Dentist Spotlight:

Patient Termination & Referral

Dentist’s Advantage, in collaboration with CNA, has published our Dental Professional Liability Claim Report: 3rd Edition (3rd Edition Report), which analyzes closed dental professional liability claims from 2020–2024. The 3rd Edition Report includes statistical data and case scenarios from CNA closed claim files, as well as risk management recommendations designed to help dentists reduce their malpractice exposures and improve patient safety.
You may access the complete 3rd Edition Report, and additional Risk Control Spotlights.
This Dental Spotlight focuses on our analysis and risk recommendations regarding an important aspect of dental practice - Terminations and Referrals.
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Patient Termination

The standard of care for dentists includes the legal duty to continue caring for patients of record. If an irreconcilable dentist-patient conflict results in a determination that you cannot continue to care for the patient at or above the required standard of care, you are obligated to end the relationship in an appropriate manner. Improper termination of the dentist-patient relationship may lead to allegations of abandonment or failure to treat.

Dental Professional Liability Spotlights

In the months ahead, please access the Dentist’s Advantage Prevention and Education Web page to download the report and Spotlights on key risk topics:

Managing the Risks of Terminating the Dentist-Patient Relationship

The dentist-patient relationship simply does not end when the patient leaves your office or your care. It continues until one party properly ends it. Unless the relationship is legally terminated, the courts may consider it to exist even years after the last communication between the patient and dentist. You may terminate the dentist-patient relationship for many reasons, including when patients become unreasonably demanding, stop paying their bill, miss and/or cancel numerous appointments, refuse your treatment recommendations, or are otherwise difficult for you and your staff.

Abandonment

Abandonment involves the unilateral dismissal of the patient by the dentist in the absence of ample and proper notice to the patient. Abandonment allegations are based upon the patient’s belief that he or she has suffered an injury due to the dentist’s failure to continue to perform his or her professional duty. In addition, laws restrict a dentist from refusing treatment to or dismissing a patient from the practice solely on the basis of a disability, race, color, creed, ethnicity, gender or age. While you may terminate a relationship with a patient who is disabled or otherwise protected by anti-discrimination laws, all patients must be treated equally. Any patient who cannot or will not comply with office policies or treatment recommendations can be dismissed, if the reasons for doing so are fair and the process adequately documented.
Caution: if you refuse to treat a patient of record in need of emergent care simply because the patient owes you money, you may become liable for a charge of abandonment.

Recognizing Risk Factors

Certain patients whom you terminate may be more likely to allege abandonment than others, including those with:
  • Poor or adverse clinical outcomes
  • Unmet expectations
  • Billing disputes
  • Argumentative personalities
  • Litigious personal histories
  • Poor compliance with postoperative care and follow-up appointments

Controlling The Risks

The doctrine of informed consent requires that the patient be given sufficient information about, and consider, three major components, which you are required to disclose and discuss with the patient. They are:

Clinical

  • Evaluate the stability of the patient’s health prior to terminating the relationship, and ensure that the patient’s health is never compromised, including during any termination period.
  • Treatment should be terminated or transferred at a logical point during care when the patient no longer requires emergent care.
  • As a general guideline, complete multiple visits associated with procedures which you have started, such as root canal therapy (obturation), crown and bridge procedures (cementation), orthodontic treatment or postoperative care following surgical procedures.
    • The exception to the general guideline occurs when the relationship is terminated due to the patient’s failure to return for unfinished treatment. In such cases, the dentist may terminate in the midst of active care, following a documented good faith attempt that has been made to get the patient to return for care.
    • Ensure that you have documented in the patient record all attempts to contact the individual before terminating the relationship. This documentation shows that every reasonable and prudent step to continue patient care was taken and helps to defend against abandonment claims.
    • A minimum of three documented attempts to contact the patient regarding the completion of unfinished treatment is recommended. One attempt should take the form of a letter sent to the patient. The others may be documented through telephone calls and/or telephone messages.
  • In most situations, the dentist is legally obligated to assist the patient during the termination of care, even when the patient terminates the relationship.
  • Before terminating care, ask yourself the following questions:
  1. Have I met the required standard of care in my past treatment and management of the patient?
  2. If not, has the patient failed to allow me to provide care that adheres to the required standard of care?
  3. Have I provided care to the point where the patient has no immediate need for emergent dental treatment?
  4. If not, has the patient refused to return for care?

