Free Periodontal Maintenance Note Template (D4910)
A periodontal maintenance note has to prove two things: that this patient completed active periodontal therapy, and how their periodontium is doing today compared with last time. This D4910 template documents both, plus the site-specific root planing and the maintenance interval.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
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Periodontal maintenance (D4910). History: [generalized Stage III, Grade B periodontitis]; active therapy completed [SRP all quadrants, March 2025]. Medical history reviewed; [no changes]. Periodontal charting updated: probing depths [generalized 2-4mm, localized 5mm #3 DB and #14 MB]; bleeding on probing [localized, 8% of sites]; [no suppuration]; recession and mobility [unchanged from previous charting]. Compared with previous charting: [stable, except 1mm increase at #14 MB]. [Light] plaque and [light subgingival] calculus noted. Supra- and subgingival plaque and calculus removed with ultrasonic and hand instrumentation; site-specific root planing at [#3 DB, #14 MB]. Teeth polished. Oral hygiene instructions reinforced: [interdental brushes, UL molars]. [Locally delivered antimicrobial placed #14 MB (D4381).] Patient tolerated procedure well. Next periodontal maintenance in [3] months. [Refer to periodontist if #14 MB continues to progress.]
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When to use this template
Use this periodontal maintenance note template for patients who have completed active periodontal therapy (scaling and root planing, periodontal surgery, or both) and are now on a maintenance schedule. CDT describes D4910 as a procedure instituted following periodontal therapy and continued at intervals set by the dentist's clinical evaluation, for the life of the dentition or any implant replacements. It includes supra- and subgingival plaque and calculus removal, site-specific scaling and root planing where indicated, and polishing.
The first line of the note should name the history: the periodontitis diagnosis (stage and grade under the 2017 AAP/EFP classification) and when active therapy was completed. Payers check for that prior therapy, and without it a D4910 claim is often downgraded to a prophy. The 2017 classification is also the clinical reason a treated patient stays on D4910 rather than returning to D1110: a successfully treated periodontitis patient keeps a lifelong higher risk of recurrence.
The heart of the note is comparison. Update probing depths and bleeding on probing, then say whether the patient is stable or showing progression, and where. Site-specific root planing on a few deepened sites is part of D4910 itself. If disease has clearly recurred, the descriptor itself says further diagnosis and treatment should be considered, so document the re-evaluation, localized therapy (for example a locally delivered antimicrobial, reported separately per tooth as D4381), or a periodontist referral. Close with the interval: many patients are seen every three months, but the interval is the dentist's call for this patient and should be recorded as such.
Step by step: how to document this periodontal maintenance
- 1
State the history
Record the periodontitis stage and grade and when active therapy (SRP or surgery) was completed.
- 2
Update charting
Probe and record pocket depths, bleeding on probing, suppuration, recession, and mobility.
- 3
Compare
Compare with previous charting and state whether the patient is stable or progressing, and at which sites.
- 4
Debride and root plane sites
Remove supra- and subgingival deposits; root plane the specific sites that need it, and name them.
- 5
Address recurrence
Where disease has recurred, document localized therapy, re-evaluation, or referral to a periodontist.
- 6
Set the interval
Reinforce home care and record the maintenance interval chosen for this patient.
Tips for using this template
- check_circleOpen with the history: periodontitis stage and grade plus the date active therapy was completed. Payers look for that prior therapy before paying D4910.
- check_circleUpdate the charting and compare it with the last visit. "Stable" or "1mm increase at #14 MB" is the clinical judgment that makes this a maintenance note and not a cleaning note.
- check_circleSite-specific root planing on a few sites is included in D4910. Name the sites so the record shows why the visit took longer than a prophy.
- check_circleIf disease has clearly recurred, document what you are doing about it: re-evaluation, locally delivered antimicrobial (D4381, per tooth), re-treatment, or referral.
- check_circleRecord the interval as a decision for this patient. Three months is common, but the CDT descriptor leaves it to the dentist's clinical evaluation.
- check_circleA treated periodontitis patient does not go back to D1110 when the tissues look good. Under the 2017 classification they remain at higher risk of recurrence, which is what D4910 is for.
- check_circleIf the patient alternates visits with a periodontist, note who is doing which visits so frequency limits are not exceeded across offices.
- check_circleKeep prophy wording out of the history line: the note should read as ongoing periodontal care, not a routine cleaning.
Standards & references
- ADA Code on Dental Procedures (CDT): D4910 (periodontal maintenance) and D4381 (locally delivered antimicrobial, per tooth) definitions.
- AAP: 2017 Classification of Periodontal and Peri-Implant Diseases and Conditions: Staging and grading used to document the periodontitis history that supports D4910.
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