| page 1
page 2 |
page 1 |
page 2 |
bleaching is a relatively simple bleaching procedure by which
you, supervised by your dentist, can easily and effectively
apply a bleaching solution to your teeth in a custom-made
plastic frame to hold the bleach against your teeth.
Ingredients of this bleaching solution are carbamide peroxide, hydrogen peroxide, glycerin, and trace
amounts of fluoride and flavorings. Do not begin treatment if
you are allergic to any of these materials.
Although peroxide solutions have long been
used as a mouth antiseptic, they have only recently been used for home bleaching with professional
assistance. The FDA (Food and Drug Administration) has approved
its use as an antiseptic but not as a home bleach.
Dentists have bleached teeth with hydrogen
peroxide for about 100 years with no long- term adverse effects
to teeth. Although preliminary results with home bleaching are
encouraging, Long-term effects, particularly on enamel, dentin,
gums, cheeks, tongue, throat are not yet established.
As with any procedure there are benefits
and risks. The hoped for benefit is whiter teeth. The risks
include, but are not limited to, occasional hot and cold teeth
sensitivity, a burning sensation of the gums, soft tissue
ulcers, nausea, soreness in the teeth and changes in bite, jaw
joint soreness or disorders form the appliance, sore throat from
swallowing bleach and facial pain. These problems occur in less
than 10% of patients treated. Discontinue treatment if any of
these symptoms occur.
Dental crowns and fillings usually do not
lighten and may be more noticeable after treatment. In
addition, these restorations can occasionally be damaged from
bleaching and may need to be replacement.
CONTRAINDICATIONS TO TREATMENT
Patients should not smoke tobacco or use other potential
carcinogens during treatment. Bleaching materials may
potentiate carcinogenic effects.
Pregnant women or those expecting to be pregnant should not
undergo treatment. Long-term effects of bleaching materials on
pregnancy have not been studied.
Patients with root sensitivity may not wish
treatment since sensitivity can be aggravated.
While there is no guarantee of tooth whitening and the amount
of tooth lightening is unpredictable, most teeth lighten 1
to 2 shades on the Vita shade guide.
Average treatment time is 2 to 6 weeks but some results may be
seen in 5 days. more difficult cases require extended treatment
times and may result in teeth looking chalky.
Yellow and brown stains usually respond best (aging,
yellowing); gray and blue stains usually improve less (i.e.
Tetracycline and Fluorosis).
In some patients, stains
relapse when treatment is discontinued.
The exact duration of whitening varies among patients. With
office bleaching, whitening usually lasts from 6 months to a few
years when some or all of the original tooth color
appears. Periodic retreatment is generally indicated with
office bleaching and should be expected with home bleaching.
Place a few drops of bleaching solution on the inner wall of the
bleaching appliance by the teeth to be
whitened. With both hands, carefully place the filled
appliance in the mouth. Expectorate excess
solution. Swallowing bleach, although not harmful, can result
in throat irritation. Wear for the recommended time.
To change the solution, remove the appliance
with both hands, rinse your mouth with water, rinse and dry the
appliance, and replace the solution. Brush the appliance
inside and out every day. Clean your teeth as usual.
The more treatments per day the faster the bleaching. However,
this can also increase sensitivity and cause other
Slow Bleach: the safest is to wear the filled appliance 3-4
hours a day, replenishing every 30 to 60 or as indicated by your
dentist. Always use the recommended replenishing time.
Fast Bleach: Maximum wearing time is 8-16 hr/day replenished as
directed. This should only be done under the direction and
supervision of your dentist and only after shorter treatment has
Nighttime treatment is an option although day use works faster
since there are more changes of bleach. If this appeals to you,
discuss it with your dentist.
Fluoride may be applied to the teeth every day before bedtime.
Some patients say this reduces sensitivity while
others say it has no effect. Discuss this with your dentist.
Discontinue bleaching if the teeth, gums, or bite become
uncomfortable. See your dentist immediately for correction.
Do not wear the appliance
Your dentist should check your mouth every 1 to 6 weeks to
ensure no damage is being done to your teeth, gums, or dental
Discontinue treatment if any discomfort or
problems occur, and see your dentist immediately.
wearing time: ____ hours Replenish
solution every ____ hours
I have read the above and any of my questions
and concerns have been answered and explained to me. I agree to
return for examination during treatment as recommended by my
dentist. I also agree to return for periodic oral examinations
after treatment is completed. I have received a copy of this
information and instruction sheet. I understand the directions
and risks, and I consent to treatment.
I also consent to photographs being taken. I
understand they will be used for documentation, treatment study,
and for educational purposes.
I further understand the first bleaching gel
syringe will be provided to me free of charge. If I desire more
bleaching gel for future use, I would need to purchase the new
__________________ Date: _________