Sugarland Office: Baytown Office: (281) 494-2626 (281) 838-8888 TEETH WHITENING INFORMATION/INFORMED CONSENT I. GENERAL INFORMATION Teeth whitening is designed to lighten the color of your teeth. Significant lightening can be achieved in the vast majority of cases, but the results cannot be guaranteed. Vhen done properly, the whitening will not harm your teeth or gums. However) like any other treatment, i has some inherenr risks and limitations. These are seldom serious enough to discourage you from having your teeth whitened, but should be considered when deciding ro have the treatment. II. CANDIDATES FOR TEETH WHITENING Just about anyone is a candidate for teeth whitening. Howevet, people with dark yellow o yellow-brown teeth tend to whiten better than people with gray or bluish-gray teeth. Muhi-colored teeth, especially if stained due to tetracycline, do not whiten very well. Teeth with many fillings, cavities, chips, etc., are usually best treated by bonding, porcelain veneers or porcelain crowns. III. TYPES OF TEETH WHITENING A. ONE-HOUR WHITENING This process can be done in one visit or may requite multiple visits depending on how your teeth respond to the whitening gel. Each appointment takes about one hour. Gum protection is applied, the whitening gel is applied, and a special light is used to further enhance the bleach whitener. The advantages of power whitening inc our doing all the work for you and in less total time than you would spend home bleaching your teeth. The disadvantages include the normal inconveniences of any dental treatment such as having to keep your mouth open for the duration of the appointment and the possibility of increased costs as compared to home whitening. B. HOME WHITENING This process, which can be done anywhere and anytime, involves wearing a custom-made bleaching tray (looks like a thin, transparent nighrguard) filled with a mild bleaching agent for optimal results. You should wear the gel-filled tray 1/2—i hour pet day for about one to two weeks, depending on the degree of whitening desired. The advantages of home whitening include performing the treatment when it is convenient for you with lower cost. The disadvantage to home bleaching is that the success of the treatment is dependent on your commitment to wearing the whitening tray consistenfly for the prescribed period. IV. YOUR RESPONSIBILITIES A. AfflNG YOUR WHITENING TRAY If you choose home whitening, it will only be effective if you conscientiously wear the tray for the prescribed numbet of hours fot one to three weeks. B. COMPLICATIONS If you experience any severe discomfort or other problems, discontinue the bleaching and contact us immediately. Most sensitivity is usually transient and disappears after one to several days. V. POTENTIAL PROBLEMS A. TOOTH SENSITIVITY During the first 24 hours following whitening, some patients experience transient sensitivity. This sensitivity is usually mild if your teeth are not normally sensitive. With power whitening, this sensitivity will usually subside in 1—2 days. With home whitening, it may be necessary for you to teduce the number of hours you are wearing the bleaching tray or stop using it for several days to resolve the sensitivity. However, if your teeth are normally sensitive, whitening may make your teeth more sensitive for an extended period of time. Under these circumstances, you may choose to delay the whitening process until we are able to complcte desensitization procedures. If your teeth are sensitive after whitening, a mild analgesic such as Tylenol or Advil will usually be effective in making you more comfortable until your tooth sensitivity returns to normal. B. GUM IRRITATION This is the result of a small amount of solution leaking under the gum protection. A burning sensation on yout gums may also occur. This should resolve by itself between a few hours to a few days. With home whitening, irritation can result from using the tray for too many hours when you first start whitening. It may be necessary for you to reduce the number of hours you wear the tray or stop using it for a few days to resolve these gum problems. C. EFFECT ON FILLINGS Tooth-colored fillings will not whiten. If the filling matches your current color, bleaching will result in mis- matched shades with your natural teeth. You may need to have your fillings replaced to match your newly whitened teeth. VI. COMPLETION OF TREATMENT A. LEVEL OF LIGHTENING There is no totally reliable way to predict how light you teeth will whiten. With power whitening, one session usually significantly whitens your teeth. Some patients require an additional session. With home whitening, this may take two to four weeks or longer of repeated applications. B. RELAPSE Following completion of whitening, pigments found in food and drinks will re-stain your teeth, commonly called bleaching relapse. To help prevent relapse, use a daily over-the- counter toothpaste, or Sapphire” Brilliance from your dentist. I have read the information provided and understand the whitening procedure. Dr._____________ has explained this procedure to me and all my questions, if any, were answered. I consent to this treatment. Patient’s Signature _________________________________ Date __________________________________ __________________________________________________ Witness
September 10, 2008 Dear Provider: The following changes will go into effect September 15, 2008, regarding our formulary coverage. Please take a moment to familiarize yourself and staff to the amendments. Additions : Duragesic 12.5 mcg (fentanyl) will be added with the same restrictions as the other strengths, available to pain mgt and oncologists. All others require prior authorizat
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