Findings Of Fact The parties stipulated that respondent is licensed as a dentist in Florida, having license no. 3721 and that, at all material times, he was engaged in the private practice of dentistry in a dental office at 311 South Eighth Street in Fort Pierce, Florida. When her oldest daughter's tooth abscessed in 1964, Jonneaue Rout visited Dr. Brown's office for the first time. He became the Rout family dentist. Mrs. Rout and her thee children, including Karen, visited Dr. Brown regularly, sometimes more frequently than at six-month intervals. Mrs. Rout suffered several dental problems over the years, including toothaches, abscessed teeth, cavities, and sometimes fillings which fell out. She accepted every suggestion Dr. Brown made in connection with her dental health, or in connection with Karen's dental health. She and Karen brushed their teeth conscientiously. She rejected no suggestion for treatment of herself or of her daughter, Karen, on account of expense. Until 1978, Karen had visited no dentist's office but respondent's. In early 1978, Karen Rout visited Drs. Starr and Barkett, orthodontists, to whom Dr. Brown referred her. At the orthodontists' offices, an x-ray film of her mouth was made, which revealed tooth decay. Before beginning their treatment of Karen, the orthodontists referred her to Dr. Dermody, a pedodontist, who first saw Karen on April 19, 1978. The pedodontist had four additional radiographs taken and found the overall condition of her mouth to be poor. He discovered decay in eight posterior teeth, including some five teeth in which respondent had placed white fillings as recently as, in one instance, five months earlier. Shallow cavities that had formed on two upper right molars may well have postdated Karen's last visit to respondent in December of 1977. But green, soft, gross decay underneath little white fillings in lower, left molars demonstrated that significant decay was present when respondent placed the fillings, as respondent himself conceded. Respondent testified that Karen squirmed while he was trying to work on her teeth. Placing fillings in the presence of significant decay does not meet minimum standards of performance for the acceptable practice of dentistry, when measured against generally prevailing peer performance. If decayed matter is not removed before a filing is placed, the process of decay will continue and destroy more of the tooth. Moreover, decay will not hold the filling as well as enamel because it is softer than enamel. Disconcerted by her daughter's problems, Mrs. Rout sought out another general dentist for herself. She chose Dr. Strawn, who first saw her on June 30, 1978. At his instance, panoramic and bite wing x-rays were done on that date. He diagnosed periodontal disease, an inflammatory condition that may cause loss of bone tissue, and which had loosened at least one of Mrs. Rout's teeth. In accordance with his policy with respect to periodontal disease severe enough to cause erosion of supporting tissue or "pockets" deeper than four millimeters, Dr. Strawn referred Mrs. Rout to Dr. Cain, a periodontist. Periodontal disease can cause the loss of perfectly healthy teeth. Its etiology is laid to plaque, the sticky, transparent, bacteria laden, mucus film that coats the teeth. These bacteria can cause inflammation and concomitant softening of the gums which then separate from the teeth giving the bacteria deeper access. Inflammation at deeper and deeper levels can lead ultimately to loss of the bone tissue supporting the teeth. Routine cleaning of the teeth is the most important prophylactic measure against periodontal disease. Once the disease has caused erosion of supporting tissues to a depth of two or three millimeters, routine cleaning does not hinder further erosion, although stimulation from cleaning is good for the gums. When a "pocket" is four millimeters deep, some bone tissue has been lost and there is nothing a victim can do at home to extricate the accumulated plaque or calculus. By the time a "pocket" is 12 millimeters deep, the situation is not treatable. Periodontitis is diagnosed by observing the condition of the gums, measuring erosion around individual teeth with a calibrated probe, and by examining x- rays. A general dentist should be able to diagnose periodontal disease and should either treat it or refer the victim to a specialist. On July 6, 1978, Mrs. Rout first visited the periodontist. At that time, her gums were reddish blue, swollen, and slow to rebound when indented. She had moderate to advanced, generalized periodontitis. Nine teeth were severely involved, with "pockets" ranging up to 12 millimeters in depth. The periodontal disease was chronic and had been present for at least ten years. Mrs. Rout lost one tooth from periodontitis after she began visiting the periodontist and has been given a "guarded prognosis" for four or five other teeth. Dr. Brown was aware that Mrs. Rout had a periodontal problem to some extent when he first saw her, although he never made any indication on her chart of any periodontal condition. Her gums bled from time to time. He became aware that she had a degenerative bone condition, particularly in the upper left part of her mouth where he discovered a deep pocket in mid-1976. He told Mrs. Rout to use dental floss, and a water pick, to brush her teeth, and to have them cleaned regularly. Dr. Brown has never employed a dental hygienist in his office. He cleaned Mrs. Rout's teeth himself, cleaning the clinical crowns and removing all sub-gingival calculus he saw; he performed deep scaling. Dr. Brown does not consider himself an expert periodontist. He believed Mrs. Rout's financial situation was such that she could not afford a periodontist's fees, and he never referred her to a periodontist. Dr. Brown conceded that he probably did tell Mrs. Rout everything was all right on her last visit to him. In addition to the periodontal disease, however, Dr. Strawn discovered widespread decay, missing fillings, and broken- down reconstructions when he examined Mrs. Rout some two months after Dr. Brown last saw her. These conditions existed at the time of Dr. Brown's last examination. At least one filling Dr. Brown placed in Mrs. Rout's mouth (in tooth No. 28) was placed in the presence of significant decay. From about 1964 until July or August of 1979, Mavis Smith went regularly to Dr. Brown for dental care. During this period, except for one occasion in the fall of 1975, when she went to another dentist for a separate opinion, she consulted no dentist other than respondent. She visited Dr. Brown's office often, had cavities filled, teeth extracted, teeth cleaned, and on one occasion, had dental surgery. She invariably abided by Dr. Brown's recommendations and never refused any treatment because of expense. On one visit, Dr. Brown decided that root canal treatment was probably indicated