Full Mouth Debridement

Policy No: 36K
Originally Created: 01/01/2011
Section: Periodontics
Last Reviewed: 01/01/2019
Last Revised: 01/01/2018
Approved: 01/01/2018
Effective: 01/01/2018


Full mouth debridement to enable comprehensive evaluation and diagnosis (D4355)
Full mouth debridement involves the preliminary removal of plaque and calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation.


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

Debridement allowed once every three years (provided D1110, D4910, D4341, D4342, D4346, have not been done within the last three years).

Debridement is not a substitute for difficult prophylaxis.

Considered inclusive if billed on same day as D0150, D0160, D1080, D1110, D4910, D4341, D4342 or D4346.

Administrative guidelines

Process to contract benefits.


CDT - D4000-D4999 - see above


Your use of this Dental Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Dental Policy Disclaimer.