The Implant Consultation Notes Template

ADI guidance states implant risk stratification must be EXPLICIT not implied — and inadequate medical history (especially missed bisphosphonate use) is a recurring gap in implant failure cases. Below is a template for UK clinicians to paste into their PMS.

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 — IRR 2017 ALARP compliance.
• Written treatment plan issued to patient — GDC consent best practice and avoids fee disputes.
• Alternatives explicitly discussed — Montgomery defence for elective procedure.

The template (paste into your PMS notes field)

Paste the implant consultation template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

PRESENTING COMPLAINT / GOAL: [Single tooth / multiple / full arch / aesthetic / function]

MEDICAL HISTORY (full systemic review — RECORD EXPLICITLY):
- Bisphosphonates / denosumab: [None / oral — drug + duration / IV — drug + duration] MRONJ risk
- Anticoagulants / antiplatelets: [None / drug + indication]
- Immunosuppressants: [None / drug + reason]
- Steroids: [None / dose + duration]
- Diabetes: [None / Type 1 / Type 2 — HbA1c if known]
- Smoking: [Never / Ex (years ago) / Current — cigs/day] — quantified
- Alcohol: [Units/week]
- Head/neck radiotherapy: [None / dose / region / years ago]
- Heart valve / replacement / prophylaxis required: [Per NICE CG64]
- Pregnancy / BF: [N/A]
- Allergies: [List or NKDA]

DENTAL HISTORY:
- Reason for tooth loss: [Periodontal / caries / trauma / failed RCT]
- Previous orthodontics: [Y/N]
- Bruxism / parafunction: [Y/N]
- Previous implant experience: [Y/N — sites + outcomes]

CLINICAL EXAMINATION:
- Edentulous site: [Tooth position(s)]
- Ridge width (clinical estimate): [Narrow / adequate / wide]
- Ridge height: [Adequate / atrophy]
- Soft tissue thickness: [Thin / adequate biotype]
- BPE full mouth: [All sextants]
- Adjacent teeth: [Vital / status / restoration]
- Opposing dentition: [Natural / denture / opposing teeth]
- Inter-arch space: [Adequate / restricted]
- Occlusion: [Class / parafunction signs]

RADIOGRAPHIC ASSESSMENT:
- OPG: Justified — initial implant assessment. Quality. Report (bone height, anatomical structures).
- CBCT: [Indicated if 2D inadequate — justification: bone width / IAN proximity / sinus assessment / 3D site planning]. ALARP (IR(ME)R 2017) documented.

ADI RISK STRATIFICATION (documented explicitly):
- Low / Medium / High risk patient
- Basis: [E.g. "Low — non-smoker, no medical conditions, good OH, adequate bone" / "High — current smoker, periodontitis history, narrow ridge needing grafting"]

ALTERNATIVE TREATMENTS DISCUSSED:
- Resin-bonded bridge
- Conventional bridge
- Removable partial denture
- No treatment / accept gap

CONSENT PROCESS:
- Risks explained (implant failure 5-10% over 10 years, peri-implantitis, nerve injury where relevant, sinus complications where relevant, infection, need for maintenance, eventual replacement)
- Benefits explained
- Longevity discussion (no implant is guaranteed lifelong)
- Maintenance requirement (annual professional + lifetime OH commitment)
- Written treatment plan issued to patient

WRITTEN TREATMENT PLAN (issued to patient): [Procedure stages / costs / timescale / what is and is not included / warranty terms]

REFERRAL DECISION: [Self-management / refer to implant specialist — rationale documented]

NEXT STAGE: [Surgical planning visit / surgical placement / referral]

Try the implant consultation note in the live demo → No account needed.

What good looks like — a worked example

The same implant consultation template, completed for a realistic case.

PRESENTING COMPLAINT / GOAL: Single missing tooth UR1 (lost to trauma 2 years ago, currently empty). Wants permanent fixed replacement, no removable.

MEDICAL HISTORY:
- Bisphosphonates / denosumab: NONE. Specifically asked.
- Anticoagulants / antiplatelets: NONE.
- Immunosuppressants: NONE.
- Steroids: NONE.
- Diabetes: NONE.
- Smoking: NEVER (asked specifically — life-long non-smoker).
- Alcohol: 8 units/week.
- Head/neck radiotherapy: NONE.
- Heart conditions: NONE — no prophylaxis indicated.
- Pregnancy / BF: N/A (male patient).
- Allergies: NKDA.

