STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
DEPARTMENT OF HEALTH, )
BOARD OF DENTISTRY, )
)
Petitioner, )
)
vs. ) Case No. 99-4549
)
GEORGE L. WILLIAMS, D.D.S., )
)
Respondent. )
)
RECOMMENDED ORDER
Pursuant to notice, a formal hearing was held in this case on May 4, 2000, 1/ in Fort Lauderdale, Florida, before Patricia Hart Malono, a duly-designated Administrative Law Judge of the Division of Administrative Hearings.
APPEARANCES
For Petitioner: Rosanna Catalano, Esquire
Agency for Health Care Administration Post Office Box 14229
Mail Stop 39
Tallahassee, Florida 32317-4229
For Respondent: Sean M. Ellsworth, Esquire
Dresnick & Ellsworth, P.A.
201 Alhambra Circle SunTrust Plaza, Suite 701
Coral, Gables, Florida 33134-5108
STATEMENT OF THE ISSUE
Whether the Respondent committed the violations set forth in the Administrative Complaint dated August 27, 1999, and, if so, the penalty which should be imposed.
PRELIMINARY STATEMENT
In an Administrative Complaint dated August 27, 1999, the Department of Health, Board of Dentistry ("Department"), charged George L. Williams, D.D.S., with incompetence or negligence for failing to meet the minimum standards of performance in diagnosis and treatment when measured against generally prevailing peer performance. Such conduct subjects a dentist to discipline pursuant to Section 466.028(1)(x), Florida Statutes (1997). The Department specifically alleged in the Administrative Complaint that Dr. Williams'
treatment of patient M.S. fell below the minimum standard of performance for the following reasons:
Improperly selected the type of implant to use on Patient M.S.
Blade implants in maxilla have a higher failure rate than root form implants.
Improperly inserted the implants such that they became loose and were above the level of their proper location.
Failed to use splints for stability of the implants.
Root canal treatment was inadequate and incomplete.
Failed to advise the patient that additional root canals should be performed before the implant surgery.
Silver point root canals are not the treatment of choice.
The prosthetic design was substandard.
The prosthetic appliances are not aesthetic, not hygenic [sic] and cause temporomandibular joint (TMJ) pain.
Failed to correct a malocclusion.
Dr. Williams timely requested a hearing involving disputed issues of material fact, and the Department transmitted the matter to the Division of Administrative Hearings for assignment of an administrative law judge. Pursuant to notice, the final hearing was held on May 4, 2000, after having been continued once on the Petitioner's motion.
On April 28, 2000, the Petitioner filed a Motion to Compel, or in the Alternative, Motion in Limine to Exclude the Direct or Indirect Use of Respondent's Testimony; the Respondent's response in opposition to the motions was filed with the undersigned at the hearing on May 4, 2000. Argument was heard on the motions at the hearing, and both the Motion to Compel and the Alternative Motion in Limine to Exclude the Direct or Indirect Use of Respondent's Testimony were denied. 2/ On
May 2, 2000, the Respondent filed a Motion to Compel Answers to Interrogatories; the Petitioner filed its Response to Respondent's Motion to Compel in which it provided the information that was the subject of the motion to compel. The Motion to Compel Answers to Interrogatories was considered at the hearing and denied as moot.
On May 2, 2000, the Petitioner filed a Motion for Leave to Amend Pre-hearing Stipulation. Argument was heard on the motion at the hearing, and the motion was granted.
On May 4, 2000, the Petitioner filed with the undersigned a Motion in Limine to Include Additional Exhibits. Argument was heard on the motion at the hearing, and the motion was granted.
At the hearing, the Department presented the testimony of Dr. Alan Stoler, D.M.D., as a treating physician, and of
Dr. David Beverly, D.M.D., who was qualified as an expert in periodontics with an emphasis in implants. Petitioner's Exhibits 1 through 8 were offered and received into evidence. The Department renewed its motion requesting that it be permitted to present the testimony of M.S. by late-filed deposition. The original motion was denied by order dated May 1, 2000, and, after considering the physician's letter
presented by the Department at the hearing and the arguments of counsel, the renewed motion was denied.
Dr. Williams testified in his own behalf and presented the testimony of Dr. Charles Weiss, an expert witness, by videotape and transcript of a deposition taken by Dr. Williams.
Respondent's Exhibits 1 through 4 were offered and received into evidence. Petitioner's Rebuttal Exhibit 1, consisting of the transcript of a deposition of Dr. Weiss taken by the Department, was offered and received into evidence.
After the final hearing, Dr. Williams filed, with leave, a Motion to Strike the Opinion Testimony of Dr. Stoler. The Petitioner filed a response in opposition to the motion on
June 15, 2000. Dr. Williams's motion is based on two grounds. First, Dr. Williams argues that Dr. Stoler was offered as a treating physician and not an expert witness and that, pursuant to Section 90.701, Florida Statutes (1999), he cannot testify regarding his opinions or inferences if those opinions and inferences require special knowledge, skill, experience or training. Accordingly, Dr. Williams requests that the undersigned strike the testimony of Dr. Stoler relating to his credentials; explaining in general terms the nature of dental implants, blade implants, periodontal disease, the process of preparing a tooth, tooth alignment, and occlusion of teeth; and offering his opinion regarding whether M.S.'s teeth were properly prepared by Dr. Williams. Dr. Williams's contention that Dr. Stoler should not be permitted to testify on these matters is without merit. Treating physicians are not considered expert witnesses for purposes of discovery, yet, as fact witnesses, they necessarily provide opinion testimony with respect to the examination and evaluation of the patient. See Ryder Truck Rental, Inc., v. Perez, 715 So. 2d 289 (Fla. 3d DCA
1998); Frantz v. Golebiewski, 407 So. 2d 283 (Fla. 3d DCA 1981).
Dr. Williams's argument that he will be "severely prejudiced" if Dr. Stoler were allowed to testify as to his opinions is, likewise, without merit since Dr. Williams was on notice that Dr. Stoler would be called by the Department as
M.S.'s treating physician to testify regarding his examination, evaluation, and recommendation for treatment and since
Dr. Williams was furnished with all of Dr. Stoler's records and the transcript of a deposition given by Dr. Stoler prior to this administrative action. Accordingly, having considered the arguments presented in the motion and in the response in opposition to the motion, the Motion to Strike the Opinion Testimony of Dr. Stoler is denied.
The one-volume transcript of the proceedings was filed with the Division of Administrative Hearings on May 30, 2000. The parties timely filed proposed recommended orders, which have been carefully considered.
FINDINGS OF FACT
Based on the oral and documentary evidence presented at the final hearing and on the entire record of this proceeding, the following findings of fact are made:
The Department of Health, Board of Dentistry, is the state agency charged with regulating the practice of dentistry pursuant to Section 20.43 and Chapters 455 and 466, Florida Statutes (1997). Pursuant to the authority of
Section 20.43(3)(g), Florida Statutes (1997), the Department has contracted with the Agency for Health Care Administration to provide consumer complaint, investigative, and prosecutorial
services required by the Division of Medical Quality Assurance, councils, or boards.
