Preview
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
---------------------------------------------------------------------------X Index No. 152972/2014
J.F.R., an infant under the age of 14 years, by his father and
natural guardian, EUGENIO M. RAMIREZ, Individually and AFFIRMATION OF
ROSALBA LUNA, Individually, THEODORE J. JENAL,
D.D.S.
Plaintiffs,
-against-
RASHMI AMBEWADIKAR, D.D.S., and METROPOLITAN
DENTAL ASSOCIATES, D.D.S., P.C.,
Defendants.
----------------------------------------------------------------------------X
THEODORE J. JENAL, D.D.S., hereby affirms the truth of the following under the
penalty of perjury, pursuant to CPLR § 2106:
1. I have been licensed to practice dentistry in the State of New York since 1989, but
am not currently registered there and have not been registered there since 2012 as I currently live
in Arizona. I am currently licensed to practice dentistry in the State of Arizona and have been so
since 2004. I attended and graduated from Stony Brook School of Dental Medicine in 1988,
receiving my Doctorate in Dental Surgery (D.D.S.), and this was followed by a one-year general
residency at Booth Memorial Medical Center. I have been in the private practice of dentistry since
1989. I am familiar with the dental/medical standard of care owed by dentists to this community.
2. I submit this Affirmation in support of Defendant RASHMI AMBEWADIKAR,
D.D.S. (hereinafter “Defendant AMBEWADIKAR” or “Dr. Ambewadikar”), who seek an order:
• Pursuant to CPLR § 3211 and CPLR § 3212, granting summary judgment
on the issue of liability in favor of Defendant RASHMI
AMBEWADIKAR, D.D.S. and dismissing Plaintiffs’ Complaint as against
said Defendant, on the grounds that there are no triable issues of material
fact regarding dental/medical negligence, dental/medical malpractice, lack
of informed consent and loss of consortium, and directing the Clerk of the
Court to enter judgment accordingly;
1
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
• Severing the dismissed action as against Defendant RASHMI
AMBEWADIKAR, D.D.S. from the continuing action as against the other
Defendant; and
• For such other, further and different relief as this Court shall deem just and
proper.
3. Prior to signing this Affirmation, I reviewed the records relevant to the claim made
by Plaintiffs, including the Summons and Verified Complaint, Stipulation of Discontinuance as to
co-Defendant DANIELLE SIM, D.M.D. and Supplemental Summons and Amended Verified
Complaint (Exhibit “B”), the Verified Answers of Defendant AMBEWADIKAR and co-
Defendant METROPOLITAN DENTAL ASSOCIATES, D.D.S., P.C. (hereinafter “co-
Defendant METROPOLITAN” and/or “Metropolitan Dental”) to the Amended Verified
Complaint, and the Verified Answers of co-Defendant DANIELLE SIM, D.M.D. and co-
Defendant METROPOLITAN to the Verified Complaint (Exhibit “C”), Plaintiffs’ Verified Bills
of Particulars as against all Defendants (Exhibit “D”), the dental records, films and photographs
maintained by co-Defendant METROPOLITAN where Defendant AMBEWADIKAR rendered
treatment to the infant Plaintiff J.F.R. (Exhibit “L”), the certified ambulance call records
maintained by New York City Fire Department (Exhibit “M”), the medical records maintained
by Bellevue Hospital Center (Exhibit “N”), the medical records maintained by Third Avenue
Pediatric Care (Ashok Ghooi, M.D.) (Exhibit “O”), and the medical records maintained by Mount
Sinai Medical Center (Exhibit “P”). I have also reviewed the deposition transcript of Plaintiff
J.F.R. (Exhibit “E”), the two deposition transcripts of Plaintiff EUGENIO M. RAMIREZ
(Exhibits “F” and “G”), the deposition transcript of Plaintiff ROSALBA LUNA (Exhibit “H”),
and the deposition transcript of Defendant RASHMI AMBEWADIKAR, D.D.S. (Exhibit “I”).
4. Plaintiffs’ Verified Bill of Particulars against Defendant AMBEWADIKAR
2
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
alleges that, from January 2011 through approximately October 14, 2011 and particularly on
October 14, 2011, she improperly administered anesthesia prior to a dental procedure, namely
multiple teeth extractions, failed to allow the infant plaintiff adequate recovery time after the
multiple teeth extractions with attendant administration of anesthesia, failed to properly follow-up
and monitor the infant plaintiff post-procedure due the use of anesthesia, failed to allow the infant
plaintiff adequate recovery time after the multiple teeth extractions when the infant plaintiff was
NPO (without food and water), failed to perform any physical examination of the infant plaintiff
following the teeth extraction, caused/allowed the infant plaintiff to leave the recovery area
prematurely, thereby causing/permitting/allowing the infant plaintiff to lose consciousness and fall
to the ground and be seriously injured, extracted an inordinate amount of teeth during one treatment
session, failed to ascertain whether the infant plaintiff was able to leave the recovery area safely
and without injury, and failed to obtain the infant plaintiff’s informed consent in that plaintiffs
were not advised as to the risks of prolonged anesthesia necessitated by multiple tooth extractions,
nor the risk of loss of consciousness thereafter. Exhibit “D” at ¶ 3, ¶ 9, ¶ 10 and ¶ 19.
5. As a result of the alleged malpractice by Defendant AMBEWADIKAR, Plaintiffs
alleges that Plaintiff J.F.R. (who is no longer an infant) suffered a skull fracture, non-displaced
fracture within the right occipital bone extending inferiorly and to the posterior right skull base,
syncope, syncopal episode post-tooth extraction, vomiting post fall, intermittent dizziness,
headache over right occiput, conclusion with loss of consciousness, concussion syndrome, blurry
vision, difficulty concentrating, memory loss, episodes of urinary incontinence, and cognitive
difficulties, all of which are claimed to be permanent. Exhibit “D” at ¶ 13.
6. It is my opinion with a reasonable degree of dental/medical certainty that the
dental/medical care and treatment rendered by Defendant AMBEWADIKAR did not depart from
3
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
good and accepted dental/medical practice, nor was the dental/medical care and treatment of
Plaintiff J.F.R. by Defendant AMBEWADIKAR a substantial factor in causing his claimed
injuries.
FACTS
7. Plaintiff J.F.R. (hereinafter “J.F.R.”) first presented to Metropolitan Dental on July
9, 2011. Exhibit “L” at page 2. He was accompanied by his mother, Plaintiff ROSALBA LUNA
(hereinafter “Rosalba”), during this visit. Exhibit “H” at page 25 to 26. A health history form
was completed on July 9, 2011 that did not contain any significant findings. Exhibit “L” at page
6. J.F.R. was not seen by Dr. Ambewadikar at this visit. Exhibit “I” at pages 14 to 15.
8. At the visit on July 9, 2011, a dental examination was performed by a dentist at
Metropolitan Dental, including an intra-oral and extra-oral examination and a dental cleaning.
Exhibit “L” at page 2. Four periapical X-rays, four bitewing X-rays and a panoramic X-ray were
taken. Exhibit “L” at pages 21 to 22. The unknown dentist noted that J.F.R. had poor oral
hygiene with no decay found on his permanent teeth, had an open bite and provided Plaintiffs with
a referral for an orthodontic consultation. Exhibit “L” at page 2. The referral for an orthodontic
consultation was made on July 9, 2011 because Plaintiff had too many teeth, and needed some of
his extra teeth extracted in order to create more space in his mouth. Exhibit “H” at page 18.
