Dental Bleaching Consent Form

In the course of the dental bleaching procedure performed at the surgery (chairside whitening) a thin, transparent plastic tray is placed on the teeth (after isolation from the gum and cleaning from the saliva) and it is filled with a whitening gel (‘Opalescence’ – USA). This procedure is performed by the dentist or the dental hygienist. The whitening material oxidizes (whitens) the colourings in the teeth.
The whitening material may cause a sensitivity of the teeth during the treatment. If you know that one or some of your teeth is/are especially sensitive you are to inform the dentist about it. In this case it is possible to administer anaesthesia on these teeth with injections. To all the teeth anaesthesia cannot be applied as it would require too many injections. Whitening is only recommended in case of teeth with no caries. If you know of any allergic reaction please inform the dentist. A pregnant lady or a breast-feeding mother should inform the dentist about her state as whitening cannot be performed in these cases, although probably it would not have any adverse effects.
The outcome of the whitening cannot be judged, different teeth react in different ways to the procedure. Multiple whitening sessions may be required in order to reach a good result. The bleaching performed at the dental surgery can be repeated after three days. By administering a whitening procedure at home a lighter shade may be reached; and this may be performed 24 hours after the bleaching procedure at the dental surgery. The expected shade cannot be guaranteed though even like this. The price of the individual whitening sessions has to be paid nevertheless. After one bleaching session the colour will be lighter by 1-2 shades (according to the Vita Classic Shade Guide). In order to document the degree of the whitening we prepare digital pictures before and after the procedure.
The colour of the fillings and prostheses will not change and their colour may differ from the colour of the bleached teeth after the procedure, so if the difference is disturbing they may have to be changed. Accordingly fillings at locations to be seen should only be prepared after the bleaching procedure. There may be some colourings on the teeth that may become more eye-catching after the whitening (at areas where the enamel has a defective matrix formation, e.g. enamel hypoplasia, hypocalcified enamel or areas poor in calcium).
Dental bleaching does not cause any lasting damage; the matrix of the teeth does not suffer any changes. Teeth may become temporarily sensitive to chewing and to certain temperatures. This will pass with time and with special materials (such as toothpastes to deal with sensitivity at the epithelial cuff, a gel to reduce concentrated sensitivity to be asked for from the dental surgery) the improvement may be accelerated.
The bleached shade of the teeth darkens a little within three weeks after the treatment and this colour will be the permanent shade. The time span of when the teeth get dark again depends on the frequency of consuming pigment-containing products (e.g. nicotine, coffee, tea, red wine, fruit juices). The process can be slowed down with perfect oral hygiene and the use of a whitening toothpaste (e.g. ‘Opalescence’).

I fully understand the above written information and I do not have additional questions.

Please perform dental bleaching:
1.: on my lower and upper teeth/ 2.:on my lower teeth/ 3.:on my upper teeth
(please underline the appropriate one and cross the rest of the lines)
The price indicated on the pricelist must be paid when the lower and upper teeth are bleached, when only the lower teeth are bleached and when only the upper teeth are bleached. When the lower and upper teeth are bleached separately the price must be paid only once if preliminary appointments are made with no more than 9 days apart (the bleaching mixture may be used up to 9 days.)

Esztergom, .....................................



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