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Shital Patel has never been a confrontational person.
But in the dental office lobby in Leland that day, she felt in her gut that something was off.
It was a Thursday afternoon in summer 2020, at the height of pandemic precautions, and her husband was undergoing a routine dental procedure. Hemant “Henry” Patel, himself a well-respected cardiologist, trusted his dentist, Mark C. Austin, and had no concerns about the procedure–a dental implant where a tooth had been extracted several months before.
The procedure was supposed to take 20 minutes. After 30 minutes, his wife checked in with the front office staff, who told her they got a late start. Ten minutes later, the staff reiterated the same message.
After another 15 minutes passed, Shital Patel dropped all pretense. “Totally out of character for me, I said, ‘I want to see my husband now.’”
Another staffer emerged and told everyone else in the waiting room to go home. “Nobody’s telling me anything,” Patel said. “I just knew.”
She ran to the door that led to the dental suites, but staffers blocked her from going farther.
Police arrived first, then paramedics. For 21 minutes, paramedics gave her husband CPR before he regained a pulse. But all that time without oxygen had taken its toll. Three days later, he was taken off life support. The 53-year-old left behind his wife, two adult children, and hundreds of patients, friends, and colleagues who revered him. His COVID-era funeral was so well-attended online that it hit the livestream’s 3,000-viewer cap.
It took a week for Shital Patel’s anger to set in. At first, she assumed her husband’s death was an accident–not something preventable.
“When you go to a place, you just assume everything is in order,” she said. “You don’t walk into a building and say, ‘Do you think the ceiling is going to fall down on us?’”
State records indicated toward the end of the procedure, Henry Patel’s oxygen levels remained dangerously low for at least 20 minutes. When paramedics arrived, Patel had no pulse, and though the dental team made some efforts, they had not attempted CPR or exhausted all lifesaving measures.
Nationwide, oral surgery is the only medical specialty with providers allowed to simultaneously operate and oversee deep sedation without a dedicated, highly skilled second observer present, aside from emergency scenarios. In hospital settings, a second trained anesthesia provider is typically present to observe a patient’s vitals while a surgeon operates.
Dentists who perform oral surgery also only receive about five to six months of training in anesthesia, said James Tom, chair of the Department of Anesthesiology and Emergency Medicine in the Herman Ostrow School of Dentistry at the University of Southern California.
“You get less training as an oral surgeon than your local veterinarian when it comes to anesthesia,” Tom said.
Hours after the procedure, a group of Patel’s cardiologist colleagues summoned Austin to the Wilmington hospital to grill him about what went wrong. Austin told them the pulse oximeter, a finger clamp that monitors blood oxygen levels, wasn’t working, so his staff fished around for another one, which also apparently didn’t work. Patel’s colleagues suspected it wasn’t a problem with the equipment but with the dental staff’s failure to recognize he’d lost circulation. “A pulse oximeter will only work if there’s a pulse,” said friend and medical partner Rob Harper.
Austin did not respond to a request to comment.
Harper filed a complaint against Austin with the North Carolina State Board of Dental Examiners days after Patel’s death, which included more general concerns about policies on deep sedation in the outpatient setting.
In August 2021, Austin signed a consent order with the dental board to permanently surrender his license, though he maintained that he didn’t violate standard of care guidelines. The consent order also stated in 2021 that the Drug Enforcement Administration audited his practice and found Austin had violated multiple pharmaceutical recordkeeping and inventory laws, and it accused him of diverting controlled substances, including fentanyl, from his practice for personal use. He has not been charged in relation to the drug violations, though a spokesman for the N.C. Department of Justice said the investigation is ongoing.
Patel’s death kick-started a years-long quest on the part of his widow, Harper, and their supporters advocating for reforms to dental rules, an effort that culminated in state hearings and updated guidelines for dentists performing deep-sedation procedures. But Shital Patel is still trying to change the requirements to mandate that a highly skilled anesthesia provider be present for deep-sedation procedures.
Dentists, however, argue such a requirement would increase costs, reduce access to care, and is medically unnecessary.
Last September, Patel’s advocacy led to her apparent appointment to the eight-member State Board of Dental Examiners as its lone consumer member–someone who is not a dentist or dental hygienist and is supposed to represent patient interests. The dentists and hygienist on the board are elected by their licensed peers.
“Please allow this email to serve as notification regarding the Governor’s decision to appoint you to serve on the North Carolina State Board of Dental Examiners,” said the email she received from the office of Gov. Roy Cooper. She submitted the required financial disclosure paperwork, and the next month she received a letter from the State Ethics Commission, which cleared her of any conflict of interest.
