Informed Consent for In-Office Tooth Whitening

Informed Consent for In-Office Tooth Whitening


Precautions
In-Office Whitening Treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with grey or bluish-grey teeth. Teeth with multiple colorations, bands, splotches or spots due to tetracycline use, orthodontics, or fluorosis do not whiten as well, may need multiple treatments or may not whiten at all. Teeth with many fillings, cavities may not light and are usually best treated with other non-bleaching alternatives. Provisionals or temporaries made from acrylics may become discoloured after exposure to In-Office Whitening Treatment.

In-Office Whitening Treatment is not recommended for pregnant or lactating women, light sensitive individuals, patients receiving PUVA (Psoralen + UVA radiation) or other photochemo-therapeutic drugs or treatment, as well as patients with melanoma, diabetes or heart conditions. In-Office Tooth Whitening uses a lamp that emits invisible blue light and that patients taking any drugs that increase photosensitivity should consult with their physician before undergoing treatment.

Potential Complications
In-Office Tooth Whitening is considered generally safe by most dental professionals, however, the treatment is not without risk. Some of the potential complications of this treatment include, but are not limited to:
• Inability to whiten - Results of In-Office Tooth Whitening cannot be guaranteed.
• Tooth sensitivity or pain – During the first 24 hours after In-Office Tooth Whitening, 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 an In-Office Tooth Whitening subsides within 24 hours, but in rare cases can persist for longer periods of time in susceptible individuals. Patients with existing sensitivity, recession, exposed dentin, exposed root surfaces, recently cracked teeth, abfractions (micro-cracks), open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after In-Office Tooth Whitening.
• Inflammation of gums, lips or cheeks – Whitening may cause inflammation of the gums, lips or cheek margins. This is due to inadvertent exposure of a small area of those tissues to the whitening gel or the light. The inflammation 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 tissues were exposed to the gel or light.
• Dry or chapped lips – In-Office Tooth Whitening involves three or four 15-minute sessions during with 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 are present, allowing gel to penetrate the tooth could result in significant pain. These conditions should be addressed before undergoing In-Office Tooth Whitening.
• Cervical abrasion or erosion – These are conditions which affect the roots of the teeth when the gums recede and they are characterized 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. These areas will be covered with a barrier prior to In-Office Tooth Whitening.
• Root resorption – This is a condition where the root of the tooth starts to dissolve either from the inside or outside. Although the cause of this is still uncertain, 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 In-Office Tooth Whitening, it is natural for the teeth that underwent 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 tooth to various staining agents. Treatment may involve wearing a take-home tray or repeating In-Office Tooth Whitening. The results of the In-Office Tooth Whitening are NOT intended to be permanent and secondary, repeat or take-home treatments may be needed for me to maintain the tooth shade desired.
Since it is impossible to state every complication that may occur as a result of In-Office Tooth Whitening, the list of complications in this form is incomplete.

Alternative Treatment Options
Alternative treatments for In-Office Tooth Whitening include:
• Whitening Toothpastes/Gels;
• Other In-Office Whitening Treatments;
• Take-Home Whitening Kits.

Cost
The cost of In-Office Tooth Whitening is as outlined in the attached treatment plan. Full payment is required on the day of the appointment.

• I have read and understand the conditions and information in this Consent Form.
• I have discussed the information contained in the Consent Form concerning In-Office Tooth Whitening with my dentist.
• I have had explained to me the cost of the treatment and I accept responsibility for that cost.
• I authorise my dentist to provide me with In-Office Tooth Whitening.