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Practice More Safely // Risk Tips // Sedation of High-Risk Patient Leads to Sanctions Against Dentist

Sedation of High-Risk Patient Leads to Sanctions Against Dentist

Case Study

Marc Leffler, DDS, Esq.
January 16, 2025

Reading time: 7 minutes

Patient being sedated by dentist in dental treatment room.

To make an informed decision about the safety of sedation for each patient, it is crucial for dentists to consider a patient’s medical history and all the possible complications that could occur when they are put under. In this case study, a dentist inappropriately sedates a high-risk patient, leading to sanctions.

Key Concepts

  • Patient selection for sedation
  • Risks associated with in-office sedation for dental procedures
  • Patient safety

Background Facts

Dr. E was a general dentist, relatively new to practice in a suburb of a large city. In an effort to maximize what she could provide for her patients, she took a series of state-approved courses which, upon completion, permitted her to deliver moderate parenteral (non-GI) sedation to patients in her office. She diligently complied with the related requirements regarding having her office properly equipped with a “crash cart” and monitoring and assuring that all her chairside staff were CPR-trained.

H was a 68-year-old male patient who had been seeing Dr. E for a few years. He wore a double-distal-extension mandibular partial denture but was dissatisfied with its retention and function. Dr. E had spoken to him about placing bilateral posterior mandibular implants to serve as a basis for fixed prosthetics, but he resisted due to his anxieties about surgery unless he were “asleep.” After Dr. E obtained her qualification to deliver IV sedation, she offered that to H, and he agreed to have the implants placed in two separate appointments, each one focusing on placement on one side only.

Medically, H was obese, at 5’8″ tall and weighing 231 pounds (a BMI of 35.1), and he had COPD from years of smoking which he had since given up, and obstructive sleep apnea (OSA) for which he regularly used a CPAP machine. Dr. E sought and obtained medical clearance for the implant surgery under IV sedation from H’s primary care physician, so she felt confident in proceeding as planned.

On the date of surgery to place 3 implants in the left mandible, H was NPO for more than 8 hours and was accompanied by his adult son. Dr. E placed a nasal mask on H, providing a 60%/40% N2O/O2 flow; this was followed by the delivery of the first dose of Midazolam intravenously, which was supplemented and titrated as necessary over the next 2 ½ hours. Local anesthesia was injected after H became relaxed and somnolent. Monitors said to Dr. E that her patient was stable throughout. Upon completion of the procedure, H unsteadily walked to the office recovery area, assisted by both a dental assistant and H’s son. After approximately 30 minutes, H appeared as still being “out of it,” so Dr. E gave him a dose of Flumazenil to reverse the effects of the Midazolam. H steadily became more alert, so he was discharged home; H’s son took him home and stayed with his father for the rest of the day. About 4 hours later, H’s son noticed that his father seemed to be slipping backward into a sleepier state, and this process continued to the point that it became difficult to arouse him, with an irregular snoring pattern happening. The son contacted EMS; upon EMS arrival, H’s SpO2 (oxygen saturation) measured 81% and H’s depressed mental status and breathing pattern did not improve. With the approval of the ED physician, H was intubated and given supplemental oxygen while being transported to the hospital, where he remained for the next 8 days until he was able to breathe on his own and maintain an SpO2 of 94-96%. According to H, his son, and H’s friends, he was never able to return to the usual daily activities that he enjoyed prior to the implant procedure.

Although H’s son met with several attorneys on his father’s behalf, he was unable to find any who would proceed with a malpractice action against Dr. E, for the general reason that it would be difficult to objectively demonstrate compensable damages. But the son was very upset by what he saw in his father’s ability loss, so he filed a Board complaint against Dr. E.

Upon receipt of the complaint, Dr. E reached out to her malpractice carrier, following which counsel was assigned by the carrier to represent her before the Board. All records were provided in a timely manner to the Board, and Dr. E appeared, with her attorney, for several interviews before Board members and a dental anesthesiologist “expert.” Dr. E’s testimony relied heavily on the facts that she had obtained pre-sedation medical clearance from H’s physician, so she felt fully justified in her patient selection, and that she had kept H in her office until he was clearly in a state that was stable enough for discharge.

At the conclusion of its investigation, the Board issued a report in which it found a number of care deficiencies on the part of Dr. E and levied sanctions against her, namely a fine, a 2-month suspension from practice, and revocation of her sedation permit. The major findings of the Board, which it detailed in its report, were that Dr. E had inappropriately delivered in-office sedation to a patient who was not a suitable candidate and for whom she did not take proper precautions during the post-sedation period; the Board viewed the obtained medical clearance as essentially irrelevant to the issues, because the ultimate decisions about treatment ultimately lie with the treating practitioner.

