Dental Restorative Procedure Note

Clinician's Specialty: Oral/Dental Hygienist Chief Complaint: Patient presented with a chief complaint of recurrent sensitivity to cold in the lower left quadrant. Medical History: Patient reports no significant medical history, non-smoker, no known allergies. Currently taking oral contraceptives. Clinical Examination: Examination of tooth #36 (lower left first molar) revealed a Class II mesio-occlusal caries lesion extending into the dentin, with no pulp exposure. Old amalgam filling on #37 intact but showing marginal breakdown. No other significant caries or periodontal issues noted. Oral hygiene generally good. Patient Education and Consent: Discussed the need for restorative treatment on #36 due to active decay, explaining the risks associated with drilling, including potential post-operative sensitivity or, in rare cases, nerve irritation requiring further treatment. Alternatives, such as observation (not recommended due to active decay) or extraction, were presented. The consequences of no treatment, including progression of decay, pain, and potential tooth loss, were clearly explained. Patient verbally consented to the composite restoration procedure. Post-Operative Instructions: Advised patient that some sensitivity to hot/cold might be expected for a few days post-procedure. Recommended avoiding chewing on the treated side for the next hour until the anaesthetic wears off completely. Instructed to maintain good oral hygiene and return for routine check-up in 6 months or sooner if experiencing persistent pain or discomfort. Treatment Performed: Direct composite resin restoration on tooth #36 (mesio-occlusal surface). Local Anesthetic: 2% Lidocaine with 1:100,000 epinephrine, 1.8ml administered via inferior alveolar nerve block and buccal infiltration for regional anaesthesia of the lower left quadrant. Access and Decay Removal: Access was gained using a high-speed handpiece with a diamond bur. Decay was selectively removed using a slow-speed handpiece with a round bur and excavator, ensuring complete caries removal while preserving sound tooth structure. Cavity Assessment: Cavity appeared clean and dry with firm dentin at the pulpal floor and sound enamel margins. No evidence of microleakage or fractures. Preparation was conservative, conforming to the natural tooth anatomy. Isolation Method: Rubber dam isolation was achieved using a W2A clamp on #36 to ensure a dry, contaminant-free operating field. Restoration Details: A3 shade Venus Pearl composite resin (Heraeus Kulzer) was incrementally placed and light-cured, ensuring good adaptation to cavity walls and marginal integrity. Matrix Band: Tofflemire matrix band with a wooden wedge placed interproximally to establish proper contact point and contour. Finishing and Polishing: Restoration was contoured with fine diamond burs, polished with composite polishing points and cups, and interproximal areas were finished with polishing strips to achieve a smooth surface and prevent plaque accumulation. Occlusion Check: Occlusion checked with articulating paper, revealing no high spots. Patient confirmed comfortable bite with no interferences. Post-Operative Instructions Given: Specific post-operative care instructions provided orally and in written format regarding avoiding hard or sticky foods for 24 hours, managing sensitivity with over-the-counter pain relievers if needed, and maintaining excellent oral hygiene. Scheduled a follow-up if any issues arise. Clinician: Dr. Olivia Davies Oral/Dental Hygienist