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Henderson dental practice
Wilkinson Dental Care - Home Whitening Information and Consent form
Who may benefit from teeth whitening?
Almost everyone. Whiter, brighter, younger looking teeth will boost your self-confidence and
make you smile more!
Your dentist will check your teeth to assess their suitability for whitening. X-rays of your teeth
may be required. Impressions are taken of your mouth from which two thin plastic
customised Perfect Trays* are made. On your return visit for tray fitting we will show you how
to apply the whitening gel and how to fit the trays onto your teeth. The colour of your teeth
will be recorded using a Vitapan Classical shade guide. We will review your teeth after 2
How long should I wear the trays for?
This depends on the amount of lightening that you desire and the original shade of the teeth.
If your teeth are quite dark or very yellow/grey/tetracycline stained, it will take longer to
bleach the teeth. If you are not experiencing any sensitivity, you may wear the trays
throughout the night or for 1-2 hours twice daily depending on the strength of the gel and as
directed by your dentist. It is important not to overload the trays with gel, there is no extra
benefit and the gel will be wasted, all excess must be wiped away from the gums and palate.
The darker your teeth, the longer your teeth will take to get lighter. In tetracycline stained
teeth, it can take up to one year to bleach the teeth. Most teeth will whiten after 2-3 weeks
and your teeth will usually get 4-5 shades whiter with this treatment.
What do I do if I have sensitivity?
Sensitivity of teeth is the most common side effect of home whitening. In fact, many patients
suffer from sensitive teeth anyway. This usually occurs around the necks of teeth where the
gums have receded. If you are experiencing any sensitivity, you should stop whitening your
teeth temporarily. You can resume after about 1-2 days. In the unlikely event that your teeth
become ultra sensitive, you can place sensitive toothpaste into the bleaching trays for an
hour a day. That will usually stop the sensitivity. If you are at all concerned, please contact
*Your impressions will be sent to the dental laboratory of Dr Wyman Chan who is a world
expert in teeth whitening. He has patented his own design of whitening tray, the Perfect tray,
which fits your teeth exactly and comfortably, is simple to use and reduces the side-effect of
What happens if my teeth do not whiten evenly?
If the teeth have white spots on them before whitening, these spots will appear whiter during
the first few days. However the contrast between the spots and the rest of the tooth will be
less and eventually they will not be noticeable.
You may notice new white spots occurring on the teeth while you are undertaking the
bleaching treatment. These white spots were already present on the teeth before whitening.
As the whole tooth itself becomes lighter, these spots will fade. You may notice these white
spots immediately after a whitening session.
Some teeth may appear banded with lighter/whiter areas. Again, these bandings are
originally present on the tooth. As the tooth is dark these bandings are not obvious. As the
tooth becomes lighter, the lighter parts of the tooth will lighten first followed by the darker
banded area. After a week or so, these will not be noticeable any more.
What about my smile?
Your smile will appear brighter as a bonus. It is very rare, but sometimes the teeth do not
lighten at all. If this happens and you are wearing the bleaching trays as recommended, you
may need to try a different whitening product or a slightly higher concentration of the
whitening material. Discuss this with your dentist.
If you have white fillings in the front teeth that match the existing shade of your teeth before
you whiten your teeth, they may not match the teeth afterwards. This is because your teeth
can lighten, but fillings do not lighten. When the desired colour has been achieved, the
dentist can replace these fillings with a lighter shade of filling material to match the new
shade of your teeth. Normally the dentist will wait a week before changing the fillings.
How long does the whitening last? Will I have to whiten my teeth again?
Normally the new white colour of your teeth holds well. The effect is dependent on what has
caused the teeth to discolour in the first place. If you drink lots of coffee, red wine and cola
drinks, the effect may darken slightly. Some patients do a top up treatment after 1-2 years.
Some patients do not need to.
Does whitening harm the teeth or gums?
Safety studies have shown that whitening the teeth using the dentist prescribed home
whitening technique is perfectly safe on the teeth, cheeks, gum and tissue of the mouth.
Bleaching the teeth with the dentist prescribed kits is equivalent to drinking one soda drink.
The technique of whitening teeth is not for everybody. There are some situations where
bleaching is contraindicated, such as where the teeth are already crowned, where there are
very large fillings in the front teeth or where the teeth are already excessively worn and there
is tooth surface loss. The most ideal situation is where there is nothing much wrong with the
teeth except for the colour, which has become more yellow with age
Home Whitening Instruction 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 an adverse reaction to this ingredient, please do not proceed with this treatment.
2. As with any treatment there are benefits and risks. The benefit is that the teeth can be
whitened fairly quickly in a simple manner. The risk involves the continued use of the peroxide solution for an extended period of time. Research indicates that using peroxide to bleach the teeth is safe.
3. You will be provided with the appropriate trays and enough gel for 2-3 weeks treatment.
After this time, extra gel may be purchased if you want your teeth to go even whiter.
4. The amount of whitening varies with the individual. Most patients achieve a change within
2-3 weeks. Try not to drink tea, coffee and red wine or eat berries or curries during or after treatment for at least a month.
5. It is advisable not to smoke during the course of whitening treatment. 6. Sensitivity may occur after a few days. This is usually slight and temporary. If this should
occur, refrain from using the whitening treatment for 1-2 days.
7. Do not use the whitening treatment if you are pregnant. There have been no adverse
reactions, but long term clinical effects are unknown.
8. Wear the tray for 1-2 hours twice daily or overnight depending on the strength of the
whitening gel, your dentist will direct you.
9. It may be necessary to do a top-up treatment in 18-24 months depending upon the
amount of staining. This is usually for 2-4 nights and can be done in the existing bleaching trays.
I have read all the above information and agree to return for an examination 2 weeks
after treatment commences and at any recommended time afterwards. I have read and
received a copy of this information sheet and agree to proceed.
Signature of Patient: - Date:-
Please print your name:-
REPUBLIKA E KOSOVËS/REPUBLIKA KOSOVA/REPUBLIC OF KOSOVA ZYRA E AUDITORIT TË PËRGJITHSHËM/KANCELARIJA GENERALNOG REVIZORA/OFFICE OF THE AUDITOR Doc. No: 2113.2-2008-08 AUDIT REPORT OF FINANCIAL REPORTING AND ASSET MANAGEMENT OF TREPÇA COMPLEX – STAN TERG MINE FOR PERIOD JANUARY- JUNE 2008 Prishtina, November 2008 Adresa: Gazmend Zajmi 59-10.000 Prishtinë-Kos
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