Free Occlusal Guard (Night Guard) Delivery Note Template (D9944–D9946)
This occlusal guard note template documents the delivery visit: the bruxism indication and the findings behind it, which arch, hard or soft appliance, how fit and retention were verified, where you left the occlusion, and the instructions you gave. Those are the details that decide between D9944, D9945, and D9946.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
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Occlusal guard delivery, [maxillary] arch, [hard] appliance, [full arch (D9944)]. Indication: [probable sleep bruxism: patient reports grinding; generalized attrition with wear facets on canines and anterior teeth; morning masseter soreness]. Appliance tried in: seats fully without rocking, retention [adequate], no tissue blanching or pressure areas. Occlusion adjusted with articulating paper to [even bilateral contacts in centric relation with smooth canine guidance in excursions]. Patient confirmed comfort. Instructions given: wear nightly, clean after each use as directed for the appliance material, store in the ventilated case, keep away from heat, and bring the appliance to recall visits. Patient advised to stop wearing it and call if jaw pain, bite changes, or tooth soreness develop. Patient tolerated procedure well. Next visit: [guard check in 2 to 4 weeks].
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When to use this template
Use this night guard delivery note when you deliver a removable occlusal guard made to minimize the effects of bruxism or other occlusal factors. Since CDT 2019 the code depends on material and coverage: D9944 is a hard appliance, full arch; D9945 is a soft appliance, full arch; D9946 is a hard appliance, partial arch. A guard with a hard occlusal surface is generally coded as hard even when it has a soft inner liner. These codes are not for sleep apnea, snoring, or TMD appliances, which have their own codes, so a guard made for TMD symptoms should not be billed as D9944.
The indication is where most guard claims are won or lost. "Patient grinds" is a report, not a finding. Document what you saw: wear facets and attrition by area, fractured cusps or restorations, masseter hypertrophy or tenderness, and the patient's report of grinding or morning jaw soreness. The international consensus on bruxism assessment grades it as possible (self-report only), probable (self-report plus clinical findings), or definite (confirmed instrumentally, for example with polysomnography), and that wording fits neatly into the indication line.
At delivery, record that the appliance seated fully without rocking, retention was adequate, and there was no tissue blanching. Then record where you left the occlusion: for a hard full-arch guard, typically even bilateral contacts with smooth excursive guidance. Partial-coverage appliances carry a risk of unwanted tooth movement with long-term wear, so document the plan and the discussion if you deliver one. Close with wear and care instructions and the follow-up visit. Later adjustments to the guard are reported as D9943.
Step by step: how to document this occlusal guard delivery
- 1
Document the indication
Record the patient's report and the clinical findings (wear facets, fractured restorations, muscle tenderness) that justify the guard.
- 2
Try in the appliance
Confirm full seating without rocking, adequate retention, and no tissue blanching or pressure areas.
- 3
Adjust the occlusion
Mark with articulating paper and adjust to even bilateral contacts with smooth excursive guidance; polish adjusted areas.
- 4
Confirm comfort
Have the patient close and move through excursions, and confirm comfort before dismissal.
- 5
Instruct
Cover nightly wear, cleaning, storage in the case, and when to stop wearing it and call.
- 6
Schedule follow-up
Book a guard check and note that future adjustments are reported separately as D9943.
Tips for using this template
- check_circlePick the code from material and coverage, not the lab's product name: hard full arch D9944, soft full arch D9945, hard partial arch D9946. A hard occlusal surface with a soft liner is generally coded as hard.
- check_circleDo not use D9944 to D9946 for sleep apnea, snoring, or TMD appliances; those have separate codes, and a mismatch between indication and code is an easy denial.
- check_circleDocument the indication with findings, not just history: wear facets by area, fractured restorations, muscle tenderness, plus the patient's report. Graded wording (possible, probable, definite bruxism) is clear and defensible.
- check_circleRecord the arch. Many payers want it on the claim, and partial-arch guards also need the area covered.
- check_circleWrite down where you left the occlusion (even bilateral contacts, canine guidance). It is the reference point if the patient later reports a bite change.
- check_circleIf you deliver a partial-coverage guard, document the risk of unwanted tooth movement with long-term wear and the monitoring plan.
- check_circleNote the follow-up visit. Later guard adjustments are D9943, and payer rules on adjustments soon after delivery vary.
Standards & references
- ADA Code on Dental Procedures (CDT): Occlusal guards D9944 (hard, full arch), D9945 (soft, full arch), D9946 (hard, partial arch), and occlusal guard adjustment D9943.
- Lobbezoo et al. International consensus on the assessment of bruxism (J Oral Rehabil 2018): Defines sleep and awake bruxism and the possible, probable, and definite grading used to document the indication.
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