When to use this night guard template

Use it for any occlusal guard, from the diagnosis and records visit through delivery and adjustments. Payers that cover occlusal guards (D9944 hard full arch, D9945 soft full arch, D9946 hard partial arch) usually want to see a diagnosis such as bruxism, supported by clinical signs. "Patient wants a night guard" isn't enough.

What to document

Symptoms the patient reports, in their own terms.
Clinical signs: wear facets, abfractions, fractures, muscle findings.
TMJ findings and maximum opening, as a baseline.
The diagnosis and the appliance type, matched to the CDT code.
Fit, occlusion, and instructions at delivery.

Example delivery note

Patient seen for occlusal guard delivery. Patient reports morning jaw soreness; partner reports grinding. Clinical signs: attrition/wear facets, linea alba. TMJ WNL, maximum opening 46mm. Diagnosis: sleep bruxism. Appliance: hard full-arch occlusal guard (D9944), maxillary. Fit: seats fully, retention adequate. Occlusion: even bilateral contacts verified with articulating paper. Instructions: wear nightly, brush the guard with cool water, store dry in the case. Follow-up: check fit in 2–4 weeks.