Background Information for Patients Considering
Whitening:

Before treatment is commenced I would like you to read the following important information. If after reading this information you have any questions in relation to any aspect of your treatment please ask.

What is Whitening?

In-office whitening is a procedure designed to lighten the colour of my teeth using a combination of a hydrogen peroxide gel and a specially designed visible LED light lamp, using the gel and lamp in conjunction with each other aims to produce maximum whitening results in the shortest possible time. The treatment involves upper and lower impressions being taken to create models of the teeth to fabricate take home whitening trays. During the procedure, the whitening gel will be applied to the teeth and then being exposed to the light from the lamp for three (3), 15-minute sessions. There is an optional fourth session for those with darker stains. During the entire treatment, a plastic retractor will be placed in the mouth to help keep it open and the soft tissues of the mouth (i.e. my lips, gums, cheeks and tongue) will be covered to ensure they are not exposed to either the gel or light. You will be provided with LED light filtering protective glasses for your eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper-front will be assessed and recorded.

What are the alternatives to Whitening treatment?

The alternative treatments for whitening teeth for which the dentist or dental professional can include whitening toothpastes/gels, other in-office whitening treatments, take-home whitening kits, porcelain crowns, veneers or composites veneers.

Possible Problem’s/Complications with Whitening Treatment

Tooth Sensitivity/Pain:During this first 24 hours after the in-office whitening treatment, some 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 in-office whitening treatment subsides within 24 hours, but in rare cases can persist for longer periods of time to susceptible individuals. People with existing sensitivity, recession exposing root surfaces, exposed dentin, untreated caries, cracked teeth, abfractions, oral tissue injury, open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow higher penetration of the gel into the tooth may find that those condition/s increase or prolong tooth sensitivity or pain after in-office whitening treatment.

Gum/Lip/Cheek Inflammation/Burn: Improper isolation during the whitening procedure may cause or result in inflammation of your gums, lips or cheek margins due to exposure of a small area of those tissues to the whitening gel or the LED light, or a chemical burn due to whitening gel coming in contact with soft tissues. The inflammation or burn is usually temporary and 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 or LED light.
Dry/Chapped Lips: The in-office whitening treatment involves three, 15 minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor which covers the lips. 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 oil.

Cavities and Fillings: Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone a root canal treatment. If any open cavities of fillings that are leaking and allowing gel to penetrate the tooth are present, significant pain could result. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings redone before undergoing the in-office whitening treatment. InOffice whitening treatments are not intended to lighten artificial teeth, caps,
crowns, veneers or porcelain, composite or other restorative materials, and that these types of restorative may need to be replaced at my expense to match my newly whitening teeth.

Cervical Abrasion/Erosion: These are conditions which affect the roots of the teeth when the gums recede and they are characterised by grooves, notches and/or depressions, that appear darker than 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 can allow the whitening gel to penetrate the teeth, causing sensitivity. I Understand that if the cervical abrasion/erosion exists on my teeth, these areas will be covered with dental dam prior to my in-office whitening treatment.

Relapse: After in-office whitening treatment, it is natural for the teeth that underwent the in-office whitening treatment to regress somewhat in their shading after treatment. 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 in-office whitening treatment. I understand that the results of the in-office whitening 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 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 in-office whitening treatment, the list of complications in this form is incomplete.

Health Funds:

Any quotation includes the Australian Dental Associations (ADA) scheduled item numbers and tooth identification if applicable. These numbers are recognised by the health funds. I answer to you for the services that I provide and the fees that I charge. That is your right and my responsibility. Your insurer answers to you for the rebates they give. That is your right and their responsibility. It is neither my responsibility nor my right to be involved in that relationship.

Finally if you should have any further queries please do not hesitate to ask.

Consent for Treatment:
Whitening

This is my consent to provide the dental treatment as indicated in this form:

• I have read any provided ADA handout for this course of treatment.
• I have received a written or verbal quotation and I am clear on the costs involved in this course of treatment.
• I have given the practice a full, complete and up to date medical and medications history.
• I fully understand the entire document and the what the treatment entails including advantages, disadvantages, limitations, risks.
• The treating dental practitioner has explained the known possible complications of and alternative treatments.
• The treating dental practitioner has answered all of my questions to my full satisfaction.
• I understand that the results of the treatment can not be guaranteed.
• I give my permission and consent for the whitening treatment to be performed.