Teeth whitening involves bleaching your teeth to lighten the colour of the enamel.

The main ingredients used in tooth whitening products are the chemicals hydrogen peroxide or carbamide peroxide. The chemicals usually come in a gel, which is applied to your teeth. Sometimes a light is used too.

Only registered dental practitioners can use the strong whitening gels and products containing more than 6% hydrogen peroxide. These are most effective.

The Australian Dental Association advises that only registered dental practitioners have the training and knowledge to assess if bleaching is appropriate and safe for you. They are responsible for meeting safety and quality regulations.

Teeth whitening services may be offered by unregulated, unqualified practitioners, for example in:

• beauty and hair salons

• shopping malls

• salons

• via mobile services

You can also buy teeth whitening kits online or at the supermarket. These may contain bleaching chemicals or charcoal or bicarbonate of soda. Some kits may not be reliable and using them incorrectly can cause further dental problems.

Teeth whitening by a non-qualified dental practitioner can damage your teeth and gums. Dental practitioners are responsible for meeting safety and quality regulations and can provide a professional assessment of your teeth.

In-chair teeth whitening

Some whitening treatments can be done while you are sitting in the dental chair.

Your dentist or dental practitioner applies strong hydrogen peroxide gel. Often a light is placed over the teeth. You should leave your dental appointment with whiter teeth.

Take-home teeth whitening

With take-home teeth whitening, your dentist will provide you the instructions on how to use the take home kit.

This method of teeth whitening takes longer to achieve results than in-chair treatment. This doesn’t mean that the final result is better or worse.

Call us on 02 8605 2261 to get the best available offer on our In-chair teeth whitening.

Consent For Teeth Whitening

This form must be signed by a person who is above 18 years of age and is undergoing a treatment for the teeth whitening. You may be asked to provide the proof of age before starting the treatment.

 TEETH/TOOTH WHITENING TREATMENT PATIENT INFORMATION SHEET 

Background: We provide this information to give you insight into Chairside professional tooth whitening.  Your cooperation and understanding of this material is necessary as we strive to achieve the best results for you. 

Procedure:  Chairside professional tooth whitening is a procedure designed to lighten the color of your teeth using a hydrogen peroxide mixture.  It produces maximum whitening results in the shortest possible time with minimum sensitivity.  During the procedure, the whitening gel will be applied to your teeth for three (3) 8-minute sessions.  For the duration of the entire treatment, a plastic cheek retractor will be placed in your mouth to help keep it open and your gums will be covered with a barrier to ensure isolation from the hydrogen peroxide gel.  Before and after the treatment, the shade of your teeth will be assessed and recorded.

Risks: All forms of health treatment, including tooth whitening, have some risks and limitations.  Complications that can occur in professional tooth whitening are infrequent and are usually minor in nature. 

·   Tooth Sensitivity: During the whitening process some patients may experience tooth sensitivity.  This is normal and generally mild if your teeth are not normally sensitive.  If your teeth are normally sensitive, please inform us before treatment.  Please let us know if you experience any discomfort during or after the procedure so we are able to minimize your discomfort. A mild analgesic will usually be effective in eliminating any discomfort.

·   Gum and soft tissue irritation: Whitening may cause inflammation of your gums, lips or cheek margins.  This is generally the result of the whitening gel coming into contact with these tissues.  Protective materials are placed in the mouth to prevent this, but despite our best efforts, it can still rarely occur. If any irritation does occur, it is generally short in duration and is very mild.  Rinsing with warm salt water can relieve it.

·   Existing restorations:  White fillings; porcelain or composite restorations, crowns or veneers may not whiten at all or evenly with your natural teeth during this procedure. Please discuss this with your dentist prior to beginning treatment.

Treatment Responsibilities:  If you do not understand something communicated to you during consultation, or in any printed material given to you before or after the procedure, please feel free to ask.

Expectations: Significant whitening can be achieved in many cases, but there is no absolute way to predict how light your teeth will get.  Please understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline staining or fluorosis do not whiten as well and may appear more spotted after treatment. These effects are generally short in duration. Chairside professional tooth whitening  is not recommended for pregnant or lactating women, children under 18 years of age or any persons having known peroxides allergies.

Alternate Treatment Options: While we feel that Chairside whitening is the fastest, most effective means of whitening your teeth, please take note that there are other options available to you, such as take home systems or Paint on whitening.  If you have questions regarding other treatment alternatives please ask the dentist.

INFORMED CONSENT FOR IN-CHAIR TOOTH WHITENING

First Name:__________________________

Last Name______________________________

Date Of Birth:________________________

Address:_____________________________________________________________________

Phone Number:_______________________

E-mail:_________________________________

Emergency Contact Name / Phone:_________________________________________________

I _________________________would like to have my teeth lightened via the “in-chair” whitening technique. 

