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How to write a pediatric prophy note
A child's hygiene note records more than the cleaning: who came with the child, how the child behaved and what guidance you used, caries risk, fluoride, sealants, and what you taught the parent. This template covers child prophylaxis (D1120) and first visits.
Enter the child's name and age, the visit type, and who accompanied them.
Review medical history with the parent or guardian, fluoride exposure, and habits such as night bottles or thumb sucking.
Record behavior on the Frankl scale, the positioning, and any behavior guidance you used.
Fill in exam findings, caries risk, and radiographs (or that they were deferred), then the cleaning, fluoride, and sealants.
Add parent and child education, tolerance, recall, and follow-up. Copy the note into your PMS.
Example pediatric prophy note
A fictional patient, filled in with this template and copied as-is.
Emma Doe, age 7, was seen by Alex Rivera, RDH on October 14, 2026 for a child prophylaxis (D1120), accompanied by parent. Medical history reviewed with parent/guardian, no changes. Fluoride exposure: Fluoridated community water. Habits: Frequent snacking or juice.
Behavior: Frankl 3, positive. Positioning: Seated in the chair independently. Behavior guidance: Tell-show-do and positive reinforcement.
Soft tissue within normal limits. Mixed dentition, eruption age-appropriate. Caries: Early (non-cavitated) lesions noted. Occlusion within normal limits for age. Gingiva: Mild plaque-induced gingivitis. Caries risk assessed as moderate. Radiographs: Bitewings taken.
Treatment: Rubber cup prophy. Fluoride varnish applied (D1206). Sealants: Sealants recommended, to schedule.
Education with parent and child: Parent to help with brushing and limit sugary drinks and snacks.
Tolerated the visit well. Recall in 6 months. Follow-up: Sealant appointment.
What a complete note covers
Who accompanied the child, and that history was reviewed with them.
Fluoride exposure and habits.
Behavior: Frankl rating, positioning, and guidance techniques.
Exam: soft tissue, dentition and eruption, caries findings, occlusion, gingiva.
Caries risk and radiographs taken or deferred.
Treatment: cleaning method, fluoride (or that it was declined), sealants with tooth numbers.
Education, recall, and follow-up, such as a sealant appointment or a referral.
Common mistakes
Not recording who was present. For a minor, note the parent or guardian, or that consent is on file for another caregiver.
No caries risk assessment. The risk level drives recall frequency, fluoride, and sealant decisions, so record it.
Declined fluoride left out. If a parent declines fluoride varnish, write it down.
Behavior left undocumented. A Frankl rating and the guidance used explain a shortened visit or deferred radiographs.
Education that's too generic. Record the specific advice, such as a smear of toothpaste under age 3 or no bottle in bed.
Questions
When do you use D1120 instead of D1110?
CDT describes D1120 for primary and transitional dentition and D1110 for permanent and transitional dentition. Many payers apply an age cutoff instead, so check the patient's plan.
What is the Frankl scale?
A four-point rating of a child's behavior in the chair, from 1 (definitely negative) to 4 (definitely positive). It's a quick, standard way to record cooperation.
Which codes go with fluoride and sealants?
Fluoride varnish is D1206, other topical fluoride is D1208, and sealants are D1351 per tooth. The fluoride and sealants template documents those procedures in detail.
Example notes use fictional patients. Coding notes are general guidance; confirm against the current CDT manual and the patient's plan.
When to use this pediatric template
Use it for child prophylaxis visits (D1120), first dental visits, and periodic recall
visits for kids. Pediatric notes need a few things an adult prophy note doesn't: who
brought the child and gave consent, how the child behaved and what guidance you used, and
what you told the parent. Payers set their own age cutoff between child and adult
prophylaxis, so check the patient's plan before billing D1120 for a teenager.
What a pediatric note should cover
The accompanying adult and their relationship to the child.
A behavior rating, such as the Frankl scale, plus the guidance techniques used.
Development: dentition stage, eruption, and occlusion for age.
Caries risk and the preventive care it led to: fluoride, sealants, recall interval.
Parent education, in specific terms, not "OHI given."
Example pediatric note
Patient, age 7, seen for child prophylaxis (D1120), accompanied by parent. Medical history
reviewed with parent, no changes. Behavior: Frankl 3, positive; tell-show-do and positive
reinforcement used. Mixed dentition, eruption age-appropriate. No caries detected. Caries
risk moderate. Bitewings taken. Rubber cup prophy; fluoride varnish applied (D1206).
Sealants recommended for #3, #14, #19, #30, to schedule. Parent advised to help with
brushing and limit juice between meals. Recall in 6 months.