Dr. Williams is, and has been at all times material to this case, a licensed dentist in the State of Florida, having been issued license number DN 0004042. Dr. Williams has been licensed for over 35 years, and he has not been the subject of any previous disciplinary action.
Dr. Williams is a board-certified general dentist and a certified and credentialed member of the American Academy of Implant Dentistry. His practice involves complex prosthetic dentistry such as dentures, crowns, bridges, and dental implants, with a strong emphasis on implants. He also does the restorative work once the implants are in place; that is, he fits the prostheses containing the "fake teeth" in the patient's mouth.
Dental implants are metal devices that are inserted into or on top of bone in the upper and lower jaws and act as anchors on which to attach a prosthetic device replacing missing teeth.
There are three major types of dental implants: plate blade implants, which are placed in the bone; root form implants, which are also placed in the bone; and subperiosteal implants, which are inserted into the gum and over the bone. Dr. Williams is a multi-modal dentist who uses all three types
of implants in his practice, and he chooses the appropriate implant based on the needs of the patient.
Dr. George Williams
Patient M.S. presented herself to Dr. Williams in August 1995 for an initial consultation about dental implants. She was in excellent general health and had a complete upper denture and a partial lower denture, with seven natural teeth remaining on the lower jaw. Dr. Williams and M.S. discussed several different options for eliminating M.S.'s need to wear dentures. The options discussed were blade implants and subperiosteal implants.
M.S. was given literature explaining the dental implant options, and she decided she wanted implants placed into bone.
Dr. Williams took panoramic radiographs to determine the general character and height of the bone, and he palpitated the bony ridge to determine the width of bone. Dr. Williams determined that blade implants would be appropriate for M.S. because the bone in her upper (maxillary) arch and lower (mandibular) arch 3/ was narrow and because the height and quality of the bone were good.
Dr. Williams advised M.S. that, if she were to choose root form implants, she would need bone grafts from her hip to provide sufficient bone to secure the implants. M.S. chose to have blade implants.
A blade implant has length and height and is very thin, like a razor. There are vents in the metal blade, and, when the implant is placed inside the bone, the bone will grow through the implant vents over a period of six to nine months and lock the implant into the bone, a process that is known as osseointegration. There are two types of blade implants, fixed- head implants and implants with screw-on heads. With implants with screw-on heads, healing caps are screwed into place over the implant heads immediately after surgery and are left in place for several months. They are then replaced with screw-on implant heads, which fit flush with the implant. It is very rare to place six implants with the heads perfectly parallel, so the screw-on heads are trimmed and shaped while the prosthesis is being fitted. If the screw-on heads are turned, loosened, or not screwed-down properly, the prosthesis will not fit properly.
On September 21, 1995, before Dr. Williams placed the blade implants in M.S.'s mouth, she signed a dental consent form in which she was advised of the risks of the procedure, including the risks of bone fracture; nasal or sinus penetration; infection; tissue discoloration; and numbness of the lip, tongue, chin, cheek, or teeth, which could last indefinitely. Dr. Williams discussed the consent form with M.S. before she signed it, and M.S. was told that there was no way to
estimate the time it would take for the bone to heal after the placement of the implants.
Dr. Williams performed the first surgical procedure on
M.S. on September 21, 1995. He placed the implants in the lower arch, the mandible, to make sure that M.S. tolerated the procedure well. Dr. Williams placed one double-post implant on the lower left side. This implant was a fixed-head implant. He intended to use the existing anterior teeth and the one posterior tooth as natural abutments for the prosthesis, and he prepared three of the lower anterior teeth to receive the prosthesis. The remaining teeth had been prepared for crowns by another dentist, and, because these teeth had been previously shaped to receive the crowns, Dr. Williams did not alter the shape of these teeth. Finally, Dr. Williams determined that endodontic treatment was necessary for only one of the remaining teeth in M.S.'s lower arch, and he did a root canal on the molar in the right posterior of M.S.'s lower arch.
Dr. Williams next saw M.S. on September 25, 1995, when he performed the surgical procedure to place the implants in M.S.'s upper arch. At that time, the tissues on M.S.'s lower arch looked normal after four days of healing, and the sutures were in place. M.S. did exhibit a "postoperative response" around the tooth on which he had performed the root canal, but such a response is not uncommon.
On September 25, 1995, Dr. Williams placed six blade implants in M.S.'s upper arch. He placed two double-post implants in the posterior areas of the upper arch and four single-post implants in the anterior area. These implants had screw-on heads, and healing caps were put on after the surgery. The surgical procedure to place the implants in M.S.'s upper arch was routine.
Dr. Williams's did not use splints to immobilize the implant heads inserted in the upper arch because he used two- stage implants in which healing caps are used for several months before the actual implant heads are screwed onto the implant. Because of this, the use of splints would have been totally inappropriate. In Dr. Williams's experience, maximum bone integration around blade implants is achieved when there is no stress placed on the implants during the healing period.
Dr. Williams next saw M.S. on September 28, 1995, for a post-operative check-up. M.S.'s mouth was healing quite well, in Dr. Williams's opinion.
Dr. Williams saw M.S. regularly over the next several months. In Dr. Williams's opinion, she progressed extraordinarily well during the post-operative period, given that she had had extensive surgery. M.S. had swelling, tenderness, and redness, which Dr. Williams considered natural
under the circumstances; the tenderness and redness of the gums diminish over time.
M.S. had no problems with the implant in her lower arch. She did, however, develop problems with the two single- post implants in the front upper arch. Dr. Williams was concerned about these implants because the bone in the area the implants were placed was very thin. Dr. Williams left these two implants in for about five months in the hope that they would integrate. Because they did not heal properly and were mobile, Dr. Williams removed them. The other implants in the upper arch healed properly.
While M.S.'s implants were healing, the prostheses were being fabricated in the technical laboratory in
Dr. Williams's office. The base of the prosthesis used with implants is metal, with holes designed to fit snugly over the implant heads to hold the bridge in place. Porcelain crowns are then constructed over the metal base. The prostheses required by M.S. were roundhouse bridges for the entire upper and lower arches; a roundhouse bridge is one solid bridge that extends the entire length of the arch. Construction of roundhouse bridges is very complex because they are quite large. In addition, because of the complexity, quite a few fittings are required to ensure that the prostheses are stable.
The lower prosthesis for M.S. was fabricated and fitted first, since the upper implants would take longer to heal than the lower implant. Dr. Williams began fitting M.S.'s lower prosthesis in late October 1995, and M.S. made several visits for fittings of the lower prosthesis between October 23, 1995, and December 18, 1995.
