Teeth Whitening Informed Consent

Description of the Process

• Professional teeth whitening is designed to lighten the shade of my teeth using a hydrogen peroxide gel.  During the process, the whitening gel will be applied to my teeth for 3, 15-20 minutes sessions (depending on my tolerance) for the initial whitening treatment or for 2, 15-20 min session for maintenance touch up treatments.  During to process a cheek retractor will be placed in my mouth and the gums will be covered to help protect from exposure to the gel.  Eye protection will be provided.  All protective items will be removed upon completion of the process.  If needed a desensitizing agent will be applied to the teeth and a Vitamin E oil mask will be applied to the soft tissue. 

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Risks of Treatment

• I understand that whitening treatment results vary and regress due to a variety of factors.  

• I understand that almost all natural teeth can achieve significant whitening.  

• I understand that whitening treatments are not intended to lighten artificial teeth, caps/ crowns, veneers, or fillings.  

• I understand whitening treatments are not intended to whiten exposed roots and could cause significant sensitivity.  

• I understand after the process, it is natural for the teeth to regress somewhat in their shading.  This should be very gradual, but can be accelerated by exposing the teeth to various staining agents.  Repeat treatments are indicated to manage this.  

• I understand refraining from consuming substances that could discolor my teeth for the first 48 hours.  

 

Things to avoid for the first 48 hours (or as long as possible):

• coffee, tea, dark colas, tobacco products, mustard, tomato based foods, blueberries, etc.  Since it is impossible to state every contraindicated item, this list is incomplete.  

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