for her lower right first bicuspid. He cut through the crown into the pulp chamber and found a partially viable nerve; ninety percent of the nerve was alive. He twice treated the tooth with paramonochlorophenol or Beechnut creosote, but, through oversight, never completed the root canal procedure by introducing a radiopaque solution into the cavity and sealing the cavity with a filling. In April of 1979, Dr. Brown finished capping Ms. Smith's upper right lateral, upper right central, and upper left central incisors. Later in 1979, Dr. Brown filled a cavity in Ms. Smith's lower left second bicuspid. When the filling fell out, Ms. Smithy decided that she had perhaps eaten too soon after the repair of her tooth and returned to Dr. Brown for a second reconstruction. This filling also fell out, taking a piece of enamel with it. Again, Dr. Brown filled the tooth. When the filling fell out a third time, Ms. Smith consulted another general dentist, Dr. Bancroft. Dr. Bancroft saw Ms. Smith for the first time on August 29, 1979, four weeks after Dr. Brown's third attempt at filling the lower left second bicuspid. On September 14, 1979, Dr. Bancroft removed the decay on which Dr. Brown had placed a filling on August 1, 1979, removed another filling which had been placed in the tooth by Dr. Brown on April 27, 1968, and placed one large filling in Ms. Smith's lower left second bicuspid. In examining the caps on Ms. Smith's incisors, Dr. Bancroft noticed open and overhanging margins. A half-millimeter opening separated the margin of one cap from the margin of the tooth to which it had been cemented. The crowns did not fit properly and their placement was substandard work. On September 26, 1979, Ms. Smith complained to Dr. Bancroft of pain and swelling in the vicinity of her lower right first bicuspid. She had an abscess. Although she told Dr. Bancroft that Dr. Brown had done a root canal procedure on the tooth, roentgenograms revealed that the procedure had not been completed, so Dr. Bancroft performed a root canal procedure on the tooth himself. This procedure was indicated; a pulpotomy would not have been appropriate. Dr. Brown was Kris Fisher's family dentist for ten or eleven years until in September of 1979, she, too, left him for Dr. Bancroft. During the time Dr. Brown was her family dentist, Ms. Fisher went every six months for check-ups and for dental work Dr. Brown recommended. After every visit, she asked whether she was "all right", and Dr. Brown answered affirmatively. Her last visit to Dr. Brown was for the filling of a cavity in her lower left backmost molar. Dr. Brown placed a filling which subsequently fell out. Ms. Fisher returned for replacement of the filling on June 8, 1979 but went to see Dr. Bancroft after the replacement also fell out. On September 9, 1979, Dr. Bancroft discovered a fractured mesial occlusal filling in Ms. Fisher's lower left backmost molar. The mesial portion of the filling was missing. There was extremely extensive decay in the area of the fractured part of the filling which indicated inadequate preparation for the filling and dental work which failed to come up to local and state minimally acceptable standards for the practice of dentistry. There was also decay in other areas of Ms. Fisher's mouth, requiring dental treatment in several areas; seven teeth had decay. From 1966 or 1967 until the latter part of 1978, Herbert C. Brooks relied exclusively on Dr. Brown for dental care, except for the two occasions he went to Dr. Skripak for extractions, on Dr. Brown's referral. Mr. Brooks only has five or six upper teeth, three of which are in bad shape. He has a partial upper denture and will likely soon need a complete upper denture. In the fall of 1978, Mr. Brooks went to respondent because a ten-year-old filling in a front tooth fell out. A week after Dr. Brown replaced the filling, the replacement also fell out. Mr. Brooks returned to Dr. Brown, who, on the second visit, placed a pin in the tooth to augment the filling, which was still in place at the time of the final hearing. Dr. Brown replaced another old filling for Mr. Brooks, this one in his upper right central incisor. Before he did so, Dr. Brown suggested a crown or addition to the partial plate instead of another filling but agreed with Mr. Brooks that the expense might not be warranted in view of the condition of Mr. Brooks' teeth. Dr. Brown advised Mr. Brooks that the filling might not stay. Mr. Brooks' bite is such that his lower teeth hit the backs of his upper incisors, creating considerable pressure. Three or four days after it had been put in, the replacement fell out. Dr. Brown replaced the replacement. Three or four days later, the second replacement also fell out. Mr. Brooks then sought out another general dentist, Dr. Deery. Mr. Brooks complained to Dr. Deery on November 10, 1978, of the broken filling in the upper right central incisor. Dr. Deery caused a periapical x-ray to be taken and advised Mr. Brooks that root canal treatment and a crown were in order. He found gross decay in the tooth, which decay was present at the time Dr. Brown placed the filling, and replaced after it fell out the first time. Mr. Brooks said he needed something done quickly so he could continue his work as a salesman. Dr. Deery acquiesced and placed a filling in the incisor which amounted to a half to two-thirds of the clinical crown involved. Dr. Brown had not used a pin to augment the filling, although in Dr. Deery's opinion, he should have because there was not adequate retention for the filling. Dr. Deery used two pins. Dr. Deery recommended that Mr. Brooks see a periodontist which, however, Mr. Brooks never did. While Mr. Brooks was under his care, Dr. Brown cleaned his teeth occasionally. Dr. Deery found numerous areas of decay in Mr. Brooks' mouth, in addition to generalized periodontal disease. Respondent regularly refers patients who have need of multiple root canal treatments, who need orthodontic care, and who require extraction of teeth to appropriate specialists. Dr. Skripak is the oral surgeon to whom Dr. Brown refers patients in need of oral surgery. In an average week, Dr. Skripak sees five or ten patients referred to him by Dr. Brown. Dr. Skripak has seen 2,000 different patients referred to him by Dr. Brown over the years. Unless a patient brings x-rays with him adequate for his purposes, Dr. Skripak causes x- rays to be made. In every instance, he examines x-rays. On only two or three occasions over a ten-year period did Dr. Skripak tell Dr. Brown that he felt something had been missed. Dr. Skripak averred that he would advise any referring dentist of a problem and has advised others. According to Dr. Skripak, Dr. Brown's work, in general, ranges from standard or adequate to excellent and is, in general, up to the standards obtaining in St. Lucie, Indian River, Martin, and Okeechobee Counties.