In a letter dated January 15, 1996, M.S. expressed her frustration that the lower prosthesis had not been fitted to her satisfaction. She identified the following concerns in the letter and stated her expectation that they would be addressed during her next appointment:
Left side remains lower than the right, still lower in the front, and a significant amount in the rear.
The rear of two front teeth have porcelain added, the others need to match.
There is a ridge of the metal frame near tooth #19 that is wider than the gum line, you can feel it with your finger, imagine how it feels to my tongue.
Gaps under both sides in rear need to fit properly, food particles are constantly wedged under the teeth.(not one single "model" shown to me displayed gaps.)
M.S. was, nonetheless, pleased with the color and general appearance of the teeth in the prosthesis.
During M.S.'s visit to his office on January 22, 1996, Dr. Williams decided to remake the metal case for the lower
prosthesis. Fittings were done during office visits on February 12, 1996, and February 23, 1996, after which there is no mention of the lower prosthesis in Dr. Williams's records.
Dr. Williams began preparations for M.S.'s upper prosthesis during an office visit April 8, 1996. During that visit, he also removed the two upper anterior single-post implants, which had concerned him because they were not healing properly. During an office visit on April 22, 1996,
Dr. Williams tried the metal framework for the upper prosthesis; he was not pleased with the fit and decided to recast the framework. During an office visit on May 16, 1996, the upper prosthesis was fixed in M.S.'s mouth with temporary cement.
The following is noted in Dr. Williams's records of an office visit by M.S. on June 3, 1996:
Patient feels maxillary anterior interfering with speech pattern. Dr. George told patient she needs to leave space for cleaning and floss.
Implants very tender on the upper arch. Patient feels maxillary anterior are not centered. Dr. George said that is the way things fall with no teeth.
Dr. Williams decided to make changes in the upper prosthesis, and he arranged an appointment for M.S. on the following day, June 4, 1996, for a fitting of the prosthesis.
During the June 4, 1996, office visit, Dr. Williams replaced the upper prosthesis in M.S.'s mouth. It was noted in his office records that
patient still feels saliva & air
to [sic] much space - still efecting [sic] speech.
Dr. Williams made additional modifications to the upper prosthesis during the June 4 visit, and he fixed the prosthesis in M.S.'s mouth with a soft temporary cement.
M.S.'s June 4, 1996, office visit was the last visit she made to Dr. Williams. Because she did not return to his office for further fittings, Dr. Williams did not complete the adjustments to M.S.'s prostheses necessary to ensure a proper fit or fix the prostheses in place permanently. If a prosthesis of the type Dr. Williams prepared for M.S.'s upper arch is not permanently placed and is removed from the mouth, the screw-on implant heads can loosen. If the implant heads are not screwed back on properly, there will either be a gap between the implant and the head or the parallelism of the heads will be altered.
If either of these things happens, the prosthesis will not fit properly.
When she left Dr. Williams's care, M.S.'s implants were not loose, and, in Dr. Williams's opinion, were properly placed into the bone. Dr. Williams was very concerned that he had not been able to complete the fitting of M.S.'s prostheses,
including the correction of any malocclusion that might exist. It is always necessary to correct the occlusion when fitting prostheses. Correcting a malocclusion is a simple matter of grinding down the porcelain crowns until the teeth meet properly.
On June 6, 1996, M.S. consulted Dr. Loui Franke, a periodontist practicing in Key West, where M.S. resided. In her examination, Dr. Franke noted that M.S. had firm pink tissues on the maxillary arch and mild to moderate inflammation associated with the natural teeth on the mandibular arch. She observed that probing depths "averaged 1mm to 3mm on the mandibular arch and 2mm to 5mm on the maxillary arch." Dr. Franke also noted that, from the radiograph she took on June 6, 1996, there appeared to be bone loss in the two single-post implants in the maxillary arch and that there was an open margin on the crown of the molar in the mandibular arch.
Dr. Franke referred M.S. to Dr. Alan Stoler, whose practice is limited to implantology. Dr. Stoler does not do restorative work fitting the prostheses that are attached to the implant heads.
Dr. Alan Stoler
Dr. Stoler saw M.S. on July 12, 1996, and again on September 27, 1996; he did an extensive examination of M.S. on July 12, 1996. He observed that M.S. was very emotional and
unhappy with the treatment she had received from Dr. Williams and complained specifically that the prostheses kept coming loose and that she had difficulty maintaining oral hygiene.
Dr. Stoler conducted a clinical examination of M.S., and he took several photographs of M.S.'s upper and lower arches, without the prostheses, which revealed the implant heads and the existing teeth in the lower arch.
When he examined M.S., Dr. Stoler noted that the upper prosthesis did not fit and "literally fell out into my hands." The abutment heads screwed into the implants in the upper arch were loose, and two of the heads did not screw down all the way. Dr. Stoler observed that the implant heads in M.S.'s upper arch were not parallel but were tending outward on both the right and left sides of the arch. It appeared to Dr. Stoler that the implant heads for the right side had been screwed into the implants on the left side, and vice versa. Dr. Stoler probed around the implant heads and found that the probing depth was eight to ten millimeters.
When Dr. Stoler inserted the upper prosthesis into M.S.'s mouth, he observed that two of the crowns in the upper arch did not fit properly on the implant heads, so that the top of the head was visible and a probe could be inserted between the crown and the implant head. He observed that another crown in the upper prosthesis overlapped the gum tissue.
Dr. Stoler consulted the radiographs of M.S.'s mouth taken by Dr. Franke on June 6, 1996, and determined that the back corner of one of the double-post implants was not inserted completely into the bone of the upper arch.
Dr. Stoler easily removed the lower prosthesis with his fingers. He observed that the tissue surrounding the six teeth M.S. had remaining in the anterior portion of the lower arch was red and inflamed. He also observed that the teeth had been prepared in a conical shape rather than in a reasonably parallel shape with flat tops.
Dr. Stoler questioned whether the root canal in the molar in the posterior of the right lower arch had been completed properly. He referred M.S. to an endodontist, who submitted a report indicating that the root canal in the molar should be retreated and that five of the remaining six teeth should be treated endodontically before any restorative work was done. The endodontist, Dr. Dennis Neilson, did not offer any basis for his recommendations in his report.
Dr. Stoler found that the crown in the right posterior of M.S.'s lower arch was significantly higher than the rest of the crowns in the prosthesis, causing malocclusion. Occlusion is the term used to describe the manner in which the teeth in the upper and lower jaws meet when they come together in various positions. Malocclusion refers to the misalignment of the teeth
so that the teeth do not come together properly when the jaws are closed. Dr. Stoler also observed that the crown in the prosthesis did not fit the prepared tooth so that there was no retention. As a result, Dr. Stoler expected that there would be recurrent decay, failure, and loss of the whole tooth.