9. The records maintained by Metropolitan Dental provide that a cephalometric X-
ray, six bitewing X-rays and six photographs of J.F.R. were taken on September 19, 2011. J.F.R.
was not seen by Dr. Ambewadikar on September 19, 2011. Exhibit “L” at pages 19 to 20, 23.
10. On October 14, 2011, J.F.R. presented to Metropolitan Dental accompanied by his
father, Plaintiff EUGENIO M. RAMIREZ (hereinafter “Eugenio”) in the morning. Exhibit “F”
at pages 23 to 24. Eugenio was with J.F.R. throughout the entire visit on October 14, 2011.
4
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
Exhibit “F” at page 41. J.F.R. did not have anything to eat or drink since the previous evening;
however, no one from Metropolitan Dental had instructed J.F.R., Eugenio or Rosalba to refrain
from eating or drinking prior to the appointment on that date. Exhibit “F” at pages 25 to 26;
Exhibit ‘H” at pages 34 to 36.
11. At this visit on October 14, 2011, J.F.R. was initially seen by Dr. Aljanabi, an
orthodontist at Metropolitan Dental. Exhibit “I” at page 9. A health history form was completed
at this visit that did not contain any significant findings. Exhibit “L” at page 9. Dr. Aljanabi
referred J.F.R. to Dr. Ambewadikar for the extraction of four baby teeth to create some more space
in his mouth that same day because J.F.R. was off from school. Exhibit “I” at pages 9 to 10.
Prior to the procedure on October 14, 2011, J.F.R. had his blood pressure and other vitals checked,
and was cleared to go ahead with the extractions. Exhibit “F” at page 36.
12. After being cleared for the extractions, J.F.R. and Eugenio entered the treatment
room when the extractions were performed. Exhibit “F” at pages 41 to 43. The treatment room
was empty when they arrived, and subsequently, Dr. Ambewadikar and a dental assistant entered.
Exhibit “F” at pages 42 to 43. Prior to commencing the extractions, Dr. Ambewadikar talked to
J.F.R. and Eugenio about the procedure and gave the usual information she provides to patients
prior to extractions of baby teeth. Exhibit “I” at pages 17 to 18.
13. For the procedure itself, Dr. Ambewadikar initially applied topical jelly-anesthetic
to the gums surrounding the four baby teeth that were to be extracted. Exhibit “I” at page 19.
Next, she administered local anesthesia, namely 2.7 cc’s (one and a half carpules) of 4%
Septocaine via buccal infiltration, and waited a few minutes for the anesthetic to completely numb
J.F.R.’s gums. Exhibit “I” at pages 18 to 20. After the anesthetic took effect, Dr. Ambewadikar
extracted four baby teeth (teeth #C, #D, #H and #I). Exhibit “I” at pages 23 to 24. She observed
5
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
that most of the four baby teeth were quite mobile and ready to fall out on their own. Exhibit “I”
at page 24. The extractions were uneventful, and did not require the use of any special
instrumentation. Exhibit “I” at page 24.
14. After the procedure was completed, Dr. Ambewadikar initially gave J.F.R. gauze
to bite down on to slow the bleeding. Exhibit “I” at page 26. She also advised J.F.R. and Eugenio
to change the gauze every twenty to thirty minutes until the bleeding stopped. Exhibit “I” at page
27. In addition, Dr. Ambewadikar gave verbal post-operative instructions, which included no
eating for about one hour after the procedure. Exhibit “I” at pages 26 to 27. Dr. Ambewadikar
also performed a visual inspection and assessment of J.F.R. after the procedure and was satisfied
with his condition. Exhibit “I” at pages 42 to 44, 63. He was responsive and talked with Dr.
Ambewadikar. Exhibit “I” at page 63. Dr. Ambewadikar did not observe J.F.R. to sluggish or
unresponsive. Exhibit “I” at pages 43 to 44, 63. In addition, Dr. Ambewadikar noted that J.F.R.
did not have any trouble breathing, trouble expressing his feelings or thoughts and did not show
any signs of distress of any kind. Exhibit “I” at pages 42 to 43. Eugenio asked Dr. Ambewadikar
if he could take J.F.R. and leave following the extractions and she replied that J.F.R. was fine,
could leave, and was permitted to attend school that same day. Exhibit “G” at page 98.
15. Dr. Ambewadikar left the treatment room before J.F.R. got out of the dental chair
and before Eugenio and J.F.R. exited the treatment room. Exhibit “I” at pages 42 to 43. J.F.R.
and Eugenio stayed with the dental assistant in the treatment room to finish up anything else that
needed to be done, such as making a follow-up appointment, wrapping up the extracted teeth and
providing extra gauze to the patient. Exhibit “I” at pages 43 to 44.
16. When Dr. Ambewadikar worked at Metropolitan Dental, she had two, sometimes
three treatment rooms, where she provided dental treatment to patients. Exhibit “I” at pages 50
6
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
to 51. After she completed dental treatment to a patient in a treatment room, she would then go to
a different treatment room to start treatment on a new patient, rather than wait for the initial
treatment room to be cleaned up. Exhibit “I” at page 51. In total, Dr. Ambewadikar estimated
she would see 25 to 30 patients per day from 8:00 A.M. to 5:00 P.M. Exhibit “I” at page 51.
17. When J.F.R. got up from the dental chair, he was escorted by Eugenio from the
treatment room to the reception desk in the main waiting area to schedule the next appointment.
Exhibit “F” at pages 50 to 53. Eugenio physically supported J.F.R. with an arm around his
shoulders until they reached the reception desk. Exhibit “F” at pages 50 to 52. The dental
assistant did not escort Plaintiff out of the treatment room, or from the treatment room to the
reception desk in the main waiting area. Exhibit “F” at pages 50 to 53.
18. J.F.R. indicated that he was weak from the time he left the dental chair until he
reached the door to exit the treatment room, but did not tell anyone of this complaint. Exhibit “E”
at page 78. He continued to feel weak during the walk from the treatment room to the reception
desk, but again did not tell anyone. Exhibit “E” at pages 80 to 81. J.F.R. felt dizzy by the time
he reached the reception desk in the main waiting area. Exhibit “E” at pages 81 to 82.
19. While J.F.R. was standing with Eugenio at the reception desk, he lost consciousness
and fell on the floor. Exhibit “E” at page 84, 87 to 88. Eugenio did not see J.F.R. fall. Exhibit
“G” at page 97. However, Eugenio was holding J.F.R.’s hand when he started to notice him fall.
Exhibit “F” at page 54. The Bellevue Hospital Center records state that J.F.R. fell backwards,
away from the reception desk and his head struck the ground of the waiting area. Exhibit “N” at
page 4. The Metropolitan Dental records state that J.F.R. fell in the waiting area five minutes after
the extractions were completed. Exhibit “L” at page 3.
20. After J.F.R. lost consciousness, Eugenio removed the gauze from J.F.R.’s mouth
7
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
and asked the receptionist to call for an ambulance. Exhibit “F” at pages 30, 56. J.F.R. was then
moved back to the treatment room and into the dental chair with the help of employees at
Metropolitan Dental. Exhibit “F” at pages 56 to 57. When J.F.R. first awoke, he was in a seat
and saw Eugenio in front of him. Exhibit “E” at page 88.
21. Dr. Ambewadikar was made aware of the fall when another employee at
Metropolitan Dental informed her that the patient on whom she just performed a dental procedure
had fainted. Exhibit “I” at pages 33 to 34. She then came into the treatment room and saw J.F.R.,
who was sitting in the dental chair. Exhibit “I” at page 34. Dr. Ambewadikar recalled that J.F.R.
looked a little pale but was conscious. Exhibit “I” at page 34. She talked to J.F.R. and Eugenio,
asked Eugenio if they needed anything, and directed the assistants to get juice for J.F.R. Exhibit
“I” at pages 34 to 35. Dr. Ambewadikar also spoke with the paramedics when they arrived.