Citing to an attached set of findings by the Board’s expert, the Board first determined that H had been misclassified by Dr. E as an ASA (American Society of Anesthesiologists) Class II patient, when he was actually a Class III; the Board pointed to the fact that the required coursework taken by Dr. E included a policy guideline that patients with greater than a Class II designation ought not to be sedated in an office setting unless a medical or dental anesthesiologist was present to manage the anesthesia aspects of care. The Board determined that, while H’s obesity status placed him as an ASA II, his OSA requiring CPAP use meant that this disease was “severe,” placing him as an ASA III, and his COPD, alone, categorized H as a Class III. All told, H was an ASA Class III, making him an inappropriate choice for in-office sedation under these circumstances, according to the Board. Furthermore, the Board found that Dr. E had failed to consider and take into account the relative half-lives of the drugs she employed, Midazolam and Flumazenil. The Board’s expert detailed that Midazolam’s half-life was measured on the order of 1.5-2.5 hours, while its reversal agent, Flumazenil, had a half-life of approximately 30 minutes; so, estimating that 4-5 half-lives are necessary for “clinical elimination,” Dr. E failed to take into account that the sedative agent would stay in H’s system for far longer than its reversal agent, leading to a revived level of sedation – with decreased respiration – once the reversal drug had effectively dissipated.

Takeaways

As many parents have said to their newly licensed teenage children, “just because you can drive doesn’t mean you really know how to drive.” The same principle holds here, specifically in the sedation realm, but also regarding dental practice generally. It is, of course, necessary for practitioners to obtain all required credentials in their jurisdictions of practice, but the abilities to perform the range of tasks needed for safe practice do not instantaneously develop on the day a degree or certificate is conferred; rather those abilities will mature with time, so it is the obligation of every practitioner to practice at levels commensurate with their skills at the time, in order to properly protect their patients.

This case study is not meant to promote the specific opinions of the involved Board or its expert, but the study’s purpose is to demonstrate some of the approaches employed in the state’s oversight of its licensed professionals. Unlike courts and juries sitting on dental malpractice cases, in which they must determine whether a plaintiff has demonstrated that negligence has directly caused damages, Boards look simply at the actions of professionals, regardless of the extent or even existence of damages, to determine whether those actions fall within the standards by which their mandates provide.

The process of obtaining pre-treatment medical clearance played a significant role in this case, but that is, by no means, an approach limited to dental treatment under sedation or general anesthesia. Dentists are often confronted with patients suffering from numerous medical conditions, and it is left to those dentists to determine whether it is safe to proceed based upon the information provided by the patient and taking into account their own knowledge and experience, as compared with seeking a medical opinion before going forward. That is a personal determination, always keeping the patient’s best interests in mind. But even when medical clearance is provided by a physician, it is the dentist who bears the ultimate responsibility for the patient’s welfare. So, while a medical clearance is a valuable, and sometimes necessary procedural step, it is best viewed as one of many factors to consider as treatment decisions are made. Perhaps the most important concept from this case is the need for every practitioner to be fully familiar with every drug employed, every potential interaction, every procedure performed, and every realistic side effect. That is precisely what makes a professional. If in doubt, it might well be what is best for the patient to defer or refer.

Note that this case presentation includes circumstances from several different closed cases, in order to demonstrate certain legal and risk management principles, and that identifying facts and personal characteristics were modified to protect identities. The content within is not the original work of MedPro Group but has been published with consent of the author. Nothing contained in this article should be construed as legal, medical, or dental advice. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your personal or business attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.

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A fulfilling dental career is powered by passion. In this article, Dr. Shafa Nathani, a member of MedPro Group’s Dental Advisory Board, offers insight on staying motivated and shaping a career that you’re passionate about.









Key Concepts





    

  • Job satisfaction and preventing burnout
    • 




  • Continuing education for dentists
    • 




  • Mental health and work-life balance
    • 










Cultivating your passion as a dentist can boost your job satisfaction throughout your career. When you genuinely enjoy what you do, it's easier to feel fulfilled and eager to come to work each day. Maintaining enthusiasm at work also helps keep you motivated, especially during difficult periods.





In addition, your passion for your dental career can trickle down into your care. Your upbeat demeanor can be contagious, helping to build trust and a sense of safety with your patients. This often leads to fewer appointment cancellations and a stronger commitment from your patients to stick to their treatment plans.





