Free Full Mouth Debridement Note Template (D4355)
Full mouth debridement exists for one reason: deposits so heavy you cannot complete a periodontal evaluation. This D4355 template documents that reason, the gross removal of plaque and calculus, and the follow-up visit where the evaluation and diagnosis happen.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
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Full mouth debridement (D4355). Medical history reviewed; [no changes]. Patient reports last professional cleaning [more than 5 years ago]. [Heavy] plaque and [heavy generalized supra- and subgingival] calculus present, preventing accurate probing and a comprehensive periodontal evaluation today. [Generalized] bleeding [with spontaneous bleeding noted]. Gross removal of supra- and subgingival plaque and calculus, full mouth, with [ultrasonic scaler and hand instruments]. [Topical anesthetic applied as needed.] No definitive root planing performed. Oral hygiene instructions given: [brushing technique, interdental cleaning]. Patient informed that a comprehensive periodontal evaluation and diagnosis will follow at the next visit and that further periodontal treatment may be needed. Next visit: [comprehensive periodontal evaluation (D0180) with full-mouth charting in 2 weeks].
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When to use this template
Use this full mouth debridement note template when plaque and calculus are heavy enough that you cannot probe accurately or complete a periodontal evaluation, typically in a patient who has not had professional care in years. The current CDT nomenclature for D4355 is full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit. That wording tells you what the note has to show: the deposits were the obstacle, and the evaluation and diagnosis come next time.
The most important sentence is the reason. State plainly that the deposits prevented accurate probing or a comprehensive periodontal evaluation, and describe them (amount, supra- and subgingival, distribution). A D4355 note that reads like a long prophy invites a downgrade. Equally, it is not scaling and root planing: there is no periodontal diagnosis yet, so do not describe root planing or quadrant-by-quadrant definitive therapy.
On same-day reporting, ADA guidance published in 2025 states that D4355 can be reported on the same date as a periodic (D0120) or comprehensive (D0150) oral evaluation, but not on the same date as a comprehensive periodontal evaluation (D0180), and not at a later visit after the evaluation has already been completed. Payer rules vary widely and many limit D4355 to once in several years, so check the plan. Close the note with the follow-up: a comprehensive periodontal evaluation with full-mouth charting once the tissues have had time to respond, which then sets the definitive plan (prophy, D4346, SRP, or referral).
Step by step: how to document this full mouth debridement
- 1
Document the obstacle
Record the deposits and state that they prevent accurate probing and a comprehensive periodontal evaluation.
- 2
Record history
Note the medical history review and when the patient last had professional care.
- 3
Gross debridement
Remove supra- and subgingival plaque and calculus, full mouth, with ultrasonic and hand instruments.
- 4
Stop short of definitive therapy
No root planing and no periodontal diagnosis at this visit; say so in the note.
- 5
Teach
Give home-care instructions and explain that an evaluation and possibly further treatment will follow.
- 6
Schedule the evaluation
Book the comprehensive periodontal evaluation with full-mouth charting and record it as the next visit.
Tips for using this template
- check_circleWrite the reason in plain words: deposits prevented accurate probing or a comprehensive periodontal evaluation. That sentence is what D4355 is for.
- check_circleDescribe the deposits (amount, supra- and subgingival, generalized or localized). "Heavy generalized subgingival calculus" supports the code; "difficult cleaning" does not.
- check_circleDo not diagnose periodontitis or describe root planing in this note. The diagnosis belongs to the follow-up evaluation, and SRP language makes the note contradict its own code.
- check_circlePer 2025 ADA guidance, D4355 can share a date with D0120 or D0150 but not with D0180, and it cannot be reported after the evaluation is already done. Verify against the current CDT manual and the payer.
- check_circleD4355 is a full mouth procedure. If only part of the mouth needed gross debridement, this is not the code.
- check_circleSchedule and document the follow-up comprehensive periodontal evaluation. Without it, the note describes a procedure whose stated purpose never happened.
- check_circleMany payers limit D4355 to once every few years or once per lifetime, and some pay it at the prophy rate. Set expectations with the patient before the visit.
- check_circleNote any patient-reported history (years since last cleaning, smoking, diabetes). It explains the deposits and feeds the periodontal risk assessment at the next visit.
Standards & references
- ADA Code on Dental Procedures (CDT): D4355 nomenclature: full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit.
- ADA News: 6 CDT codes you should know (2025): ADA guidance on reporting D4355 on the same date as D0120 or D0150, but not D0180.
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