Exhibit “I” at page 35.
22. The employees at Metropolitan Dental called EMS after the fall. Exhibit “I” at
page 34. Eugenio estimated that fifteen to twenty minutes had passed between J.F.R. losing
consciousness and the paramedics arriving to the dental office. Exhibit “F” at page 59. The
paramedics gave J.F.R. oxygen and checked his blood pressure, which they noted was low. They
then took J.F.R. to Bellevue Hospital for evaluation. Exhibit “F” at page 59. The New York
City Fire Department ambulance call records state that paramedics were assigned to the incident
and on route to Metropolitan Dental at 9:51 A.M., arrived at Metropolitan Dental at 10:19 A.M.,
left Metropolitan Dental at 10:23 A.M. and arrived at Bellevue Hospital at 10:32 A.M. Exhibit
“K” at page 1.
23. J.F.R. was seen in triage in the Bellevue Hospital Emergency Department by RN
Cheryl DeDios at 10:42 A.M. with a chief complaint of syncope (fainting) subsequent to a tooth
8
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
extraction. Exhibit “N” at pages 5 to 6. He looked pale and felt dizzy, but denied pain and was
alert and oriented x3. Exhibit “N” at pages 5 to 6. J.F.R. was evaluated by attending Dr. Jeffrey
S. Fineat 11:14 A.M. and bloodwork was taken, which was normal. Exhibit “N” at pages 8 to
10, 14 to 15. He was formally discharged at 2:50 P.M. on October 14, 2011 to home with
directions to follow-up with his primary medical doctor in one week. Exhibit “N” at pages 16,
18.
24. Eugenio said that J.F.R. was discharged from Bellevue Hospital because he
appeared to be fine and his vitals were stable. Exhibit “G” at pages 71 to 73. J.F.R. said he felt
dizzy, nauseous, and had pain in his head at Bellevue Hospital, but was not as dizzy or as tired as
he was right before he fainted at Metropolitan Dental. Exhibit “G” at page 104. Both Dr.
Ambewadikar and the receptionist at Metropolitan Dental contacted Eugenio later in the day and
were told that J.F.R. was fine. Exhibit “I” at pages 35 to 36.
25. On October 20, 2011, J.F.R. presented with his mother, Rosalba, to his pediatrician,
Dr. Ashok Ghooi, at Third Avenue Pediatric Care. Exhibit “O” at page 37. Rosalba informed
Dr. Ghooi that J.F.R. was experiencing dizzy spells, nausea, vomiting, and pain in his head.
Exhibit “H” at page 40. Dr. Ghooi initially instructed Rosalba to take J.F.R. home, but then
called her later and told her to take him to the emergency room for a CT scan. Exhibit “H” at
page 40.
26. That same day, October 20, 2011, Rosalba took J.F.R. to the Mount Sinai Hospital
emergency room and was seen by attending Dr. Adam E. Vella. Exhibit “P” at page 11. J.F.R.
had complaints at the time of intermittent dizziness, headache over right occiput and blurry vision
for five days. Exhibit “P” at page 11. He received a CT scan of the head without contrast, which
contained an impression of a nondisplaced fracture within the right occipital bone, extending
9
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
inferiorly and to the posterior right skull base. Exhibit “P” at page 29. The clinical impressions
were skull fracture, concussion with loss of consciousness and complication of concussion.
Exhibit “P” at page 8. J.F.R. was discharged from Mount Sinai Hospital on October 20, 2011
with instructions to follow-up with neurosurgery for a consultation in two weeks. Exhibit “P” at
page 8.
27. On December 19, 2011, J.F.R. was accompanied by Rosalba to see a neurosurgeon,
Dr. Chun Chen, at an office visit at Mount Sinai Medical Center upon referral of his pediatrician,
Dr. Ghooi, for evaluation of headaches and the prior head trauma with right occipital fracture.
Exhibit “P” at page 41. At this visit, J.F.R. made complaints of headaches occurring five times
per week with a duration of twelve hours and intensity of 7 out of 10 on a 1 to 10 scale. Exhibit
“P” at pages 41, 43. Dr. Chen performed a neurological examination and ordered a new CT scan
without IV contrast for better diagnostic evaluation and planning, and directed J.F.R. to return for
a follow-up office visit after the CT scan was obtained. Exhibit “P” at page 43.
28. A CT scan of the head was taken at Mount Sinai Medical Center on December 27,
2011, which contained an impression of no intracranial masses, no evidence of blood products,
and a note that the right occipital fracture seems somewhat less obvious connoting ossification.
Exhibit “P” at pages 46 to 47.
29. On December 29, 2011, J.F.R. was seen by Dr. Douglas J. Mayson, accompanied
by Rosalba, at an office visit in the pediatric neurology department at Mount Sinai Medical Center.
Exhibit “P” at pages 3 to 5. At this visit, he noted that J.F.R. had bad headaches for about two
weeks after the incident, but had been doing well since that time. Exhibit “P” at page 3. Dr.
Mayson also performed an examination and reviewed the CT scan of the head taken on December
27, 2011. Exhibit “P” at page 4. His assessment included notes that headaches and dizziness
10
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
had resolved, the CT scan of the head demonstrated the beginnings of ossification, and
forgetfulness was most consistent with post-concussive syndrome. Exhibit “P” at page 4. Dr.
Mayson’s plan was for no further neuroimaging, recommend wearing a helmet when biking, defer
return to sports to neurosurgery but recommend wearing a helmet in the short term while playing
soccer, and follow-up as needed. Exhibit “P” at page 4.
30. J.F.R. returned to Dr. Chen on January 5, 2012 accompanied by Rosalba and his
older sister. Exhibit “P” at pages 45 to 48. At this visit, Dr. Chen conducted a neurological
examination and discussed the CT scan of the head taken on December 27, 2011, which showed
improvement of the fracture. Exhibit “P” at page 47. A follow-up office visit was recommended
in four months. Exhibit “P” at page 47. J.F.R. did not return to Mount Sinai Medical Center
after this visit. Exhibit “P”.
OPINIONS
31. It is my opinion with a reasonable degree of dental/medical certainty that the
extraction of four baby teeth in J.F.R.’s mouth was a proper, indicated treatment choice, as the
extraction of these teeth would create some more space in his mouth and further the overall
orthodontic treatment plan, which is evident in my review of the films provided by Metropolitan
Dental dated July 9, 2011 and September 19, 2011. It is also my opinion with a reasonable degree
of dental/medical certainty that Dr. Ambewadikar was within accepted standards of dental/medical
practice and did not depart from the standard of care in choosing not to perform an independent
examination/evaluation of J.F.R.’s four baby teeth prior to commencing the extraction procedures
as he had already been seen by an orthodontist at the same office, Metropolitan Dental, who had
examined his mouth and recommended the extractions of the teeth, and because J.F.R. had his
blood pressure and other vitals checked and was cleared to go ahead with the extractions shortly
11
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
before presenting to Dr. Ambewadikar.
32. It is also my opinion with a reasonable degree of dental/medical certainty that
proper and complete medical information was obtained prior to the extraction procedures in order
to account for a medical emergency that might have occurred and did in fact occur at the office of
Metropolitan Dental with J.F.R. Since syncope is by far the most common medical emergency
that occurs in the dental office, it is the standard of care for dentists (and dental offices) to obtain
a complete medical history, as the incidence of medical emergencies increases with older and
chronically ill patients. In this situation, a complete medical history was obtained both at the initial
visit on July 9, 2011 and again on the subject visit in question, October 14, 2011, both of which
revealed that J.F.R. was a healthy ten-year old male with a negative medical history. It is my
opinion, therefore, with a reasonable degree of dental/medical certainty that Metropolitan Dental
and in turn, Dr. Ambewadikar, obtained a complete medical history of J.F.R. in line with the
standard of care in order to address any medical emergencies that arose at the dental office.
