Free Child Prophy and Fluoride Varnish Note Template (D1120/D1206)
A child prophy note is short, but the parts that make it defensible are easy to drop. This D1120 and D1206 template documents caries risk, plaque and calculus, behavior, the fluoride varnish and why it was given, the guidance given to the caregiver, and a recall interval tied to the child's risk.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
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Child prophylaxis (D1120) with fluoride varnish (D1206). Accompanied by [mother], who gave consent. Medical history reviewed; [no changes; no known allergies]. Caries risk: [moderate] ([frequent snacks between meals; no current caries]). Behavior: [Frankl 4; tell-show-do]. [Light] plaque [on the lower posterior teeth]; [no] calculus; gingiva [healthy]. Plaque and stain removed with [rubber cup and prophy paste]; teeth flossed. 5% sodium fluoride varnish applied to all erupted teeth after drying; post-varnish instructions given to [mother] per the manufacturer. Guidance given to [mother]: [supervised brushing twice daily with a pea-size amount of fluoride toothpaste; limit sugary drinks and snacks between meals]. Periodic evaluation completed by Dr. [name], see exam note. Recall: [6] months.
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When to use this template
Use this child prophy note template for a preventive cleaning with fluoride varnish on a child in the primary or mixed dentition. CDT describes D1120 as removal of plaque, calculus and stains from the tooth structures and implants in the primary and transitional dentition, intended to control local irritational factors. When a child moves to D1110 is a payer rule, not a CDT rule, so check the plan. Fluoride is reported separately from the prophy: D1206 for fluoride varnish, and D1208 for topical fluoride other than varnish. The dentist's evaluation is a separate service with its own note, and caries risk assessment can be reported with D0601, D0602, or D0603 (low, moderate, or high risk) where the payer accepts those codes.
Caries risk is the line that ties the visit together. It explains why varnish was applied, how often it should be repeated, and the recall interval. The AAPD recommends professionally applied topical fluoride, such as 5% sodium fluoride varnish, at least twice a year to reduce caries, and states that children at risk for caries should receive a professional fluoride treatment at least every six months. Both the ADA's 2013 topical fluoride guideline and the AAPD limit children younger than six to fluoride varnish among professionally applied agents. Record the risk level with the factors behind it.
Document who brought the child and who consented, the behavior (a Frankl score is quick), the deposits and gingival condition, how the teeth were cleaned, and the varnish applied. Then record the guidance given to the caregiver, specific to the child's age and risk: supervised brushing twice daily with an age-appropriate amount of fluoride toothpaste (a smear or rice-grain size under three, a pea-size amount from three to six), diet and drinks between meals, and bottle or sippy-cup habits for the youngest children. Close with a recall interval set by risk rather than habit.
Step by step: how to document this child prophy and fluoride varnish
- 1
Record who is present
Note who accompanied the child, who consented, and the medical history review.
- 2
Assess risk and behavior
Record caries risk with its factors and a Frankl score with the guidance used.
- 3
Clean
Record plaque, calculus, and gingival condition; remove deposits and stain and floss.
- 4
Apply varnish
Dry the teeth, apply fluoride varnish to all erupted teeth, and give the post-varnish instructions.
- 5
Guide the caregiver
Give and record age- and risk-specific guidance on brushing, toothpaste amount, and diet.
- 6
Set recall
Record the recall interval chosen for this child's risk and confirm the exam is documented separately.
Tips for using this template
- check_circleRecord caries risk with the factors behind it. It justifies the varnish and the recall interval, and it can be reported (D0601 to D0603) where payers accept it.
- check_circleRecord who accompanied the child and who consented. For minors, the caregiver line is part of the consent record.
- check_circleReport fluoride on its own line: D1206 for varnish, D1208 for other topical fluoride. Record the product or concentration.
- check_circleFor children under six, varnish is the professionally applied fluoride recommended by both the ADA 2013 guideline and the AAPD.
- check_circleD1120 versus D1110 is decided by the payer's age rule, not by CDT. Check the plan before the claim goes out.
- check_circleMake the guidance specific to the child: toothpaste amount by age, supervised brushing, drinks between meals, and bottle habits for toddlers.
- check_circleRecord behavior with a Frankl score and the guidance used. It explains a short visit and helps plan the next one.
- check_circleSet the recall by risk: high-risk children may need fluoride and review more often than every six months.
Standards & references
- AAPD Best Practices: Fluoride Therapy: Professionally applied fluoride at least twice a year; children at risk at least every six months; varnish as the only professional agent for children under six.
- ADA Topical Fluoride Clinical Practice Guideline (2013): ADA guideline on professionally applied fluoride: only 2.26% fluoride varnish is recommended for children younger than six.
- AAPD: Caries-Risk Assessment and Management for Infants, Children, and Adolescents: AAPD caries-risk assessment tools and risk-based management, including fluoride and recall.
- AAPD: Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment: Age-based preventive services and anticipatory guidance for children and adolescents.
- ADA Code on Dental Procedures (CDT): D1120 (prophylaxis, child), D1206 (fluoride varnish), D1208, and caries risk assessment codes D0601 to D0603.
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