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understand that the results of my Zoom! Treatment cannot be guaranteed.
I understand
that in-office whitening treatments are considered generally safe by
most dental professionals. I understand that although my dentist has
been trained in the proper use of the Zoom! wlvtening system, the treatment
is not without risk. I understand that some of the potential complications
of this treatment include, but are not limited to:
Tooth
Sensitivity/Pain - During the first 24 hours after Zoom! treatment,
some patients can experience some tooth sensitivity or pain. This is
normal and is usually mild, but it can be worse in susceptible individuals.
Normally, tooth sensitivity or pain following a Zoom! treatment subsides
within 24 hours, but in rare cases can persist for longer periods of
time in susceptible individuals. People with existing sensitivity, recession,
exposed dentin, exposed root surfaces, recently cracked teeth, abfractions
(micro-cracks), open cavities, leaking fillings, or other dental conditions
that cause sensitivity or allow penetration of the gel into the tooth
may find that those conditions increase or prolong tooth sensitivity
or pain after Zoom! treatment.
Gum/Lip/Cheek
Inflammation - Whitening may cause inflammation of your gums,
lips or cheek margins. This is due to inadvertent exposure of a small
area of those tissues to the whitening gel or the ultraviolet light.
The inflammation is usually temporary which will subside in a few days
but may persist longer and may result in significant pain or discomfort,
depending on the degree to which the soft tissues were exposed to the
gel or ultraviolet light.
Dry/Chapped
Lips - The Zoom! treatment involves three, 15-minute sessions
during which the mouth is kept open continuously for the entire treatment
by a plastic retractor. This could result in dryness or chapping of
the lips or cheek margins, which can be treated by application of lip
balm, petroleum jelly or Vitamin E cream.
Cavities
or Leaking Fillings - Most dental whitening is indicated for
the outside of the teeth, except for patients who have already undergone
a root canal procedure. If any open cavities or fillings that are leaking
and allowing gel to penetrate the tooth are present, significant pain
could result. I understand that if my teeth have these conditions, I
should have my cavities filled or my fillings redone before undergoing
the Zoom! treatment.
Cervical
Abrasion/Erosion - These are conditions which affect the roots
of the teeth when the gums recede and they are characterized by grooves,
notches and/or depressions, that appear darker than the rest of the
teeth, where the teeth meet the gums. These areas appear darker because
they lack the enamel that covers the rest of the teeth. Even if these
areas are not currently sensitive, they can allow the whitening gel
to penetrate the teeth, causing sensitivity. I understand that if cervical
abrasionlerosion exists on my teeth, these areas will be covered with
dental dam prior to my Zoom! treatment.
Root
Resorption - This is a condition where the root of the tooth
starts to dissolve either from the inside or outside. Although the cause
of this is still uncertain, I understand that there is evidence that
indicates the incidence of root resorption is higher in patients who
have undergone root canals followed by whitening procedures.
Relapse
- After the Zoom! treatment, it is natural for the teeth that underwent
the Zoom! treatment to regress somewhat in their shading after treatment.
This is natural and should be very gradual, but it can be accelerated
by exposing the teeth to various staining agents. Treatment usually
involves wearing a take-home tray or repeating the Zoom! treatment.
I understand that the results of the Zoom! treatment are not intended
to be permanent and secondary, repeat or take-home treatments may be
needed for me to maintain the tooth shade I desire for my teeth.
I understand
that after treatment, I will be required to refrain from consuming any
substances that could discolor my teeth for the first 48
hours after treatment. These substances include: coffee,
tea, colas, ALL tobacco
products, mustard or ketchup, red wine, soy sauce, berry pie, red sauces.
I understand that there are other substances that could discolor my
teth which I should avoid during the first 48 hours after treatment.
If I have any questions regarding any such substance, I understand that
I can discuss its stain potential with my dentist.
The safety,
efficacy, potential complications and risks of Zoom! treatment can be
explained to me by my dentist and I understand that more information
on this will be provided to me upon my request. Since it is impossible
to state every complication that may occur as a result of Zoom! treatment,
the list of complications in this form is incomplete.
The basic
procedures of Zoom! treatment and the advantages and disadvantages,
risks and known possible complications of alternative treatments have
been explained to me by my dentist and my dentist has answered all my
questions to my satisfaction.
In signing
this informed consent I am stating I have read this informed consent
(or it has been read to me) and I fully understand it and the possible
risks, complications and benefits that can result from the Zoom! treatment
and that I agree to undergo the treatment as described by my dentist.
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