 

Acting in the affirmative on points one and three may help provide evidence that you took steps to meet your responsibilities.

Communication

  • At the outset of the dentist-patient relationship, inform patients of your practice rules, including reasons why patients may be asked to leave the practice. Providing a practice brochure to all new patients as a standard procedure should suffice for this purpose.
  • Make reasonable attempts to resolve patient conflicts and document those attempts.

Documentation

  • Document in the patient record all attempts to contact the individual before terminating the relationship.
  • If a patient terminates the dentist-patient relationship for any reason, clearly and fully document the patient’s decision in the dental record, including verbatim comments from the patient or copies of patient correspondence.
  • If the dentist terminates the relationship, notify the patient in writing by mail. Send two copies of your letter: one via certified mail, return receipt requested, and the second via standard first-class mail. Even if the patient refuses to sign for the certified letter, the first- class mailing will be delivered. The letter should include the following information:
  1. Clearly state that the dentist-patient relationship is being terminated and indicate the specific date that the relationship will end.
  2. Indicate the current status of care and any further treatment needs of the patient, including the risks of not receiving the needed treatment.
  3. Offer to provide emergency care to the patient for a reasonable period of time, which must be sufficient for a reasonable person to secure an appointment with a new dentist (30 days is generally sufficient in most areas).
  4. Indicate how the patient can find a new dentist, such as the telephone directory or the local or state dental society referral service, if one exists where you practice.
  5. Offer to forward copies of records to the patient, or to the patient’s next dentist, upon written request of the patient. Be sure to retain the original records. You may not refuse to supply copies even if the patient has an outstanding balance.

 

Although you are entitled to charge a “reasonable fee” for duplication and mailing, we strongly encourage you to provide a copy of the record free of charge when terminating a patient. This approach avoids any (additional) ill will between you and the patient that may trigger a malpractice action or dental board complaint.

 

  • Keep a copy of the letter and any related correspondence or documented discussions in the patient’s dental record.
  • Retain the certified mail receipt as part of the file whenever you send correspondence by certified mail.
  • If your certified letter is returned to you unopened, retain it unopened in the patient chart. Your previously sent first-class letter will serve as notification for the patient.

Sedation in Dental Professional Liability Claims

In the 3rd Edition Report, claims involving sedation represented approximately 8.1 percent of the dataset. Despite their relatively low frequency, sedation-related claims were associated with markedly higher severity:
The average total incurred for all claims in which sedation was administered, regardless of the injury type, was $248,821.
When sedation was a primary or contributing factor to patient injury or death, the average total incurred exceeded $437,000 overall. Figure 8 presents the average total incurred by sedation level. Individual cases exceeded $1 million in total incurred costs in 22.2 percent of such claims.
Although there were no sedation injuries associated with minimal sedation (Figures 7 and 8), it is important to note that while minimal sedation was intended by the provider, 45.5 percent of cases resulted in moderate sedation as defined by the American Dental Association (ADA) Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016), which were in effect at the time of all dental incidents included in the 3rd Edition Report.* This set of cases represents one third of the moderate sedation cases associated with sedation injuries.
As with many dental professional liability matters, sedation-related injury may be only one of multiple allegations associated with an incident. Consequently, sedation issues frequently function as contributory factors that exacerbate the severity of claims involving patient assessment, medication management, monitoring, documentation, and emergency response. When adverse outcomes occur, concerns associated with sedation can significantly narrow defense options and intensify scrutiny of the dentist’s decision-making.

7

Distribution of Claims Associated with Sedation Resulting in Sedation-Related Injuries
Closed Claims with Paid Indemnity of ≥ $10,000
Level of Anesthesia
Percent of Sedation Cases with Sedation-Related Injury
Minimal sedation
0.0%
Moderate sedation
31.3%
Deep sedation / General anesthesia
21.4%

8

Average Total Incurred for Claims Associated with Sedation-Related Injuries
Closed Claims with Paid Indemnity of ≥ $10,000
Level of Anesthesia
Average Total Incurred with Sedation-Related Injury
Minimal sedation
$0
Moderate sedation
$428,155
Deep sedation / General anesthesia
$481,924

