(Please print this form out and bring it with you to the office)

Teeth Whitening Informed Consent

This information is provided to give the patient insight into professional methods of teeth whitening.  As in all health care, there are limitations and risks.  Absolute success cannot be guaranteed.

Teeth whitening, as performed in the dental office, has been in existence for many years.  Its safety is considered very high.  The methods used in this practice are no exception.

There are variables which can affect the outcome of the procedure, such as the type of discoloration that affects your teeth, the degree to which you follow our instructions (take-home bleach) and the overall condition of your teeth.

1. Who are the best candidates for whitening?

Almost anyone is a candidate for whitening.  Experience shows that people with dark yellow or yellowish brown teeth sometimes achieve better whitening results that those with gray or bluish gray teeth.  Multi-colored teeth, especially if stained due to tetracycline, do not whiten as well.  In addition, teeth with many fillings, cavities, chips, etc., are usually best treated through bonding, porcelain veneers, or porcelain crowns.

2. What types of whitening are available?

In-Office whitening: We use the ZOOM System, which can be done in one visit.  The total appointment time is about 1.5 hours.

Due to the strong whitening gel used in this procedure, either a resin or a rubber shield must protect your gums.  Once the gums are protected, the gel is applied to the tooth surface.  In many cases, a special high intensity light will be used to further activate the gel.

In-office whitening can also be done to lighten a tooth that has had a root canal.  In this case, the tooth is whitened both from the inside and the outside; (inside whitening of root canal treated teeth is done at an added expense).

The advantage of In-Office whitening is that we do the work for you, and spend less overall time whitening your teeth.  The disadvantages include some of the normal inconveniences associated with any dental treatment, such as having to keep your mouth open for the duration of the procedure, and that possibility of increased costs, as compare to Take-Home whitening.

Take-Home Whitening: This process can be done anywhere not just at home.  It involves wearing a custom-made whitening tray that looks like a thin, transparent nightguard.  You fill the tray with a mild whitening gel.  You then need to wear the gel filled tray for the specified period of the time each day (per our instructions).  This procedure must be continued over a period of time that generally extends from 2-4 weeks.  We will check your whitening progress as necessary during the period you are using the whitening gel.

The advantage of Take-Home whitening is the ease of use.  The disadvantages include the inconvenience of wearing the whitening tray, and that your results will depend on your consistent use of the tray.

Combination of In-Office & Take Home: We encourage this method to maintain the results over a long period of time.

3.  What should be expected upon completion of professional whitening?

We have obtained excellent results in most cases, but there is not a definite way to predict how light your teeth wil get.  Teeth in the yellow shade range tend to whiten better than those in the gray or gray brown ranges.

Teeth discolored by certain antibiotics, decalcification, root canal therapy or trauma do not respond as predictably, and often require additional treatment.  This is best accomplished by the Take-Home treatment.

If your teeth are already a shade of A-1 to B-1, on an in-office shade guide, your additional results will be minimal.

During the consultation you may be shown before/after pictures of other patients.  These are all patients we have treated in this office.

Dr. Marinkovich will provide an approximation assessment as to the level of whiteness you may achieve.  Remember, these procedures only whiten natural teeth, not existing fillings or crowns.  If you have any questions about this, please discuss them with us prior to signing this form, and proceeding with this whitening procedure.

4. What are the potential side effects of whitening teeth?

Tooth sensitivity: During the first 24 hours following an In-Office whitening most patients experience some sensitivity.  This will usually be mild and subside in one or two days.

With the take-home whitening, it may be necessary to reduce the number of hours you can wear the tray, or stop using it for a short period of time.

If your teeth are hypersensitive to begin with, please ask us about desensitization procedures before we start the treatment.

Occasionally, a patient may require a mild pain reliever such as Tylenol or Advil, to make them comfortable until their teeth return to normal.

Other problems: These can include gum irritation, (usually minor), sore throat, sensitivity from leaking fillings or cavities, toothbrush abrasion/erosion, root resorption in root canal treated teeth.

5.  What sort of maintenance and relapse can be expected?

Your teeth shade will revert back slightly, in the first 24 hours.  This is due to slight dehydration of your teeth during the In-Office procedure.  Also, through the normal staining process of daily eating and drinking, a slight regression may occur.  This will depend on the frequency of your use of tobacco products, coffee, tea, red wine, and other staining foods/drinks.  This is usually managed by the Take-Home procedure.

6.  What are some alternative treatment options?

Although the ZOOM whitening is effective in many cases, other options do exist for whitening teeth.  These include:
    A. Porcelain Fused to Metal crowns
    B. All porcelain crowns
    C. Porcelain Veneers
    D. Composite Bonding
    E. Other brands of In-Office and Take-Home products

7.  What are the special considerations?

The ZOOM In-Office whitening system uses a light source that emits ultraviolet light.  Although the output is less than half of the typical UVA exposure of commonly used facial and full body tanning units, the procedure incorporates significant protective and precautionary measures, all of which, our office follows.

Nevertheless, individuals undergoing PUVA therapy (Psoralen & UV Radiation), or other photo-chemotherapy, as well as those with melanoma should consult their physician prior to treatment.  Patients taking light sensitive drugs should also consult with their physician regarding possible photo-reaction.

In an attempt to help patients understand the benefits of certain dental treatments, we often times show them "before and after" photographs of procedures we have completed in this office.  With your permission, we would like to use your photographs, if suitable, for our "examples files." This may include in-office use, teaching seminars for other health care providers, and/or use on our website.

PHOTOGRAPHIC RELEASE

[ ]  Yes, I grant permission to use my photos for educational purposes.
     You can also use my name when doing so.

[ ]  Yes, I grant permission to use my photos for educational purposes, but please do not include my name.

[ ]  No, I prefer that you do not use my photos for this purpose.

AUTHORIZATION & RELEASE

I certify that I have thoroughly read and understand the above information.  I have had all of my questions answered to my satisfaction.  With this understanding, I give the authorization to Dr. Marinkovich and his staff to perform the whitening procedure on me.  I agree to be responsible for payment of services rendered on my behalf, or my dependents.