Recommendation Upon consideration of the foregoing, it is RECOMMENDED: That petitioner suspend respondent's license until he shall demonstrate his competency by passing the written and practical examinations administered to applicants for initial licensure as dentists. DONE and ENTERED this 8th day of October, 1980, in Tallahassee, Florida. COPIES FURNISHED: L. Haldane Taylor, Esquire 1902 Independent Square Jacksonville, Florida 32202 Rupert Jasen Smith, Esquire 715 Delaware Avenue Fort Pierce, Florida 33450 ROBERT T. BENTON, II Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 9th day of October, 1980.
The Issue The issue in this case is whether the Department should give the Petitioner a passing grade on the June, 1993, Board of Dentistry Clinical Examination.
Findings Of Fact The Petitioner, Jose P. Cruz, took the June, 1993, Board of Dentistry Clinical Examination. Initially, he received a grade of 2.91, whereas a grade of 3.0 is passing. He requested a review of his grades and received some additional credit, raising his grade for the examination to 2.98--still failing, but quite close to a passing grade. The examination grade is a weighted aggregate made up of scores given on each tested procedure, using a formula for weighting the scores on each procedure. The possible scores for each procedure range from zero to five, with a score of three considered "passing" for a particular procedure. Likewise, weighted aggregates can range from zero to five, with a grade of 3.00 passing. Each procedure performed by the Petitioner (and the other examinees) was graded by three graders from pool of qualified graders. The Petitioner's graders not only were qualified, but they also were "standardized." "Standardization" is a process undertaken on the day before the examination to explain to the prospective qualified graders for an examination the criteria for grading the different procedures and how the criteria should be evaluated. The purpose of "standardization" is to insure that the graders are looking at the criteria in the same way, so that ideally each grader would grade the same performance the same way. Averaging the scores given by three "standardized graders" increased the reliability of the examination results. Procedure 8 on the examination was a pin amalgam preparation on an ivorine (plastic) tooth. Criteria for the procedure include: (a) outline; (b) depth; (c) retention; (d) pin placement; and (e) mutilation of opposing adjacent teeth. Two of the three graders gave the Petitioner a score of 3 on Procedure 8; the other gave him a 2. Procedure 9 on the examination was a pin amalgam final restoration on an ivorine (plastic) tooth. Criteria for the procedure include: (a) functional anatomy - appropriate occlusal and interproximal anatomy; (b) proximal contour and contact - contact is considered present when resistance is met with specified floss given at the time of the exam; (c) margins; (d) gingival overhang - overhang is considered to be excess amalgam in either a proximal or gingival direction at the gingival cavosurface margin; and (e) ma[n]agement of soft tissue. Two of the three graders gave the Petitioner a score of 2 on Procedure 9; the other gave him a 3. An ivorine (plastic) tooth is not the same as a real tooth. It is easier to carve, but it does not have the major external and internal landmarks created by the enamel, dentin and nerve root of a real tooth. Without additional instructions, the latter differences make it difficult or impossible for the examinee or a grader to apply certain criteria. The evidence was that the examinees received an examination booklet that instructed them to "treat simulated teeth as normal human teeth, that is, assume the simulated teeth have the same enamel, dentin, and pupil morphology as human teeth." The instruction in the examination booklet, by itself, leaves some important questions unanswered. "Normal human teeth" differ in the thickness of the enamel, not only from one person to another but also from tooth to tooth within any one person's mouth and even from place to place on any one tooth. Also, the direction in which the enamel rods run in "normal human teeth" differ, depending essentially on the shape of the tooth. The direction of the enamel rods is important in determining whether enough dentin is left under the enamel rods to support the enamel. "Normal human teeth" also have fissures, i.e., little cracks and grooves, and the margins of a preparation and restoration should be extended to include fissures that cannot be eliminated by enamelplasty. But ivorine teeth do not have all the fissures normal teeth have. As a result of these difference between "normal human teeth" and the test mannequin's ivorine teeth, it still would be difficult or impossible--even with the information in the examination booklet--for an examinee or a grader to apply, with any degree of precision, the following criteria for Procedure 8: outline form; depth of preparation; and retention. In addition, as to Procedure 9, functional anatomy depends upon a tooth's interaction with its opposing and adjacent teeth, but the mannequins did not have opposing teeth. As a result, it still would be difficult or impossible--even with the information in the examination booklet--for an examinee or a grader to apply, with any degree of precision, the criterion functional anatomy for Procedure 9. Similarly, the ivorine teeth in the mannequins were cemented in place, and points were to be deducted for moving them. This made it difficult, if not impossible--even with the information in the examination booklet--for the candidates to control proximal contour and contact, which are criteria for Procedure 9. Despite the deficiencies in the information in the examination booklet, taken by itself, there also was evidence that the graders were instructed orally during standardization, and the candidates were instructed during an orientation prior to the administration of the examination, that they were to assume an "ideal, minimal preparation" and that the purpose of the examination was simply to demonstrate basic knowledge of acceptable techniques. They also were told to assume "normal" or "ideal" enamel thickness of approximately 0.5 millimeter. Given those qualifications, they were told that the preparations were to have a "normal outline form" and "normal depth." As for functional anatomy, they were told that restorations were to "set up ideal (or normal) occlusion" by making the marginal ridges even and by replacing the restoration to the "normal shape of a cusp of a tooth." As for proximal contour, a restoration's marginal ridges were to meet (i.e., match) those of the adjacent tooth. Candidates also were allowed to ask questions