Building a dental career you love begins with securing reliable dental malpractice insurance – so you can practice safely and confidently with protection against potential malpractice claims. With trusted coverage from industry leader MedPro Group, you’ll get the peace of mind you need to deliver the best care to your patients and focus on fostering a fulfilling career.





Read this article for tips on how to choose the right dental malpractice insurance policy.





Q&A with a MedPro Group Dental Advisory Board Member





We interviewed Dr. Shafa Nathani, DMD, a member of MedPro’s Dental Advisory Board, to learn how she maintains her enthusiasm for her practice.





What’s your favorite part about working with patients?





"Every patient who sits in my chair comes with a story, and that’s something I never take for granted. On most days, the office is busy and fast-paced, and I may only get a few moments with each patient. Still, those moments often carry the most meaning. Whether it’s meeting a new patient for the first time, delivering complete dentures to someone we’ve been caring for over months or years, or seeing a recall patient after a long gap and catching up on their life, those brief connections matter deeply to me. Outside of the technical side of dentistry, it’s these human moments that ground me. After a day that feels like a total blur, they remind me why I chose this profession in the first place and how privileged I am to be trusted with someone’s care, comfort, and confidence.”





How do you prevent burnout as a dentist?





"I’m a little over a year into my career, and I’m currently in a phase of saying ‘yes’ as much as possible, working hard to gain experience and take full advantage of the momentum from dental school. While that growth has been exciting, it also comes with physical and mental challenges.” 





“There are days when my back aches, the mental load of running a busy office feels overwhelming, and the idea of taking time off sounds incredibly appealing. Early on, my routine after work was to go straight home, sit on the couch, and try to decompress. However, I quickly realized that I was still waking up tired and feeling like my life revolved entirely around work.”





“Making intentional changes helped shift that mindset. I joined a yoga studio, spent time at the library, and found ways to stay mentally and physically engaged outside of dentistry. Even though I was still tired, I felt fulfilled. That sense of balance has been essential in preventing burnout and helping me remain enthusiastic, motivated, and present for my patients."





Learn more about recognizing and preventing burnout in this article.





Can you share a pivotal moment that reaffirmed your passion for dentistry?





"Within my first month of practicing as a dentist, I treated an older patient whose upper bridge and partial had completely failed. He required full-mouth extractions, but financial limitations prevented him from receiving care from an oral surgeon. I wanted to help him, but I also questioned whether I was capable of managing a case of that complexity so early in my career.” 





“I reached out to a mentor who guided me step by step through the surgical process and denture delivery. While he was incredibly grateful for the care, that wasn’t the moment that truly reaffirmed my passion for dentistry. It was everything that followed. Over the next year, I saw him regularly for adjustments and follow-up exams, and during those visits we shared life updates and built a genuine connection. On my last day at that office, we tearfully said goodbye, and he offered me his blessings.”





“That moment reminded me that dentistry is about far more than procedures. It’s about relationships, trust, and long-term impact. He will be attending my wedding later this fall, a testament to how meaningful patient relationships can become."





How important is continuing education to staying passionate about your career?





"Continuing education is incredibly important to me, both professionally and personally. Dental school provides a strong foundation, but it can’t possibly cover everything. Depending on how you want to practice, CE can help shape you into a well-rounded dentist or allow you to focus deeply on a specific niche. I identify strongly with being a well-rounded practitioner.” 





“I’ve discovered countless resources and taken courses that reignite my excitement for learning and push me to try new techniques that lead to better clinical outcomes and smoother recovery for patients. Dentistry is constantly evolving, and staying current isn’t optional, it’s a responsibility. Engaging in CE keeps me challenged, curious, and inspired, which directly translates into better patient care."





How do you stay connected to the dental community? How does that affect your passion for your work?





“Having a supportive dental community is vital to my success and longevity in this profession. I’m incredibly grateful for the friendships I formed in dental school. We often joke that between all of us, we somehow cover every time zone in the country. Even though we aren’t geographically close, those friends are the first people I reach out to because they truly understand the challenges, pressures, and victories that come with dentistry. It’s a judgment free space where I can ask questions, vent, or celebrate wins.” 





“Additionally, my current role allows me to work within a DSO alongside a strong group of dentists. Through monthly calls and in person collaboration, we’ve built relationships rooted in mutual support and shared growth. This community has been essential in keeping my passion for dentistry alive because I never feel isolated. Instead, I feel supported, encouraged, and reminded that I’m part of something much bigger than myself.”





Passion starts with security 





You're passionate about your patients. We're passionate about protecting your good name. With over a century of dental malpractice expertise, we'll protect your practice so you can focus on building a career you love.





To learn more, contact our team or get a quote today.


