Filling Notes

PROCEDURE DATE:

PATIENT ID#

Patient ID number in practice management system.

EMAIL NOTES TO PATIENT:

- Yes
- No

PATIENT EMAIL:

RESTORATION TYPE:

Composite

TOOTH TYPE:

- Permanent tooth
- Baby tooth
- Supernumerary tooth

TOOTH#:

BABY TOOTH#:

PRE-TREATMENT CONDITION:

PRE-TREATMENT RADIOLOGY:

A pre-treatment radiograph available confirms no periapical pathosis associated with the root filling.
The pre-treatment radiograph available shows some periapical radiolucency. Endodontic retreatment was offered and declined. Consent to proceed with tooth restoration was attained.
Other

PRE-TREATMENT RADIOLOGY OTHER:

SURFACES RESTORED:

CUSPS CAPPED

TOOTH/CAVITY PREPARATION:

LINER/BASE PLACED:

GLASS IONOMER PLACED:

OTHER LINER:

Name of the liner used on dentine before the restoration is placed.

AFFECTED DENTINE TREATMENT:

- Silver fluoride
- Ozone treatment
- Other dentine treatment

OTHER DENTINE TREATMENT:

PULP CAPPING:

OTHER PULP CAPPING MATERIAL:

PLUP TREATMENT DETAIL:

OTHER TOOTH/CAVITY PREPARATION DETAIL:

PIN PLACED:

POST PLACEMENT:

- Stainless steel Parapost
- Cast post/core
- Other

CAVITY SURFACE PREPARATION:

- Rubber dam isolation.
- Cotton wool roll, dryguard and saliva ejector isolation.
- Etched for 10 seconds and washed, dried
- Applied universal bonding resin and set with curing light
- Single step etch/bond applied

CAVITY FILLED WITH:

- Flowable composite
- Packable composite
- Other composite material

OTHER COMPOSITE MATERIAL:

FLOWABLE COMPOSITE BRAND:

- 3M Filtek Supereme set with curing light
- SDI Stella self cure
- Other flowable composite

OTHER FLOWABLE COMPOSITE:

What is the other flowable composite material used?

PACKABLE COMPOSITE BRAND:

OTHER PACKABLE COMPOSITE:

What is the brand of the other packable composite?

FILLING FINISHING:

- Shaped and polished.
- Occlusion checked, adjusted.
- Contacts checked with floss.

FILLING FINISHING:

- Shaped and polished.
- Occlusion checked, adjusted.
- Contacts checked with floss.

PATIENT ADVICE FOR DEEP FILLING:

- The cavity in the tooth filled today was very deep and close the the tooth nerve.
- Expect sensitivity to cold for about two weeks.
- Return to the practice if the sensitivity gets worse or has not improved after two weeks

PATIENT ADVICE FOR PULPOTOMY:

- Your dentist has removed part of the tooth pulp (nerve) and placed a medicinal dressing in the hope that the rest of the tooth nerve will survive.
- The tooth nerve may die and cause pain and or tooth abscess, if this occurs the tooth will need to be removed or a root canal treatment will need to be done.
- Please return to the practice if pain or a tooth abscess develops.

PATIENT ADVICE FOR PULPECTOMY:

- Your dentist has removed a non-repairable nerve from within your tooth and placed a medicinal dressing to help relieve pain or sensitivity.
- This tooth must be removed, or root canal treatment will be required to save it.
- If the tooth becomes painful, please return to the practice to have it removed or discuss saving it with root canal therapy.

TREATMENT: CAPPING ADVICE

PATIENT ADVICE FOR SILVER FLUORIDE TREATMENT:

- After silver fluoride treatment, the decay left in your tooth will permanently turn dark brown or black.
- The black colour is a sign that the decay has stopped growing.
- If not already done the black colour can be covered later with a filling or a stainless-steel crown if appropriate.
- This tooth will require require monitoring and follow-up. Reapplication may be necessary.

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