as part of the orientation to clarify the oral instructions, as necessary. Given the additional oral instructions, the candidates and graders were given a clear enough understanding of the examination criteria. Evaluation of the candidates' and the graders' performance by the Department's psychometrician indicated that the examination was valid and reliable. The Petitioner's performance of Procedure 8 was primarily deficient in that the outline form was 0.25 millimeter short of the lingual occlusal groove, which was clearly visible on the ivorine tooth and which should have been included within the outline form. The Petitioner did not prove that his performance of the procedure, when looked at as a whole, should have been given a passing grade. The Petitioner's performance of Procedure 9 was primarily deficient in that the restoration did not replace the "normal shape of a cusp of a tooth" and that the marginal ridges did not meet those of the adjacent tooth. The Petitioner did not prove that his performance of the procedure, when looked at as a whole, should have been given a passing grade. There was evidence that, since the examination on ivorine teeth only simulates real teeth, which are easier to carve than real teeth, and is necessarily limited to a demonstration of basic knowledge of acceptable techniques, the examination does not directly test the candidate's ability to actually practice dentistry. But, due to heightened concern for the transmission of infectious disease, including HIV, ivorine teeth have been used in dental schools and in dental clinical examinations exclusively for over ten years, and the Petitioner did not prove that the use of ivorine teeth, instead of extracted real teeth, for his examination was unreasonable.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Department of Business and Professional Regulation, Board of Dentistry, enter a final order denying the Petitioner's examination challenge. RECOMMENDED this 28th day of July, 1994, in Tallahassee, Florida. J. LAWRENCE JOHNSTON Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 28th day of July, 1994. APPENDIX TO RECOMMENDED ORDER, CASE NO. 93-6923 To comply with the requirements of Section 120.59(2), Fla. Stat. (1993), the following rulings are made on the parties' proposed findings of fact: Petitioner's Proposed Findings of Fact. 1. Accepted and incorporated. 2.-4. Accepted but subordinate and not necessary. Rejected as not proven. (The exam should not necessarily measure a person with more dental experience as receiving a higher grade.) Accepted but subordinate and not necessary. Accepted and incorporated. 8.-10. Rejected as not proven. (It would be more accurate to say that the Department's examination reviewer could neither say that the the score of 2 was erroneous or unreasonable or that a score of 3 would have been erroneous or unreasonable.) 11. Accepted and incorporated. 12.-16. Accepted but subordinate and not necessary. (As to 16, however, he reiterated his opinion that the appropriate score was a 2.) 17. Accepted and incorporated to the extent not subordinate or unnecessary. 18.-19. Accepted and incorporated. Rejected as not proven that the dentin is the "stronger material." Otherwise, accepted and incorporated. Accepted and incorporated. 22.-26. Accepted and incorporated to the extent not subordinate or unnecessary. However, as found, notwithstanding the limitations inherent in not being able to see on the ivorine tooth exactly where the enamel would end and the dentin would begin, or where the enamel rods would be, certain basic knowledge of acceptable techniques can be demonstrated on the ivorine teeth, given certain additional instructions. 27.-29. Rejected as not proven. The Petitioner's expert was not "standardized" and was not privy to what the graders were told during standardization or what the candidates were told during orientation. 30. See 22.-26. 31.-32. See 27.-29. 33. See 22.-26. Respondent's Proposed Findings of Fact. 1.-8. Accepted and incorporated to the extent not subordinate or unnecessary. 9.-10. Accepted and subordinate to facts found. 11. Rejected as contrary to the evidence that the Petitioner introduced no competent and substantial evidence in support of his challenge. COPIES FURNISHED: Salvatore A. Carpino, Esquire Colonial Square Office Park 8001 North Dale Mabry Highway Suite 301-A Tampa, Florida 33614 William M. Woodyard, Esquire Assistant General Counsel Department of Business and Professional Regulation Northwood Centre 1940 North Monroe Street Tallahassee, Florida 32399-0750 Jack McRay, Esquire Acting General Counsel Department of Business and Professional Regulation Northwood Centre 1940 North Monroe Street Tallahassee, Florida 32399-0792 William Buckhalt, Executive Director Board of Dentistry Northwood Centre 1940 North Monroe Street Tallahassee, Florida 32399-0792
Findings Of Fact The Respondent is a dentist licensed in the State of Florida, having been issued license number 0001575. The Petitioner is an agency of the State of Florida charged with regulating the standards for licensure and for practice of dentists in the State of Florida and with enforcing compliance with those licensure and practice standards contained in Chapter 466, Florida Statutes (1981). Jewel Taub is an elderly dental patient who first saw Dr. Seth Rhodes on January 28, 1980. On February 14, 1980, the Respondent took impressions of Mrs. Taub's mouth to construct a partial denture for her. On February 26, 1980, the denture was tried in the patient's mouth by Dr. Tyrone Cheeping, an associate of the Respondent. On March 4, 1980, the denture was delivered to Mrs. Taub by the Respondent and an initial adjustment performed by him, Mrs. Taub complaining that the denture palate was too thick. On April 28, 1980, the Respondent again adjusted the denture in response to Mrs. Taub's complaint that the denture or its palatal portion, was still too thick. In approximately March of 1980, the patient had stopped putting the partial denture in a container of liquid as she had been instructed by the Respondent. She began at that time to keep the partial denture in a dry envelope in her medicine chest. The patient had worn lower dentures and had been advised many times that if she did not properly care for and maintain this upper denture it could be damaged. She stopped caring for and maintaining the partial denture because she had no intention of ever wearing it again because of her dissatisfaction with its fit. Dr. Marshall Brothers, a contract dentist for the Department of Professional Regulation/Board of Dentistry, was accepted as an expert witness. He examined Jewel Taub in his office on November 25, 1981, and examined the upper partial denture in