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In this case study, dentists learn how an implant placement evolved into a malpractice lawsuit after the patient developed persistent postoperative nerve injury symptoms. The case demonstrates how clinical choices made at the planning stage can significantly influence the legal trajectory of a case.









Key Concepts





    

  • Understanding divergent opinions between experts
    • 




  • Determining standard of care for different radiographic techniques
    • 




  • Understanding the pure consent to settle clause
    • 










Background Facts





Dr. P practiced restorative dentistry in a suburban community, since her completion of dental school and a general practice residency. During her formal training and after, she engaged in didactic and clinical coursework involving implant placement and restoration and regularly recommended and employed dental implants in her treatment plans. That was the case when a new area resident, O, a healthy man in his 40s, presented for general care and consideration for replacing missing tooth #30, which was extracted years ago following a trauma-induced fracture.





O's mouth was in generally good repair, as he practiced good home hygiene and had been a regular dental patient for his entire adult life. Dr. P discussed the replacement options of a 3-unit fixed bridge and an endosseous implant, upon which a single crown would be placed. After taking and viewing a panoramic radiograph, Dr. P advised O that he had "plenty of bone" to support an implant, and she suggested that approach. The costs were similar, so O opted for the implant plan. Dr. P advised O of the usual risks of implant surgery, including a nerve injury which could even be permanent in "rare" situations. O agreed to go forward and set up an appointment within the next few weeks.





At the surgical visit, a chairside assistant presented O with a document entitled Implant Consent Form, telling O that this was exactly what Dr. P had discussed with him. O quickly perused the form and signed it. Based upon measurements she made on the panoramic film, Dr. P determined there to be 14.5 mm of mandibular bone superior to the inferior alveolar canal (IAC), so she planned for and placed a 13 mm fixture. Upon elevating a gingival flap, Dr. P noticed that the lingual height of bone was "a good deal" higher than on the buccal aspect. Other than O briefly wincing toward the end of the preparation phase, all went smoothly, with the implant covered with soft tissue and sutured. A post-placement periapical radiograph showed the implant in very close approximation to the IAC, but Dr. P saw "daylight," so she was not concerned.





One week later, at the suture removal visit, O complained of "pins and needles" and "numbness" on the right side of his lower lip and chin. Dr. P stated that she remained "unconcerned," explaining that this is common and all should be back to normal over the next weeks or months. O returned for crown placement 5 months after implant surgery, still with the same "annoying sensations." Dr. P was surprised that the situation had not normalized, but she continued to reassure O of a return to normal. That never came.





Legal Action





O always found the tingling and numbness to be uncomfortable, but he never thought to do anything about it until he met up with a college classmate of his, now an attorney, at an alumni event. The classmate did not practice law where O now lived but suggested that he consult with an attorney he knew who did "a lot of malpractice work." O met with that lawyer, who gathered all of Dr. P's records and sent O to a local neurologist to assess the extent of the injury. The neurologist confirmed that O's mandibular nerve was in fact injured and did not conceive of any improvement, now nearly two years after the surgical event.





O's attorney contacted an experienced dentist whom he knew, who had testified in dental malpractice cases in the past, and who, like Dr. P, regularly placed and restored implants, seeking to retain that dentist as an expert on behalf of O. Following a review of the records, the expert reported back to the attorney that, in his opinion, Dr. P had deviated from the standard of care, which in the expert's view required the use of CBCT radiography in order to accurately determine available bone for implant placement. The expert cited specifically to Dr. P's intraoperative finding of a sloped mandibular crest, which could not have been determined on the 2-D panoramic but would have been seen on a 3-D CBCT, had one been taken. The expert added to that opinion the concept that, once Dr. P noted that lingual-to-buccal slope, she should have immediately stepped back and reconsidered whether the planned-for 13 mm implant was appropriate, which it ended up not being, as the measurement was based upon the highest point of the crest, rather than lower points on that slope which were closer to the IAC.





The attorney quickly filed suit against Dr. P, as the statute of limitations was approaching. Dr. P contacted her professional liability carrier, which assigned defense counsel to Dr. P. O's attorney voluntarily shared his expert's report with defense counsel, hoping to demonstrate a strong basis for an early settlement. However, defense counsel retained its own expert, who opined that the standard of care allowed for 2-D panoramic films for the purpose of implant planning, although acknowledging a deep split within the dental profession. Some dentists and organized dental groups asserted that (exactly because of anatomic situations as Dr. P found) 3-D studies were required prior to posterior mandibular implant placement, with other dentists and dental groups agreeing with this defense expert's stance. In part, the latter view is supported by the statistical fact that, according to recent assessments, only 29% of U.S. general/restorative dentists have on-site CBCT availability, with less than 2/3 of dental specialists having such access.