Common Allegations in Sedation-Related Claims

Claim analyses and expert reviews reveal recurring themes in sedation-related allegations, including:
  • Inadequate pre-procedure medical assessment, medical consultation, and patient selection
  • Failure to recognize or comply with state sedation permitting requirements
  • Inadequate informed consent for the procedure and/or sedation
  • Intended “minimal sedation” that resulted in a deeper level of sedation, based on the patient’s level of consciousness and/or the definitions of moderate and deep sedation under applicable guidelines
  • Inappropriate medication selection or dosing for medically complex patients
  • Inadequate intra-procedure monitoring and documentation
  • Delayed recognition of respiratory compromise
  • Inadequate emergency preparedness and response
  • Misunderstanding of shared patient management and safety responsibilities when external anesthesia providers are involved

Misclassification of Sedation Level and Cognitive Bias

CNA claim analyses demonstrate that many severe sedation-related events occur in cases where the dentist did not initially view the planned care as involving “sedation.” When terms such as “anxiolysis,” “oral premedication,” or “just something to relax the patient” are used, providers may unintentionally minimize the physiologic risk associated with sedative agents—particularly when combined with opioids, local anesthetics, or patientspecific risk factors such as current health conditions and medications.
This cognitive bias contributes to downstream failures observed in claims, including inadequate monitoring, absence of required permits, insufficient emergency preparedness, and incomplete informed consent. As explained in the 2016 ADA Guidelines, and in the latest ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2025), sedation level (level of consciousness) is defined by the patient’s response to the medication(s). In other words, a patient’s sedation level is independent of the intended sedation level and the route of administration. As previously described, a substantial proportion of closed claim cases associated with sedation injuries in the 3rd Edition Report dataset that were intended as minimal sedation with oral medications met the moderate sedation definition.
In litigation and board review, expert evaluation focuses on the actual depth of sedation produced, rather than what the dentist believed was being provided. This mismatch limits expert support and narrows defensibility when adverse outcomes occur.
A substantial proportion of closed claim cases associated with sedation injuries in the 3rd Edition Report dataset that were intended as minimal sedation with oral medications met the moderate sedation definition.

Clinical Guidelines, Standards, and Claim Evaluation

Sedation claims are typically evaluated against a combination of state regulations, professional guidelines, and expert opinion. During claim investigation and litigation, national clinical guidelines are frequently cited by plaintiff and defense experts—even in states where regulatory requirements differ or are less specific.
ADA Guidelines are among the most frequently referenced professional resources in claim analysis related to sedation and other matters. It’s important to emphasize that both the 2016 and 2025 ADA Sedation and General Anesthesia Guidelines emphasize that:
  • Sedation exists on a continuum.
  • Sedation level is defined by depth of consciousness, not route of administration.
  • Practitioners and support personnel must be prepared to manage patients who inadvertently enter a deeper level of sedation than intended.
In sedation-related claims, lack of awareness or misunderstanding of these principles often undermines defensibility. Therefore, dentists are strongly encouraged to review the 2025 ADA Sedation Guidelines (published April 2026), as well as requirements within their practice state(s), to ensure that sedation-related patient assessments and appropriate policies/procedures are in place and current.
Furthermore, dentists who provide or contract for sedation services should be aware that evolving interdisciplinary professional guidance also may influence expectations related to dental office-based sedation for patient assessment, monitoring, documentation, and clinical decision-making. See the Resources section for selected interdisciplinary content.
Dentists also may be interested to learn that the ADA recently approved development of a new guidance document on pediatric sedation in dental practice (publication date to be determined). Track the status of ADA sedation guidelines and related information on ADA.org by accessing the Oral Health Topics Anesthesia and Sedation page.

Medical Consultation and Patient Selection

As the prevalence of medically complex patients in dental practice continues to increase, questions regarding procedural risk, treatment setting, and sedation appropriateness arise with greater frequency. In sedation-related claims, allegations commonly focus not only on medication selection or monitoring failures, but on whether the dentist appropriately recognized the patient’s overall medical risk and sought timely, meaningful medical consultation.

