Home whitening instructions and consent form

Patient’s Name:____________________________
Date :____________________________________
We are planning to whiten your teeth using carbamide peroxide solution. Please read the
following instructions carefully.
The active ingredient is carbamide peroxide in a glycerine base. If you know of any allergy or
are aware of an adverse reaction to this ingredient, please do not proceed with this treatment.
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
such as a few years. Research indicates that using peroxide to bleach teeth is safe. There is
new research indicating the safety for use on the soft tissues (gingivae, cheek, tongue,
throat). The long-term effects are as yet unknown. Although the extent of the risk is unknown,
acceptance of treatment means acceptance of risk.
This type of whitening treatment has been done for some patients for over 40 years. During
that time, nobody needed a root canal or damaged a tooth following home bleaching
The amount of whitening varies with the individual. Most patients achieve a change within 2 –
5 weeks. Try to reduce the amount of tea, coffee, red wine and refrain from eating berries or
curries during or after treatment for at least 1 month. You may use the toothpaste supplied
with the kit to clean your teeth during treatment.
It is advisable not to smoke during the course of bleaching treatment for at least 5 - 8 weeks.
Sensitivity may result after a few days. This is usually slight and temporary. If this should
occur refrain from using the bleaching treatment for 1day or apply the soothing gel into the
tray that you will be given.
Do not use the bleaching treatment if you are pregnant. There have been no reports of
adverse reactions, but long term clinical effects are unknown.
Wear the tray overnight or for a minimum of two hours per day.
Some teeth do not bleach evenly particularly around gum recession on the lower premolar
teeth. The enamel bleaches well but the exposed dentine does not bleach as well.
When the treatment is completed, please keep the trays so that they can be used for a top-up
maintenance treatment. It may be necessary to do a top-up treatment in 18 - 24 months
depending on the amount of staining.
I have read the above information and agree to return for examination after the treatment
begins and at any recommended time afterwards. I have read and received a copy of this
information sheet. I consent to the treatment and accept the risks described above.
I consent to photographs being taken. I understand that they may be used for
documentation and for illustration of my treatment.
Signed Patient:_________________________
How to manage sensitivity during whitening treatment
Sensitivity of teeth is the most common side effect of whitening treatment. This
usually occurs around the necks of the teeth. Patients can experience some degree
of sensitivity which ranges from mild awareness to a throb on a specific tooth. Up to
50% of patients suffer with some sensitivity.
If you are experiencing sensitivity during your whitening treatment these are the
different treatments that you should follow.
1. We will provide you with a desensitising toothpaste to place in your bleaching
trays. This should be placed in the trays in exactly the same way that the bleaching
material is placed. You should alternate each night, one night with the Sensitive
toothpaste and the following night with the bleaching material, or you can apply it
onto the tray for one hour per night. This should be continued until the sensitivity
2. You can also brush with the desensitising toothpaste during the whitening
treatment. Place a small amount of the tooth paste on your finger and rub it into the
sensitive area. You should repeat this each night until the sensitivity disappears.
3. You can stop the whitening for one night if the sensitivity is too severe. Do not stop
for more than two nights otherwise the effect of the whitening will slow down.
Sometimes the gums may also feel a little sensitive. If you notice the gums are
feeling sore, you need to refrain from bleaching for one day or reduce the
concentration of the whitening gel.
If symptoms persist please contact the practice on 01880820387

Patient log for home tooth whitening
Patient’s Name:__________________________________________ Date:_________________ Present shade of teeth: Please complete this log while you are whitening your teeth at home so that we can see the amount of progress you are making. Store it together with your kit for ease of access. If you have any untoward problems, please call the practice. Please bring this log sheet to each appointment. What to expect during your whitening treatment
Your dentist has given you a bleaching kit to take home with you together with your bleaching trays. It is essential that you follow the instructions given by your dentist and the manufacturer’s instructions in wearing the trays and applying the bleaching agent. Below are answers to the most frequently asked questions. 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 very yellow/ grey/ tetracycline stained it will take longer to bleach 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 all the excess material around the gums or the palate prior to sleeping with the trays. The darker your teeth, the longer your teeth will take to get lighter. Tetracycline stained teeth can take 6 months or up to one year to bleach 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. Bleach your teeth according to your own schedule. Some people put the trays in after dinner and wear them for the first hour while watching TV or doing the dishes. Then if everything is fine they replenish the trays and sleep with them in the mouth. What do I do if I have any sensitivity? Sensitivity of teeth is the most common side effect of home bleaching. In fact many patients suffer from sensitive teeth any way. This occurs usually around the necks of the teeth where the gums have receded. If you are experiencing any sensitivity you should stop bleaching your teeth for a few days. You can resume after about 2-3 days. If the teeth become ultra sensitive you can place sensitive toothpaste into the bleaching trays for an hour a day. That will usually stop the sensitivity. Alternatively you can rub the desensitising toothpaste into the gum margins with your finger 5 times per day for a few days. If you are at all concerned, please call the practice. What happens if the teeth do not bleach evenly? If the teeth have white spots on them before bleaching, these spots will appear whiter during the first few days, however the contrast between the spots and the rest of the tooth will be less and eventually they will not be noticeable. Sometimes the dentist can do a special procedure called Microabrasion for you where the white spots can be more permanently removed. Ask your dentist about the procedure if you are concerned about this. You may notice new white spots occurring on the teeth while you are undertaking the bleaching treatment. These white spots were already present on the teeth before bleaching. As the teeth become lighter they become more visible. Do not worry. As the whole tooth itself becomes lighter these spots will fade. You may notice these white spots immediately after a bleaching session or in the morning if you have been wearing the trays for the whole night. Some teeth may appear banded with lighter/ whiter areas. Again these bandings are originally 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 will lighten first followed by the darker banded area. After a week or so these will not be noticeable any more.

Source: http://www.tarbertdentalsurgery.co.uk/assets/Home%20whitening%20instructions%20and%20consent%20form.pdf


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