question. The theory of the design of the upper partial denture was correct because the Respondent planned that appliance to have full palatal coverage because the patient needed the additional support from the roof of her mouth and that type of denture would aid her in making a transition eventually to a full upper denture. Dr. Brothers opined that the thickness of the plate, the impingement, the openness of the bite and a lateral rock rendered the execution of the partial denture to be below community standards for manufacture and fit of such dentures. Dr. Brothers did not, in formulating this opinion, consider the passage of time during which the denture was not used by the patient and not properly cared for and was not aware whether there had been any movement in the teeth, change in size of the gums or adjacent tissue, during more than one and one-half years since the attempted adjustments. It is quite unusual that a denture should fit the first time it is tried in a patient's mouth. Thickness alone, even if a denture is too thick, does not alone render the execution of that denture below the standard of care. If a substantial period of time elapses (here in excess of one and one-half years) between the time when the denture was made and the time expert opinions are rendered regarding the fit of the denture in this patient, there can be movement in the teeth and changes in the dimensions of gums or tissue which can alter the fit of the denture. This is particularly true in the case of an 80- year-old patient. The fit of the denture can be altered for the additional reason that the patient failed to maintain the denture properly during that intervening one and one-half years between the time she quit wearing it, in approximately April of 1980, and the time expert examination and opinions regarding its fit were rendered, shortly prior to this hearing. The manufacture of the denture with a palatal portion of a thickness in excess of one and a half millimeters is not necessarily too thick and the fact that that thickness exceeds one and a half millimeters does not render the manufacture and fit of that denture a departure from the proper standards of care of the dentist who manufactures and fits it. Indeed, proper palatal thickness varies considerably from one patient to another and the prescribing of a proper palatal thickness in such a denture is not an exact science since patients' mouths and their dimensions are all different. Indeed, the Respondent prescribed and fitted dentures for a substantial number of his patients who required a palatal thickness of between 3 and 6.2 millimeters and those patients all reported satisfaction with the fit of their dentures. The material used in the denture in question is an acrylic material containing a metal reinforcing mesh. That material is manufactured and supplied to dentists such as the Respondent with a thickness slightly in excess of one and a half millimeters. That then is the minimum dimension of the palatal material which then must be built-up by the dentist in constructing an accurate fit in the palatal portion of the denture to conform to a particular patient's mouth. The slightly more than one and a half millimeter palatal material is therefore a minimum or starting point for the dentist in constructing the denture and it is practically impossible for the material to be thinner than that dimension. Indeed most of the similar dentures satisfactorily fitted by the Respondent were of a palatal thickness of between 3 and 6.2 millimeters. Thus, a palatal thickness in excess of one and a half millimeters cannot be per se excessive. The Respondent's expert witness, Dr. Gary Golden, is also a contract dentist with the Department of Professional Regulation/Board of Dentistry. He conducts a limited clinical specialty practice in prosthodontics and in maxillofacial prosthetics. He is assistant professor of orthodontics and oral surgery at the University of Miami and has conducted extensive study in his specialty area. He is the author of numerous papers and articles on the subject. One article in particular, admitted into evidence as Respondent's Exhibit 3, deals specifically with the issue of palatal size in dental prosthetics. It is not possible to merely observe a denture and determine if one and a half millimeters, the so-called "old standard" is too thick or too thin for a given patient. The partial denture in this case was outside of the patient's mouth for over one and a half years and that fact alone makes it difficult for the patient to reinsert it comfortably. This is true because of shrinkage of areas of her mouth or gums not containing teeth and the resultant movement of her remaining teeth. In an 80-year-old lady such as the complaining witness, particularly, teeth tend to "drift" because of previous extraction of teeth which the denture was designed to replace. It is quite likely that with this patient movement of her teeth occurred during the one and a half years when she did not use the denture, causing the poor fit. A patient's cooperation is quite necessary in obtaining the proper fit for such a partial denture and it is not unusual for numerous adjustments to have to be made. Here the patient quit coming to the Respondent's office for adjustments after the fourth adjustment during a short period of time after the initial fitting. After that the patient ceased cooperating with the Respondent and did not care for the denture properly by not maintaining it in a liquid environment. The lack of care by the patient, coupled with the fact that only a one-half millimeter movement of the teeth in any direction can render the fit of such a denture improper was more likely the cause of the improper fit than the initial design and manufacture of the denture and the adjustments made during the four opportunities the Respondent had to adjust the denture. When the patient complained of excessive palate thickness, the Respondent made adjustments and trimmed the thickness and the coverage of the palatal portion of the denture. After that, the patient failed to appear in his office again (for any further adjustment). Finally, the Respondent established that the interior metal mesh in the material from which the palate was construction is itself one and a half millimeters thick and thus it was impossible for the palate, including the acrylic material surrounding the mesh, to be only one and a half millimeters thick and although one and a half millimeters could possibly be too thick for some patients, it was not the case with this patient. The patient's complaint was really a generalized one regarding "all that stuff in the roof of my mouth" and in reality it was not established that the denture in question