Defense counsel recognized that a motion for summary judgment––one seeking dismissal of the case without trial––would not be fruitful because such a motion can only be successful when, among other things, there is no legitimate difference between opposing expert opinions.  Therefore, defense counsel thoroughly presented Dr. P with her options: (1) go to trial and ask a jury to determine whether she had run afoul of the standard of care, allowing them to award money to compensate O for his injuries if they determined that she did not meet the standard of care, and if that was causative of his injuries; or (2) trying to reach a pre-trial settlement, presuming that the carrier agreed with that prospect, which it did.





Dr. P frankly said to her attorney that, in multiple continuing education classes she had taken, the need for pre-implant CBCT studies was discussed, for the very reasons highlighted in O's treatment. She further acknowledged that she would have to testify to that experience if asked at trial. Dr. P was concerned, so she authorized attempts to resolve the case. Because O's injuries were viewed, even by his own lawyer, as not severe, evidenced in part by O having never sought subsequent evaluations or care other than at the direction of his attorney, a modest settlement was reached.





Takeaways





It is the rule, and not the exception, that experts for plaintiffs and defendants will disagree, and that is also the case for dentists, outside of the litigation realm. Those disagreements take center stage during dental malpractice trials, with jurors left to determine which of the opposing positions they accept. As Dr. P reasoned here, it is rarely, if ever, simply a coin flip, because a host of factors play into jury determinations, so the pre-trial "prediction calculus" takes into account a common sense approach as to how lay people will most likely come to their conclusions on matters of science and professional expertise. Sometimes demeanors of the parties and/or experts carry the day. Sometimes the bases of expert opinions are determinative, and sometimes, as might play here, particular professional experiences in the dentist's past are of significance. While legitimate (not fabricated) differences of expert conclusions generally preclude dismissal before trial by way of motions, those differences will need to be resolved by a trial jury. There is no getting around that.





This case study briefly touches on the concept of statute of limitations (SOL), so a short description is in order. The SOL is the time following a claimed negligent event (or sometimes the subsequent discovery of that event) within which a plaintiff must file suit or be forever time-barred. Of course, as with so many issues in the law, there are nuances and issues which can serve to lengthen the allowable timeframe, but they are exceptions, with the statutory SOL generally being the bedrock. The concept of SOL is perhaps the most variable legal issue as between the States––or at least close to the top of the list––but it is a consideration for attorneys (or self-represented plaintiffs) to grapple with, and not something with which dentists need to familiarize themselves.





As the body of this case study references, divergent views exist within dentistry as to what radiographic techniques are "best" for various planned procedures or diagnostic approaches, which in the litigation arena often translates to opinions as to standard of care. Articles in respected journals present competing ideas. Some take the approach that dentists are in the most ideal position to make patient-based, procedure-based, and circumstance-based decisions as to which radiographic techniques––whether CBCT, panoramic, periapical, etc.––are most appropriate clinically. Others are more rigid, asserting, for example, that nearly all invasive dental/oral surgical procedures require CBCT studies in advance. While we do not advocate here in either direction, dentists and oral surgeons ought to be aware of these opposing schools of thought and consider them in decision-making, realizing that jurors might get the final say.





We end on a note about the decision faced by Dr. P. Given that she had a "consent-to-settle" policy, it was her right to refuse any type of settlement, regardless of the input or advice of her counsel or insurer. Had she not had such a policy, that decision would not have been hers to make. This is yet another issue for dentists to consider when choosing a malpractice carrier and policy.





MedPro Group is the marketing name used to refer to the insurance operations of The Medical Protective Company, Princeton Insurance Company, PLICO, Inc. and MedPro RRG Risk Retention Group. All insurance products are underwritten and administered by these and other Berkshire Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is based upon business and/or regulatory approval and/or may differ among companies. © MedPro Group Inc. All rights reserved.


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In this case study, dentists will discover how a rushed procedure, antibiotic selection, and non-clinical staff advice led to a malpractice lawsuit and patient harm. This article highlights the importance of informed consent, careful risk management, and keeping patient communications strictly professional.









Key Concepts





    

  • Antibiotic risks and complications in dental care
    • 




  • Non-clinical staff-patient communication
    • 




  • Patient choice vs. the standard of care
    • 










Underlying facts





D, a 26-year-old man, presented to an endodontist, Dr. Q, on referral of his family dentist, some 6-7 years following his having been struck in the face by a batted baseball. Over the past few months, tooth #8 had begun to darken and become episodically painful. Approximately a week prior to this visit, D developed a pea-sized swelling in the gingiva at the level of the tooth's apex. Radiographically, a periapical radiolucency on #8 was visible, and the tooth was non-vital. The endodontist suggested endodontic therapy, to which the patient agreed.





