Free Periodic Dental Exam Note Template (D0120)
This periodic dental exam note template (D0120) covers all 7+ required sections — interval medical history, intraoral exam, oral cancer screening, perio update, and radiographic findings. Generate a compliant note in 30 seconds.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
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**Chief Complaint:** Patient presents for periodic recall examination. **Medical History:** Reviewed and updated. No interval changes reported. No contraindications to treatment. **Extraoral Examination:** Head and neck exam performed. TMJ evaluation: no clicking, popping, or deviation noted. Lymph nodes: non-palpable. Facial symmetry: within normal limits. **Intraoral Soft Tissue Examination:** Lips, buccal mucosa, tongue, floor of mouth, hard palate, soft palate, oropharynx, gingiva examined: all within normal limits. Oral cancer screening performed: negative. **Periodontal Findings:** [No changes from baseline. Bleeding on probing localized to posteriors. Stable.] **Radiographic Findings:** [BW] taken and reviewed. No new caries identified. **Recall:** [6-month] recall recommended. Patient tolerated procedure well. Post-operative instructions given.
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When to use this template
Use this periodic dental exam note template for established-patient periodic oral evaluations (CDT D0120) — typically the 6-month recall visit. Covers interval medical history changes, focused extraoral and intraoral exams, oral cancer screening, periodontal update from the last comprehensive, radiographic interpretation (typically bitewings), and the recall recommendation.
D0120 is distinct from D0150 (comprehensive). It is a focused recall exam, NOT a full new-patient workup, and the documentation should make the focused nature of the exam explicit. Reviewers occasionally downgrade D0150 to D0120 reimbursement when the documentation reads as a focused recall rather than a comprehensive evaluation. Conversely, billing D0150 every six months on the same patient triggers audit attention — D0150 is appropriate at intervals of three or more years for an established patient.
Adjust the bracketed bitewing-type and any noted findings. For pediatric periodics, add fluoride-varnish documentation if applied at the visit (CDT D1206 separately billable). For high-risk caries patients on a 3- or 4-month recall, document the rationale (active disease, ortho appliances, xerostomia) so the shortened interval is defensible. The recall interval recommendation is an essential element — it should match the patient's caries and perio risk, not just default to six months.
Step by step: how to document this periodic dental exam
- 1
Update interval history
Medical and dental history reviewed for changes since last visit; medications and conditions updated.
- 2
Focused extraoral exam
Head, neck, TMJ, lymph nodes assessed (focused, not comprehensive).
- 3
Intraoral soft tissue exam
Soft tissues examined; oral cancer screening performed and documented.
- 4
Periodontal update
Spot-probing or full perio update if interval indicated; BOP and plaque noted.
- 5
Radiographs (if due)
Bitewings taken per ADA frequency guidelines based on caries risk; reviewed for new caries.
- 6
Document findings
New findings (caries, fractures, perio changes) added to chart; treatment plan updated as needed.
- 7
Set recall interval
Recall recommendation made based on caries and perio risk, not default 6 months.
Tips for using this template
- check_circleAlways document interval medical history changes — even "no changes reported" — to satisfy update-history requirements.
- check_circleBitewing interpretation is required when bitewings are taken at the visit. "BW reviewed; no new caries" is the standard sentence.
- check_circleRecall interval should match the patient's caries risk and perio status, not just default to 6 months.
- check_circleIf you noted plaque or calculus during the exam, document it briefly even if a separate prophy note will follow.
- check_circleFor pediatric periodics, add fluoride-varnish documentation if applied at the visit.
- check_circleAvoid the common pitfall of billing D0120 with documentation that looks comprehensive — keep the note focused on interval changes to support the code choice.
- check_circleFor shortened recall intervals (3-month, 4-month), document the rationale (active perio, high caries risk, xerostomia) so the deviation from standard 6-month is defensible.
- check_circleDocument oral cancer screening at every periodic — "Oral cancer screening performed: negative" is the gold-standard sentence regardless of exam type.
Standards & references
- ADA Code on Dental Procedures (CDT) — D0120 vs D0150 — Periodic D0120 vs comprehensive D0150 distinction and documentation requirements.
- JADA Clinical Guidelines: Recall & Maintenance — ADA-published clinical guidelines on risk-based recall intervals and periodontal-maintenance scheduling for adult patients.
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