Home Whitening Instructions, Information and Consent Form

We are planning to whiten your teeth using carbamide peroxide solution. Please read the following instructions carefully.

  1. The active ingredient is carbamide peroxide in a glycerine base. If you know of any allergy or are aware of any adverse reaction to this ingredient, please do not proceed with this treatment.
  • You should be aware that most bleaching systems use carbamide peroxide. This breaks down to urea and hydrogen peroxide. Hydrogen peroxide is the oxidising agent which is active against the stains within a tooth. As a rough rule of thumb, the concentration of hydrogen peroxide is one third of that of carbamide peroxide. Our bleaching gels are 10% and 16% carbamide peroxide. This equates to 3%and 5.3% hydrogen peroxide. In the UK hydrogen peroxide concentrations above 6% are illegal.
  • The bleaching system also contains potassium nitrate toreduce sensitivity, and are PH neutral to protect tooth enamel.
  1. As with any treatment there are benefits and risks. The benefit is that the teeth can be whitened fairly quickly in a simple manner. It is our experience, supported in the scientific literature, that 60% of patients who bleach suffer some degree of sensitivity. This has proven to be reversible. If the bleaching stops the sensitivity resolves. There is no evidence that the tooth surface is damaged in any way.
  1. The amount of whitening varies with the individual and whether the initial colour of the teeth was yellow, brown or grey. Better results are achieved with yellow brown shades. Most patients achieve a change within 2-5 weeks. Try not to drink tea, coffee and red wine or eat berries or curries during or immediately after treatment.
  1. It is advisable not to smoke during the course of bleaching.
  1. As mentioned above, sensitivity may result during whitening. This is usuallyslight and temporary. It is advisable to brush for at least two weeks prior to whitening using a toothpaste containing potassium nitrate eg Colgate Sensitive Pro-relief or Sensodyne. If sensitivity should occur see section 7 below. If symptoms persist contact the surgery on 01270 765771 for further advice.
  1. Do not use the bleaching treatment if you are pregnant. There have been no adverse reactions, but long-term clinical effects are unknown.
  1. Protocol to reduce likelihood of sensitivity.
  • Do not attend for scaling whilst teeth are sensitive
  • Avoid acidic foods and drinks: fruit and fruit juices, wine and yoghurt
  • Use a toothpaste designed to help alleviate sensitivity, before, during and following treatment
  • Alternate whitening sessions with an application of sensitive toothpaste in the whitening trays
  • Skip whitening sessions, for example whiten for 1 night then leave for 1 night
  1. Wear the tray overnight. We would recommend overnight for the best results. The longer the hydrogen peroxide is in contact with the tooth the more likely a better result.

What does the treatment involve?

Dental impressions are taken at the surgery and custom made acrylic trays are produced which fit snugly over the teeth and are fitted at the next visit. A small amount of whitening agent is placed in the tray and worn by the patient at home, usually through the night, according to instructions, for a period of two weeks. Please note that to achieve the desired shade you may need to follow the procedure for an extended period and purchase additional syringes of whitening gel during that time at a cost of £29.90 for 2.

Is everybody suitable for treatment?

Not all types of staining or discolouration respond well to tooth whitening. Results on teeth which are very dark or have patchy staining may be less predictable. Smoking and a high intake of tea, coffee, red wine or colas can affect the result. Teeth which are worn or eroded or which have been restored with large white fillings may also be unsuitable.

How will my teeth feel during the process?

Sensitivity of the teeth is the most common side effect of bleaching. This usually occurs around the necks of the teeth where the gum has receded. A desensitising agent is contained in the whitening gel to reduce sensitivity as much as possible Further techniques to reduce sensitivity are listed above.

How long will the treatment take?

This depends on the shade of your original teeth and how much whitening you require.

The first phase of the treatment involves using the trays every night at home for two weeks. The teeth will become whiter after this first stage but may require longer. To maintain your new shade, use of the tray about once every two to three months as a ‘top-up’ is recommended.

What about the rest of my mouth?

You should be aware that the colour of any white fillings or porcelain crown and bridgework you may have will remain unchanged through the whitening process. This is a very important consideration that needs to be addressed before whitening. You may need to consider renewing these restorations to match the new colour of your natural teeth, once the whitening process has been completed.

Treatment Plan Outline:

Appointment 1

A new patient must be seen for a consultation to determine suitability for the whitening procedure. The cost of this appointment is £42.75.

Existing patients’ suitability will be determined by their dentist.

Appointment 2

An appointment where the dentist will discuss in detail the procedure and obtain a signature of consent, they will also take impressions for whitening trays, scale (if necessary) and take ‘before’ photographs.

Appointment 3

2 weeks later to fit the whitening trays and demonstrate use of the kit.

Try not to drink tea, coffee and red wine or eat berries or curries during or immediately after treatment.

Appointment 4

A review appointment following the patient’s home whitening procedure to assess the progress when ‘after’ photographs may be taken. The timescale for this appointment will be determined at appointment 3. Additional syringes of whitening gel are available to purchase at this stage following advice given regarding the maintenance of the new stable whitened shade. Additional syringes may be necessary in resistant cases. Syringes costs £29.90 for 2.

Appointment 5

Not always necessary but an additional review appointment may be arranged should further home whitening be required. A consultation appointment may also be required to discuss any further treatment required following the lightening of the teeth for example replacement of fillings and/or crowns.

How much does it cost?

The cost of the treatment using the trays at home is £262.25

(Practice plan patients benefit from a 20% reduction on this fee and pay £212.20)

The additional top-up syringes cost £29.90 – you should expect that this extra expense may be required.

Desensitising Swabs can be purchased at a cost of £19.20.

Payment Schedule:

Appointment 1

£42.75

Appointment 2

£200.00

Appointment 3

£62.25

I have read and received a copy of this information sheet.

I consent to treatment and assume the risks described above.

I agree to the payment schedule.

I consent to photographs being taken. I understand that they may be used for documentation and for illustration of treatment.

Patient:………………………………………………….

Signed: …………………………………………………. (Patient)Date: ……………………….