How to write a periodontal maintenance note
Periodontal maintenance (D4910) follows active periodontal therapy such as scaling and root planing or periodontal surgery. The note has to show the patient's periodontal history and compare today's findings to the last visit, so the recall interval and any re-evaluation or referral are clearly justified. The template also works for SRP and full mouth debridement visits; for SRP, the dedicated SRP template covers anesthesia and quadrants in more detail.
- Choose the visit type and the quadrants treated, then the periodontal diagnosis and when active therapy was last done.
- Record what the patient reports, including home care habits in their own terms.
- Enter clinical findings: tissue appearance, bleeding on probing as a percentage of sites, suppuration, probing depths, and the deepest sites by tooth and surface.
- Add recession, mobility, furcation involvement, plaque, and calculus, then the treatment provided and any irrigation or fluoride.
- Finish with tolerance, recall interval, re-evaluation or referral, and home care instructions. Copy the note and paste it into your PMS.
Example periodontal maintenance note
A fictional patient, filled in with this template and copied as-is.
John Smith was seen by Alex Rivera, RDH on October 14, 2026 for periodontal maintenance (D4910), quadrant(s) full mouth. Periodontal diagnosis: Periodontitis Stage III. Last periodontal treatment: 3–6 months ago. Compliant with recall interval.
The patient reported bleeding gums. Home care: Brushing only, inconsistent flossing.
On clinical exam, gingival tissue was erythematous, edematous, with bleeding on probing of 10–25% of sites. No suppuration noted. Probing depths were localized 4–5mm, with notable deep sites at #3 DB, #14 MB, #19 DL. Localized recession. No mobility noted. Furcation involvement: Grade I.
Plaque was assessed as moderate, with light supragingival and light subgingival calculus noted.
Treatment provided: anesthesia, topical only; ultrasonic scaling, hand scaling, and selective polishing. Irrigation: Chlorhexidine irrigation. Fluoride varnish applied.
Tolerated procedure well. Mild sensitivity expected.
Recall interval: 3 months. No re-evaluation needed. Home care instructions reviewed: Reinforced flossing/interdental cleaning and recommended interdental brushes.
What a complete note covers
- Periodontal history: diagnosis, when active therapy was completed, and recall compliance.
- Subjective findings and the patient's own report of home care.
- Bleeding on probing as a percentage of sites, plus suppuration.
- Probing depths with the specific deep sites (for example, #3 DB), so they can be compared next visit.
- Recession, mobility, and furcations, graded.
- Treatment: anesthesia, instrumentation, irrigation or local antimicrobials, and fluoride.
- Plan: recall interval, re-evaluation or referral to a periodontist, and home care instructions.
Common mistakes
- Billing D4910 without documented active therapy. The chart should show the SRP or surgery that came before maintenance.
- No comparison with the last visit. "Probing depths stable" means little unless the deep sites are named and can be compared.
- Pockets getting deeper with no plan. If sites worsen, document a re-evaluation, re-treatment, or referral.
- No reason for the recall interval. Tie a 3-month interval to the findings: bleeding, deep sites, home care.
- Copying last visit's note forward. Reused findings are easy to spot in an audit and undermine the whole chart.
Questions
How often is periodontal maintenance scheduled?
Commonly every 3 months after active therapy, adjusted to the patient's response. The template offers 3, 4, and 6 months; record why you chose the interval.
Can a patient go back from D4910 to D1110?
Payers treat this differently. Whatever is decided, the note should show the current periodontal status that supports the code billed. Check the patient's plan.
Where do I record full probing charts?
In your PMS perio chart. The note summarizes the range and names the deepest sites, and the full chart holds every reading.
Related templates and guides
Example notes use fictional patients. Coding notes are general guidance; confirm against the current CDT manual and the patient's plan.