33. It is also my opinion with a reasonable degree of dental/medical certainty that the
extractions of four baby teeth (teeth #C, #D, #H and #I) performed by Dr. Ambewadikar at
Metropolitan Dental on October 14, 2011 on the referral of the orthodontist treating J.F.R. at the
office, Dr. Aljanabi, were done within accepted standards of dental/medical practice and did not
depart from the standard of care in that Dr. Ambewadikar properly applied topical jelly-anesthetic
to the gums surrounding the four baby teeth that were to be extracted, correctly administered local
anesthesia, namely 2.7 cc’s (one and a half carpules) of 4% Septocaine via buccal infiltration, and
appropriately waited a few minutes for the anesthetic to completely numb J.F.R.’s gums.
34. It is also my opinion with a reasonable degree of dental/medical certainty that it
was entirely appropriate under the circumstances for Dr. Ambewadikar to remove four baby teeth
12
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
in one visit, and that any claim that this was an inordinate amount of treatment to be performed in
one visit is completely untrue. In particular, removal of baby teeth which exhibit root resorption
is typically a routine procedure and often much quicker and less traumatic than longer restorative
procedures, often only lasting merely a few minutes. This is demonstrated in the record by Dr.
Ambewadikar’s testimony that most of the four baby teeth removed were quite mobile and ready
to fall out on their own, and by the evidence that the extractions were uneventful and did not
require the use of any special instrumentation.
35. It is also my opinion with a reasonable degree of dental/medical certainty that Dr.
Ambewadikar used an appropriate amount and type of local anesthetic during the extraction
procedures for this particular patient, who was ten years old and weighed approximately sixty
pounds, specifically 2.7 cc’s (one and half carpules) of 4% Septocaine via buccal infiltration,
which is the proper method to administer local anesthesia prior to a dental procedure. It is also my
opinion with a reasonable degree of dental/medical certainty that local anesthetics do not increase
the incident of syncope or incapacitate the patient in any way and do not affect the consciousness
of the patient or the recovery time after the performance of extractions, regardless of the patient’s
age or medical condition, and regardless of whether the patient was NPO (not eaten or drank
anything for a period of time), and that this opinion is therefore fully applicable to the
circumstances presented by J.F.R. in this matter. It is also my opinion with a reasonable degree of
dental/medical certainty that the use of local anesthetics by Dr. Ambewadikar in the amount and
type used in the extractions of the four baby teeth from J.F.R.’s mouth would not require any
additional follow-up and monitoring of him post-procedure other than that which would be given
to a typical patient of his age and non-contributory medical condition.
36. It is also my opinion with a reasonable degree of dental/medical certainty that Dr.
13
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
Ambewadikar was within accepted standards of dental/medical practice and did not depart from
the standard of care in not disclosing the risk of loss of consciousness after the procedure as such
an event was a medical emergency. As medical emergencies occur so infrequently and with such
variability, it is my opinion with a reasonable degree of dental/medical certainty that it is not the
standard of care to include the possibility of a medical emergency (in this case, loss of
consciousness) during informed consent. It is also my opinion with a reasonable degree of
dental/medical certainty that there was no requirement for Dr. Ambewadikar to disclose a risk of
prolonged anesthesia necessitated by multiple teeth extractions because, as noted above, no such
risk existed given that local anesthetics do not increase the incident of syncope or incapacitate the
patient in any way and do not affect the consciousness of the patient or the recovery time after the
performance of extractions. It is also my opinion with a reasonable degree of dental/medical
certainty that a proper informed consent to the extraction procedures was provided by Dr.
Ambewadikar, as she talked to J.F.R. and Eugenio about the procedure and gave the usual
information she provides to patients prior to extractions of baby teeth.
37. It is also my opinion with a reasonable degree of dental/medical certainty that Dr.
Ambewadikar provided properly and timely treatment to J.F.R. after completing the extractions
procedure as she gave J.F.R. gauze to bite down on to slow the bleeding, and advised J.F.R. and
Eugenio to change the gauze every twenty to thirty minutes until the bleeding stopped. It is also
my opinion with a reasonable degree of dental/medical certainty that Dr. Ambewadikar provided
proper post-operative instructions to J.F.R. and Eugenio, which included no eating for about one
hour after the procedure, and that it was within accepted standards of dental/medical practice and
did not depart from the standard of care for Dr. Ambewadikar to provide these instructions verbally
as opposed to in writing.
14
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
38. It is also my opinion with a reasonable degree of dental/medical certainty that Dr.
Ambewadikar properly and timely assessed the medical status of J.F.R. after completion of the
extractions procedure, and made the appropriate decision under the circumstances to allow him to
leave the treatment room under the care of his father, Eugenio. In this case, J.F.R. did not present
with a significant medical history or a medical history that would cause a greater concern for a
medical emergency than the level of suspicion for a possible medical emergency in a healthy ten-
year old male, which was very low. Accordingly, the standard of care would require Dr.
Ambewadikar to post-operatively assess J.F.R., and in this case, given his young age and negative
medical history, a post-operative assessment would typically be visual and verbal, and would not
require a full physical examination. In this instance, Dr. Ambewadikar performed a visual
inspection and assessment of J.F.R. after the procedure and was satisfied with his condition. J.F.R.
was responsive and talked with Dr. Ambewadikar. Dr. Ambewadikar did not observe J.F.R. to
sluggish or unresponsive. Dr. Ambewadikar noted that J.F.R. did not have any trouble breathing,
trouble expressing his feelings or thoughts, and did not show any signs of distress of any kind.
Although J.F.R. testified that he was weak after getting up from the dental chair, he did not notify
anyone of this complaint, and demonstrated no other signs of distress. It is my opinion, therefore,
with a reasonable degree of dental/medical certainty, that the evidence indicates J.F.R. was not
demonstrating signs of distress such as pallor or sweating and was verbal; as such, dismissal from
the treatment room, whether assisted or not, was indicated. It is also my opinion with a reasonable
degree of medical/dental certainty that a syncopal episode in this case could not be predicted or
prevented, and in fact, patients who faint may present with completely normal vital signs shortly
before the incident.
39. It is also my opinion with a reasonable degree of dental/medical certainty that Dr.
15
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022
Ambewadikar allowed J.F.R. adequate recovery time under the circumstances presenting on
October 14, 2011 before permitting him to get up from the dental chair and leave the treatment
room with the assistance of his father, Eugenio, as adequate recovery time is determined under the
circumstances and is not a specific set amount of time. The dental records provided by
Metropolitan Dental indicate that J.F.R. lost consciousness and fell five minutes after the
extractions procedure was completed. In this case, when Dr. Ambewadikar performed a visual
inspection and assessment of J.F.R. after the procedure and was satisfied with his condition for the
reasons as noted above, she met the standard of care for determining whether J.F.R. had adequate
recovery time after the procedure and accordingly, he was permitted to get up from the dental chair
and leave the treatment room. It is also my opinion, as noted above, with a reasonable degree of
dental/medical certainty that the use of local anesthesia in the amount and type used by Dr.
Ambewadikar does not affect the recovery time after the performance of extractions, nor does it
lengthen by itself the adequate recovery time needed by a patient, including J.F.R. in this situation,
after such a procedure.
