Informed constent for dental whitening description of the procedure

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Artistic Dentistry of Atlanta

Dr. Peter V. Vanstrom, D.D.S.

Dr. Anna M. Refai, D.M.D.



In-office tooth whitening is a procedure designed to lighten the color of my teeth using a combination of a hydrogen peroxide gel and a specially designed ultraviolet lamp MAY be used. The treatment involves using the gel and possibly a lamp in conjunction with each other to produce maximum whitening results in the shortest possible time. During the procedure, the whitening gel will be applied to my teeth and my teeth may be exposed to the light lamp for one to three sessions. During the entire treatment, a plastic retractor will 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 either the gel or light. Vaseline may also be applied as needed and I will be provided an ultraviolet light filter for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth.


I understand I may decide not to have the whitening treatment at all. However, should I decide to undergo the treatment, I understand there are alternative treatments for whitening my teeth for which my dentist can provide me additional information. These treatments include: Whitening Toothpastes/Gels, other In-office Whitening Treatments, Take-Home Whitening Kits


I also understand that whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can benefit from whitening treatments and significant whitening can be achieved in most cases. I understand that whitening treatments are NOT

intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative

materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better

results than people with gray or bluish-gray teeth. I understand that teeth with multiple colorations,

bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, may need multiple

treatments or and may not whiten at all. I understand that teeth with many fillings, cavities may not

lighten and are usually best treated with other non-bleaching alternatives. I understand that

provisionals or temporaries made from acrylics may become discolored after exposure to whitening treatment.

I understand that whitening treatment is not recommended for pregnant or lactating women, light sensitive individuals, patients receiving PUVA (Psoralen + UVA radiation) or other photochemotherapeutic drugs or treatment, as well as patients with melanoma, diabetes or heart conditions. I understand that the Zoom! Lamp emits ultraviolet radiation (UVA) and that patients taking any drugs that increase photosensitivity should consult with their physician before undergoing Zoom! treatment.

I understand that the results of my Zoom! Treatment cannot be guaranteed.

I understand that in-office whitening treatments are considered generally safe by most dental


I understand that some of the potential complications of this treatment include, but are not limited to:

  1. Tooth Sensitivity/Pain

During the first 24 hours after whitening treatment, some patients can experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain following a whitening treatment subsides

within 24 hours, but in rare cases can persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed root surfaces, recently cracked teeth, abfractions (micro-cracks), open 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.

  1. Gum/Lip/Cheek Inflammation

Whitening may cause inflammation of your gums, lips or cheek margins. This is due to inadvertent exposure of a small area of those tissues to the whitening gel or the ultraviolet light. The inflammation is usually temporary which will subside in a few days but may persist longer and may result in significant pain or discomfort, depending on the degree to which the

soft tissues were exposed to the gel or ultraviolet light.

  1. Dry/Chapped Lips

The whitening treatment involves sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor. This could result in dryness or chapping of the lips or cheek margins, which can be treated by application of petroleum jelly.

  1. Cavities or Leaking Fillings

Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone a root canal procedure. If any open cavities or fillings that are leaking and allowing gel to penetrate the tooth are present, significant pain could result. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings redone before undergoing the whitening treatment.

  1. Cervical Abrasion/Erosion

These are conditions which affect the roots of the teeth when the gums recede and they are characterized by grooves, notches and/or depressions, that appear darker than the rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the enamel that covers the rest of the teeth. Even if these areas are not currently sensitive, they can allow

the whitening gel to penetrate the teeth, causing sensitivity. I understand that if cervical

abrasion/erosion exists on my teeth, these areas will be covered with dental dam prior to my whitening treatment.

  1. Relapse

After the whitening treatment, it is natural for the teeth that underwent the treatment to

regress somewhat in their shading after treatment. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents. Treatment usually involves wearing a take-home tray or repeating the in-office whitening treatment. I understand that the results of the whitening treatment are not intended to be permanent and secondary, repeat or take-home treatments may be needed for me to maintain the tooth shade I desire for my teeth.

Since it is impossible to state every complication that may occur as a result of whitening treatment, the list of complications in this form is incomplete.
The basic procedures of whitening treatment and the advantages and disadvantages, risks and known

possible complications of alternative treatments have been explained to me by Dr. Peter Vanstrom or Dr. Anna Refai and/or their staff and all my questions have been answered to my satisfaction.

In signing this informed consent I am stating I have read this informed consent (or it has been read to

me) and I fully understand it and the possible risks, complications and benefits that can result from the whitening treatment and that I agree to undergo the treatment.


Patient (Printed name) Date

Patient Signature

Relationship to patient if not the patient:


Witness Date

Doctor Date

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