Informed Consent For Zoom! Tooth Whitening Treatment (Page 2 of 4) in pdf

materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better

results than people with gray or bluish-gray teeth. I understand that teeth with multiple colorations,

bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, may need multiple

treatments or and may not whiten at all. I understand that teeth with many fillings, cavities may not

lighten and are usually best treated with other non-bleaching alternatives. I understand that

provisionals or temporaries made from acrylics may become discolored after exposure to Zoom!

treatment.

I understand that Zoom! treatment is not recommended for pregnant or lactating women, light sensitive

individuals, patients receiving PUVA (Psoralen + UVA radiation) or other photochemotherapeutic

drugs or treatment, as well as patients with melanoma, diabetes or heart conditions. I understand that

the Zoom! Lamp emits ultraviolet radiation (UVA) and that patients taking any drugs that increase

photosensitivity should consult with their physician before undergoing Zoom! treatment.

I 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!

whitening 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.

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