Bleaching info and consent
3 Wortley Road, High Green, Sheffield, S35 4LQ Tel: 0114 2846 723
Estimate of the Cost of Tooth Whitening
Daytime tooth whitening using trays and whitening gel
3rd Visit (2-4weeks) Review Cost £ _____________________
This includes: Upper and lower custom made trays
4 tubes of whitening gel
Signatures: _______________________ (Patient)
Cost of future tubes of gel:
£25.00 for 1 tube
Consent and Instructions for Tooth Whitening
We are planning to whiten your teeth using hydrogen peroxide, please
read the following instructions carefully.
1. The active ingredient is hydrogen peroxide in a glycerol base. If you
are aware of any adverse reaction to this ingredient, please do not proceed with the treatment.
2. As with any treatment there are benefits and risks. The benefit is that
teeth can be whitened fairly quickly in a simple manner. The risk involves the continued use of the peroxide solution for an extended period of time. Research indicates that using peroxide to whiten teeth is safe. The long term effects are unknown, acceptance of treatment means acceptance of risk.
3. The amount of whitening varies with the individual. Most patients
achieve a change within 2-5 weeks. Try not to drink tea, coffee, red wine or eat berries or curries during or after treatment for at least 1 month as this stains the teeth.
4. It is advisable not to smoke during treatment and for one month after.
5. Sensitivity may occur after a few days. This is usual y slight and
temporary, desensitising toothpaste can be used. If your teeth become very sensitive stop treatment for 3-4 days whilst it settles down.
6. Do not use this treatment if you are pregnant. There have been no
reported adverse reactions, but the long term clinical effects are unknown.
7. After the desired amount of tooth whitening has been achieved, stop
treatment. Top up treatment may be required 6-26 months after.
8. The amount of whitening can vary from patient to patient, and the
desired level of whitening cannot always be achieved. Any previously placed white fil ings/restorations may need replacing after whitening.
I have read and understood the information on the previous page and I agree to return in _________weeks after treatment begins and at any recommended time afterwards. I have read and received a copy of this information sheet and I consent to treatment and assume the risks described.
Quick Reference Sheet for Tooth Whitening
Daytime Home Whitening
Brush your teeth thoroughly for 2 minutes with your normal toothpaste.
Prepare your tray by placing a smal amount of whitening gel into each of the reservoirs.
Place the tray in your mouth and ensure that it is wel seated.
Do not swal ow any excess gel, remove any excess with a tissue or cotton rol .
Remove the trays and rinse your mouth and tray with water.
Use the trays individual y, and every other day for the first 12 weeks DO NOT WEAR OVERNIGHT
If your teeth become very sensitive to hot or cold, apply sensodyne toothpaste
to the trays and wear for 20 minutes or use as normal toothpaste whilst
brushing. If you experience any adverse reactions, stop treatment and contact
What to expect during your bleaching treatment
Your dentist has given you a bleaching kit to take home with you together with
your bleaching trays. It is essential that you fol ow the instructions given by
your treating dentist and the manufacturers instructions in wearing the trays
and applying the bleaching agent. How long should I wear the trays for?
This depends on the amount of lightening that you desire and the original
shade of the teeth. If your teeth are quite dark or yel ow/grey/or tetracycline
stained it wil take longer to whiten the teeth. If you are not experiencing any
sensitivity you may wear the trays for at least 1-2 hours and even sleep with
the trays in your mouth. It is very important to remove al the excess material
around the gums and palate.
The darker your teeth, the longer they wil take to get lighter. Tetracycline
stained teeth can take 6 months or up to 1 year to whiten the teeth. Some
teeth can whiten after one month.
If you cannot wear the trays for a few days because of your hectic schedule, it
does not matter. Whiten your teeth according to your own schedule. Some
people put the trays in after dinner and wear them for the first hour whilst
watching TV or doing the dishes. Then if everything is fine they replenish the
trays and sleep with them in the mouth (If you are using a night time
package). What to do if I have sensitivity?
Sensitivity of teeth is the most common side effect of home whitening. In fact
many patients suffer from sensitive teeth anyway. This occurs usual y around
the necks of the teeth where the gums have receded. If you are experiencing
any sensitivity you should stop using the whitener for a few days. You can
resume after 3-4 days . If the teeth become ultra sensitive you can place
sensitive toothpaste into the bleaching trays for an hour a day. That wil
usual y stop the sensitivity. Alternatively you can rub the sensitive toothpaste
into the gum margins with your finger 5 times a day for a few days. If you are at all concerned, please do not hesitate to contact the practice
on 0114 2846723.
Your treating dentist is __________________________
What happens if the teeth do not bleach evenly?
