This information is to help you make an informed decision about having tooth whitening. You should take as much time as you wish to make the decision in relation to signing the following consent form. You are encouraged to ask any questions, and have the answers to your satisfaction before you give permission for the whitening.
Home Tooth Whitening
Your dentist will take an impression (mould) of your teeth to construct a tooth whitening tray. These trays ensure that there is minimal leakage and maximum cosmetic effect. Once constructed the trays will be checked for accuracy of fit and specific instructions will be provided on your tooth-whitening regime. Customised trays are loaded with the easily applicable carbamide peroxide and worn for 2-4 hours (although they can be kept in overnight) for 4 days or longer.
In Chair Whitening
The dentist isolates your teeth from your cheeks and gums and applies a stronger hydrogen peroxide whitening gel. This will be activated with a special light. Due to the strength of the gel, results are much quicker than home whitening.
INFORMED CONSENT FOR TOOTH WHITENING TREATMENT
Smile Cliniq provides this information to give you insight into tooth whitening. Your cooperation and understanding of this material is necessary as we strive to achieve the best results for you.
Risks: All forms of health treatment, including tooth whitening, have some risks and limitations. Complications that can occur in home tooth whitening are infrequent and are usually minor in nature.
Tooth Sensitivity: During the whitening process some patients may experience tooth sensitivity. This is normal and generally mild if your teeth are not normally sensitive. If your teeth are normally sensitive, please inform your Dentist before treatment. Please let your Dentist know if you experience any discomfort during or after the procedure. A mild analgesic will usually be effective in eliminating any discomfort. A desensitising toothpaste/mouth wash will also help symptoms.
Gum and soft tissue irritation: Whitening may cause inflammation of your gums, lips or cheek margins. This is generally the result of the whitening gel coming into contact with these tissues. If any irritation does occur, it is generally short in duration and is very mild. Rinsing with warm salt water can relieve it.
Existing restorations: White fillings; porcelain or composite restorations, crowns or veneers will not whiten with your natural teeth during this procedure. This will have been discussed with you by your Dentist and replacement of these restorations may have been recommended.
Defective fillings/Cavities: If these are present the gel may leak into the cavities, between the defective fillings and tooth, which may cause some discomfort. In the worst case it may lead to the need for root canal treatment. It is strongly advised any cavities, decay, defective fillings are treated before any cosmetic tooth whitening is carried out.
Expectations: Significant whitening can be achieved in many cases, but there is no absolute way to predict how light your teeth will get. Exact results are not guaranteed. Teeth with multiple colourations, bands or spots due to tetracycline staining or fluorosis do not whiten as well and may appear more spotted after treatment. These may require further treatment to achieve a uniform result in the form of veneers. A patchy appearance of teeth with white spots may occur after whitening, this usually blends in after a few weeks.
Relapse: Tooth whitening is not permanent and teeth may regress in shade somewhat. This is natural and is dependent on diet. To maintain teeth at their optimal whiteness, it is advised to avoid staining foods, drinks and smoking, i.e. coffee, tea, red wine and curries. Repeat treatments may be needed to maintain the tooth colour you desire.
Alternative options: Scale and polish or air abrasion can improve tooth colour by removing surface staining. Crowns and veneers can change the shade as well as the shape of the teeth, however, they involve shaving part of the tooth away and replacing with porcelain.
Tooth whitening is not recommended for pregnant or lactating women, children under 14 years of age or any persons having known peroxide allergies.
I understand that the outcome of my whitening treatment cannot be guaranteed.
I understand during treatment and for 48 hours after, I will be required to refrain from consuming any chromogenic substances (i.e. tomato sauce, coffee, all tobacco products).
If any problems are experienced whilst using the product you will discontinue use immediately and consult your Dentist.
You will not use the product if you are pregnant or a nursing mother or allergic to peroxide products.
POST-OP INSTRUCTIONS: TOOTH WHITENING
Follow instructions from your Dentist.
If you are a smoker, do not smoke for 48 hours.
Stay away from highly coloured foods (red sauce, carrot juice, blueberries, curries, etc.) and beverages (coffee, tea, etc.) for 48 hours.
Sensitivity to hot or cold liquids may occur. This usually passes within 1-7 days after completion of treatment and during treatment sensitivity can be reduced by filling your trays with a “sensitive” toothpaste for an hour a day and brushing with a sensitive toothpaste such as Colgate sensitive Pro-Relief or Sensodyne, or placing the said toothpastes on the teeth overnight.
If sensitivity is severe or persists, contact your Dentist.
Whitening may cause inflammation of your gums, lips or cheek margins. This is generally the result of the whitening gel coming into contact with these tissues. If any irritation does occur, it is generally short in duration and is very mild. Rinsing with warm salt water can relieve it.
If you experience gum sensitivity do not brush the affected area while brushing your teeth, instead use an antiseptic mouthwash like Curasept.
Immediate whitening results can be quite dramatic due to minor dehydration of your teeth. It is normal for the colour to tone down somewhat after treatment when your teeth rehydrate to a natural white tone.
Long term results vary from patient to patient. This can depend on the original shade of your teeth and include habits such as smoking or drinking coloured beverages (red wine, coffee, tea, etc.)
“Touch-up” treatments may be needed every 6-12 months to retain colour. You can ask your Dentist about different “touch-up” options
Existing fillings and crowns, etc. will not whiten. Therefore, these may need to be changed in order to match your new smile