Dr. Stoler concluded that M.S. had failing implants and failing prosthetics. He advised M.S. that she had three options. The first option was to leave everything alone. He explained that, if she chose this option,
[t]he bone destruction would be rampant. She would loose [sic] most of the bone of her upper jaw and when it did fail in the
near future we would have a massive surgical reconstruction of her maxilla to bring her back to some degree of reasonable function and aesthetics. The longer she waited the more bone destruction would go on making the problem worse and worse the longer she waited. 4/
Dr. Stoler's prognosis for M.S. with the option was poor.
that
The second option Dr. Stoler presented to M.S. was
we could go in there and try to save some of the implants by cutting the bad parts out and trying to save what was left. Getting rid of the infection but trying to save as many or all of the implants as possible and then rebuilding her new prosthesis. 5/
Dr. Stoler's prognosis for M.S. with the option was poor to fair.
The third option Dr. Stoler presented to M.S. and the option he considered to be the best treatment plan
was to remove the failing implants, reconstruct her upper jaw with grafting of bone to rebuild her upper jaw, place new implants in and a new prosthetic reconstruction both of the upper and lower arches. 6/
As part of this third treatment plan, Dr. Stoler also intended to refer M.S. to an endodontist for endodontic therapy on the natural teeth in M.S.'s lower arch. Dr. Stoler's prognosis for
M.S. with the option was fair to good.
In Dr. Stoler's opinion, "if her [M.S.'s] problem is not corrected now, a total disaster might occur in the near future. 7/
M.S. never received treatment from Dr. Stoler, and, at the time of the hearing, continued to wear Dr. Williams's implants and prosthesis. 8/
Dr. David Beverly
Dr. David Beverly is a dentist practicing in North Florida, who testified for the Department as an expert in periodontics, with an emphasis in implants. Dr. Beverly has practiced dentistry for 35 years, and he placed one blade implant in the year prior to the final hearing; 99.9 percent of his practice is devoted to placement of root form implants,
which he prefers over blade implants. In his career, Dr. Beverly has placed between 15 and 20 blade implants.
Dr. Beverly did not examine M.S. but based his opinions on his review of the Department's investigative report; Dr. Williams's treatment files; copies of radiographs; a letter written to Dr. Williams by M.S.; and the reports of M.S.'s treating physicians, including the report of Dr. Stoler and the photographs Dr. Stoler took of M.S.'s mouth during her office visit on July 12, 1996. Dr. Beverly first reviewed the file regarding M.S.'s complaint in April 1998.
Dr. Beverly found that there was no indication in the materials he considered that Dr. Williams used the same pre- operative procedures that Dr. Beverly used in his practice, such as preparing a dental mold or radiographs with BB's affixed to the gum to show the exact placement of the implants.
Dr. Beverly agreed with Dr. Stoler's assessment that Dr. Williams "over-prepared" the teeth in M.S.'s lower arch, so that there would be very little retention for the prosthesis. He did not, however, have any criticism of the implants in the mandibular arch.
Dr. Beverly concluded that the post-operative radiograph taken by Dr. Williams on September 25, 1995, showed a "big dark area around the blade" inserted in the left upper arch that Dr. Beverly attributed to a lack of bone, leading
Dr. Beverly to conclude further that Dr. Williams ground away the bone when he inserted the implant. 9/ This dark area was not, however, identified by Dr. Stoler in his exhaustive examination of the radiographs taken of M.S.'s upper arch.
Dr. Beverly also testified that it appeared from the post-operative radiograph taken by Dr. Williams on September 25, 1995, that the two single-post blade implant inserted into M.S.'s right and left anterior upper arch appeared to overlap the double-post blade implant inserted on the right and left sides of the upper arch, although he admitted that the appearance of an overlap could have been the result of a shift in the machine. 10/ Dr. Beverly found that the single-post implant in the left upper arch appeared to have "little, if any, bone support around it," 11/ finding that was not supported by Dr. Stoler's examination and evaluation. Dr. Beverly found nothing of concern in the radiograph of the other single-post implant. 12/
Dr. Beverly testified that the single-post implant in M.S.'s right anterior upper arch
appears to penetrate the sinus.
Q. How can you tell that from this radiograph?
A. Well, I can't, but that's what I said, given the parameters. This is a two dimensional view of a three dimensional situation, but it's overlapping the
radiolucent areas of the sinus. It could be in front of it. It could be behind it or it could be in it. 13/
Dr. Beverly is not convinced that blade implants belong in the upper jaw, and he would not have used a blade implant in the maxilla of this patient. He based this conclusion on training he received from Dr. Don Masters in a series of seminars he attended in 1984, before he placed his first implant, and on his experience that "the maxillary bone quality is never strong enough to support the forces of mastication with a thin blade implant." 14/ Dr. Beverly based his opinion that the use of blade implants for M.S. was "questionable" on unspecified "literature that can support a higher failure rate in the maxilla." 15/
In Dr. Beverly's opinion,
it is okay for a blade implant to get just slightly mobile because they are able
to survive with a fibro-osseous integration as opposed to a root form implant that cannot and must have only osseous integration. . . . A detectable mobility on a blade implant with a healthy gingival cuff, no bleeding, no exudate, no pain, I don't think would be a problem. In fact, I know it's not a problem. Mobility that creates discomfort every time the patient closes their mouth, exudate, pus, if you will, that would be coming from the neck of the implant every time it's pushed upon or probed with a periodontal probe, plastic probe, that's an indication of implant failure. The shear [sic] fact that there is a detectable mobility on a blade implant doesn't spell failure. 16/
According to Dr. Beverly, an implant can be stabilized by splinting, and he noted that, even though the implants were splinted at the time Dr. Williams fixed the prostheses into place, Dr. Williams failed to splint the blade implants when they were first inserted. In Dr. Beverly's opinion, the failure to splint blade implants at the time they are placed "is going to potentially move the implants, so that they never have a chance to totally osseointegrate if there is any mobility in them during the healing period." 17/ Dr. Beverly stated that he
would have thought that splints should have been placed immediately to support blade implants in the maxilla, yes. My understanding in talking, in the past, long before this ever came up, in the early implant seminars that I attended that in full arch cases, if one was to choose to do blades, which weren't the treatment of choice anyway, but if one were to choose to do that, that they should be splinted for immediate primary stability. 18/
Dr. Beverly found that tooth number 32, which is the last molar on the lower right arch, appeared to be high, with a mesial tilt. In Dr. Beverly's opinion, this would cause malocclusion and, potentially, lead to temporomandibular joint syndrome; that is, pain in the temporomandibular joint.
Dr. Beverly also testified that Dr. Williams used silver points to fill the root cavity when he performed the root canal by Dr. Williams on the molar in M.S.'s posterior lower
right arch and that the placement of the silver points was not normal. Although Dr. Beverly often examines radiographs showing root canals, he has not practiced endodontics since 1975.
Dr. Beverly concluded from looking at the radiographs taken by Dr. Franke on June 6, 1996, that the prostheses looked "terribly unhygienic" because there was no evidence of embrasure spaces, which are the spaces between the teeth, that would allow
M.S. to pass floss between her teeth.
