This information has been given to me so that I can make an informed decision about having my teeth whitened. I have the right to ask questions about any procedure before agreeing to undergo the procedure.
Description of the Procedure
Take-home whitening is a procedure designed to lighten the color of my teeth using hydrogen peroxide gel. Upper and Lower alginate impressions will be taken in office for the bleaching trays and will be delivered in one week with tube(s) of bleach. Once you have received bleach trays and bleach, you can then begin using your take-home whitening kit. Instructions: First, floss and brush your teeth with fluoridated toothpaste. Second, remove cap from syringe and place a small amount of gel in each tooth compartment in the tray, about a pen size drop, and replace cap onto syringe. After placing gel in tray, insert tray in your mouth. Â When inserting the tray, be careful not to push the gel out, but be sure that the tray is completely seated. You may see "bubbling" within the trays while wearing them. This bubbling is actually part of the whitening process. Remove excess gel with your finger or dry toothbrush. Avoid direct contact of the tooth whitening gel with gums and/or salivary flow. Bleach for only 1 hour once or twice per day; DO NOT exceed more than 1 hour of bleaching. After whitening, remove and rinse the trays with cold water. Hot water may damage the trays. If necessary, use a toothbrush to remove any residual gel. Place the trays in the storage case, and store them in a room temperature place. Rinse and brush excess gel from your teeth.
DO: Avoid direct contact with gums and salivary flow. Consult your Doctor before using if pregnant or lactating. Place tip cap on syringe nozzle after each use to avoid potential product leakage. Continue good oral hygiene throughout the treatment.
Store any remaining whitening gel in a cool, dry place for later use once the whitening process is complete. When storing unused gel, replace mixing nozzle with the original twist off plastic cap to help ensure product efficacy.
DON'T: Do not freeze whitening gel. Do not use any household or other whitening products to whiten your teeth. Do not eat, drink or smoke while wearing your custom trays.
I understand there are alternative treatments for whitening my teeth for which my dentist can provide me additional information. These treatments include: Whitening toothpaste/gels and other In-Office Whitening Treatments.
I understand that the cost of my take-home whitening treatment is determined by my dentist. I understand that my dentist will inform me if there are any other costs associated with my take-home whitening treatment.
Risks of consent for treatment
I understand that treatment results may vary or regress due to a variety ofcircumstances. I understand that almost all natural teeth can benefit from take-home whitening treatment and significant whitening can be achieved in most cases. I understand that this whitening treatment is not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative Â materials and that peoplewith darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, may need multiple treatments and/or may not whiten at all. I understand that teeth with many fillings or cavities may not lighten and are usually best treated with other non-bleaching alternatives.
I understand that take-home whitening treatment is not recommended for pregnant or lactating women.
I understand that take-home whitening treatment CANNOT be guaranteed.
The treatment should be uninterrupted. If you must skip a night or two, the process must be extended to compensate for the time missed. In order to maintain the whitest tooth shade possible, it is always best to avoid substances such as coffee, tea, red wine and tobacco.
I understand that treatment is considered generally safe by most dental professionals and 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 /Pain- Some patients can experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse for some individuals. People 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 bleaching.
Gum Inflammation- Whitening may cause inflammation of your gums. This is due to exposure of a small area of those tissues to the whitening gel. The inflammation is usually temporary which 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.
Relapse- 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 teeth to various staining agents. Touch up treatment may be necessary.
In signing this informed consent I am stating I have read this informed consent (or it has been read to me) and I fully understand it and the possible risks, complications and benefits that can result from the Take-Home Whitening treatment and that I agree to undergo the treatment as described by my dentist.
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