Dental Prophylaxis, Adult and Child

Policy No: 08
Originally Created: 03/01/1997
Section: Preventive
Last Reviewed: 01/01/2019
Last Revised: 01/01/2018
Approved: 01/01/2018
Effective: 01/01/2018


Prophylaxis – adult (D1110)
A dental prophylaxis performed on transitional or permanent dentition which includes scaling and polishing procedures to remove coronal plaque, calculus and stains. Some patients may require more than one appointment or one extended appointment to complete a prophylaxis.

Prophylaxis – child (D1120)
Refers to a dental prophylaxis performed on primary or transitional dentition only.

Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346):

Should not be reported in conjunction with prophylaxis, scaling and root planning or debridement procedures.


Procedures are in accordance with generally accepted standards of dental practice.

Billing for an adult verses a child prophylaxis is determined by the dentist based on the dentition of the patient.

Administrative guidelines

Process to contract benefits.

If the dentist reports two routine dental prophylaxis on the same claim and indicates the treatment required more than one visit to complete, process each routine prophylaxis separately.


CDT - D1000-D1999 - see above


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