could be made successfully in any other way. In summary, Dr. Brothers could not determine whether or not there had been any movement in the teeth or change in size of the gums or adjacent tissue in the patient's mouth. The patient had not maintained the denture properly during the substantial period of time when she did not wear the denture. It is not possible to accurately determine the appropriate original fit and function of the partial denture in question at the time Dr. Brothers examined it and the patient, since it was outside the mouth of the patient for a period of one and a half years and because of possible shrinkage of edentulous areas which do not contain teeth; the extrusion and drifting of the remaining teeth (since the denture is precisely cast to the teeth and gum tissue in a certain position at a certain time); and any movement or change in the teeth or gums would make it impossible to seat the denture satisfactorily. It is to be expected that in a patient 80 years of age who had not worn a partial denture for a period of one and a half years, that at least some movement of the teeth would have occurred, altering the fit of the partial denture. Thus, it was established that the fit of the denture to the patient's mouth more than one and a half years after the Respondent initially manufactured and fitted the denture was not the same. It is quite rare that a prosthetic dental device can be manufactured and simply inserted and not require a number of adjustments. It was not established that the denture was improperly made or that it should have been remanufactured.
Recommendation Having considered the foregoing Findings of Fact, Conclusions of Law, the evidence in the record and the candor and demeanor of the witnesses, it is, RECOMMENDED: That the Respondent be found not guilty of a violation of Section 466.028(1)(y) and that the Administrative Complaint be dismissed in its entirety. DONE and ENTERED this 30th day of June, 1983, in Tallahassee, Florida. P. MICHAEL RUFF, Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 30th day of June, 1983. COPIES FURNISHED: Julie Gallagher, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Richard A. Hamar, Esquire 155 South Miami Avenue Suite 111 Miami, Florida 33130 Fred Varn, Executive Director Board of Dentistry Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Fred M. Roche, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301
The Issue The issue for consideration in this case is whether Petitioner should be awarded a passing grade on the clinical portion of the dental licensing examination given on December 12 through 14, 1996.
Findings Of Fact At all times pertinent to the issues herein, the Board of Dentistry was responsible for the licensing of dentists in this state and the regulation of the dental profession. Petitioner is a graduate of the University of Florida School of Dentistry and was eligible to sit for the examination for licensure as a dentist in Florida. Petitioner previously has taken and passed the written portion of the dental examination. He has taken the clinical portion of the examination twice and has received a failing grade each time. He is eligible to take the clinical portion alone for a third time, but must do so within a period of 13 months of taking it the second time or must take both the written and oral portions again. Dr. Scheutz first took the examination in June 1996. He received a passing grade in each of those examination portions which dealt with Florida laws and rules and with oral diagnosis. However, he received a grade of 2.31 on the clinical examination portion of the examination, and a passing grade was 3.0. Thereafter, in December 1996 he again took the clinical portion and this time received a grade of 2.71, still below the 3.0 passing grade. Dr. Theodor Simkin is a licensed dentist and consultant to the Board of Dentistry, who has been in the private practice of dentistry since 1950 and in Florida since 1975. He has been involved in the development, administration, and grading of the dental examination in Florida since 1979 and was a supervisor for the December 1996 examination. He is familiar with the standards applied in the clinical portion of the examination and how the examination is given and graded. Petitioner has challenged the grade he received on five separate procedures he performed during the December 1996 examination. The procedures chosen for accomplishment during the examination are not unusual procedures, but are common problems seen on a routine basis by a practicing dentist. Dr. Simkin reviewed the mannequin on which Petitioner did his work and which he presented to the examiners for grading. One of the grades challenged related to a "composite restoration" (Clinical D) for which Petitioner received a grade of 0. In this procedure the candidate is presented with a tooth on a mannequin. The candidate is instructed to cut off a corner of the tooth and then restore that corner with an amalgam restoration. The examiners are not present when the procedure is accomplished, but grade the procedure after completion. Instruction on the procedure is given to the candidate by a monitor who is present in the room but who does not grade the work done. The examination process is accomplished using the candidate number, not the candidate name, so that examiners do not know whose work at which they are looking. Once the procedure is done by the candidate, the mold is packed in the candidate's presence and is then held in the custody of the Board of Dentistry until examined independently by each of three examiners. Once graded, it is then shipped to Tallahassee and kept in a vault until needed, as here, for review by Dr. Simkin and others. Ordinarily, even if dropped, a model will not break. In the instant case, Petitioner performed the procedure on an upper right central incisor. The right corner of the tooth, approximately one-third of the tooth, was cut off and the candidate was instructed to rebuild it with a composite material. When the examiners evaluated Petitioner's work, they found that the filling was not bonded to the tooth and was loose. The loose restoration would be useless to the patient, whereas a properly done restoration should last for at least several years. On a human, the stresses applied to a tooth repair are significant, and the repair must be sufficient to withstand them. Notwithstanding Petitioner's claim that the tooth used was an artificial tooth to which the filling material does not easily bond, Dr. Simkin asserts that the bonding which occurs with a plastic tooth is different from that which occurs in a real tooth but the material can bond to the plastic tooth. He knows of no other complaints by other candidates