If the teeth have white spots on them before bleaching, these spots wil
appear whiter during the first few days, however, the contrast between these
spots and the rest of the tooth wil become less and less and eventual y they
wil not be noticeable. Sometimes the dentist can carry out a procedure cal ed
microabrasion which permanently removes these spots from your teeth, but
this costs extra. Ask your dentist about the procedure if you are interested in
You may notice new white spots appearing on the teeth while you are
undergoing the whitening treatment. These white spots were already present
on the teeth, as the teeth become lighter the spots wil fade. You may notice
these white spots immediately after a whitening session or the morning after if
you have worn the trays for a ful night (If you are using the night time
Some teeth may appear banded with lighter/whiter areas. Again these
bandings are original y present on the tooth. As the tooth is dark these
bandings are not obvious. As the tooth becomes lighter, the lighter parts of
the tooth wil lighten first fol owed by the darker banded areas. After a week or
so these wil not be noticeable anymore. How will my teeth feel?
Normal y the teeth feel very clean after the whitening procedure. The
bleaching materials also have an indirect effect on the gums helping them to
heal or improve the health of the gums. This is how the technique was
invented as it was first used to heal gum irritation during orthodontic
treatment. What about my smile?
Your smile wil appear brighter as a bonus. It is very rare, but sometimes the
teeth do not lighten at all. If this happens and you are wearing the bleaching
trays as recommended you wil need to try a different product with a higher
concentration of hydrogen peroxide. The dentist can do a few “ power
bleaching sessions “ for you while you relax in the chair. Discuss this with
If you have white fil ings in the front teeth that match the existing shade of
your teeth before bleaching, they may not match the teeth afterwards. This is
because your teeth can lighten, but the fil ing material cannot. When the
desired shade has been achieved then the dentist wil replace these fil ings
with a matching shade of fil ing material. Normal y the dentist wil wait a few
weeks before changing the restorations. This involves further cost.
How long does the bleaching last and will I have to bleach my teeth
Normal y the new light shade of your teeth keeps quite wel . The effect is
dependant on what has caused the teeth to discolour in the first place. If you
drink lots of coffee, red wine or cola drinks then the effect may darken slightly.
Some patients do a top up treatment after 3-4 years. Some patients however
do not need this.
The dentist wil normal y ask you to return your trays after the desired shade
has been achieved. This is to ensure you do not over bleach your teeth. Does bleaching harm the teeth or gums?
Safety studies have shown that bleaching teeth using the dentist prescribed
home bleaching technique is perfectly safe for your teeth, cheeks, gums and
soft tissue in the mouth. Whitening the teeth with the dentist prescribed kit is
equivalent to drinking one soda drink. The whitening material has a pH, which
There are problems with the whitening kits that are purchased over the
counter. Although they are inexpensive, they normal y contain and acid rinse,
which can damage the enamel on the teeth. The acid rinse can be extremely
harmful to the teeth. There was a case where a patient purchased a kit over
the counter. As the patient was bleaching their teeth they went darker in
shade. The patient continued to use the kit and over bleached the teeth. They
continued to appear darker because the acid rinse had worn away the enamel
on the teeth and the darker shade was the dentine that was exposed.
It is not however advisable to bleach your teeth if you smoke. It is best to try
and quit smoking at least 3 weeks before commencing the whitening process.
Smoking causes the teeth to darken anyway and the effects wil be
The technique of whitening teeth is not for everybody. There are some
situations where whitening teeth is contradicted such as where the front teeth
are already crowned or have very large fil ings or where the teeth are
excessively worn and there is loss of the tooth’s surface. The most ideal
situation is where there is not much wrong with the teeth except for the colour
which has become yel ow and discoloured with age.
Patient whitening record sheet
Date bleaching started: ____________ Age: __________
Patients main complaint: ________________________________________
Discolouration type: ___________________________
Preoperative shade: _________________ Shade guide used: ___________
Patients desired shade: _____________________________ Informed consent:
The patient is informed that there are no guarantees as to
the shade that can be achieved with this treatment. Further dental treatment
maybe required to bleach the teeth. These options may include
microabrasion, bonding, porcelain laminate veneers, crowns or a combination
of these. The patient is instructed to discontinue treatment should any
Patients signature: _________________________ Date: ______________ Bleaching Method:
(delete as appropriate)
• Non vital tooth: Tooth notation ___________Root canal treatment
• Patency of apical seal __________Radiographs checked_________
• Bleaching method: Walking bleach ____ Inside/outside technique___
• Bleaching material used: ____________Concentration:___________
• Power bleach: _______ Upper teeth _________ Lower teeth_______
• Bleaching material used: ___________________________________
• Radiographs checked: _____________________________________
• Home bleach: ________ Upper teeth: ______ Lower teeth: ________
• Presence of anterior composites: _____________________________
• Pt informed they may need replacing: _________________________
• Bleaching materials used: ______________ Concentration: ________
Shade preoperative: ______________
Shade postoperative: ______________
Recommended re-bleaching in applicable: ________________________
Problem encountered: ________________________________________
Maintenance: __________ ____________________________________
Further aesthetic treatment: ____________________________________
MEDICATION ADMINISTRATION FORM FOR STUDENTS Columbia-Montour Area Vocational Technical School THIS FORM MUST BE COMPLETED IF A STUDENT NEEDS TO TAKE MEDICATION AT SCHOOL. (Please read details below.) Students will be given prescription medication or other medications not routinely stocked in the nurse’s office only by the direct written order of a physician, according to rec
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