Patel checked on the appointment’s status in October and November–wanting to be sure not to miss any board meetings–and the governor’s office told her it would be in touch. By January, Gov. Josh Stein had been sworn in, and weeks later Patel again spoke with the same representative for the governor’s office, who again told her they’d be in touch.
But after The Assembly contacted Stein’s office, the new governor named someone else to the board on March 31: retired Greensboro judge Teresa Vincent.
Patel has still never heard from the governor’s office. She learned there was a new appointee from The Assembly. “I thought I still had a chance,” she said. “I thought I was probably the most qualified person to be a patient advocate, considering what I’ve been through.”
Like Pulling Teeth
The dental board’s CEO, Bobby White, said Cooper’s office never notified them that an appointee had been named, though they had requested one. A spokesperson for Stein said it could not speak to the previous administration’s communications with Patel.
Records The Assembly obtained shed some light on what happened behind the scenes.
“Patel’s wife is in the Que [sic] for consumer member of the board,” dental board member Lori Hendrick, a dental hygienist, texted fellow board member and dentist Catherine Watkins in October, followed by flushed and weary face emojis.
“Who? Someone I should know?” Watkins responded.
“The wife of the dead cardiologist that wants to change the face of dentistry,” Hendrick replied.
Hendrick emphasized Patel’s position as an outsider in early March in a separate text with board president Mark Johnson: “Patel is/was a travel agent. No medical or dental experience.”
In a different exchange, White told a staffer he’d received a call from Gary Oyster, a Raleigh-based dentist and trustee for the American Dental Association district that includes North Carolina, as well as the chair of the legislative committee for the N.C. Dental Society, a group that represents the interests of 3,900 dentists across the state.
“He’d talked to Cooper’s chief of staff who said S. Patel was in the running but not yet the pick,” White texted the board’s deputy operations officer. “He Told oyster that dentists better get organized & let the gov know if they think she would be a bad pick.”
Oyster told The Assembly that individuals and organizations submit names to the governor for consideration. He wouldn’t address Patel’s appointment but said the new appointee, Vincent, is very qualified.
Kristi Jones, Cooper’s former chief of staff who now works in the private sector, directed questions about the board to the current administration. Stein’s office declined to address why he didn’t move forward with Patel’s appointment.
“I thought I was probably the most qualified person to be a patient advocate, considering what I’ve been through.”
Shital Patel
White denied that the board played any official role in nixing Patel’s appointment. “We didn’t have any involvement at all,” he said, but noted that board members are within their rights to express their personal opinions.
Jim Goodman, CEO of the N.C. Dental Society, did not address a question about Patel and responded only with praise for the new appointee. Hendrick said it would be inappropriate for her to speculate on the governor’s selection process, which she wasn’t a part of, and redirected inquiries to White and Stein’s office.
No one, it seems, will explain why Patel was iced out. Last month, The Assembly filed a records request with the governor’s office seeking communications about her appointment that has not yet been fulfilled.
Patel finds the ordeal grating. “I felt so belittled. Especially the part about the dead cardiologist’s wife,” she said. “So disrespectful and unethical.”
“My question to them is: Why didn’t you want me? What are you so afraid of?”
Insiders and Outsiders
Close observers of the dental board say Patel’s spiked appointment is disappointing, but not surprising. The board’s critics argue that its structure is protectionist and self-dealing, and that it’s been allowed to operate with little independent oversight. Boxing out an outsider fits that pattern.
People with issues or ideas are always welcome to engage with the board, White counters. “We do our best not to have a fortress mentality,” he said.
The board’s primary functions are to shape policies, award new licenses, and conduct investigations of alleged violations. The bulk of its funding comes from licensing fees, which support a staff of 14 employees, including six investigators.
Steve Petersen, a Raleigh-based dentist-turned-attorney, has dealt with the board for decades, including representing more than a dozen dental service organizations, groups that help dentists run the business side of their operations. He says he thinks White and others who operate it are honorable people who have laws stacked in their favor. If he were in their position, he’d also want to enforce the existing rules to keep board members happy.
“They are definitely a recognizable force in the legislature,” Petersen said of the board’s lobbying power. While the board itself can’t lobby state leaders, the Dental Society can–and often their interests are aligned. Between 2021 and 2023, the Dental Society spent $285,000 on its lobbying efforts, state records show. “The Dental Society lobbyists carry the baggage for the dental board on legislative issues,” he said.
Aspiring board members have to rise through the ranks of the North Carolina Dental Society if they hope to be elected by their peers, Petersen said, making the profession’s leadership close-knit and cozy. “It’s a rotating good ol’ boys club,” he said.