Upon entry into the pulp chamber, yellow, foul-smelling purulent discharge exuded through the tooth; the apical swelling immediately reduced in size. The tooth was thoroughly irrigated internally until no pus was visible. Because D was soon going out of town for work for several weeks, he asked the endodontist if she could "just finish it up" that same day, rather than returning a week later as Dr. Q had suggested. Dr. Q acceded. After the filing was completed, obturation with gutta percha was performed by Dr. Q, with the apical extent approximately 1mm short of the radiographic apex. NSAIDs were recommended as needed.





Two days later, D called the office and told the receptionist that he had a sudden increase in swelling and a low-grade fever; the receptionist reassured the patient by saying, "we see this all the time so it's nothing to worry about," without having consulted with Dr. Q. Three days after that, while still traveling and with the swelling now approaching the eye, D called the endodontist after hours and spoke directly with her; the patient reported an allergy to Penicillin, so Dr. Q called in a prescription for Clindamycin, which the patient started that same evening.





Now nine days after the initial treatment, the patient again called the office and spoke with Dr. Q, advising her that his facial swelling was much reduced and getting better continually, but he had spasmodic diarrhea; the endodontist told her patient that, as long as the dental symptoms were improving, which they were, he should continue and finish out the antibiotic and take over-the-counter anti-diarrheal medications. The patient did exactly that but ended up in a hospital emergency room a few days later for worsening and uncontrollable diarrhea with severe GI pain, where he was diagnosed with Clindamycin-induced pseudomembranous colitis. He was admitted for IV fluids/antibiotics and supportive care; he was monitored for a potential peritonitis, which never came to pass, and was discharged home after losing seven pounds. D was unable to secure the sales deal he had traveled for, as he was hospitalized during several scheduled meetings; the potential client made the transaction with another vendor.





Legal action





In addition to the physical upheaval that he had experienced, and the medical and hospital bills which were only partially covered by his insurance plan, D was mostly distressed by the fact that he had lost the opportunity for a large sale that he believed would have positioned him for an early-career promotion, with its associated salary increase. He sought out and retained an attorney.





The newly hired attorney forwarded the dental and medical records to two potential experts, an endodontist and a medical infectious diseases specialist. The endodontist was of the views: that under the existing conditions, the root canal treatment should not have been completed in one visit, but acknowledged that this was a judgment call such that other practitioners might well disagree; that if Dr. Q did agree to complete the procedure in one step, as she did, the prescribing of antibiotics at that time would have been preferred, but again recognized that some other endodontists would not agree; that Dr. Q's providing Clindamycin in the face of a potential Penicillin allergy, in a patient with a worsening infection and unable to be seen clinically, was an acceptable choice, although it was unclear whether Dr. Q adequately discussed the possible GI risks with D; and that the office receptionist was clearly and inappropriately acting beyond her non-professional status in providing the advice that she gave.





The medical expert confirmed that it was clearly the Clindamycin that was responsible for all of the GI symptoms experienced by D, as well as the hospital care that followed, and that the 3-day delay (and worsening infection) created by the receptionist's advice deprived both D and Dr. Q of the opportunity to have an antibiotic with less severe side effects than Clindamycin to have been used.





D's attorney opted for a simple litigation approach. On behalf of D, he filed suit against Dr. Q's practice entity – but not Dr. Q – based upon what the attorney viewed as strong arguments on both the liability and causation fronts as to the practice, with only "judgment call" issues available against Dr. Q. The damages claimed were the GI-based pain and suffering, the unpaid medical costs, the monetary values of the "lost" sale and the "loss" of salary increase. Given that Dr. Q's practice entity was covered for malpractice, the carrier provided defense counsel to put forth a defense for the practice, working with Dr. Q for that purpose, although not defending her personally.





After depositions were taken, the defense attorney applied to the Court to have the values of the lost sale and potential salary excluded from any potential damages able to be recovered. The Court agreed, determining those amounts to be entirely speculative, in that even if D would have had the chance to attend the meetings he missed, those were merely "opportunities,” so there is no way to prove that he would have been successful in his endeavor. The other claims in the case remained. Realizing the pitfalls of trying to defend the actions of the receptionist, Dr. Q and the practice's attorney, with the agreement of the carrier, worked toward and completed a settlement on behalf of the practice, for an amount which took care of expenses and physical pain and suffering, with no permanent after-effects, at a far lower value than had lost earnings been included.