DENTAL HISTORY:
- Reason for tooth loss: Trauma (RTA 2 years ago, UR1 avulsed and not replantable due to extra-oral time).
- Previous orthodontics: None.
- Bruxism / parafunction: No clinical signs.
- Previous implants: None.

CLINICAL EXAMINATION:
- Edentulous site: UR1
- Ridge width: Adequate clinically (~6mm buccolingual estimate)
- Ridge height: Adequate (preserved alveolar architecture)
- Soft tissue: Thick biotype, adequate keratinised gingiva
- BPE: All sextants 0-1. No periodontitis.
- Adjacent teeth: UR2 and UL1 both vital, intact, no restorations
- Opposing: LR1, LL1 natural intact
- Inter-arch space: Adequate
- Occlusion: Class I, no parafunction

RADIOGRAPHIC ASSESSMENT:
- OPG: Justified for initial implant assessment. Quality A. Report: UR1 site shows adequate bone height (12mm), no pathology, adjacent root anatomy normal, sinus floor at acceptable distance.
- CBCT: Recommended for 3D site planning before placement — particularly bone width and labial plate thickness in anterior aesthetic zone. ALARP (IR(ME)R 2017) justified. To be taken at surgical planning visit if patient proceeds.

ADI RISK STRATIFICATION: LOW RISK
Basis: Healthy non-smoker, no medical contraindications, no periodontitis, adequate bone clinically, thick biotype, single straightforward site, motivated patient with good OH.

ALTERNATIVE TREATMENTS DISCUSSED:
- Resin-bonded bridge UR2-UR1: Aesthetic compromise (slight grey shine through), debonding risk, simpler + cheaper
- Conventional bridge UR2-UL1-pontic: Requires preparation of two virgin teeth (significant cost in tooth structure), aesthetic and longevity good
- Removable partial denture (single-tooth flipper): Patient strongly declined
- No treatment: Patient declined

CONSENT PROCESS:
- Risks: Implant failure (~5% over 10 years for healthy non-smoker), peri-implantitis (depends on OH compliance), infection at surgery (~2%), need for bone grafting if CBCT shows inadequate width (~30% likelihood given clinical estimate), need for connective tissue graft for aesthetic outcome (~50% likelihood in anterior zone for ideal aesthetics), lifetime maintenance commitment, no guarantee of lifelong success
- Benefits: Fixed restoration, no preparation of adjacent teeth, preserves bone, aesthetic
- Longevity discussion: 90%+ at 10 years for healthy non-smoker with good OH; implants are not "guaranteed lifelong"
- Maintenance: Annual professional implant maintenance + lifetime OH commitment — patient understands
- Written treatment plan issued to patient (printed copy + emailed)

WRITTEN TREATMENT PLAN ISSUED:
- Stages: Surgical planning (CBCT) → implant placement (£__) → healing 4-6 months → impression + crown (£__) → annual maintenance
- Costs: Itemised
- Timescale: 6-8 months total
- Warranty: 12-month warranty on workmanship (per practice policy)
- Inclusions: Implant + abutment + crown + initial review
- Exclusions: Bone grafting, soft tissue grafting, peri-implant maintenance after 12 months

REFERRAL DECISION: Self-management — within practice scope (anterior single-tooth case, low risk, restorative dentist with implant training).

NEXT STAGE: Surgical planning visit with CBCT in 2 weeks.

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 documentation mistakes

• 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 documented justification — a breach of IR(ME)R 2017 regulation 11 (justification), with doses kept as low as reasonably practicable (ALARP, regulation 12).

Sources

• GDC Standards for the Dental Team, Principle 3: Obtain valid consent (accessed 18 October 2026)
• The Ionising Radiation (Medical Exposure) Regulations 2017 (SI 2017/1322) (accessed 18 October 2026)
• Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (accessed 18 October 2026)
• NICE CG64: Prophylaxis against infective endocarditis (accessed 18 October 2026)
• SDCEP: Oral Health Management of Patients at Risk of Medication-related Osteonecrosis of the Jaw (March 2017) (accessed 18 October 2026)

Frequently asked questions

Guides that cover this

• Montgomery in Dentistry: the Legal Test and Material Risks

Patient leaflets for this treatment

• Your Guide to Dental Implants
• Your Guide to Your Dental Implant Consultation
• Replacing a Missing Tooth — Your Options

Related dental note templates

Browse the full set of free dental notes templates.