Informed Consent For In Chair Tooth Whitening

INFORMED CONSENT FORM FOR IN-CHAIR TOOTH WHITENING

IN-CHAIR TOOTH WHITENING TREATMENT INTRODUCTION 

• I would like to have my teeth lightened via the “in-chair” whitening technique. 
• This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision before signing this informed consent form. I have been encouraged to ask questions before agreeing to undergo the procedure. 
• I understand dark yellow or yellow‐brown teeth tend to whiten better than grey or bluish‐grey 
  teeth. I understand for the best results a cleaning is recommended to remove any deposits prior to whitening.
• I understand if I suffer from periodontal disease (bone loss around my teeth), and the roots of my teeth are exposed and dark, whitening will not change the colour of my roots, only of the enamel. I also understand it is likely that these areas may be more sensitive when exposed to the whitening material. 
• I understand there is no totally reliable way to predict how light my teeth will whiten however, on average, I can hope for four shades lighter on a standard shade guide.
• I understand that this procedure is not recommended for children under 16 or women that are pregnant or breastfeeding.
• I believe, to the best of my knowledge, I am not allergic to any of the following: Hydrogen Peroxide, Glycerin, Carbomer Sorbitol, Sodium Hydroxide, EDTA, Potassium Nitrate or Silicone.

DESCRIPTION OF THE PROCEDURE 

• In-Chair Whitening is a procedure designed to lighten the colour of my teeth by application of a hydrogen peroxide gel. The In-Chair Whitening treatment involves using the gel to safely produce a maximum whitening result in the shortest possible time. The gel concentration meets the Australian TCA recommendations and guidelines. 
• During the procedure the whitening gel will be applied to my teeth for two or three 8-minute sessions, with an optional fourth 8-minute session. During the entire treatment, a plastic retractor may be placed in my mouth to help keep it open and the soft tissues of my mouth (i.e. my lips, gums, cheeks and tongue) will be covered to ensure they are not exposed to the gel. 
• Lip balm may also be applied as needed and I will be provided protective eyewear for my 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 teeth will be assessed and recorded. 
• I understand the application of a LED light is not universally acknowledged to aid the whitening effect longterm however it is available at my request to aid in the short term whitening effect by dehydrating the tooth (think of a wet fabric versus a dry fabric) but this will result in an increase in sensitivity.

RISKS OF TREATMENT 

• I understand that In-Chair Whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials. 
• I understand that teeth with multiple mixed discolorations, eg., discoloured bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, and may need multiple treatments or may not whiten at all. I understand that teeth with many fillings, cavities, chips or cracks may not lighten and are usually best treated with other non-bleaching alternatives. 
• I understand that the results of my In-Chair Whitening cannot be guaranteed. 
• I understand that although great care is taken using state of the art techniques the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to: 
• Tooth Sensitivity, this is normal and is usually mild, but it can be worse in susceptible individuals. In most cases tooth sensitivity following a whitening treatment subsides after a few days, but it may persist for longer periods of time in some people. People with existing sensitivity, recession, exposed dentine, exposed root surfaces and large wear facets (severely worn teeth), damaged or missing enamel, cracked teeth, 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 whitening treatment. I understand I may need to take some form of over the counter pain relief medication until my tooth sensitivity returns to normal.
• Gum Irritation may result if some of solution leaks under the gum protection. I may feel a warm sensation on my gums and I may notice a white film on my gums. This will resolve by itself between a few hours to a few days. I may also experience tenderness and/or swelling of the lips. 
• I understand tooth coloured fillings will not whiten. If the filling matches my current colour, whitening will result in mis‐matched shade with my natural teeth. If this concerns me, I may need to consider having my existing fillings replaced to match the newly whitening teeth. 
• I understand that the results of the whitening treatment is not intended to be permanent and additional, repeat or take-home treatments may be needed to maintain my desired tooth shade. 
• I understand that after treatment, I will be required to refrain from consuming any substances that could discolour my teeth for the first 48 hours after treatment. These substances include: coffee, teas, and colas, all tobacco products, mustard or ketchup, red wine, soy sauce, berries and red sauces. 
• I understand that the longevity of my whitening results will vary based on the types of food and drink that I consume, brushing habits, and optional maintenance with other whitening maintenance products, eg., take home whitening kits. 

IN CONCLUSION 

• I understand the above list includes all the common complications and I am aware the list of complications in this form is incomplete. 
• My dental health care provider has explained to me the basic whitening procedures, the advantages and disadvantages, the risks and known possible complications, also alternative treatments have been discussed and my questions have been answered to my satisfaction. 
• In signing this informed consent I am stating I have read this informed consent and I fully understand it and the possible risks, complications and benefits that can result from the whitening treatment and that I agree to undergo the treatment as described by my dental health care provider.   

Me: ____________________________ Date:__________

Witness: ___________________________ Date:__________