Takeaways





In essence, D's expert endodontist determined that all of the actions taken by Dr. Q – the one-visit RCT, the non-prescribing of antibiotics at that time, and the choice of Clindamycin – were judgment calls, subject to opinions as to appropriateness on both sides of the fence, thereby leading D's attorney to refrain from pursuing those claims. [We note here that not all attorneys for plaintiffs would approach this in the same way.] Instead, the lawsuit was focused on what D's attorney viewed as a sole "winning argument," which was in fact the result. To reiterate a concept discussed in prior case studies, the general principle is that a plaintiff must prove through expert testimony that – with a general standard of "more likely than not" – a defendant dentist departed from good and accepted practice standards, thereby directly causing injury to the patient. For all issues except for the receptionist's involvement, the endodontist expert for D did not adequately meet that hurdle, at least in the eyes of D's attorney; the medical expert causally connected the receptionist's actions with the injuries to D.





There has been and continues to be controversy in the dental community regarding the use of Clindamycin. While its potentially severe side effects are well-publicized, it has therapeutic benefits as well: the classic double-edged sword. We do not comment upon the propriety of a given practitioner's choice to prescribe it in a particular situation, but just as with all choices, they are best made with a sound and deliberative thought process, so that a defense can be meaningfully put forward if untoward results come to pass.





As a side thought, we visit the issue of a case settling as against a practice entity versus the dentist him/herself; if such a potential ever exists during a malpractice case management, it is something to be coordinated between the dentist, liability carrier, and defense counsel. As a general rule, although potentially with exceptions, payments for professional liability against individual practitioners are reportable to national – and sometimes state – data banks and authorities, whereas those against an entity, as here, are not. To be clear, it is never a given that case resolutions of the type done here can always be made; to the contrary, it is not very common in the world of dental malpractice, with carriers constrained to do so only after an assessment that no specific provider bore any liability. But none of this negates the importance of dental practitioners assuring that dental/medical advice to patients must only be given by dental professionals, leaving only administrative tasks to non-professional staff members.





We end with a brief discussion about dentists acceding to performing procedures that patients "demand," even when those dentists do not believe that doing so is in those patients' best interests. Yes, patients have an absolute right to decide which of multiple alternatives they wish to pursue, but only if those alternatives are dentally and/or medically viable. Patients can refuse anything, but they should not dictate what a dentist must do.





Note that this case presentation includes circumstances from several different closed cases, in order to demonstrate certain legal and risk management principles, and that identifying facts and personal characteristics were modified to protect identities. The content within is not the original work of MedPro Group but has been published with consent of the author. Nothing contained in this article should be construed as legal, medical, or dental advice. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your personal or business attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.


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A fulfilling dental career is powered by passion. In this article, Dr. Shafa Nathani, a member of MedPro Group’s Dental Advisory Board, offers insight on staying motivated and shaping a career that you’re passionate about.









Key Concepts





    

  • Job satisfaction and preventing burnout
    • 




  • Continuing education for dentists
    • 




  • Mental health and work-life balance
    • 










Cultivating your passion as a dentist can boost your job satisfaction throughout your career. When you genuinely enjoy what you do, it's easier to feel fulfilled and eager to come to work each day. Maintaining enthusiasm at work also helps keep you motivated, especially during difficult periods.





In addition, your passion for your dental career can trickle down into your care. Your upbeat demeanor can be contagious, helping to build trust and a sense of safety with your patients. This often leads to fewer appointment cancellations and a stronger commitment from your patients to stick to their treatment plans.





Building a dental career you love begins with securing reliable dental malpractice insurance – so you can practice safely and confidently with protection against potential malpractice claims. With trusted coverage from industry leader MedPro Group, you’ll get the peace of mind you need to deliver the best care to your patients and focus on fostering a fulfilling career.





Read this article for tips on how to choose the right dental malpractice insurance policy.





Q&A with a MedPro Group Dental Advisory Board Member





We interviewed Dr. Shafa Nathani, DMD, a member of MedPro’s Dental Advisory Board, to learn how she maintains her enthusiasm for her practice.





What’s your favorite part about working with patients?





"Every patient who sits in my chair comes with a story, and that’s something I never take for granted. On most days, the office is busy and fast-paced, and I may only get a few moments with each patient. Still, those moments often carry the most meaning. Whether it’s meeting a new patient for the first time, delivering complete dentures to someone we’ve been caring for over months or years, or seeing a recall patient after a long gap and catching up on their life, those brief connections matter deeply to me. Outside of the technical side of dentistry, it’s these human moments that ground me. After a day that feels like a total blur, they remind me why I chose this profession in the first place and how privileged I am to be trusted with someone’s care, comfort, and confidence.”





