The Implant Review / Maintenance Notes Template
Nosht
Published by Nosht Limited
No baseline bone level recorded at crown fit means no way to quantify subsequent peri-implant bone loss — and no defence against peri-implantitis claims. Below is a template for UK clinicians to paste into their PMS for every implant review.
Why this implant review / maintenance template wins
- BoP with LIGHT FORCE (0.2-0.25N per ITI) — implants require lighter probing than teeth; standard pressure causes bleeding artefact.
- Baseline bone level reference — without this, progressive loss undetectable.
- Screw torque check / re-torque schedule — defends against screw loosening complications.
- Cement excess check (or screw-retained note) — peri-implantitis cement-related is a recognised cause.
- Patient-reported outcome — function, comfort, aesthetic — captures the holistic outcome.
The template (paste into your PMS notes field)
Paste the implant review / maintenance template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.
IMPLANT: [Site FDI / system / placement date / loading date] REVIEW INTERVAL: [3 months / 6 months / 12 months — specify based on time since loading] PATIENT REPORT: - Function: [Chewing comfortably / specific issues] - Comfort: [No discomfort / pain on biting / sensitivity] - Aesthetics: [Pleased / specific concerns] SOFT TISSUE ASSESSMENT (peri-implant): - Peri-implant mucosa: [Healthy pink / inflammation / swelling] - BoP (LIGHT FORCE 0.2-0.25N per ITI): [None / sites bleeding] - Suppuration: [None / present at site — Y/N] - Keratinised mucosa: [Adequate / inadequate] PERI-IMPLANT POCKET DEPTHS: [4 or 6 points per implant — recorded] - Compared to baseline: [Same / increased — describe] RADIOGRAPHIC BONE LEVEL: - Baseline (crown fit date): [Recorded — saved in PMS] - Today: [Comparison — none / 0.5-1mm physiological remodelling / >1mm progressive loss → peri-implantitis suspected] - Radiograph: [PA / PA standardised — quality / justification documented] CROWN / ABUTMENT CHECK: - Crown integrity: [Stable / chipped / fractured] - Screw torque: [Stable / re-torqued — Ncm per manufacturer] - Occlusion: [ICP contact / lateral excursion / protrusive — any changes / adjustments] - Cement excess: [None / removed if cement-retained] ORAL HYGIENE ASSESSMENT: - Plaque around implant: [None / interproximal / circumferential] - Compliance: [Excellent / good / needs reinforcement] - Aids used: [Interdental brushes / floss / superfloss] BRUXISM / PARAFUNCTION: - Splint compliance: [If prescribed — nightly / occasional] - Wear signs on crown: [None / chipping / fracture] PROFESSIONAL MAINTENANCE THIS VISIT: - Cleaning: [Plastic / titanium scaler / Airflow with Perio powder / specialised implant ultrasonic tip] - Polish: [Non-abrasive paste] - Fluoride: [If natural teeth at risk] NEXT REVIEW INTERVAL: [Justified — annual / 6-monthly if compliance / risk concerns]
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What good looks like — a worked example
The same implant review / maintenance template, completed for a realistic case.
