whitening Almost any person over 16 years old, who is not pregnant or breast-feeding, is a candidate for teeth whitening. However, people with dark yellow or yellow-brown teeth tend to whiten better than people with grey or bluish-grey teeth.
Multi-coloured teeth, especially if due to tetracycline or fluorosis, do not whiten well and may require additional treatments. Multi-coloured teeth, banded teeth, mottled teeth, teeth with tetracycline or fluorosis conditions may not be obvious before whitening due to being masked by staining.

2. Potential Side-effects
Teeth Sensitivity – During the first 24 hours following whitening, occasionally some patients experience transient sensitivity. This sensitivity is usually mild if your teeth are not normally sensitive. This sensitivity will usually subside in 1-2 days; however, rarely sensitivity can last for an extended period of time.

Gum Irritation – This is the result of a small amount of solution coming into contact with the gums. This can cause temporary white spots and may cause some irritation when brushing. A burning sensation on your gums could also occur. This should resolve itself between a few hours to a few days. Very rarely some clients experience a burning sensation and/or swelling of the lips.

Dental Teeth Clean - You must wait 14-days after Scaling & Polishing to have you teeth whitening appointment.
Scaling & Polishing can cause gums to recede from the base of the teeth, and therefore can expose Patients to the risk of exposing the dentin root of a tooth. If teeth is whitened in this condition there is an unacceptable risk of acute hypersensitivity due to the whitening gel sliding down into 'a Pocket' between the tooth base and a detached gum therefore, it is recommended for patients to wait 14 days for gums to come back before your whitening procedure.

Effect On Fillings - Tooth coloured fillings will not whiten. If the filling matches your current colour, whitening will result in mis- matched shades with your natural teeth. Any current restoration you have, such as, crowns, onlays and inlays cannot be whitened. You may need to have your fillings/restorations replaced to match you newly whitening teeth.

Dry/Chapped Lips- The treatment involves three, 20-minute sessions during which the mouth is kept open continuously for the entire treatment by plastic retractor. This could result in dryness or chapping of the lips or cheek margins. During the treatment we will apply lip balm, petroleum jelly or vitamin E cream to limit this.

3. Completion of Treatment
Level of Whitening – There is no totally reliable way to predict how light your teeth will whiten. With cosmetic whitening, one session usually significantly whitens your teeth. Some patients require an additional session.
There are no guarantees as to the degree of whitening of your teeth. The amount of whiteness varies with each individual.

4. Relapse – Following completion of whitening, pigments found in feed and drinks will restain your teeth, commonly called whitening relapse. You may use daily whitening toothpaste to help slow this process.
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