Free Adult Prophylaxis (Prophy) Note Template (D1110)
The prophy is the note you write most often and think about least. This template documents what makes D1110 the right code: a periodontal status of health or gingivitis, the deposits removed, the instruments used, specific home-care advice, and a recall interval set for this patient.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
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Adult prophylaxis (D1110). Medical history reviewed; [no changes]. Periodontal status: [localized mild gingivitis]. Probing depths [1-3]mm; no clinical attachment loss; no radiographic bone loss on current radiographs. [Light] plaque and [light supragingival] calculus noted; bleeding on probing [localized, #2-3 and #14-15 interproximal]. Supra- and subgingival plaque and calculus removed with [ultrasonic scaler and hand instruments]. Stain removed and teeth polished with prophy paste. Teeth flossed. Oral hygiene instructions given: [interdental cleaning on upper molars, modified Bass brushing]. [Fluoride varnish applied (D1206) with patient consent.] Patient tolerated procedure well. Periodic evaluation completed by Dr. [name], see exam note. Recall: [6] months.
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When to use this template
Use this prophy note template for routine preventive cleanings on patients with periodontal health or gingivitis. CDT describes D1110 as removal of plaque, calculus and stains from tooth structures and implants in the permanent and transitional dentition, intended to control local irritational factors. That definition carries an assumption the note should make explicit: the patient does not have periodontitis. A prophy note that never mentions periodontal status cannot defend the code if the chart elsewhere shows bone loss.
The coding boundaries around D1110 are where most prophy claims go wrong. A patient previously treated for periodontitis (SRP or surgery) belongs in periodontal maintenance (D4910), not prophylaxis: under the 2017 AAP/EFP classification a successfully treated periodontitis patient stays at lifelong higher risk of recurrence. A patient with generalized moderate or severe gingival inflammation but no attachment loss may fit D4346 instead. Heavy deposits that stop you completing an evaluation point to full mouth debridement (D4355). Difficulty alone never changes the code: a long, stain-heavy prophy is still D1110.
The prophy is usually performed alongside the dentist's periodic evaluation (D0120), which is documented and reported separately. Keep the two distinct in the record: the hygiene note covers what was removed and taught, and the exam note covers the findings and the diagnosis. Fluoride varnish, if given, gets its own line and its own code (D1206). Close with a recall interval set for this patient's risk rather than a reflexive six months.
Step by step: how to document this adult prophylaxis
- 1
Review history and status
Medical history reviewed; periodontal status recorded as health or gingivitis, with probing depths and no attachment or bone loss.
- 2
Record deposits
Note the amount of plaque and calculus and where bleeding on probing occurred.
- 3
Debride
Remove supra- and subgingival plaque and calculus with ultrasonic and hand instruments.
- 4
Polish and floss
Remove stain, polish with prophy paste, and floss all contacts.
- 5
Teach
Give specific home-care instructions tied to what you found today.
- 6
Set the recall
Record the recall interval chosen for this patient and confirm the dentist's periodic evaluation is documented separately.
Tips for using this template
- check_circleState the periodontal status in every prophy note. D1110 assumes health or gingivitis, and a note that is silent on it cannot defend the code against bone loss shown elsewhere in the chart.
- check_circlePreviously treated for periodontitis? That patient is a periodontal maintenance (D4910) patient, not a prophy patient, even when today's tissues look healthy.
- check_circleGeneralized moderate or severe gingival inflammation without attachment loss may fit D4346. It is a diagnosis-based code, so document the extent of inflammation and bleeding on probing if you use it.
- check_circleDifficulty is not a code. A long, stain-heavy or calculus-heavy prophy is still D1110; only deposits that block a comprehensive evaluation justify full mouth debridement (D4355).
- check_circleD1110 covers the permanent and transitional dentition and D1120 the primary and transitional dentition. The age cutoff between them is a payer rule, not a CDT rule, so check the plan.
- check_circleMake the home-care advice specific: "interdental brushes, UR and UL molars" shows real teaching, while a bare "OHI given" reads as boilerplate.
- check_circleDocument fluoride varnish separately with its own code (D1206) and the consent or caries-risk reason behind it.
- check_circleSet the recall interval for this patient's risk and say so. A blanket six months is a habit, not a clinical decision.
Standards & references
- ADA Code on Dental Procedures (CDT): D1110 (prophylaxis, adult), D1120 (child), D4346 and D4910 definitions and reporting.
- AAP: 2017 Classification of Periodontal and Peri-Implant Diseases and Conditions: Defines periodontal health, gingivitis, and periodontitis staging, which decide whether D1110 or D4910 applies.
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