Dr. Beverly concluded on the basis of the radiographs taken by Dr. Franke on June 6, 1996, that the double-post blade implant in M.S.'s right posterior upper arch was not completely submerged in the bone, so that bone was not covering the neck of the second head of the implant.
Dr. Beverly found that, based on the radiographs, the prostheses Dr. Williams made for M.S. were "very unaesthetic and unhygienic," and he concluded that the prosthetic design was not adequate "from that standpoint. 19/
Dr. Beverly stated that, in his opinion, Dr. Williams practiced dentistry below the standard of care. He also testified that Dr. Williams's examination and protocol in M.S.'s case were good and that the implants were inserted properly, as a matter of surgical technique.
Dr. Charles M. Weiss
Dr. Charles M. Weiss, a dentist in general practice with a focus on implantology and restoration of implant cases, examined M.S. on February 27, 1998, on behalf of Dr. Williams. Between 30 and 40 percent of Dr. Weiss's practice is devoted to inserting implants and doing the corresponding restorative work of fabricating and fitting the prostheses which are affixed to the implants.
Dr. Weiss observed that M.S. was "a well-groomed, friendly, loquacious, lovely, intelligent, active young woman. She was at all times alert, without negative attitude and fully responsive to the requirements of the examination." 20/
Dr. Weiss examined M.S. with regard to her appearance, her speech, M.S.'s comfort level with the prostheses, and her ability to chew and enjoy food. He also examined her to determine if she had any infection.
Dr. Weiss observed that M.S.'s features were symmetrical and that she had a pleasant appearance and appealing smile. Her teeth appeared very realistic, and her smile line was compatible with her lips.
Dr. Weiss observed that M.S.'s speech patterns were excellent, and the vowels and consonants were clear. He did not notice any lisp, slurring, or salivary spray. M.S. talked at a normal and rapid rate without conscious effort. M.S. admitted to Dr. Weiss that she had had a great deal of difficulty with
speech initially and that it had taken her a long time to adjust her speech. This is to be expected when a patient goes from a removable full upper denture, where the palate is completely covered with plastic, to a fixed roundhouse bridge with a normal open palate.
Dr. Weiss examined M.S.'s comfort level with her implants and prostheses by observing her appearance, by using a depth probe to determine if there were any pockets in the gums, and by digitally manipulating the prostheses. His examination revealed no abnormality in the temporomandibular joint, and M.S. did not exhibit or report any pain during Dr. Weiss's manipulation of her jaw. He did not observe any malocclusion.
Dr. Weiss's examination revealed no abnormality in the molar in the posterior of M.S.'s right lower arch, on which
Dr. Williams did a root canal. He probed the gum around the tooth and found that the pocket was within normal range; there was no bleeding, swelling, or inflammation around the tooth. He pressed hard on the tooth and did not observe any movement or any evidence that M.S. experienced pain. He also inserted a probe into the gum alongside the root of the tooth and found no tenderness or any evidence that M.S. experienced pain.
Dr. Weiss took radiographs of the three mandibular incisors that Dr. Williams had prepared for the prosthesis and determined that there was no problem with the teeth. Had the
teeth needed root canal therapy at the time the implants were inserted, Dr. Weiss would have expected to see tenderness or mobility two-and-one-half years after the root canal was performed.
Dr. Weiss also examined M.S.'s maxillary implants.
M.S. exhibited no pain or discomfort when she bit down and clenched her teeth or when she moved her teeth forward and side- to-side or when she ground her teeth together. The maxillary fixed bridge was completely immobile and functioned as it was intended to function. M.S. told Dr. Weiss that, shortly before he examined her, the prosthesis had been removed by another dentist, who had manipulated the implants themselves and found that there was movement.
Dr. Weiss accepted the findings of the other dentist that the individual implants moved. He agreed with Dr. Beverly that there was no problem with the implants even though they had some mobility when manipulated. The implants inserted by
Dr. Williams were not intended to be rigid to succeed. They were fibro-osseointegrated; that is, they were integrated in the bone in the same way that natural teeth are. Some movement of the implants is to be expected, although the range of movement decreases over time. The important thing, in Dr. Weiss's opinion, was that the prosthesis itself was immobile and functioned as it was intended to do.
Dr. Weiss observed that M.S.'s mouth was very clean and hygienic. The gingiva was pink, and there was no bleeding or tenderness to pressure or probing. He found no infection, purulence, or inflammation anywhere in M.S.'s oral cavity. Finally, M.S. told Dr. Weiss that she ate a well-rounded diet in comfort.
In Dr. Weiss's opinion, the type of implant used by Dr. Williams was appropriate, although he could have made another choice. Although there is a slightly higher failure rate for blade implants inserted in the maxillary arch than for blade implants inserted into the mandibular arch or for root form implants inserted in the maxillary arch, the use of blade implants in the maxillary arch is accepted by the American Association of Dentistry. Dr. Weiss often uses blade implants successfully in the maxillary arch.
Dr. Weiss's clinical examination and study of the radiographs he took that day revealed no infection, no abnormal bone loss, no inflammation, and no bleeding; M.S. had normal peri-implant ligaments. He considered this an ideal result. In his opinion, Dr. Williams's treatment of M.S. was within the acceptable standard of care.
Dr. Beverly received a copy of Dr. Weiss's report and of the transcript of his deposition in early September 1998. He reviewed these materials and found no reason to change his
opinion that Dr. Williams practiced dentistry "below the standard of care."
Summary
The evidence presented by the Department is not sufficient to establish with the requisite degree of certainty that Dr. Williams fell below the minimum standards of care on the ground that he "[i]mproperly selected the type of implant to use on M.S." The only testimony to this effect was that of
Dr. Beverly, who stated that, based on the training he received in 1984 and on his own experience, he was not convinced that blade implants should be used in the upper jaw because the maxillary bone is not as dense as the mandibular bone.
Dr. Beverly's experience with blade implants is very limited because virtually 100 percent of the implants he inserts are root form implants. Dr. Stoler did not mention the choice of blade implants in his testimony, and Dr. Weiss agreed with Dr. Williams that blade implants, while not the only choice, were a good choice for M.S.
The evidence presented by the Department is sufficient to establish with the requisite degree of certainty that "[b]lade implants in maxilla have a higher failure rate than root form implants." This evidence is not, however, sufficient to establish that Dr. Williams fell below the minimum standards of care by choosing to insert blade implants in M.S.'s maxillary
arch. Indeed, the uncontradicted testimony of Dr. Weiss establishes that the use of blade implants is approved by the American Dental Association, and Dr. Weiss routinely and successfully inserts blade implants in the maxilla.