Late last month, Senate Majority Whip Amy Galey (R-Alamance, Randolph) filed a bill that would overhaul the board’s makeup by eliminating the peer-selected board election process. Under her bill, the governor would get five appointees–including two dentists and two consumer members–while the General Assembly would get four–two dentists, named by the leaders of each chamber.
Sens. Benton Sawrey (R-Johnston) and Jim Burgin (R-Harnett, Lee, Sampson) have signed on as cosponsors of what appears to be the first attempt of its kind.
“This is just a fundamental structure that is flawed to its core,” Galey said.
The proposed changes would also require that the two consumer members have no financial interest in the provision of dentistry, have never been licensed to practice dentistry, and can’t be the spouse of a dentist or dental hygienist. (The previous longtime consumer member, Dominic Totman, works as an attorney who routinely represents dental practices, while Stein’s new appointee, Vincent, was the spouse of a now-deceased dentist.)
The current board lacks outside accountability, Galey said, and is using its power to control the market for dentists’ benefit, not the public’s. “That’s when you run into the risk of self-dealing,” she said. “And I think that that’s what we have seen with the way that Mrs. Patel has been treated.”
Concerns about the board’s composition aren’t new; a decade ago, they reached the nation’s highest court. As teeth whitening rose in popularity in the 2000s, the dental board cracked down on non-dentists who were providing the service. The board issued cease-and-desist letters, pressured mall operators who rented to teeth-whitening kiosks, and persuaded the N.C. Board of Cosmetic Arts Examiners to warn cosmetologists against offering the services. The Federal Trade Commission intervened in 2010, calling the conduct anticompetitive. In 2015, the U.S. Supreme Court agreed with the FTC, ruling the board couldn’t claim governmental immunity because its majority is ruled by active market participants–meaning voting members that hold dental licenses.
The FTC also weighed in before the state legislature passed rules in 2012 to further restrict dental service organizations, viewing the board’s plan as anticompetitive. Petersen believes today’s rules still stifle competition.
White agreed the board has had quarrels with these groups but said the rules are in place to protect the public.
Petersen thinks that explanation is dubious. “That’s been their position,” he said. “I don’t buy it.”
Despite the concerns, state dental boards controlled by dentists are standard.
In the wake of the Supreme Court decision, no other state dental board adjusted its composition to accommodate the precedent. A 10-year review from the public interest law firm Pacific Legal Foundation, which has sued dental boards it deems anticompetitive, in February found dental boards in all 50 states are at least 60 percent controlled by active market participants.
Often, such structures result in rules and regulations that perpetuate dentists’ self-interest, said Charles Coté, Professor Emeritus in Anesthesia at Harvard Medical School who has advocated for reform to dental sedation rules since the 1980s. “Every single state has their own dental practice laws, and the rules and regulations in each state are made up by dentists,” he said. “It’s the wolf watching the henhouse.”
An Aberration
While researching pediatric sedation deaths in 2006, Coté and his colleagues stumbled on an aberration in the data that found a disproportionate number of deaths had occurred during dental procedures, after controlling for other factors. The researchers concluded patients were not adequately protected by existing training requirements related to airway management, sedation assessment, or resuscitation skills.
In other words, dentists often “didn’t know what to do to save the patient” if something went wrong during the procedure, Coté said.
Coté has long served as primary editor for the American Academy of Pediatrics’ sedation guidelines, which advise there should be a second skilled observer present during deep anesthesia, in addition to the oral surgeon, and that person should be either an anesthesiologist, certified registered nurse anesthetist, dentist anesthesiologist, or another oral surgeon.
But the guidelines mostly aren’t followed, Coté said. Most oral surgeons performing procedures with patients under deep sedation, whether they are children or adults, are accompanied only by dental hygienists or assistants, who receive minimal anesthesia training.
Coté argues it’s difficult for an oral surgeon to do both. “It’s kind of like texting while driving down the highway,” he said. “You can’t do the two things at the same time safely.”
But there’s a financial incentive to do just that, he said, as they can bill for both procedures while avoiding paying a second provider. “It’s all about money,” he said.
Dentists can perform thousands of successful deep sedation procedures, Coté said, but aren’t always equipped with life-saving skills should something go awry. “It’s unconscionable to me that you would take the life of a child or an adult in your hands by giving them very, very powerful drugs and not have the skills to rescue them when something goes wrong,” he said.
Attempts to require a second highly skilled provider have been met with fierce opposition. Recent efforts failed in California, New Hampshire, and North Carolina.
After Henry Patel’s death, Sen. Michael Lee (R-New Hanover) met with dental board representatives and encouraged them to change deep sedation rules on their own accord, the board’s attorney said in a hearing. Lee threatened–politely, the attorney noted–to move forward with legislation if the dental board didn’t pursue rule changes on its own. In 2022, the board floated a provision to require a second anesthesia provider for deep sedation procedures, inviting public comments and hosting a well-attended hearing.