From a risk management perspective, it is important to distinguish medical consultation from the concept often referred to as “medical clearance.” Medical clearance implies a transfer of responsibility that does not occur in practice or law. Courts, licensing boards, and expert reviewers consistently view the operating dentist as the clinician responsible for dental treatment planning, patient selection, and management of procedural risk.
Medical consultation is best understood as a structured exchange of information intended to inform, rather than replace, the dentist’s independent clinical judgment.
In sedation-related claims, consultation failures typically fall into one of three categories:
  • Consultation is not obtained when it would be prudent.
  • Consultation is narrowly focused on a single issue (e.g., anticoagulation), without consideration of other medical issues and sedation-related physiological risk.
  • Consultation is obtained, but the information provided does not meaningfully inform the sedation or treatment setting decision.
A defensible approach to medical consultation requires taking into account baseline patient status, stability of underlying conditions, and the physiological demands of the planned procedure and sedation depth. The American Society of Anesthesiologists (ASA) Physical Status Classification is often referenced in expert analysis and provides a useful starting point for stratifying risk. Patients with stable, well-controlled chronic disease (often categorized as ASA II–III) may be reasonable candidates for office-based procedures with appropriate safeguards. In contrast, patients with unstable disease, recent exacerbations, or significant cardiopulmonary compromise (often ASA IV or higher) may warrant deferral of elective care, enhanced consultation, or referral to a higher-acuity setting.
In CNA claim experience, sedation-related losses frequently involve patients with overlapping risk factors—such as obesity, obstructive sleep apnea (OSA), cardiopulmonary disease, renal impairment, or recent acute illness—where consultation was absent or incomplete. In these cases, defense experts often concluded that the dentist underestimated how multiple conditions and associated medications interacted to increase sedation risk, even when individual conditions were known and disclosed.
Equally important is how consultation requests are framed. Requests that simply ask whether a patient is “cleared for dental treatment” offer limited value and tend to generate generalized responses that do little to support defensibility. In contrast, effective consultation requests are procedure-specific and risk-focused. They typically describe the planned dental intervention, anticipated sedation approach, duration of treatment, and targeted questions regarding physiological stability, medication management, or appropriate treatment setting. If a consultant’s response does not address these factors, the dentist should view the consultation as incomplete.
Documentation plays a central role in translating consultation into defensibility. Records should reflect not only that consultation occurred, but how the information informed the dentist’s decision to proceed, modify treatment, defer care, or refer. When adverse outcomes are later reviewed, investigators and experts focus on whether the dentist’s actions demonstrate a thoughtful, individualized risk assessment grounded in available information—not merely whether a consultation form exists in the record.
As illustrated in the following case studies, consultation that is absent, narrowly scoped, or disconnected from sedation decision-making frequently becomes a central weakness in the defense of sedation-related claims. A documented, well structured, risk-based consultation process may reinforce patient safety and may help provide tangible evidence that treatment decisions were made deliberately and in the best interest of patient care.

Case Study: Failure to Refer for RCT

The practitioner in this case was a general dentist. An established patient presented with pain from biting pressure related to a mandibular first molar. The insured dentist (dentist 1) obtained an intraoral periapical radiograph and recommended root canal therapy (RCT). Following the completion of the RCT, dentist 1 placed a composite restoration at a subsequent visit. Several months later, the patient sought care for two painful areas— one in the posterior maxilla and the other in the mandible, near the prior RCT. While dentist 1 was out of the office for several days, the patient sought care from another dentist (dentist 2).

Dentist 2 recommended that the root canal filling in the mandibular first molar be removed and that the tooth be re-treated. A radiograph showed a slightly underfilled distal canal with a small periapical radiolucency. The patient then returned to dentist 1. Since the patient’s discomfort had subsided, dentist 1 scheduled appointments to complete preventive and restorative care over several weeks, before addressing the RCT re-treatment.

Following completion of the re-treatment procedure with dentist 1, the patient had a reoccurrence of pain and presented to dentist 2, as dentist 1 was not available that day. Dentist 2 administered a local anesthetic for pain relief, removed occlusal contacts from the first molar tooth, prescribed an antibiotic and suggested referral to an endodontist, or extraction of the tooth.
A few days later, the patient sought care at a local hospital emergency department (ED). Examination revealed substantial swelling and fever due to an apparent infection in the vicinity of the re-treated first molar tooth. The swelling required a visit to the operating room for incision and drainage, as well as removal of the offending mandibular first molar. The diagnosis: lateral pharyngeal abscess with hematoma, extending into the floor of the mouth. Post-surgery, the patient continued to seek treatment for ongoing paresthesia, hyperalgesia, and other complaints.
The total incurred (indemnity payment plus legal fees and other claim expenses) was approximately $150,000.