• This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision before signing this informed consent form. I have been encouraged to ask questions before agreeing to undergo the procedure. 

• I understand dark yellow or yellow‐brown teeth tend to whiten better than grey or bluish‐grey teeth. I understand for the best results a cleaning is recommended to remove any deposits prior to whitening.

• I understand if I suffer from periodontal disease (bone loss around my teeth), and the roots of my teeth are exposed and dark, whitening will not change the colour of my roots, only of the enamel. I also understand it is likely that these areas may be more sensitive when exposed to the whitening material. 

• I understand there is no totally reliable way to predict how light my teeth will whiten however, on average, I can hope for four shades lighter on a standard shade guide.

• I understand that this procedure is not recommended for children under 18 or women that are pregnant or breastfeeding.

• I believe, to the best of my knowledge, I am not allergic to any of the following: Hydrogen Peroxide, Glycerin, Carbomer Sorbitol, Sodium Hydroxide, EDTA, Potassium Nitrate or Silicone.

• I understand In-Chair Whitening is a procedure designed to lighten the colour of my teeth by application of a hydrogen peroxide gel. The In-Chair Whitening treatment involves using the gel to safely produce a maximum whitening result in the shortest possible time. The gel concentration meets the Australian TCA recommendations and guidelines. 

• I understand During the procedure the whitening gel will be applied to my teeth for two or three 8-minute sessions, with an optional fourth 8-minute session. During the entire treatment, a plastic retractor may be placed in my mouth to help keep it open and the soft tissues of my mouth (i.e. my lips, gums, cheeks and tongue) will be covered to ensure they are not exposed to the gel. 

• Lip balm may also be applied as needed and I will be provided protective eyewear for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper-front teeth will be assessed and recorded. 

• I understand the application of a LED light is not universally acknowledged to aid the whitening effect and POLA Rapid teeth whitening process is done without LED light.

• I understand that In-Chair Whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials. 

• I understand that teeth with multiple mixed discolorations, eg., discoloured bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, and may need multiple treatments or may not whiten at all.

• I understand that teeth with many fillings, cavities, chips or cracks may not lighten and are usually best treated with other non-bleaching alternatives. 

• I understand that the results of my In-Chair Whitening cannot be guaranteed. 

• I understand that although great care is taken using state of the art techniques the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to: 

• Tooth Sensitivity, this is normal and is usually mild, but it can be worse in susceptible individuals. In most cases tooth sensitivity following a whitening treatment subsides after a few days, but it may persist for longer periods of time in some people. People with existing sensitivity, recession, exposed dentine, exposed root surfaces and large wear facets (severely worn teeth), damaged or missing enamel, cracked teeth, cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after whitening treatment. I understand I may need to take some form of over the counter pain relief medication until my tooth sensitivity returns to normal.

• Gum Irritation may result if some of solution leaks under the gum protection. I may feel a warm sensation on my gums and I may notice a white film on my gums. This will resolve by itself between a few hours to a few days. I may also experience tenderness and/or swelling of the lips. 

• I understand tooth coloured fillings will not whiten. If the filling matches my current colour, whitening will result in mis‐matched shade with my natural teeth. If this concerns me, I may need to consider having my existing fillings replaced to match the newly whitening teeth. 

• I understand that the results of the whitening treatment is not intended to be permanent and additional, repeat or take-home treatments may be needed to maintain my desired tooth shade. 

• I understand that after treatment, I will be required to refrain from consuming any substances that could discolour my teeth for the first 48 hours after treatment. These substances include: coffee, teas, and colas, all tobacco products, mustard or ketchup, red wine, soy sauce, berries and red sauces. 

• I understand that the longevity of my whitening results will vary based on the types of food and drink that I consume, brushing habits, and optional maintenance with other whitening maintenance products, eg., take home whitening kits. 

Informed Consent

 I understand the above list includes all the common complications and I am aware the list of complications in this form is not complete. 

My dental health care provider has explained to me the basic whitening procedures, the advantages and disadvantages, the risks and known possible complications, also alternative treatments have been discussed and my questions have been answered to my satisfaction.  I understand that my Chairside professional whitening  treatment cannot be guaranteed.  I can ask my doctor about whitening treatments that will most benefit my case.I understand that after treatment, I will be required to refrain from consuming any chromogenic substances (i.e. tomato sauce, coffee, all tobacco products) for 48 hours.

In signing this informed consent, I am stating I have read this informed consent and I fully understand it and the possible risks, complications and benefits that can result from the Chairside tooth whitening system. . I  agrees to indemnify 32 Pearls Dentists (32 Pearls Pty Ltd) , its staff and directors against all claims, actions, demands, suits, damages, liabilities, losses and expenses made by me or any other person in respect to the dental treatment / service rendered.

Patient’s Signature: ____________________________________  Date: _______________

Patient’s Name (printed):