40. It is also my opinion with a reasonable degree of dental/medical certainty that the
statements by J.F.R. and his parents that he was NPO (without food and water) on the date of the
incident (October 14, 2011) could not have been taken into consideration by Dr. Ambewadikar in
making her assessment of the medical status of J.F.R. after completion of the extractions proced
Preview
FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK ---------------------------------------------------------------------------X Index No. 152972/2014 J.F.R., an infant under the age of 14 years, by his father and natural guardian, EUGENIO M. RAMIREZ, Individually and AFFIRMATION OF ROSALBA LUNA, Individually, THEODORE J. JENAL, D.D.S. Plaintiffs, -against- RASHMI AMBEWADIKAR, D.D.S., and METROPOLITAN DENTAL ASSOCIATES, D.D.S., P.C., Defendants. ----------------------------------------------------------------------------X THEODORE J. JENAL, D.D.S., hereby affirms the truth of the following under the penalty of perjury, pursuant to CPLR § 2106: 1. I have been licensed to practice dentistry in the State of New York since 1989, but am not currently registered there and have not been registered there since 2012 as I currently live in Arizona. I am currently licensed to practice dentistry in the State of Arizona and have been so since 2004. I attended and graduated from Stony Brook School of Dental Medicine in 1988, receiving my Doctorate in Dental Surgery (D.D.S.), and this was followed by a one-year general residency at Booth Memorial Medical Center. I have been in the private practice of dentistry since 1989. I am familiar with the dental/medical standard of care owed by dentists to this community. 2. I submit this Affirmation in support of Defendant RASHMI AMBEWADIKAR, D.D.S. (hereinafter “Defendant AMBEWADIKAR” or “Dr. Ambewadikar”), who seek an order: • Pursuant to CPLR § 3211 and CPLR § 3212, granting summary judgment on the issue of liability in favor of Defendant RASHMI AMBEWADIKAR, D.D.S. and dismissing Plaintiffs’ Complaint as against said Defendant, on the grounds that there are no triable issues of material fact regarding dental/medical negligence, dental/medical malpractice, lack of informed consent and loss of consortium, and directing the Clerk of the Court to enter judgment accordingly; 1 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 • Severing the dismissed action as against Defendant RASHMI AMBEWADIKAR, D.D.S. from the continuing action as against the other Defendant; and • For such other, further and different relief as this Court shall deem just and proper. 3. Prior to signing this Affirmation, I reviewed the records relevant to the claim made by Plaintiffs, including the Summons and Verified Complaint, Stipulation of Discontinuance as to co-Defendant DANIELLE SIM, D.M.D. and Supplemental Summons and Amended Verified Complaint (Exhibit “B”), the Verified Answers of Defendant AMBEWADIKAR and co- Defendant METROPOLITAN DENTAL ASSOCIATES, D.D.S., P.C. (hereinafter “co- Defendant METROPOLITAN” and/or “Metropolitan Dental”) to the Amended Verified Complaint, and the Verified Answers of co-Defendant DANIELLE SIM, D.M.D. and co- Defendant METROPOLITAN to the Verified Complaint (Exhibit “C”), Plaintiffs’ Verified Bills of Particulars as against all Defendants (Exhibit “D”), the dental records, films and photographs maintained by co-Defendant METROPOLITAN where Defendant AMBEWADIKAR rendered treatment to the infant Plaintiff J.F.R. (Exhibit “L”), the certified ambulance call records maintained by New York City Fire Department (Exhibit “M”), the medical records maintained by Bellevue Hospital Center (Exhibit “N”), the medical records maintained by Third Avenue Pediatric Care (Ashok Ghooi, M.D.) (Exhibit “O”), and the medical records maintained by Mount Sinai Medical Center (Exhibit “P”). I have also reviewed the deposition transcript of Plaintiff J.F.R. (Exhibit “E”), the two deposition transcripts of Plaintiff EUGENIO M. RAMIREZ (Exhibits “F” and “G”), the deposition transcript of Plaintiff ROSALBA LUNA (Exhibit “H”), and the deposition transcript of Defendant RASHMI AMBEWADIKAR, D.D.S. (Exhibit “I”). 4. Plaintiffs’ Verified Bill of Particulars against Defendant AMBEWADIKAR 2 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 alleges that, from January 2011 through approximately October 14, 2011 and particularly on October 14, 2011, she improperly administered anesthesia prior to a dental procedure, namely multiple teeth extractions, failed to allow the infant plaintiff adequate recovery time after the multiple teeth extractions with attendant administration of anesthesia, failed to properly follow-up and monitor the infant plaintiff post-procedure due the use of anesthesia, failed to allow the infant plaintiff adequate recovery time after the multiple teeth extractions when the infant plaintiff was NPO (without food and water), failed to perform any physical examination of the infant plaintiff following the teeth extraction, caused/allowed the infant plaintiff to leave the recovery area prematurely, thereby causing/permitting/allowing the infant plaintiff to lose consciousness and fall to the ground and be seriously injured, extracted an inordinate amount of teeth during one treatment session, failed to ascertain whether the infant plaintiff was able to leave the recovery area safely and without injury, and failed to obtain the infant plaintiff’s informed consent in that plaintiffs were not advised as to the risks of prolonged anesthesia necessitated by multiple tooth extractions, nor the risk of loss of consciousness thereafter. Exhibit “D” at ¶ 3, ¶ 9, ¶ 10 and ¶ 19. 5. As a result of the alleged malpractice by Defendant AMBEWADIKAR, Plaintiffs alleges that Plaintiff J.F.R. (who is no longer an infant) suffered a skull fracture, non-displaced fracture within the right occipital bone extending inferiorly and to the posterior right skull base, syncope, syncopal episode post-tooth extraction, vomiting post fall, intermittent dizziness, headache over right occiput, conclusion with loss of consciousness, concussion syndrome, blurry vision, difficulty concentrating, memory loss, episodes of urinary incontinence, and cognitive difficulties, all of which are claimed to be permanent. Exhibit “D” at ¶ 13. 6. It is my opinion with a reasonable degree of dental/medical certainty that the dental/medical care and treatment rendered by Defendant AMBEWADIKAR did not depart from 3 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 good and accepted dental/medical practice, nor was the dental/medical care and treatment of Plaintiff J.F.R. by Defendant AMBEWADIKAR a substantial factor in causing his claimed injuries. FACTS 7. Plaintiff J.F.R. (hereinafter “J.F.R.”) first presented to Metropolitan Dental on July 9, 2011. Exhibit “L” at page 2. He was accompanied by his mother, Plaintiff ROSALBA LUNA (hereinafter “Rosalba”), during this visit. Exhibit “H” at page 25 to 26. A health history form was completed on July 9, 2011 that did not contain any significant findings. Exhibit “L” at page 6. J.F.R. was not seen by Dr. Ambewadikar at this visit. Exhibit “I” at pages 14 to 15. 8. At the visit on July 9, 2011, a dental examination was performed by a dentist at Metropolitan Dental, including an intra-oral and extra-oral examination and a dental cleaning. Exhibit “L” at page 2. Four periapical X-rays, four bitewing X-rays and a panoramic X-ray were taken. Exhibit “L” at pages 21 to 22. The unknown dentist noted that J.F.R. had poor oral hygiene with no decay found on his permanent teeth, had an open bite and provided Plaintiffs with a referral for an orthodontic consultation. Exhibit “L” at page 2. The referral for an orthodontic consultation was made on July 9, 2011 because Plaintiff had too many teeth, and needed some of his extra teeth extracted in order to create more space in his mouth. Exhibit “H” at page 18. 9. The records maintained by Metropolitan Dental provide that a cephalometric X- ray, six bitewing X-rays and six photographs of J.F.R. were taken on September 19, 2011. J.F.R. was not seen by Dr. Ambewadikar on September 19, 2011. Exhibit “L” at pages 19 to 20, 23. 10. On October 14, 2011, J.F.R. presented to Metropolitan Dental accompanied by his father, Plaintiff EUGENIO M. RAMIREZ (hereinafter “Eugenio”) in the morning. Exhibit “F” at pages 23 to 24. Eugenio was with J.F.R. throughout the entire visit on October 14, 2011. 