at this examination of not being able to complete the restoration because the materials would not bond. Petitioner admits that when he did the procedure during the June 1996 examination, the tooth bonded correctly. In light of all the evidence regarding this point, it is found that Petitioner's claim is without merit. Petitioner also challenges his score of 2.0 received for his work on an "amalgam cavity preparation" (Clinical B). This composite score was based on a 2.0 awarded by each of the three examiners. An amalgam preparation is what is done to the tooth to get it ready for filling. In this case, an actual patient, supplied by the examines, had a cavity which was reviewed by the examiners. Once the patient was accepted by the examiners, the candidate then cleaned out the cavity and got it ready for filling. Dr. Simkin's review of the documentation prepared in regard to this candidate's performance of this procedure, in his opinion, supports the grades given by the examiners. Here, Petitioner sent the examiners a note as to what he proposed to do with his patient. Petitioner sought to deviate from a normal preparation due to the location of the caries, and the monitor agreed, as did the examiners. Thereafter, the candidate did the procedure. All three examiners graded his work against his proposal and gave him a failing grade. The examiners determined that his work on this patient merited only a grade of 2.0 because, according to two examiners, the margin of the filling was not separated from the next tooth as required. As to the "posterior endodonture procedure" (Clinical M), Petitioner received an overall score of 1.3. In this procedure, the candidate is required to bring in an extracted tooth which is mounted in an acrylic block. The candidate is to remove the nerve and diseased tissue, clean the cavity, file it, fill the canals, and seal the tooth. This is known as a root canal. In grading a candidate's work, the examiners look to see that the canal is properly cleaned out, is filled properly and sealed with a surface that is slightly shorter than the apex (highest point) of the tooth. On the x-ray taken of Petitioner's sample, it is obvious, according to Dr. Simkin, that one canal is at or short of the apex, but the other is long, and this is considered unacceptable treatment. Even Petitioner agrees. Petitioner received grades of 3.0, 2.0 and 1.0 for an overall failing grade of 2.0 on the "prep. cast restoration" (Clinical F). In this instance, the procedure called for the candidate to install a gold onlay. Normally the surface to which the onlay is to be placed is reduced slightly below the abutting face. Here, though one side was acceptable, Petitioner reduced too much on the other side without reason. Petitioner claims, however, that only one of the three examiners indicated excessive reduction. That determination calls for a very subjective opinion. He cannot understand how the propriety of reduction can be determined without looking into the mouth of a patient. However, Petitioner has presented no evidence in support of his opinion. The fifth challenge relates to the grade Petitioner received in the "pin amalgam pre. procedure" (Clinical G). This involves a situation where one cusp has been removed, and in order to hold a restoration, Repin must be placed in the solid portion of the tooth. The examiners determined that Petitioner's occlusal was too shallow at 1 mm, when it should have gone down 1~ to 2 mm. This, the examiners considered, would not give enough strength to hold the amalgam properly without risk of fracture. Dr. Simkins is of the opinion that Petitioner was subjected to a standardized test which was graded fairly. It would so appear and Petitioner introduced no evidence to the contrary. Ms. Carnes, a psychometrician and an expert in testing and test development who trains examiners to ensure they are consistent in their evaluations, agrees with Dr. Simkins' appraisal. The Department of Business and Professional Regulation tries to insure through its standardization efforts that the approach to grading of each examiner is consistent and that all examiners are grading with the same set of criteria. This was done in preparation for the December 1996 dental examination and a check done after the examination showed it was graded this way. Petitioner cites by way of explanation, if not excuse, that during his senior year in dental school, he was badly injured in an automobile accident and required stitches and several weeks of physical therapy for, among other injuries, a herniated disc. When he recovered sufficiently, he finished his course work and sat for the dental examination in June 1996, passing two of three sections, but not the clinical portion. Dr. Scheutz took the clinical portion of the examination again in December 1996 and again failed to earn a passing score. In his opinion, his knowledge has improved over time, but his procedural skills have diminished over the months due to his injuries. He contends he has work in dentistry he can do which will make accommodations for his physical condition, but does not believe he should have to wait another six months to take the examination again, especially since he would have to again take the entire examination, including those portions he has already passed since at that time more than 13 months from his last examination would have passed. Petitioner contends the clinical testing portion of the examination is too subjective to be valid. He wants to close this chapter in his life, but does not want to deal any more with the Board.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Board of Dentistry enter a Final Order denying Petitioner's challenge and sustaining the award of a failing grade on the clinical portion of the dental examination taken by the Petitioner on December 12 through 14, 1996. DONE AND ENTERED this 27th day of June, 1997, in Tallahassee, Leon County, Florida. ARNOLD H. POLLOCK Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (904) 488-9675 SUNCOM 278-9675 Fax Filing (904) 921-6847 Filed with the Clerk of the Division of Administrative Hearings this 27th day of June, 1997. COPIES FURNISHED: Dr. Eric J. Scheutz, pro se 332 Whispering Oaks Court Sarasota, Florida 34232 Karel Baarelag, Esquire Agency for Health Care Administration 2295 Victoria Avenue Fort Myers, Florida 33906-0127 Jerome W. Hoffman, General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32309 William Buckhalt, Executive Director Board of Dentistry 1940 North Monroe Street Tallahassee, Florida 32399-0792
The Issue The issue is whether Respondent is guilty of incompetence or negligence and failing to keep adequate dental records and, if so, what penalty should be imposed.