The evidence presented by the Department is not sufficient to establish with the requisite degree of certainty that Dr. Williams fell below the minimum standards of care on the ground that he "[i]mproperly inserted the implants such that they became loose and were above the level of their proper location." In fact, although Dr. Weiss did not challenge the assertion by M.S. that another dentist had determined that the implants moved, the Department presented no evidence to establish that the implants inserted in M.S.'s mouth were "loose." In addition, the testimony of Dr. Weiss and
Dr. Beverly established that mobility in blade implants is not a problem as long as the prosthesis is immobile and functional when it was properly affixed to the implants. There was no evidence presented by the Department to establish that the implants were "above the level of their proper location."
The evidence presented by the Department is not sufficient to establish with the requisite degree of certainty that Dr. Williams fell below the minimum standards of care on the ground that he "[f]ailed to use splints for the stability of the implants." Dr. Beverly's opinion that Dr. Williams should
have splinted the implants immediately after they were surgically inserted into M.S.'s mouth is based on the information Dr. Beverly received "in the early implant seminars" that he attended. There is no evidence to establish that
Dr. Beverly was aware that the implants used by Dr. Williams were two-stage implants, in which healing caps were used during the first months after surgery to allow the implants to heal and be integrated into the bone without stress being placed on the implants themselves. In addition, as noted above, there was insufficient evidence to establish the implants were "loose."
The evidence presented by the Department is not sufficient to establish with the requisite degree of certainty that Dr. Williams fell below the minimum standards of care on the grounds that "[r]oot canal treatment was inadequate and incomplete"; that he "[f]ailed to advise the patient that additional root canals should be performed before the implant surgery"; and that "[s]ilver point root canals are not the treatment of choice." Dr. Stoler does not practice endodontics, but he was concerned that the root canal done by Dr. Williams in the molar in the posterior right lower arch had not been done properly, so he referred M.S. to an endodontist. The only evidence submitted by the Department from a practicing endodontist consists of nothing more than Dr. Neilson's unsubstantiated conclusion that all but one of the natural teeth
in M.S.'s lower arch need to be treated endodontically. Dr. Beverly, who has not practiced endodontics since 1975,
testified only that the silver points in the root cavity were "squiggly" and not straight or gently curved as in a normal root canal. Dr. Weiss observed that M.S. had no problem with the teeth in the lower arch when he examined her in September 1998, three years after the root canal was performed by Dr. Williams, and Dr. Weiss specifically found that the molar in question was totally asymptomatic when he examined M.S. There was no evidence presented to establish that the use of silver points in root canals is improper; rather, Dr. Weiss uncontradicted testimony establishes that the use of silver points is approved by the American Dental Association.
The evidence presented by the Department is not sufficient to establish with the requisite degree of certainty that Dr. Williams fell below the minimum standards of care on the ground that "[t]he prosthetic design was substandard." First, this allegation is extraordinarily vague, and there was no evidence describing a "standard" prosthetic design and comparing the design of the prostheses Dr. Williams prepared for
M.S. with a prosthesis of the "standard" design. To the extent that this allegation refers to the fitting anomalies identified by Dr. Stoler, the evidence establishes that M.S. left
Dr. Williams's care at a time when he had just begun the process
of fitting and adjusting the prosthesis in the upper arch. Accordingly, Dr. Williams never had the opportunity to finish the prosthesis and affix it permanently in M.S.'s mouth.
Additionally, because the prosthesis was affixed with only temporary cement, it probably loosened and could have been removed subsequent to M.S.'s last visit to Dr. Williams; the screw-on heads for the implant could well have loosened or the heads could have been removed entirely and then screwed on again, causing the prosthesis to fit poorly and expose the implant heads. Nonetheless, in September 1998, Dr. Weiss observed that the prostheses in M.S.'s mouth fit well, with no gaps, and Dr. Beverly testified that he did not find any problem with the prosthesis Dr. Williams prepared for M.S.'s lower arch.
The evidence presented by the Department is not sufficient to establish with the requisite degree of certainty that Dr. Williams fell below the minimum standards of care on the ground that "[t]he prosthetic appliances are not aesthetic, not hygenic [sic] and cause temporomandibular joint (TMJ) pain." First, there is no evidence that M.S. ever experienced temporomandibular joint pain; Dr. Stoler testified only that there was the potential for such pain if the malocclusion he identified in the posterior lower right arch were not corrected. In fact, in September 1998, Dr. Weiss concluded on the basis of extensive physical manipulation of M.S.'s jaw that she did not
experience temporomandibular joint pain. Likewise, in September 1998, Dr. Weiss observed that M.S.'s mouth was very
clean and that the gums were normal, with no sign of bleeding or tenderness. Dr. Beverly's conclusion that the prostheses were "unaesthetic" was based solely on his review of the radiographs taken by Dr. Franke on June 6, 1996, because he did not examine
M.S. On the other hand, Dr. Weiss found from his examination of
M.S. in September 1998 that the prostheses were very attractive and natural-looking and that M.S.'s features were symmetrical.
The evidence presented by the Department is not sufficient to establish with the requisite degree of certainty that Dr. Williams fell below the minimum standards of care on the ground that he "[f]ailed to correct a malocclusion."
Dr. Stoler observed a malocclusion caused by the elevation of the crown on the molar in the posterior lower arch of the prosthesis. Because Dr. Williams was not given the opportunity to complete fitting M.S.'s prostheses, it cannot be inferred that he would have failed to correct the malocclusion had he completed the fitting and adjustment of M.S.'s prostheses. In addition, Dr. Weiss did not notice any malocclusion during his examination of M.S. in September 1998.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter of this proceeding and of
the parties thereto pursuant to Sections 120.569 and 120.57(1), Florida Statutes (1999).
In its Administrative Complaint, the Department seeks to impose penalties against Dr. Williams that include suspension or revocation of his license to practice dentistry and/or the imposition of an administrative fine. Therefore, the Department has the burden of proving by clear and convincing evidence that Dr. Williams committed the violations alleged in the Administrative Complaint. See Department of Banking and Finance, Division of Securities and Investor Protection v. Osborne Stern and Co., 670 So. 2d 932 (Fla. 1996); and Ferris v. Turlington, 510 So. 2d 292 (Fla. 1987). See also Nair v.
Department of Business and Professional Regulation, Board of Medicine, 654 So. 2d 205, 206-07 (Fla. 1st DCA 1995)("[t]he revocation or suspension of a professional license is of sufficient gravity and magnitude to warrant a standard of proof greater than a mere preponderance of the evidence. The
correct standard for revocation or suspension of a professional license is that the evidence must be clear an convincing.").
In Evans Packing Co. v. Department of Agriculture and Consumer Services, 550 So. 2d 112, 116, n. 5 (Fla. 1st DCA 1989), the court explained:
[C]lear and convincing evidence requires that the evidence must be found to be credible; the facts to which the witnesses
testify must be distinctly remembered; the evidence must be precise and explicit and the witnesses must be lacking in confusion as to the facts in issue. The evidence must be of such weight that it produces in the mind of the trier of fact the firm belief of conviction, without hesitancy, as to the truth of the allegations sought to be established. Slomowitz v. Walker, 429 So.