How do you prevent burnout as a dentist?





"I’m a little over a year into my career, and I’m currently in a phase of saying ‘yes’ as much as possible, working hard to gain experience and take full advantage of the momentum from dental school. While that growth has been exciting, it also comes with physical and mental challenges.” 





“There are days when my back aches, the mental load of running a busy office feels overwhelming, and the idea of taking time off sounds incredibly appealing. Early on, my routine after work was to go straight home, sit on the couch, and try to decompress. However, I quickly realized that I was still waking up tired and feeling like my life revolved entirely around work.”





“Making intentional changes helped shift that mindset. I joined a yoga studio, spent time at the library, and found ways to stay mentally and physically engaged outside of dentistry. Even though I was still tired, I felt fulfilled. That sense of balance has been essential in preventing burnout and helping me remain enthusiastic, motivated, and present for my patients."





Learn more about recognizing and preventing burnout in this article.





Can you share a pivotal moment that reaffirmed your passion for dentistry?





"Within my first month of practicing as a dentist, I treated an older patient whose upper bridge and partial had completely failed. He required full-mouth extractions, but financial limitations prevented him from receiving care from an oral surgeon. I wanted to help him, but I also questioned whether I was capable of managing a case of that complexity so early in my career.” 





“I reached out to a mentor who guided me step by step through the surgical process and denture delivery. While he was incredibly grateful for the care, that wasn’t the moment that truly reaffirmed my passion for dentistry. It was everything that followed. Over the next year, I saw him regularly for adjustments and follow-up exams, and during those visits we shared life updates and built a genuine connection. On my last day at that office, we tearfully said goodbye, and he offered me his blessings.”





“That moment reminded me that dentistry is about far more than procedures. It’s about relationships, trust, and long-term impact. He will be attending my wedding later this fall, a testament to how meaningful patient relationships can become."





How important is continuing education to staying passionate about your career?





"Continuing education is incredibly important to me, both professionally and personally. Dental school provides a strong foundation, but it can’t possibly cover everything. Depending on how you want to practice, CE can help shape you into a well-rounded dentist or allow you to focus deeply on a specific niche. I identify strongly with being a well-rounded practitioner.” 





“I’ve discovered countless resources and taken courses that reignite my excitement for learning and push me to try new techniques that lead to better clinical outcomes and smoother recovery for patients. Dentistry is constantly evolving, and staying current isn’t optional, it’s a responsibility. Engaging in CE keeps me challenged, curious, and inspired, which directly translates into better patient care."





How do you stay connected to the dental community? How does that affect your passion for your work?





“Having a supportive dental community is vital to my success and longevity in this profession. I’m incredibly grateful for the friendships I formed in dental school. We often joke that between all of us, we somehow cover every time zone in the country. Even though we aren’t geographically close, those friends are the first people I reach out to because they truly understand the challenges, pressures, and victories that come with dentistry. It’s a judgment free space where I can ask questions, vent, or celebrate wins.” 





“Additionally, my current role allows me to work within a DSO alongside a strong group of dentists. Through monthly calls and in person collaboration, we’ve built relationships rooted in mutual support and shared growth. This community has been essential in keeping my passion for dentistry alive because I never feel isolated. Instead, I feel supported, encouraged, and reminded that I’m part of something much bigger than myself.”





Passion starts with security 





You're passionate about your patients. We're passionate about protecting your good name. With over a century of dental malpractice expertise, we'll protect your practice so you can focus on building a career you love.





To learn more, contact our team or get a quote today.


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Additional Risk Tips content

How to Stay Passionate in Your Dental Career

Insights on sustaining passion in a dental career through education, community support, work-life balance, and meaningful patient relationships.

Dentist’s Choice of Radiographic Technique Leads to Lawsuit

In this case study, radiographic imaging decisions for a dental implant procedure leads to a malpractice suit. Read the case to learn how the case unfolded.

Clindamycin Side Effects Lead to Dental Malpractice Lawsuit

A dental malpractice case reveals the risks of clindamycin, informed consent gaps, and the impact of non-clinical staff advice on patient safety.

This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.

MedPro Group is the marketing name used to refer to the insurance operations of The Medical Protective Company, Princeton Insurance Company, PLICO, Inc. and MedPro RRG Risk Retention Group. All insurance products are underwritten and administered by these and other Berkshire Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is based upon business and/or regulatory approval and/or may differ among companies.

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