A review of the records and expert opinions for this claim highlight a number of risk management topics, including the following:

Recordkeeping and documentation.
When RCT or any other treatment is recommended, objective clinical findings, test results and diagnosis must support the treatment plan and be adequately documented. While a radiograph was taken to aid in the diagnosis in this case, the findings were not recorded. Moreover, as RCT may be complex, it should be performed only after obtaining and documenting the patient’s informed consent, including disclosure of the nature of treatment, treatment alternatives and foreseeable risks (such as tooth loss and infection), as well as the risks associated with no treatment. The patient record did not include a written/signed consent form or a supporting progress note.
Specialist treatment/referral.
hile all dentists may perform root canal therapy, non-endodontists should offer referral to an endodontist as a viable treatment alternative to reduce the risk of a failure-to-refer allegation. Dentists must honestly assess their own skill and experience and discuss the alternatives with the patient. In this case, file sizes and file lengths were not documented, and no post-fill radiograph was produced or documented in the records. Later radiographs revealed radiolucent areas associated with other teeth with RCT performed by dentist 1. Root canal fillings were well short of the root apices. Although dentist 2 recommended that the patient consider re-treatment of the molar RCT by an endodontist, the patient returned to dentist 1, CNA and Dentist’s Advantage Dental Spotlight: Patient Termination & Referral 8 having been a long-time patient at the insured’s office. However, re-treatment was delayed for unknown reasons and other treatment needs were addressed instead. If a referral to a specialist was suggested or made prior to the initial RCT or re-treatment, it was not documented.
Abandonment.
Dentists should inform patients how to access care in the event of a dental emergency, whether it occurs during customary business hours or after hours. Treatment may be provided by the dentist or by colleagues with whom the dentist has made such arrangements. In this case, the dentist was not available to manage the patient’s pain and swelling immediately after the root canal re-treatment, and he failed to inform the patient of emergency care options. He subsequently failed to examine the patient, who later sought care at a local hospital ED. Failure to effectively manage the patient’s post-treatment emergency care needs left dentist 1 open to an allegation of abandonment.

Key Risk Drivers in Sedation-Related Claims

Across CNA closed claim files, several recurring risk drivers stand out:

Patient Assessment and Selection ›
Patient Assessment and Selection ›
Medication
Management ›
Medication
Management ›

Monitoring and Documentation ›

Monitoring and Documentation ›
Emergency Preparedness and Delayed Escalation ›
Emergency Preparedness and Delayed Escalation ›
Shared Liability and
Apparent Agency ›
Shared Liability and
Apparent Agency ›
Practices that deliver sedation or contract with anesthesia providers benefit from clearly defined escalation thresholds, regular emergency drills,and documentation that staff are trained to act decisively when patient status deteriorates.

Risk Control Considerations for Dental Practices

Dentists may wish to consider the following risk control strategies:
  • Perform and document a focused pre-procedure medical assessment, including airway and respiratory risk.
  • Implement a defensible approach to medical consultation that supports the dentist’s independent risk assessment and treatment-setting decision, including whether to proceed, modify treatment, defer care, or refer to a higher-acuity setting.
  • Match the treatment setting and sedation depth to the patient’s overall risk profile.
  • Understand state specific sedation permit requirements and their relationship to national guidelines.
  • In addition to training and permit requirements for a dentist to provide dental office sedation services, individual states also may impose requirements on dentists who contract with sedation and anesthesia providers.
  • Ensure monitoring and documentation are appropriate to the sedation level provided, whether administering sedation, or working with a sedation provider.
  • Maintain explicit patient discharge and medical emergency management protocols, conduct regular emergency drills, and document emergency response training.
  • Clearly define and disclose relationships with contracted anesthesia providers to mitigate the risk of apparent agency/vicarious liability associated with their services.

Conclusion

Whether ending a dentist-patient relationship or coordinating care through referral, the primary goals are to protect patient welfare and ensure continuity of care. Dentists can reduce the risk of abandonment, failure-to-refer, and related professional liability allegations by communicating clearly with patients and colleagues, documenting all significant discussions and clinical decisions, and following a consistent process for termination and referral. Thoughtful planning, timely communication, and thorough documentation remain the foundation of effective risk management in these situations.

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