2d 797, 800 (Fla. 4th DCA 1983).
In the Administrative Complaint filed by the Department against Dr. Williams, the Department charged that Dr. Williams violated Section 466.028(1)(x), Florida Statutes. Section 466.028, Florida Statutes (1997), provides in pertinent part:
The following acts shall constitute grounds for which the disciplinary actions specified in subsection (2) may be taken:
* * *
(x) Being guilty of incompetence or negligence by failing to meet the minimum standards of performance in diagnosis and treatment when measured against generally prevailing peer performance, including, but not limited to, the undertaking of diagnosis and treatment for which the dentist is not qualified by training or experience or being guilty of dental malpractice. . . .
* * *
When the board [of dentistry] finds any applicant or licensee guilty of any of the grounds set forth in subsection (1), it may enter an order imposing one or more of the following penalties:
Denial of an application for licensure.
Revocation or suspension of a license.
Imposition of an administrative fine not to exceed $3,000 for each count or separate offense.
Issuance of a reprimand.
Placement of the licensee on probation for a period of time and subject to such conditions as the board may specify, including requiring the licensee to attend continuing education courses or demonstrate competency through a written or practical examination or to work under the supervision of another licensee.
Restricting the authorized scope of practice.
The Department specifically identified in the Administrative Complaint the factual allegations upon which it relied to establish that Dr. Williams fell below the minimum standard of performance, as follows:
Improperly selected the type of implant to use on Patient M.S.
Blade implants in maxilla have a higher failure rate than root form implants.
Improperly inserted the implants such that they became loose and were above the level of their proper location.
Failed to use splints for stability of the implants.
Root canal treatment was inadequate and incomplete.
Failed to advise the patient that additional root canals should be performed before the implant surgery.
Silver point root canals are not the treatment of choice.
The prosthetic design was substandard.
The prosthetic appliances are not aesthetic, not hygenic [sic] and cause temporomandibular joint (TMJ) pain.
Failed to correct a malocclusion.
Based on the findings of fact herein, the Department has failed to prove by clear and convincing evidence that Dr. Williams failed to meet the minimum standards of performance in diagnosis
and treatment of M.S. with respect to the allegations contained in the Administrative Complaint.
In its Proposed Recommended Order, the Department identified several additional bases for finding that
Dr. Williams practiced below the minimum standards of performance in his diagnosis and treatment of M.S., citing "bad alignment," "implant heads not properly screwed in," and "sinus perforation." Even if the evidence presented by the Department was sufficient to establish that Dr. Williams committed these errors in his diagnosis and treatment of M.S., such errors could not form the basis for discipline in this case because
Dr. Williams can only be found guilty of having committed the violations alleged in the Administrative Complaint. See Marcelin v. Department of Business and Professional Regulation, Construction Industry Licensing Board, 753 So. 2d 745 (Fla. 3d
DCA 2000)(Violations found by the Administrative Law Judge stricken because they were outside the administrative complaint.); Cottrill v. Department of Insurance, 685 So. 2d 1371 (Fla. 1st DCA 1996)(Even though an Administrative Complaint contains reference to a particular statutory violation, facts or conduct warranting disciplinary action must be alleged in the Administrative Complaint; fact that evidence was introduced that "might well support a violation" does not provide basis for finding violation when the facts or conduct are not pled in the
Administrative Complaint.); and Sternberg v. Department of
Professional Regulation, Board of Medical Examiners, 465 So. 2d 1324, 1325 (Fla. 1st DCA 1985). Cf. Maddox v. Department of Professional Regulation, 592 So. 2d 717, 720 (Fla. 1st DCA 1991)(Administrative Complaint contained sufficient allegations of the specific behavior and criteria charged to support violation.)
Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Board of Dentistry enter a final order dismissing the Administrative Complaint against
Dr. George L. Williams.
DONE AND ENTERED this 30th day of June, 2000, in Tallahassee, Leon County, Florida.
PATRICIA HART MALONO
Administrative Law Judge
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-3060
(850) 488-9675 SUNCOM 278-9675
Fax Filing (850) 921-6847 www.doah.state.fl.us
Filed with the Clerk of the Division of Administrative Hearings this 30th day of June, 2000.
ENDNOTES
1 The cover page of the transcript of the proceeding filed with the Division of Administrative Hearings incorrectly identifies the date of the hearing as May 5, 2000. The cover page of the transcript also erroneously states that the hearing commenced at 11:15 a.m.; the hearing was actually commenced at 9:00 a.m.
2/ Extensive argument was heard on several motions at the hearing, prior to the presentation of evidence. The transcript of the proceeding filed with the Division of Administrative Hearings does not include the argument and rulings on these motions, but includes only that portion of the hearing in which evidence was presented. The rulings on the motions heard at the hearing are memorialized herein.
3/ These terms will be used interchangeably in this order.
4/ Transcript at 89. 5/ Transcript at 90. 6/ Transcript at 90.
7/ Petitioner's Exhibit 4.
8/ This fact was the subject of a stipulation by the parties, which was placed on the record during the portion of the hearing that is not contained in the transcript of the proceeding. The stipulation is, however, contained in the notes taken by the undersigned during the hearing.
9/ Transcript at 120.
Transcript | at | 125. |
Transcript | at | 123. |
Transcript | at | 127. |
Transcript | at | 127. |
Transcript | at | 102, 128. |
Transcript | at | 107. |
Transcript | at | 130-31. |
10/
11/
12/
13/
14/
15/
16/
17/ Transcript at 148. 18/ Transcript at 149. 19/ Transcript at 147.
20/ Transcript of Dr. Weiss's deposition at 22.
COPIES FURNISHED:
Rosanna Catalano, Esquire
Agency for Health Care Administration Post Office Box 14229
Mail Stop 39
Tallahassee, Florida 32317-4229
Sean M. Ellsworth, Esquire Dresnick & Ellsworth, P.A.