Dental organizations forcefully resisted the proposed changes. The deans of the University of North Carolina at Chapel Hill’s Adams School of Dentistry and the East Carolina University School of Dental Medicine submitted a joint letter stating the rules would cripple their ability to train residents and would be a “fatal blow” to their programs.
“It’s kind of like texting while driving down the highway. You can’t do the two things at the same time safely.”
Charles Coté, Harvard Medical School
In public comments, dentists called the proposal “rash” and “rooted in emotion rather than science,” and described Patel’s death as an unfortunate outlier–the result of a dentist not following best practices rather than indicative of insufficient rules.
“My gosh, what would your overreaction be if you were in charge of hospital care where people die every day,” one dentist wrote to the board in a public comment. “One incident should not make everyone suffer,” another wrote. “To save one person we will ruin the lives of countless others.”
The state Department of Health and Human Services also opposed the proposal on the basis that it would create barriers for Medicaid recipients and jeopardize the health of those who would delay or skip treatment.
In a 2023 American Association of Oral and Maxillofacial Surgeons publication, the then-president of the North Carolina chapter, Bryan Neuwirth, recounted the clash as a cautionary tale for other states. Had it not been for the financial support of the national organization to quickly secure a lobbyist, coordinate industry opposition, and the neutrality of the state chapter of anesthesiologists, Neuwirth wrote, the result could have been different. “This story starts as so many unfortunately do–with an adverse event that sparked a crusade,” he wrote. The American Association of Oral and Maxillofacial Surgeons and its North Carolina chapter didn’t respond to requests for comment.
The dental board abandoned the initial proposal in September 2022 but later approved a few pared-down deep sedation rule changes. “We do not wish this decision to be viewed as a callous disregard of those who have died due to anesthesia mishaps in dental offices,” the board wrote in its position statement, which went on to acknowledge Henry Patel but explained that implementing the second-provider rule could have led to a false sense of security.
In 2023, Lee filed “Henry’s Law,” a bill outlining extensive deep sedation dental reforms, which stalled in committee. Since then, Lee has said little on the issue. He didn’t return a request to comment for this story prior to publication.
How Many Deaths is Too Many?
Shital Patel has struggled with the message the whole experience suggested to her: Your husband’s death wasn’t enough.
White says eight dental anesthesia-related deaths have occurred in North Carolina over the past 20 years. One of the changes the board implemented as a result of Henry Patel’s death was to strengthen requirements about the reporting of serious complications, like brain damage, death, or required hospitalizations. Before, dentists had to report sedation incidents to the board if patients had died within 24 hours of a procedure. Now, they must report any patients who are hospitalized within 24 hours.
“My gosh, what would your overreaction be if you were in charge of hospital care where people die every day.”
public comment from a dentist
Coté and others believe reporting and recordkeeping laws across the country keep death counts artificially low. A 2015 study estimates dental anesthesia deaths nationwide likely exceed one per month.
Tom, the department chair at Southern Cal, said dentistry policies are often “written in blood”–meaning, new rules only arise from a tragedy. “If we don’t have a close relationship with some of the victims, the families of these victims, then we don’t have an impetus to keep on developing better practices,” he said.
Many in the dental industry see dental anesthesiologists like Tom, who receive years of additional anesthesia training, as a threat to their business model. In 2019, he was instrumental in getting dental anesthesiology recognized as an official specialty by the American Dental Association’s National Commission on Recognition of Dental Specialties and Certifying Boards–an ordainment he sees as decades overdue. There are just four such specialists in North Carolina, according to the American Society of Dentist Anesthesiologists’ directory.
“The reason why we don’t have a lot of folks who are practicing anesthesia and dentistry isn’t because it’s one of those things where it’s a fringe type of specialty, but there have been downward pressures for us to even exist in the first place,” Tom said.
Tom compared the industry’s efforts to buck deep sedation reform with those of big tobacco and said change must be patient-driven.
“Dentistry itself is not going to promote that there are safer options,” he said. “So, unfortunately, we have to place the burden upon the patient to be educated.”
For Shital Patel, the cascade of setbacks has fueled her advocacy. “My husband saved lives in life,” she said. “I want to make sure he saves lives in death.”
She knows that if their fates were reversed, and Henry was still here, he’d be doing the same.
Correction: This article has been updated to include Sen. Lee’s “Henry’s Law.”
Johanna F. Still is The Assembly’s Wilmington editor. She previously covered economic development for Greater Wilmington Business Journal and was the assistant editor at Port City Daily.