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The Regence Group Dental Policy
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Periodontics Section - Full Mouth Debridement

Topic: Full Mouth Debridement Date of Origin: January 2011
Section: Periodontics Policy No: 36K
Last Reviewed: January 2015 Last Revised:
Approved: January 2015  

This Dental Policy has been developed through consideration of generally accepted standards of dental practice, review of dental literature, dental necessity, and as appropriate, government approval.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of dental policy is to provide a guide to coverage. Dental policy is not intended to dictate to providers how to practice dentistry. Providers are expected to exercise their clinical judgment in providing the most appropriate care.


Full mouth debridement to enable comprehensive evaluation and diagnosis (D4355):
The removal of subgingival and/or supragingival plaque and calculus. This procedure does not preclude the need for other procedures.

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

  1. Debridement allowed once every three years (provided D1110, D4910, D4341, have not been done within the last three years).
  2. Debridement is not a substitute for difficult prophylaxis.
  3. Considered inclusive if billed on same day as D1110, D4910 or D4341.

Administrative Guidelines
Process to contract benefits.

Codes Number Description

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