Tooth bleaching questionnaire
Name……………………………………… .Age ……… Date today………………………
Medical History
Have you ever taken Tetracycline antibiotic for any period of time yes/no?
Do you have any of the following medical conditions?
Genetic disease?
Cerebral Palsy?
Kidney damage?
Severe allergies?
Cystic fibrosis?
Rock mountain spotted fever?
Acne?
As a child
Was there any RH incompatibility when you were born?
Did you receive a head or neurological injury?
Did you ever take fluoride tablets?
Did you ever live in a high fluoride area?
Did you ever have a vitamin deficiency?
Did you ever have a blood disorder?
Did you ever have erythroblastosis, foetalis,porphyria, or haemolytic anaemia?
Did you ever have infant jaundice?
Do you smoke?
If yes how many per day?...... how long have you smoked for?…………years
Have you ever smoked?
Dental history
Did you ever receive a blow to the face?
Did you ever have any accidents involving teeth?
Have you ever used over the counter bleaching products?
Are any of your teeth sensitive?
Have you ever been told or are you aware of any gum recession?
Do you use any mouthwashes on a regular basis?
Have you noticed your teeth becoming more yellow in the last few years?
Diet
Do you eat any of the following?Yes/no
Berries when in season
Fried foods
Which oils do you use to fry your food?
Do you drink any of the following?
Tea /Coffee/Herbal tea/Coca cola/Red wine
12, Lake Street, Leighton Buzzard, Bedfordshire, LU7 1RT .Telephone/fax 01525379559
Home Bleaching Instructions and Consent form
The active ingredient we are using to whiten your teeth is Carbamide Peroxide solution.
The following information is important please read it carefully.
The carbamide peroxide is in a glycerine base.If you know of any allergy or adverse reaction to this product, please do not proceed with this treatment.
As with all treatments there are risks and benefits. The benefit is that you have whiter teeth in a short space of time in a relatively simple manner. The risk is related to the continued use of the peroxide solution over an extended period of time [a few years].Research indicates that peroxide used to bleach teeth is safe. The latest research is indicating the safety for use on soft tissues [gums, tongue throat]. The long term effects are not yet know. Although the extent of risk is unknown, the acceptance of treatment means acceptance of risk.
This type of tooth whitening has been done regularly over 40 years. During that time whitening when done by dentists has not needed root canal treatment or damaged a tooth.
The degree of whitening varies with the individual. Most people achieve a change within 2-5 weeks. This can be optimised by reducing or ideally stopping the amount of tea coffee, red wine, red berries or curries consumed during treatment and for one month after. You can use desensitisingtoothpaste during routine brushing.
Toothpastes with baking soda or designed for smokers should be avoided. The toothpaste should feel smooth and not gritty in nature.
Sensitivity may result after a few days. This is usually slight and temporary. If this occurs refer to the “How to manage sensitivity” information sheet.
It is advisable not to smoke during a course of whitening for at least 5-8 weeks.
Do not use the whitening product if you are pregnant. There have been no adverse reactions, but the long term effects are still unknown.
Wear the tray for a minimum of 4 hours a day. Ideally overnight.
Some teeth do not whiten evenly especially around gum recession on lower premolar teeth. The enamel lightens well but the dentine appears not to lighten to the same degree.
Once treatment is complete you are advised to keep the trays in a safe place, so they can be used for top-up maintenance treatments. These may be done in 18-24 months depending on the degree of staining. If you retain the trays the charge is based on the provision and supervision of the supplementary ampoules.
I have read the above information and agree to return for an examination and supplemental appointments when I have been recommended. I have received a copy of this information sheet.
I consent to treatment and assume the risks described above.
I consent to photographs being taken. I understand that they may be used for documentation and for illustration of my treatment.
Signed ………………………………….. Patient Date………………………….