Kenmuirortho.co.za

INFORMATION AND CONSENT FORM
following braces removal for the office of Dr Kenmuir OVERVIEW
This tooth bleaching/whitening technique uses a custom-fitted retainer and peroxide-
containing whitening agents. Night wear uses one application at bedtime. Treatment time is generally 2-6 weeks. The more times or longer the solution is applied, the faster the bleaching occurs. However, faster bleaching may invite side effects of tooth or gingival sensitivity. The limitation to the amount of wear-time will be determined by the mouth's response to treatment. Excessive extended wear beyond the prescribed treatment time should be avoided. There is no reason, nor is it desirable, to continue treatment with "touch-up" or periodic applications unless there is an obvious relapse of the colour change.
ABOUT STAINS
Human clinical studies have shown 9 out of 10 patients have a successful experience. Most
persons experience some lightening of their teeth, even if it may not be to the extent they desire. However, not all patients are responsive to the treatment, and not all patients respond at the same rate. The only way to know at this time whether or not your teeth will respond to the treatment is to attempt the treatment, with no guarantee of success. Tetracycline-stained teeth are the least responsive, brown-fluoresced teeth and single dark teeth respond moderately, and teeth discoloured by age, genetics, smoking or coffee stains are the most responsive to bleaching. Teeth in the two "less-responsive" categories often require an extended treatment-time to achieve the maximum benefit, which may only be a lightening of the same colour of the teeth. White spots are not removed, but may be less noticeable. There is no noticeable colour change in composite restorations or crowns, so these restorations may need replacement for proper colour-matching after the treatment. If you have many restorations that show in your smile, the fee for replacement of these existing restorations may be a contra-indication for bleaching treatment.
SIDE EFFECTS
Two common side effects have been noted by researchers in approximately 2/3 of the persons using this dentist-prescribed, home-applied bleaching treatment: 1. Tooth sensitivity: The most common side effect noted (1/4-1/2 patients) is that
some teeth may be more sensitive to temperature changes during treatment. However, sensitive teeth return to normal when treatment is terminated, and no long-term effects noted from this sensitivity (7-year recalls). Should the teeth become too sensitive to continue treatment in the proposed fashion, treatment should be discontinued and the office contacted. Often, reduction of the amount of treatment time per application, or reduction of the frequency of treatment applications will reduce or alleviate the sensitivity such that the bleaching treatment may still be continued. Occasionally other materials such as fluoride or desensitizing agents like potassium nitrate may be applied with the tray to reduce sensitivity. These applications may alternate with bleaching, or to be used 10-30 minutes before or after bleaching as needed. Brushing with a desensitizing toothpaste may be helpful.
2. Tissue sensitivity: For 1/3 of patients, the peroxide solution may initially cause
some tissue irritation on an isolated portion of the gums. Irritation also can be due to mechanical causes, as well as chemical causes. Irritations usually occur in the first week or two of treatment. Chemical irritations may resolve in 1-4 days without cessation of treatment. Should the irritation be too uncomfortable to continue bleaching, treatment should be discontinued, and the office informed of this circumstance. For the first-time occurrence, treatment will be stopped for one day, after which the prosthesis can be re-inserted and the treatment continued. If the irritation persists, an office visit may be needed. Mechanical irritations may require altering the shape of the prosthesis, or the technique of removal. Occasionally a new impression will be made and a new prosthesis will be fabricated, but at no charge to you.
Limitations and age related differences
The major limitations to wearing time are personal preference and the incidence or magnitude of tissue irritation/tooth sensitivity. However, some persons do not like the taste, while others cannot sleep well with the prosthesis in place. There are no age limitations. Older person's teeth respond well, although some root surfaces do not lighten much. Generally children in the 10-14 year-old range comprise the lower limit of treatment. Bleaching is generally not indicated on primary teeth (milk teeth) except in trauma instances. Treatment has not been recommended on pregnant women or nursing mothers because there is no reason to prescribe an elective procedure in the face of their more important responsibilities. If you become pregnant during bleaching, there is no indication of any harm to the baby. However, treatment will be stopped due to changes occurring in the body from pregnancy, such as gingivitis or nausea. Most often the limitations for bleaching are the amount of restorative treatment that would be necessary to be replaced should the bleaching be successful, the severity of tooth sensitivity, or the taste. You, the patient, must also take responsibility to apply the material at home for it to The process used in our office immediately following braces removal:
An examination will determine the probable cause of the discolouration (aging, drug-
induced, genetic, smoking, fluorosis, etc.), as well as the prognosis of this treatment. Causes for discolouration, such as non-vital teeth, caries, internal resorption, or discoloured restorative materials, will need a different treatment procedure, other than bleaching alone. Advisement as to the need for replacement of other esthetic restorations will be determined. Concern has been expressed about the long-term use of a material containing hydrogen peroxide. However, recent literature indicates that this form of dentist-prescribed, home-applied bleaching, when preceded by a proper examination and correct diagnosis, applied with a properly-fitted prosthesis and monitored as needed by a dentist, is as safe as other accepted dental procedures or commonly ingested foodstuffs. The average duration of colour change appears to be 1-3 years, although it may be permanent. Re-treatment usually requires only 1-4 days.
The fee is due at the impression appointment, and cannot be waived if treatment is discontinued voluntarily or due to side effects. Should the prosthesis be lost or destroyed, An impression of the arch(es) to be treated will be made upon braces removal, as well as photographs. The following appointment involves inserting and fitting the prosthesis and evaluating the occlusion (bite). The bleaching solution will be dispensed along with instructions for use. Only a small amount is needed in the tray to be effective. A case will be provided in which to store the prosthesis when not in use. Avoid scratching the gums (gingiva) with long fingernails during removal of the prosthesis, especially in the canine (eye tooth) area. The prosthesis is best removed by grasping the rear on one back side of the mouth, and “pealing” out the prosthesis.
The treatment will continue until the desired shade is achieved, or four weeks has passed, whichever comes first. A follow-up third appointment will determine whether the bleaching was successful, or if it is desirable to continue treatment. Some discolourations require 2-6 months of nightly treatment, and may have additional recall appointments. The final appointment may include photographs, a decision as to whether to treat the other arch, plans for restorative needs, and instructions for future needs. Re-treatment at a later date using the same prosthesis is an option if there has not been significant changes in the teeth. However, it is the responsibility of the patient to maintain possession of the prosthesis. The patient should contact the office prior to re-initiating treatment, both to determine the adequacy of the fit of the prosthesis, and because occasionally discolouration will be an indication of some other problem not treated by bleaching. There is an additional charge for re-treatment exam & touch-up materials. Please refer to the “Information brochure” for appointment & fee details.

I have read the “Information & Consent Form on Nightguard Vital Bleaching” for the
office of Dr. Craig Kenmuir and understand and accept the conditions and limitations of
this treatment"
___________________________________ _______________ ___________________________________ _______________Parent Signature (if patient under 18 y.o.) Date

Source: http://www.kenmuirortho.co.za/consent_form.pdf