IMPLANT: UR1 / Straumann BLT 4.1×10mm / placed 8 months ago / loaded 4 months ago (crown placed) REVIEW INTERVAL: 4 months since loading (first post-loading review) PATIENT REPORT: - Function: Chewing comfortably. Patient pleased with bite feel. - Comfort: No discomfort. - Aesthetics: Very pleased — natural-looking crown, gum margin stable. SOFT TISSUE ASSESSMENT: - Peri-implant mucosa: Healthy pink, no inflammation. - BoP (light force 0.2-0.25N): None at any site. - Suppuration: None. - Keratinised mucosa: Adequate (~3mm buccal). PERI-IMPLANT POCKET DEPTHS: 4-point chart (B / D / L / M) - Buccal: 3mm - Distal: 3mm - Lingual: 3mm - Mesial: 3mm - Compared to baseline (at crown fit): Same — no change. RADIOGRAPHIC BONE LEVEL: - Baseline (crown fit): Recorded on file - Today: Bone level stable. ~0.5mm of physiological remodelling consistent with normal crestal bone settling. No progressive loss. - Radiograph: PA today, quality A. Justification — baseline + 4-month comparison for peri-implant monitoring. CROWN / ABUTMENT CHECK: - Crown integrity: Stable, no chips - Screw torque: Stable (not re-torqued — protocol is to torque at fit and re-check at 6-month review; today is 4 months) - Occlusion: ICP contact even with adjacent teeth. Canine guidance preserved. No excursive interferences. No adjustments needed. - Cement: This is screw-retained crown — no cement, so no excess. ORAL HYGIENE: - Plaque around implant: None visible. - Compliance: Excellent — patient flossing daily, using superfloss for under contacts. - Aids: Superfloss + manual brushing. BRUXISM / PARAFUNCTION: - Splint not prescribed (no parafunction) - Wear signs: None. PROFESSIONAL MAINTENANCE: - Cleaning: Plastic implant scaler (Acteon) + Airflow with Perio powder (Perioflow nozzle subgingivally to 3mm) - Polish: Non-abrasive paste with rubber cup - Fluoride: 22,600 ppm applied to natural teeth (UL1, UR2) NEXT REVIEW INTERVAL: 6 months. Patient is excellent compliance, stable case — annual interval acceptable after this visit if continued stability.
Compliance: the medico-legal angle
- ITI Consensus 2023 (Morton et al.) — light probing force, BoP parameter, baseline radiograph requirement.
- EAO peri-implant monitoring consensus.
- ADI maintenance guidance.
- GDC Principle 4 — implant records must allow longitudinal monitoring.
Common documentation mistakes
- No baseline radiograph at crown fit — cannot detect progressive bone loss subsequently.
- Standard probing force used — causes false-positive BoP.
- Cement excess not assessed — a recognised cause of late peri-implantitis.
- No occlusion re-check — overloading drives screw loosening and crown fracture.
- Generic "implant stable" with no specific assessment — indefensible if peri-implantitis develops.
Sources
- GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
Frequently asked questions
Why use light probing force on implants?
Implants lack the periodontal ligament that gives teeth their probing resistance. Standard force (0.25N+) on an implant causes bleeding artefact. ITI Consensus 2023 specifies 0.2-0.25N light force for peri-implant assessment to differentiate true inflammation from probing trauma.
How do I establish a baseline?
At crown fit (definitive loading): take a PA radiograph showing bone level around the implant. Save in PMS as "Baseline — Implant UR1 Crown Fit". All subsequent review radiographs compare to this. Without baseline, you cannot quantify bone loss.
When should screw torque be re-checked?
At each maintenance visit — particularly first 6-12 months when loosening is most common. Re-torque to manufacturer specification (typically 20-35Ncm depending on system). Document the torque value.
Plastic or metal scaler for implants?
Plastic / titanium scalers (avoid stainless steel which damages titanium surface). Specialised implant ultrasonic tips (carbon fibre or specialised PEEK / plastic) for sub-marginal access. Airflow with Perio powder (glycine, not sodium bicarbonate) for subgingival biofilm removal.
What's peri-implantitis vs peri-mucositis?
Peri-mucositis: inflammation of soft tissues only (BoP, no bone loss) — reversible with OH improvement. Peri-implantitis: inflammation + progressive bone loss (>2mm beyond physiological remodelling, >25% threads exposed in some classifications). Requires active intervention and possible referral.
How often for implant maintenance?
First year: 3-monthly. Stable thereafter: 6-monthly to annual based on risk factors (smoking, OH compliance, periodontitis history). Document interval rationale.
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Nosht
Published by Nosht Limited
Nosht Limited makes structured clinical note templates for UK dental professionals. Articles refer to guidance from the GDC, CGDent, BSP, SDCEP and NICE. Check the current version of a source before relying on it.