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D1110Typical limit: 2 per yearAdult dentitionNot with D4346 same day

Adult prophylaxis note template

A complete, fill-in-the-blank D1110 note written around what insurance reviewers ask for — with the documentation checklist, the denial patterns, and an Open Dental auto-note format built in.

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01 · Before you bill it

Know what the payer wants first.

The note should answer every item on the left — and read so that nothing on the right applies.

What documentation D1110 requires

Missing any of these is why the claim pends for records.
  • A periodontal screening (PSR or full chart) proving the prophy was appropriate for the tissue state
  • Plaque and calculus levels with distribution — the "why" of the cleaning
  • What was actually instrumented (supra- and subgingival) and with what
  • OHI given, supporting preventive intent
  • Recall interval and radiograph due dates for the frequency trail

Why D1110 gets denied

The denial patterns payers actually use for this code.
  • Frequency exceeded — most plans cover two per calendar year or one per 6 months; the date trail in your ledger decides
  • Perio history conflict: patient has billed D4341/D4910 history, then a D1110 appears without documentation of a healthy or stabilized periodontium
  • Charting shows generalized 5 mm+ pockets the same day as a routine prophy

02 · The template

Copy it, chart with it.

Square brackets are the blanks — replace each one as you chart. Switch the format to turn every blank into an Open Dental auto-note prompt.

D1110 · Format
MEDICAL HISTORY: Reviewed [date]; changes: [none / list]. BP [___/___].
CHIEF COMPLAINT: [Routine hygiene recall; no new concerns / patient's words].
ASSESSMENT: Plaque: [light/moderate/heavy, distribution]. Calculus: [supragingival/subgingival, location]. Gingiva: [color, tone, bleeding]. PSR: [_-_-_ / _-_-_].
TREATMENT: Full-mouth supra- and subgingival scaling with [ultrasonic and hand instruments]; [selective/full] polish with [paste grit]; flossed all contacts.
FLUORIDE: [D1206 varnish applied / declined / not indicated].
FINDINGS FOR DOCTOR: [Watch areas, suspected lesions, broken restorations / none].
OHI: [Technique reviewed; aids recommended].
RADIOGRAPHS: [BWX taken and reviewed / due next visit].
NEXT VISIT: [Interval] recall; [radiographs due; doctor exam due].

03 · Common questions

Frequently asked about D1110

D1110 or D4346?
D4346 is scaling in the presence of generalized moderate-to-severe gingival inflammation without attachment loss. If bleeding is generalized and heavy but bone is intact, D4346 documents better than forcing a D1110.
Prophy after SRP?
After active perio therapy the maintenance code is D4910, not D1110. Some plans allow alternating; document the periodontal status either way.
Does the doctor exam need its own note?
Yes — the D0120 periodic exam should have its own findings and diagnosis line, separate from the hygiene note.

More templates

D4341Scaling & root planing, four or more teeth per quadrantD2392Posterior composite, two surfacesD2740Crown — porcelain / ceramic

Or never fill in a blank again.

Molaris listens to the visit and drafts this exact note in your wording — placeholders already filled from what was actually said. You review, you sign, it files to Open Dental.

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Reviewed August 2026. These templates are original Molaris reference samples showing how the scribe structures documentation. They are educational examples, not billing, coding, or legal advice; payer requirements vary by plan and state. CDT codes are maintained by the ADA.