The Implant Consultation Notes Template
An implant consultation notes template captures the comprehensive pre-implant assessment — full medical history with explicit bisphosphonate / anticoagulant / immunosuppressant / smoking / diabetes / radiation history, ridge and periodontal examination, CBCT or OPG with IRMER justification, ADI risk stratification (low/medium/high), alternative treatments discussed, written consent process, and written treatment plan issued — meeting ADI UK Guidelines and ITI Consensus 2023.
ADI guidance states implant risk stratification must be EXPLICIT not implied — and inadequate medical history (especially missed bisphosphonate use) is the dominant indemnity gap in implant failure cases. Below is the template UK clinicians paste into their PMS.
Download the free Implant Consultation template — plain text, GDC/FGDP(UK)-aligned.
Why this implant consultation template wins
- MHx items asked SPECIFICALLY (bisphosphonates, smoking, diabetes) — not implied. ADI requires explicit risk assessment.
- ADI risk stratification documented with basis — defends failure cases.
- CBCT justification recorded — IRMER ALARA compliance.
- Written treatment plan issued to patient — GDC consent best practice and avoids fee disputes.
- Alternatives explicitly discussed — Montgomery defence for elective procedure.
Compliance: the medico-legal angle
- ADI UK Guidelines for Implant Dentistry — risk stratification and consent framework.
- ITI Consensus 2023 (Morton et al., Clin Oral Implants Res) — current evidence-based protocols.
- IR(ME)R 2017 — CBCT justification documented.
- GDC Principle 3 (informed consent) + GDC Standards on Consent for Cosmetic / Elective procedures.
- Montgomery — alternatives + risks + maintenance commitment.
Common mistakes UK dentists make
- Bisphosphonate use not explicitly asked — leads to MRONJ post-placement, indefensible.
- Smoking status vague ("social smoker") — must be quantified.
- No written treatment plan — fee disputes and consent challenges follow.
- ADI risk stratification implied rather than explicit — leaves the assessment undocumented.
- CBCT taken without ALARA justification — IRMER breach.
Frequently asked questions
Why ask about bisphosphonates specifically?
MRONJ (medication-related osteonecrosis of the jaw) is a recognised complication of bisphosphonates and denosumab, particularly post-extraction or implant placement. SDCEP MRONJ 2024 requires explicit risk assessment. Even oral bisphosphonates raise risk (lower than IV). Many patients don't mention "Fosamax" if asked "any medications" generically. ASK BY NAME.
Do I need CBCT for every implant case?
Not for every case. OPG often adequate for initial assessment. CBCT justified when: bone width uncertain, IAN/sinus proximity, anterior aesthetic zone (labial plate assessment), grafting planning, multiple implants. ALARA principle — document the IRMER justification.
How do I document ADI risk stratification?
Low / Medium / High explicitly written. Basis must be specific: smoker status, periodontitis history, bone availability, medical conditions, OH compliance, parafunction. Generic "low risk" without basis is indefensible.
When should I refer to an implant specialist?
Beyond your competence: complex grafting, full-arch cases, severe systemic risk factors, anterior aesthetic zone if you lack experience, peri-implantitis management. ADI guidelines support GP implant placement for simple cases within training/competence. Document the referral decision.
What's in a written treatment plan?
Stages with prices, expected timescale, what is and is not included, warranty terms, complications/risks summary, maintenance requirements, refund policy. Patient must receive a copy (paper or email). This is best practice AND defensive against fee disputes.
What's the realistic success rate I should quote?
90-95% at 10 years for healthy non-smokers. Lower for smokers (75-85%), diabetics (depends on control), periodontitis history. Be honest. Document the figures discussed.