CONSENT FORM FOR Scaling_Polishing_Whitening

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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

In-office tooth whitening is a procedure designed to lighten the color of my teeth using a hydrogen peroxide gel. During the procedure, the whitening gel will be applied to my teeth for three (3), 15-minute sessions. Before and after the treatment, the shade of my upper-front teeth will be assessed and recorded.

ALTERNATIVE TREATMENTS

I understand there are alternative treatments for whitening my teeth for which my dentist can provide me additional information. These treatments include: Whitening Toothpastes/Gels, Take-Home Whitening Kits

RISKS OF TREATMENT

  • Tooth Sensitivity/Pain - During the first 24 hours after treatment, many patients can experience some tooth sensitivity or pain. This is normal...
  • Gum/Lip/Cheek Inflammation - Whitening may cause inflammation of your gums, lips, or cheek margins...
  • Dry/Chapped Lips - The treatment involves three 15-minute sessions during which 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 and allowing gel to penetrate the tooth are present, significant pain and damage to the tooth could result. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings re-done before undergoing the treatment...
  • Cervical Abrasion/Erosion - These are conditions which affect the roots of the teeth when the gums recede. 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, pain, and possible damage to the nerve. I understand that if my teeth have these conditions, I should not undergo the treatment...
  • 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, I understand that 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 the treatment, it is natural for the teeth that underwent the whitening procedure to regress somewhat in their shading. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents. Treatment usually involves wearing a take-home tray or repeating the treatment. I understand that the results of the treatment are not intended to be permanent, repeat or take-home treatments may be needed for me to maintain the tooth shade I desire for my teeth...

The safety, efficacy, potential complications, and risks of treatment can be explained to me by my dentist, and I understand that more information on this will be provided to me upon my request. Since it is impossible to state every complication that may occur as a result of treatment, the list of complications in this form is incomplete.

I consent to photography, filming, recording, and x-rays of the procedure to be performed for the advancement of dentistry, provided my identity is not revealed.

The basic procedures of treatment and the advantages and disadvantages, risks, and known possible complications of alternative treatments have been explained to me by my dentist, and my dentist has answered all my questions to my satisfaction.

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 treatment, and that I agree to undergo the treatment as described by my dentist.



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