Home Whitening Instructions & Consent Form

Please remember there are no guarantees as to the amount of lightening that can be achieved with the whitening treatment.

Please discontinue the bleaching if problems occur, and contact the surgery during our normal working hours for advice.

Alternatives to tooth whitening include micro-abrasion (this will only remove extrinsic surface staining), veneers and crowns (this is an invasive procedure that involves removal of tooth enamel/dentine which can result in irreversible damage to the nerve of the tooth).

We are planning to whiten your teeth using a 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 treatments there are benefits and risks. The benefits are that teeth can be whitened fairly quickly in a simple manner. Research indicates that using peroxide to bleach teeth is safe. 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 used by dentists for over 40 years.

The amount of whitening varies with the individual. Most patients achieve a change within 2-5 weeks. 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.

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.

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.

Instructions for tooth whitening

• Brush your teeth thoroughly and floss as normal.
• Remove the tip from the syringe containing the gel and extrude a little of the contents of the syringe into the appropriate part of the tray towards the deeper and front part of the tray. About half of the syringe will normally be necessary for your top and bottom trays.
• Seat the tray over the teeth and press down firmly.
• A tissue or a cotton wool roll should be used to remove excess gel that will flow beyond the edge of the tray. The tray is usually worn whilst sleeping, (the bleach is active up to 8 hours.
• In the morning remove the tray and brush the residual gel from the teeth. Rinse out the tray with COLD water only. Store your trays in a safe container. Do not brush the trays.
• Do not eat, drink or smoke while wearing the whitening tray.
• The gel should be stored in the fridge and not exposed to heat or sunlight.

The fee for the bleaching treatment cannot be waived if we decide that this treatment is voluntarily discontinued due to side effects, or if you decide to voluntarily discontinue the treatment.

The photographs taken of my teeth will be referred to for clinical purposes relating to my treatment and kept with my confidential dental records.

I agree to the photographs being taken by my dentist and consent to their use for the purposes described above. I understand that their use will be in accordance with the 1998 Data Protection Act.

I have read and understood the above information and agree to return for review appointments 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.