4 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 Exhibit “F” at page 41. J.F.R. did not have anything to eat or drink since the previous evening; however, no one from Metropolitan Dental had instructed J.F.R., Eugenio or Rosalba to refrain from eating or drinking prior to the appointment on that date. Exhibit “F” at pages 25 to 26; Exhibit ‘H” at pages 34 to 36. 11. At this visit on October 14, 2011, J.F.R. was initially seen by Dr. Aljanabi, an orthodontist at Metropolitan Dental. Exhibit “I” at page 9. A health history form was completed at this visit that did not contain any significant findings. Exhibit “L” at page 9. Dr. Aljanabi referred J.F.R. to Dr. Ambewadikar for the extraction of four baby teeth to create some more space in his mouth that same day because J.F.R. was off from school. Exhibit “I” at pages 9 to 10. Prior to the procedure on October 14, 2011, J.F.R. had his blood pressure and other vitals checked, and was cleared to go ahead with the extractions. Exhibit “F” at page 36. 12. After being cleared for the extractions, J.F.R. and Eugenio entered the treatment room when the extractions were performed. Exhibit “F” at pages 41 to 43. The treatment room was empty when they arrived, and subsequently, Dr. Ambewadikar and a dental assistant entered. Exhibit “F” at pages 42 to 43. Prior to commencing the extractions, Dr. Ambewadikar talked to J.F.R. and Eugenio about the procedure and gave the usual information she provides to patients prior to extractions of baby teeth. Exhibit “I” at pages 17 to 18. 13. For the procedure itself, Dr. Ambewadikar initially applied topical jelly-anesthetic to the gums surrounding the four baby teeth that were to be extracted. Exhibit “I” at page 19. Next, she administered local anesthesia, namely 2.7 cc’s (one and a half carpules) of 4% Septocaine via buccal infiltration, and waited a few minutes for the anesthetic to completely numb J.F.R.’s gums. Exhibit “I” at pages 18 to 20. After the anesthetic took effect, Dr. Ambewadikar extracted four baby teeth (teeth #C, #D, #H and #I). Exhibit “I” at pages 23 to 24. She observed 5 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 that most of the four baby teeth were quite mobile and ready to fall out on their own. Exhibit “I” at page 24. The extractions were uneventful, and did not require the use of any special instrumentation. Exhibit “I” at page 24. 14. After the procedure was completed, Dr. Ambewadikar initially gave J.F.R. gauze to bite down on to slow the bleeding. Exhibit “I” at page 26. She also advised J.F.R. and Eugenio to change the gauze every twenty to thirty minutes until the bleeding stopped. Exhibit “I” at page 27. In addition, Dr. Ambewadikar gave verbal post-operative instructions, which included no eating for about one hour after the procedure. Exhibit “I” at pages 26 to 27. Dr. Ambewadikar also performed a visual inspection and assessment of J.F.R. after the procedure and was satisfied with his condition. Exhibit “I” at pages 42 to 44, 63. He was responsive and talked with Dr. Ambewadikar. Exhibit “I” at page 63. Dr. Ambewadikar did not observe J.F.R. to sluggish or unresponsive. Exhibit “I” at pages 43 to 44, 63. In addition, Dr. Ambewadikar noted that J.F.R. did not have any trouble breathing, trouble expressing his feelings or thoughts and did not show any signs of distress of any kind. Exhibit “I” at pages 42 to 43. Eugenio asked Dr. Ambewadikar if he could take J.F.R. and leave following the extractions and she replied that J.F.R. was fine, could leave, and was permitted to attend school that same day. Exhibit “G” at page 98. 15. Dr. Ambewadikar left the treatment room before J.F.R. got out of the dental chair and before Eugenio and J.F.R. exited the treatment room. Exhibit “I” at pages 42 to 43. J.F.R. and Eugenio stayed with the dental assistant in the treatment room to finish up anything else that needed to be done, such as making a follow-up appointment, wrapping up the extracted teeth and providing extra gauze to the patient. Exhibit “I” at pages 43 to 44. 16. When Dr. Ambewadikar worked at Metropolitan Dental, she had two, sometimes three treatment rooms, where she provided dental treatment to patients. Exhibit “I” at pages 50 6 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 to 51. After she completed dental treatment to a patient in a treatment room, she would then go to a different treatment room to start treatment on a new patient, rather than wait for the initial treatment room to be cleaned up. Exhibit “I” at page 51. In total, Dr. Ambewadikar estimated she would see 25 to 30 patients per day from 8:00 A.M. to 5:00 P.M. Exhibit “I” at page 51. 17. When J.F.R. got up from the dental chair, he was escorted by Eugenio from the treatment room to the reception desk in the main waiting area to schedule the next appointment. Exhibit “F” at pages 50 to 53. Eugenio physically supported J.F.R. with an arm around his shoulders until they reached the reception desk. Exhibit “F” at pages 50 to 52. The dental assistant did not escort Plaintiff out of the treatment room, or from the treatment room to the reception desk in the main waiting area. Exhibit “F” at pages 50 to 53. 18. J.F.R. indicated that he was weak from the time he left the dental chair until he reached the door to exit the treatment room, but did not tell anyone of this complaint. Exhibit “E” at page 78. He continued to feel weak during the walk from the treatment room to the reception desk, but again did not tell anyone. Exhibit “E” at pages 80 to 81. J.F.R. felt dizzy by the time he reached the reception desk in the main waiting area. Exhibit “E” at pages 81 to 82. 19. While J.F.R. was standing with Eugenio at the reception desk, he lost consciousness and fell on the floor. Exhibit “E” at page 84, 87 to 88. Eugenio did not see J.F.R. fall. Exhibit “G” at page 97. However, Eugenio was holding J.F.R.’s hand when he started to notice him fall. Exhibit “F” at page 54. The Bellevue Hospital Center records state that J.F.R. fell backwards, away from the reception desk and his head struck the ground of the waiting area. Exhibit “N” at page 4. The Metropolitan Dental records state that J.F.R. fell in the waiting area five minutes after the extractions were completed. Exhibit “L” at page 3. 20. After J.F.R. lost consciousness, Eugenio removed the gauze from J.F.R.’s mouth 7 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 and asked the receptionist to call for an ambulance. Exhibit “F” at pages 30, 56. J.F.R. was then moved back to the treatment room and into the dental chair with the help of employees at Metropolitan Dental. Exhibit “F” at pages 56 to 57. When J.F.R. first awoke, he was in a seat and saw Eugenio in front of him. Exhibit “E” at page 88. 21. Dr. Ambewadikar was made aware of the fall when another employee at Metropolitan Dental informed her that the patient on whom she just performed a dental procedure had fainted. Exhibit “I” at pages 33 to 34. She then came into the treatment room and saw J.F.R., who was sitting in the dental chair. Exhibit “I” at page 34. Dr. Ambewadikar recalled that J.F.R. looked a little pale but was conscious. Exhibit “I” at page 34. She talked to J.F.R. and Eugenio, asked Eugenio if they needed anything, and directed the assistants to get juice for J.F.R. Exhibit “I” at pages 34 to 35. Dr. Ambewadikar also spoke with the paramedics when they arrived. Exhibit “I” at page 35. 22. The employees at Metropolitan Dental called EMS after the fall. Exhibit “I” at page 34. Eugenio estimated that fifteen to twenty minutes had passed between J.F.R. losing consciousness and the paramedics arriving to the dental office. Exhibit “F” at page 59. The paramedics gave J.F.R. oxygen and checked his blood pressure, which they noted was low. They then took J.F.R. to Bellevue Hospital for evaluation. Exhibit “F” at page 59. The New York City Fire Department ambulance call records state that paramedics were assigned to the incident and on route to Metropolitan Dental at 9:51 A.M., arrived at Metropolitan Dental at 10:19 A.M., left Metropolitan Dental at 10:23 A.M. and arrived at Bellevue Hospital at 10:32 A.M. Exhibit “K” at page 1. 