201 Alhambra Circle SunTrust Plaza, Suite 701
Coral Gables, Florida 33134-5108
Angela T. Hall, Agency Clerk Department of Health
4052 Bald Cypress Way Bin A00
Tallahassee, Florida 32399-1701
William W. Large, General Counsel Department of Health
4052 Bald Cypress Way Bin A00
Tallahassee, Florida 32399-1701
William H. Buckhalt, Executive Director Board of Dentistry
Department of Health 4052 Bald Cypress Way
Tallahassee, Florida 32399-1701
NOTICE OF RIGHT TO SUBMIT EXCEPTIONS
All parties have the right to submit written exceptions within
15 days from the date of this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the Final Order in this case.
| Issue Date | Proceedings |
|---|---|
| Nov. 30, 2000 | Final Order filed. |
| Jun. 30, 2000 | Recommended Order sent out. CASE CLOSED. Hearing held May 4, 2000. |
| Jun. 15, 2000 | Petitioner`s Response to Respondent`s Motion to Strike the Opinion Testimony of Dr. Stoler (filed via facsimile). |
| Jun. 09, 2000 | Motion to Strike the Opinion Testimony of Dr. Stoler filed. |
| Jun. 09, 2000 | Dr. Williams` Proposed Recommended Order filed. |
| Jun. 09, 2000 | Petitioner`s Proposed Recommended Order filed. |
| May 30, 2000 | Transcript filed. |
| May 08, 2000 | Dr. Williams` Response to Petitioner`s Motion to Compel, or in Alternative Motion in Limine to Exclude the Direct or Indirect Use of Respondent`s Testimony filed. |
| May 04, 2000 | CASE STATUS: Hearing Held. |
| May 04, 2000 | Motion in Limine to Include Additional Exhibits at Final Hearing, Petitioner`s Fifth Supplemental Response to Respondent`s Request to Produce,Motion for Leave to Amend Pre-Hearing Stipulation, Dr. Williams` Response to Petitioner`s Motion to Compel, or in |
| May 02, 2000 | (Petitioner) Motion for Leave to Amend Pre-Hearing Stipulation (filed via facsimile). |
| May 02, 2000 | Petitioner`s Response to Respondent`s Motion to Compel (filed via facsimile). |
| May 02, 2000 | (Respondent) Motion to Compel Answers to Interrogatoties (filed via facsimile). |
| May 01, 2000 | Petitioner`s Fourth Supplemental to Respondent`s First Request to Produce (filed via facsimile). |
| May 01, 2000 | Order Denying Motion for Leave to Late-File Deposition sent out. |
| Apr. 28, 2000 | (Petitioner) Motion to Compel, or in the Alternative, Motion in Limine to Exclude the Direct or Indirect Use of Respondent`s Testimony (filed via facsimile). |
| Apr. 25, 2000 | (R. Catalano, S. Ellsworth) Pre-Hearing Stipulation (filed via facsimile). |
| Apr. 19, 2000 | Notice of Service of Petitioner`s Answers to Respondent`s Second Set of Interrogatories (filed via facsimile). |
| Apr. 19, 2000 | (Petitioner) Motion for Leave to Late Filing of Deposition (filed via facsimile). |
| Apr. 17, 2000 | Notice of Service of Petitioner`s Third Supplemental to Respondent`s First Request to Produce (filed via facsimile). |
| Apr. 14, 2000 | (S. Ellsworth) Notice of Taking Video Deposition in Perpetuation of Testimony for Use at Formal Hearing (filed via facsimile). |
| Apr. 12, 2000 | (Petitioner) Notice of Taking Expert Telephone Deposition (filed via facsimile). |
| Mar. 30, 2000 | Notice of Service of Petitioner`s Second Supplemental to Respondent`s First Request to Produce (filed via facsimile). |
| Mar. 28, 2000 | Respondent`s Notice of Serving Second Set of Interrogatories Upon Petitioner, Department of Health (filed via facsimile). |
| Mar. 13, 2000 | Dr. Williams` Objection to Petitioner`s Request for Admissions (filed via facsimile). |
| Mar. 09, 2000 | (Petitioner) Notice of Service of Supplemental to Petitioner`s Response to Respondent`s First Request to Produce (filed via facsimile). |
| Mar. 03, 2000 | Order sent out. (Respondent`s Motion to Compel Interrogatories and Request for Production is DENIED as moot) |
| Mar. 03, 2000 | Order Granting Continuance and Re-scheduling Hearing sent out. (hearing set for May 4 and 5, 2000; 9:00 a.m.; Fort Lauderdale, FL) |
| Mar. 02, 2000 | (Respondent) Re-Notice of Taking Deposition Duces Tecum (Change of Date, Time and Location) (filed via facsimile). |
| Feb. 28, 2000 | (Petitioner) Motion for Continuance (filed via facsimile). |
| Feb. 28, 2000 | (Petitioner) Notice of Substitution of Counsel (filed via facsimile). |
| Feb. 28, 2000 | Notice of Serving Petitioner`s Request to Produce, Interrogatories, and Petitioners Request for Admissions (filed via facsimile). |
| Feb. 28, 2000 | Notice of Serving of Petitioner`s Response to Respondent`s First Set of Interrogatories; Notice of Serving of Petitioner`s Response to Respondent`s Request for Production filed. |
| Feb. 24, 2000 | Petitioner`s Response to Respondent`s Motion to Compel and Request for Production (filed via facsimile). |
| Feb. 23, 2000 | (S. Ellsworth) Motion to Compel Interrogatories and Request for Production (filed via facsimile). |
| Feb. 22, 2000 | (S. Ellsworth) Motion to Change Venue (filed via facsimile). |
| Feb. 22, 2000 | (S. Ellsworth) Notice of Taking Deposition Duces Tecum (filed via facsimile). |
| Jan. 19, 2000 | (Respondent) Request for Production; Respondent`s Notice of Serving First Set of Interrogatories Upon Petitioner, Department of Health (filed via facsimile). |
| Nov. 30, 1999 | Order of Pre-hearing Instructions sent out. |
| Nov. 30, 1999 | Notice of Hearing sent out. (hearing set for March 30, 2000; 9:00 a.m.; West Palm Beach, FL) |
| Nov. 19, 1999 | Petitioner`s Response to Initial Order (filed via facsimile). |
| Nov. 02, 1999 | Initial Order issued. |
| Oct. 27, 1999 | Notice of Appearance as Counsel, Request for Complete Investigative File and Exhibits; Request for Probable Cause Panel Transcript; Request for the Opportunity to Discuss a Consent Agreement; Alternative Request for a Formal Hearing filed. |
| Oct. 27, 1999 | Agency Referral Letter; Administrative Complaint filed. |
| Oct. 22, 1999 | Notice of Appearance as Counsel, Request for Complete Investigative File and Exhbits; Request for Probable Cause Panel Transcript; Request for the Opportunity to Discuss a Consent Agreement; Alternative Request for a Formal Hearing filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Nov. 07, 2000 | Agency Final Order | |
| Jun. 30, 2000 | Recommended Order | Department failed to prove by clear and convincing evidence that Respondent failed to meet the minimum standards of performance in the practice of dentistry. Administrative complaint should be dismissed. |
DEPARTMENT OF HEALTH, BOARD OF DENTISTRY vs TATYANA STEPANCHUK, D.M.D., 99-004549 (1999)
DEPARTMENT OF HEALTH, BOARD OF DENTISTRY vs LORYN R. MERRILL, D.D.S., 99-004549 (1999)
DEPARTMENT OF HEALTH, BOARD OF DENTISTRY vs SHERRIE LYNN CROSSEN, D.D.S., 99-004549 (1999)
DEPARTMENT OF HEALTH, BOARD OF DENTISTRY vs MARVIN ROSENBERG, D.D.S., 99-004549 (1999)
