Composite Filling Notes Template for UK Dentists

A composite filling note that just says "MOD comp UR6" won't survive a complaint. Below is a template for UK clinicians to paste into their PMS — every section a defensible record needs, no patient demographics (PMS captures those), under 250 words for a routine restoration.

Why this composite filling template wins

• Montgomery consent in full: risks specific to a filling (sensitivity, marginal failure, pulp proximity), benefits, alternatives, patient decision — defensible against "I wasn't warned" claims.
• Operative findings prompt explicit: caries depth, pulp exposure Y/N, dentine quality — the detail you'd need if the tooth later needs endo.
• Bonding protocol broken into actual steps (etch time per enamel/dentine, bond system, cure seconds) — defensible against bond-failure claims under FGDP(UK) Direct Restorations guidance.
• Rubber dam status recorded — best-practice standard of care for composite; explicit field signals you met it.
• Post-op advice mirrors the patient's realistic experience: 2-week sensitivity expectation, when to return — proving you discharged your duty of after-care under GDC Principle 4.

The template (paste into your PMS notes field)

Paste the composite filling template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

TOOTH / SURFACE: [FDI — surfaces: M/O/D/B/L/P]
REASON FOR TREATMENT: [Primary caries / 2° caries / failed restoration / fracture / wear]

MHx: [Reviewed — unchanged / changes / allergies]

CONSENT (Montgomery): Risks discussed — post-op sensitivity (common, usually settles 2 weeks), marginal failure / replacement, possibility caries closer to pulp than expected (may require RCT — likelihood: [low/mod/high] based on pre-op assessment), colour match over time. Benefit: arrest caries, restore function. Alternative: [GIC / indirect / no treatment — symptom progression]. Patient verbalised understanding and consented.

LA: [Agent — volume — cartridges — technique (infiltration/IDB/PSA/mental)]. Profound anaesthesia confirmed.

ISOLATION: [Rubber dam — clamp/wedges / cotton roll + suction — justification]

OPERATIVE FINDINGS: [Old restoration removed / caries depth — dentinal/close to pulp / pulp exposure: Y/N / remaining dentine pink, not soft / caries detector dye confirmed clearance]

CAVITY PREP: [Bur sequence / conservative prep / bevel: Y/N / lining if required — calcium silicate / GIC base]

RESTORATION:
- Bonding: [System — etch (sec enamel / sec dentine) — bond cured (sec)]
- Composite: [Brand — shade — bulk-fill / conventional]
- Increments: [Number — each cured (sec)]
- Matrix: [Sectional / circumferential — wedge — separator]
- Contact verified: [Floss tight]

OCCLUSION: [Articulating paper — high points removed in ICP and lateral excursion. Patient confirms comfortable bite.]

POST-OP ADVICE: LA wearing off in 2-3h — avoid hot drinks until sensation returns. Mild sensitivity possible up to 2 weeks — ibuprofen 400mg PRN. Return if sensitivity persists >2 weeks or bite feels high.

REVIEW: [No routine review / specific review at __ weeks / next exam per recall]

Try the composite filling note in the live demo → No account needed.

What good looks like — a worked example

The same composite filling template, completed for a realistic case.

TOOTH / SURFACE: UL5 — MOD
REASON FOR TREATMENT: Replacement of failing MOD amalgam — 2° caries mesial margin confirmed on BW (reported [date]).

MHx: Reviewed — unchanged. Penicillin allergy confirmed; LA choice adjusted accordingly.

CONSENT (Montgomery): Risks discussed — post-op sensitivity (common, settles within 2 weeks), marginal failure requiring replacement, possibility caries closer to pulp than anticipated (likelihood low given pre-op BW), colour match over time. Benefit: arrest caries, restore function. Alternative: watch + monitor (declined — patient wishes Tx now). Patient verbalised understanding and consented.

LA: Articaine 4% w/ adrenaline 1:100,000 — 1.7ml, 1 cartridge — buccal infiltration UL5 region. Profound anaesthesia confirmed.

ISOLATION: Rubber dam placed UL4-UL6, clamp-free with floss ligature. Excellent moisture control throughout.

OPERATIVE FINDINGS: Amalgam removed. Dentinal caries — not extending to pulp. No exposure. Remaining dentine pink, not soft. Caries detector dye confirmed clearance. Cavity depth ~3mm from CEJ.

CAVITY PREP: Conservative prep, no bevel. Sound margins. No lining required.

RESTORATION:
- Bonding: Optibond FL (Kerr). 35% phosphoric acid — 15s enamel / 10s dentine. Bond applied, air-thinned, cured 20s.
- Composite: Filtek Supreme Ultra (3M), shade A2 Body
- Increments: 3, each cured 20s
- Matrix: Palodent V3 sectional. Wooden wedges mesial + distal
- Contact verified: Floss tight

OCCLUSION: Articulating paper — no high spots in ICP or lateral excursion. Patient confirmed comfortable.

POST-OP ADVICE: LA wearing off in 2-3h — avoid hot drinks until sensation returns. Mild sensitivity possible up to 2 weeks — ibuprofen 400mg PRN. Contact if sensitivity persists >2 weeks or bite feels high.

REVIEW: No routine review required. Next exam per recall schedule.

Compliance: the medico-legal angle

• GDC Standards Principle 3 — informed consent. Montgomery section covers options, risks specific to a composite, benefits, alternatives, and patient questions.
• FGDP(UK)/CGDent Clinical Examination & Record-Keeping (3rd ed.) Ch.6 — operative records. Tooth, surfaces, reason, LA, isolation, material with shade, occlusion, and post-op all prompted.
• CQC Mythbuster 8 (Dental care records) — consent must be documented before treatment. Consent block comes before LA in the template.
• Re LA batch numbers: Dental Protection 2024 confirms no legal requirement to record batch + expiry for routine LA. The template omits this by default; add it locally if your practice policy requires.

Common documentation mistakes

• Listing "Composite UR6 MOD" with no consent discussion documented — fails Montgomery test if later challenged.
• No rubber dam status recorded — undermines defence if bond failure is alleged (CQC W2 expects evidence-based practice).
• Single "etch" time recorded — should be enamel and dentine times separately to match the bonding system's manufacturer instructions.
• No mention of caries depth or pulp proximity in operative findings — leaves you exposed if the tooth later requires RCT.
• Post-op advice missing or templated as "advice given" — must be specific (sensitivity expectation, when to return).

Sources

• GDC Standards for the Dental Team, Principle 3: Obtain valid consent (accessed 18 October 2026)
• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• CGDent: Clinical Examination and Record-Keeping, Good Practice Guidelines (3rd edition) (accessed 18 October 2026)
• Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (accessed 18 October 2026)

Frequently asked questions

Guides that cover this

• Using a Dental Notes App Alongside Dentally (UK)
• Clinical Notes Templates for SOE Exact (UK): Paste-Ready Workflow
• Clinical Notes Templates for R4 (Carestream) UK: Paste-Ready Workflow
• Clinical Notes Templates for Pearl & Dental4Windows (UK)
• Voice-to-Text for Dental Notes: UK Practice Guide
• Dental AI Scribe vs Structured Templates

Patient leaflets for this treatment

• After Your Dental Filling
• Your Guide to White Fillings

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