23. J.F.R. was seen in triage in the Bellevue Hospital Emergency Department by RN Cheryl DeDios at 10:42 A.M. with a chief complaint of syncope (fainting) subsequent to a tooth 8 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 extraction. Exhibit “N” at pages 5 to 6. He looked pale and felt dizzy, but denied pain and was alert and oriented x3. Exhibit “N” at pages 5 to 6. J.F.R. was evaluated by attending Dr. Jeffrey S. Fineat 11:14 A.M. and bloodwork was taken, which was normal. Exhibit “N” at pages 8 to 10, 14 to 15. He was formally discharged at 2:50 P.M. on October 14, 2011 to home with directions to follow-up with his primary medical doctor in one week. Exhibit “N” at pages 16, 18. 24. Eugenio said that J.F.R. was discharged from Bellevue Hospital because he appeared to be fine and his vitals were stable. Exhibit “G” at pages 71 to 73. J.F.R. said he felt dizzy, nauseous, and had pain in his head at Bellevue Hospital, but was not as dizzy or as tired as he was right before he fainted at Metropolitan Dental. Exhibit “G” at page 104. Both Dr. Ambewadikar and the receptionist at Metropolitan Dental contacted Eugenio later in the day and were told that J.F.R. was fine. Exhibit “I” at pages 35 to 36. 25. On October 20, 2011, J.F.R. presented with his mother, Rosalba, to his pediatrician, Dr. Ashok Ghooi, at Third Avenue Pediatric Care. Exhibit “O” at page 37. Rosalba informed Dr. Ghooi that J.F.R. was experiencing dizzy spells, nausea, vomiting, and pain in his head. Exhibit “H” at page 40. Dr. Ghooi initially instructed Rosalba to take J.F.R. home, but then called her later and told her to take him to the emergency room for a CT scan. Exhibit “H” at page 40. 26. That same day, October 20, 2011, Rosalba took J.F.R. to the Mount Sinai Hospital emergency room and was seen by attending Dr. Adam E. Vella. Exhibit “P” at page 11. J.F.R. had complaints at the time of intermittent dizziness, headache over right occiput and blurry vision for five days. Exhibit “P” at page 11. He received a CT scan of the head without contrast, which contained an impression of a nondisplaced fracture within the right occipital bone, extending 9 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 inferiorly and to the posterior right skull base. Exhibit “P” at page 29. The clinical impressions were skull fracture, concussion with loss of consciousness and complication of concussion. Exhibit “P” at page 8. J.F.R. was discharged from Mount Sinai Hospital on October 20, 2011 with instructions to follow-up with neurosurgery for a consultation in two weeks. Exhibit “P” at page 8. 27. On December 19, 2011, J.F.R. was accompanied by Rosalba to see a neurosurgeon, Dr. Chun Chen, at an office visit at Mount Sinai Medical Center upon referral of his pediatrician, Dr. Ghooi, for evaluation of headaches and the prior head trauma with right occipital fracture. Exhibit “P” at page 41. At this visit, J.F.R. made complaints of headaches occurring five times per week with a duration of twelve hours and intensity of 7 out of 10 on a 1 to 10 scale. Exhibit “P” at pages 41, 43. Dr. Chen performed a neurological examination and ordered a new CT scan without IV contrast for better diagnostic evaluation and planning, and directed J.F.R. to return for a follow-up office visit after the CT scan was obtained. Exhibit “P” at page 43. 28. A CT scan of the head was taken at Mount Sinai Medical Center on December 27, 2011, which contained an impression of no intracranial masses, no evidence of blood products, and a note that the right occipital fracture seems somewhat less obvious connoting ossification. Exhibit “P” at pages 46 to 47. 29. On December 29, 2011, J.F.R. was seen by Dr. Douglas J. Mayson, accompanied by Rosalba, at an office visit in the pediatric neurology department at Mount Sinai Medical Center. Exhibit “P” at pages 3 to 5. At this visit, he noted that J.F.R. had bad headaches for about two weeks after the incident, but had been doing well since that time. Exhibit “P” at page 3. Dr. Mayson also performed an examination and reviewed the CT scan of the head taken on December 27, 2011. Exhibit “P” at page 4. His assessment included notes that headaches and dizziness 10 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 had resolved, the CT scan of the head demonstrated the beginnings of ossification, and forgetfulness was most consistent with post-concussive syndrome. Exhibit “P” at page 4. Dr. Mayson’s plan was for no further neuroimaging, recommend wearing a helmet when biking, defer return to sports to neurosurgery but recommend wearing a helmet in the short term while playing soccer, and follow-up as needed. Exhibit “P” at page 4. 30. J.F.R. returned to Dr. Chen on January 5, 2012 accompanied by Rosalba and his older sister. Exhibit “P” at pages 45 to 48. At this visit, Dr. Chen conducted a neurological examination and discussed the CT scan of the head taken on December 27, 2011, which showed improvement of the fracture. Exhibit “P” at page 47. A follow-up office visit was recommended in four months. Exhibit “P” at page 47. J.F.R. did not return to Mount Sinai Medical Center after this visit. Exhibit “P”. OPINIONS 31. It is my opinion with a reasonable degree of dental/medical certainty that the extraction of four baby teeth in J.F.R.’s mouth was a proper, indicated treatment choice, as the extraction of these teeth would create some more space in his mouth and further the overall orthodontic treatment plan, which is evident in my review of the films provided by Metropolitan Dental dated July 9, 2011 and September 19, 2011. It is also my opinion with a reasonable degree of dental/medical certainty that Dr. Ambewadikar was within accepted standards of dental/medical practice and did not depart from the standard of care in choosing not to perform an independent examination/evaluation of J.F.R.’s four baby teeth prior to commencing the extraction procedures as he had already been seen by an orthodontist at the same office, Metropolitan Dental, who had examined his mouth and recommended the extractions of the teeth, and because J.F.R. had his blood pressure and other vitals checked and was cleared to go ahead with the extractions shortly 11 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 before presenting to Dr. Ambewadikar. 32. It is also my opinion with a reasonable degree of dental/medical certainty that proper and complete medical information was obtained prior to the extraction procedures in order to account for a medical emergency that might have occurred and did in fact occur at the office of Metropolitan Dental with J.F.R. Since syncope is by far the most common medical emergency that occurs in the dental office, it is the standard of care for dentists (and dental offices) to obtain a complete medical history, as the incidence of medical emergencies increases with older and chronically ill patients. In this situation, a complete medical history was obtained both at the initial visit on July 9, 2011 and again on the subject visit in question, October 14, 2011, both of which revealed that J.F.R. was a healthy ten-year old male with a negative medical history. It is my opinion, therefore, with a reasonable degree of dental/medical certainty that Metropolitan Dental and in turn, Dr. Ambewadikar, obtained a complete medical history of J.F.R. in line with the standard of care in order to address any medical emergencies that arose at the dental office. 33. It is also my opinion with a reasonable degree of dental/medical certainty that the extractions of four baby teeth (teeth #C, #D, #H and #I) performed by Dr. Ambewadikar at Metropolitan Dental on October 14, 2011 on the referral of the orthodontist treating J.F.R. at the office, Dr. Aljanabi, were done within accepted standards of dental/medical practice and did not depart from the standard of care in that Dr. Ambewadikar properly applied topical jelly-anesthetic to the gums surrounding the four baby teeth that were to be extracted, correctly administered local anesthesia, namely 2.7 cc’s (one and a half carpules) of 4% Septocaine via buccal infiltration, and appropriately waited a few minutes for the anesthetic to completely numb J.F.R.’s gums. 34. It is also my opinion with a reasonable degree of dental/medical certainty that it was entirely appropriate under the circumstances for Dr. Ambewadikar to remove four baby teeth 12 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 in one visit, and that any claim that this was an inordinate amount of treatment to be performed in one visit is completely untrue. In particular, removal of baby teeth which exhibit root resorption is typically a routine procedure and often much quicker and less traumatic than longer restorative procedures, often only lasting merely a few minutes. This is demonstrated in the record by Dr. Ambewadikar’s testimony that most of the four baby teeth removed were quite mobile and ready to fall out on their own, and by the evidence that the extractions were uneventful and did not require the use of any special instrumentation. 35. It is also my opinion with a reasonable degree of dental/medical certainty that Dr. Ambewadikar used an appropriate amount and type of local anesthetic during the extraction procedures for this particular patient, who was ten years old and weighed approximately sixty pounds, specifically 2.7 cc’s (one and half carpules) of 4% Septocaine via buccal infiltration, which is the proper method to administer local anesthesia prior to a dental procedure. It is also my opinion with a reasonable degree of dental/medical certainty that local anesthetics do not increase the incident of syncope or incapacitate the patient in any way and do not affect the consciousness of the patient or the recovery time after the performance of extractions, regardless of the patient’s age or medical condition, and regardless of whether the patient was NPO (not eaten or drank anything for a period of time), and that this opinion is therefore fully applicable to the circumstances presented by J.F.R. in this matter. It is also my opinion with a reasonable degree of dental/medical certainty that the use of local anesthetics by Dr. Ambewadikar in the amount and type used in the extractions of the four baby teeth from J.F.R.’s mouth would not require any additional follow-up and monitoring of him post-procedure other than that which would be given to a typical patient of his age and non-contributory medical condition. 36. It is also my opinion with a reasonable degree of dental/medical certainty that Dr. 13 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 Ambewadikar was within accepted standards of dental/medical practice and did not depart from the standard of care in not disclosing the risk of loss of consciousness after the procedure as such an event was a medical emergency. As medical emergencies occur so infrequently and with such variability, it is my opinion with a reasonable degree of dental/medical certainty that it is not the standard of care to include the possibility of a medical emergency (in this case, loss of consciousness) during informed consent. It is also my opinion with a reasonable degree of dental/medical certainty that there was no requirement for Dr. Ambewadikar to disclose a risk of prolonged anesthesia necessitated by multiple teeth extractions because, as noted above, no such risk existed given that local anesthetics do not increase the incident of syncope or incapacitate the patient in any way and do not affect the consciousness of the patient or the recovery time after the performance of extractions. It is also my opinion with a reasonable degree of dental/medical certainty that a proper informed consent to the extraction procedures was provided by Dr. Ambewadikar, as she talked to J.F.R. and Eugenio about the procedure and gave the usual information she provides to patients prior to extractions of baby teeth. 37. It is also my opinion with a reasonable degree of dental/medical certainty that Dr. Ambewadikar provided properly and timely treatment to J.F.R. after completing the extractions procedure as she gave J.F.R. gauze to bite down on to slow the bleeding, and advised J.F.R. and Eugenio to change the gauze every twenty to thirty minutes until the bleeding stopped. It is also my opinion with a reasonable degree of dental/medical certainty that Dr. Ambewadikar provided proper post-operative instructions to J.F.R. and Eugenio, which included no eating for about one hour after the procedure, and that it was within accepted standards of dental/medical practice and did not depart from the standard of care for Dr. Ambewadikar to provide these instructions verbally as opposed to in writing. 14 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 38. It is also my opinion with a reasonable degree of dental/medical certainty that Dr. Ambewadikar properly and timely assessed the medical status of J.F.R. after completion of the extractions procedure, and made the appropriate decision under the circumstances to allow him to leave the treatment room under the care of his father, Eugenio. In this case, J.F.R. did not present with a significant medical history or a medical history that would cause a greater concern for a medical emergency than the level of suspicion for a possible medical emergency in a healthy ten- year old male, which was very low. Accordingly, the standard of care would require Dr. Ambewadikar to post-operatively assess J.F.R., and in this case, given his young age and negative medical history, a post-operative assessment would typically be visual and verbal, and would not require a full physical examination. In this instance, Dr. Ambewadikar performed a visual inspection and assessment of J.F.R. after the procedure and was satisfied with his condition. J.F.R. was responsive and talked with Dr. Ambewadikar. Dr. Ambewadikar did not observe J.F.R. to sluggish or unresponsive. Dr. Ambewadikar noted that J.F.R. did not have any trouble breathing, trouble expressing his feelings or thoughts, and did not show any signs of distress of any kind. Although J.F.R. testified that he was weak after getting up from the dental chair, he did not notify anyone of this complaint, and demonstrated no other signs of distress. It is my opinion, therefore, with a reasonable degree of dental/medical certainty, that the evidence indicates J.F.R. was not demonstrating signs of distress such as pallor or sweating and was verbal; as such, dismissal from the treatment room, whether assisted or not, was indicated. It is also my opinion with a reasonable degree of medical/dental certainty that a syncopal episode in this case could not be predicted or prevented, and in fact, patients who faint may present with completely normal vital signs shortly before the incident. 39. It is also my opinion with a reasonable degree of dental/medical certainty that Dr. 15 FILED: NEW YORK COUNTY CLERK 09/27/2022 03:08 PM INDEX NO. 152972/2014 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 09/27/2022 Ambewadikar allowed J.F.R. adequate recovery time under the circumstances presenting on October 14, 2011 before permitting him to get up from the dental chair and leave the treatment room with the assistance of his father, Eugenio, as adequate recovery time is determined under the circumstances and is not a specific set amount of time. The dental records provided by Metropolitan Dental indicate that J.F.R. lost consciousness and fell five minutes after the extractions procedure was completed. In this case, when Dr. Ambewadikar performed a visual inspection and assessment of J.F.R. after the procedure and was satisfied with his condition for the reasons as noted above, she met the standard of care for determining whether J.F.R. had adequate recovery time after the procedure and accordingly, he was permitted to get up from the dental chair and leave the treatment room. It is also my opinion, as noted above, with a reasonable degree of dental/medical certainty that the use of local anesthesia in the amount and type used by Dr. Ambewadikar does not affect the recovery time after the performance of extractions, nor does it lengthen by itself the adequate recovery time needed by a patient, including J.F.R. in this situation, after such a procedure. 40. It is also my opinion with a reasonable degree of dental/medical certainty that the statements by J.F.R. and his parents that he was NPO (without food and water) on the date of the incident (October 14, 2011) could not have been taken into consideration by Dr. Ambewadikar in making her assessment of the medical status of J.F.R. after completion of the extractions proced