Findings Of Fact Respondent is a licensed dentist, holding license number DN 0010415. He has been licensed continuously in Florida since 1985, and he practices in Naples. On February 13, 1992, M. D. presented to Respondent at Kings Lake Dental Services. M. D. complained of a loose three-unit fixed bridge, which had replaced tooth number 4, using teeth numbers 3 and 5 as abutments. Respondent performed a focused emergency examination. He found a decaying, loose bridge that was falling apart and coming out of M. D.'s mouth; tooth number 5 was decayed and had fractured off; and tooth number three was decayed around the abutment crown and post. Respondent took an x-ray and found root canals on teeth numbers 3 and 5. Based on these findings, Respondent recommended to M. D. that he have post and cores on teeth numbers 3 and 5 and a new bridge. Respondent noted in his dental records these findings during this initial visit and the limited nature of the examination. At the time of this initial examination, Respondent determined that teeth numbers 3 and 5 could serve as abutment teeth to support the bridge for tooth number 4. His determination was correct as tooth number 5, but the record suggests that his determination was questionable as to tooth number 3. However, Petitioner failed to prove by clear and convincing evidence that the suitability determination for tooth number 3 was incompetent or negligent. On M. D.'s next visit, which took place on February 26, 1992, Respondent prepared teeth numbers 3 and 5 for the new bridge by removing the existing post and core in tooth number 3 and preparing tooth number 5 for a post and core. Respondent installed a temporary bridge during this visit. A post and core is an appliance that is cemented into a tooth that has undergone previous endodontic treatment. A post goes into the residual root, and the core replaces the natural crown of the tooth. The post and core can then be prepared for a crown or, as in this case, a fixed bridge. The final result resembles the placement of a peg into a tooth on which additional material is built up. On M. D.'s third visit, which took place on March 4, 1992, Respondent re-cemented the temporary bridge, which had come loose. On M. D.'s fourth and final visit, which took place on March 13, 1992, Respondent installed the permanent fixed bridge. At no time did any blood collect in M. D.'s post preparations. At no time during the post-and-core work, including during the unanaestheticized installation procedure, did M. D. experience pain. As material to this case, a perforation would result from excessive drilling in the process of preparing the tooth for the post, so as to create an extra opening into the bone. The absence of blood during the post preparation is generally inconsistent with a post perforation. The absence of pain during the ensuing installation procedure also militates against a finding that Respondent inadvertently perforated the tooth. The crucial findings on the issue whether Respondent perforated the tooth are thus the absence of blood during the drilling attendant to the post-and-core procedure and the absence of pain during the ensuing installation procedure. These findings are based in part on the self-serving testimony of Respondent, but also are supported by other evidence. At the time of the incident, Respondent had practiced dentistry in Florida for over six years. It is likely that he would have known that an untreated perforation would eventually cause the restorative work to fail. Respondent had treated numerous patients, presumably including seasonal Naples residents, without this issue previously arising, even though excessive-drilling perforations themselves are not that uncommon. When M. D. later contacted Respondent and complained of the dental work, he made no mention of the pain that typically would have accompanied the installation of a core over a perforated tooth. M. D. was a winter resident of Naples. Fourteen months after his final visit to Respondent, a dentist in Massachusetts discovered a perforation of the root on tooth number 5 and an acute periodontal abscess on tooth number 3. An acute periodontal abscess occurs at the end of the root and is secondary to infection involving the dental pulp in the soft tissue part of the tooth. Periodontal abscesses occur around the supporting structures of the teeth. Petitioner has failed to prove by clear and convincing evidence that Respondent perforated M. D.'s tooth. Although excessive drilling may cause a perforation, decay, a root fracture, and rampant periodontal disease may also cause perforations. Given the considerable period of time between Respondent's treatment of M. D. and the discovery of the perforation, the likelihood of decay, a root fracture, and rampant periodontal disease increases as the cause of the perforation. Given the other factors, such as lack of blood during the post procedure or pain during the core procedure, Petitioner has failed to prove by clear and convincing evidence that Respondent's treatment of M. D. was incompetent or negligent. The record provides even less basis to find by clear and convincing evidence that Respondent's work caused the periodontal abscess 14 months later. Respondent's dental records are adequate in many respects. The records adequately describe the cast post and core technique; Petitioner has failed to prove by clear and convincing evidence that the failure to distinguish between the two types of cast post and core is material in this case. Petitioner has also failed to prove by clear and convincing evidence that the records fail to provide an adequate basis for another dentist to infer the removal of the old post and core. The x-ray is of extremely poor quality, but it is merely a duplicate. The original is not in the record, and the record provides insufficient basis for inferring the quality of the original. Petitioner has failed to prove by clear and convincing evidence that the actual x-ray was of such poor quality as to preclude reliance upon it. Respondent's records indicate that tooth number 5 is decayed and fractured off, that tooth number 3 is decayed, and that the x-rays reveal root canals on both these teeth. While adequately documenting these findings, the records do not document Respondent's evaluation of the suitability of teeth numbers 3 and 5 to serve as abutment teeth. Nor do the records document the "moderate" periodontal disease that Respondent testified that he also observed. Respondent's restorative work eventually failed. The most likely cause of failure was the perforation of tooth number 5. However, fourteen months later, tooth number 3 was no longer capable of serving as an abutment tooth. By inference, its condition at the time of Respondent's decision to use it as an abutment tooth at least warranted documentation in the dental records. Similarly, the acute periodontal abscess also evidences the need to document Respondent's finding of moderate periodontal disease. These omissions from Respondent's dental records are material due to the questionable suitability of tooth number 3 as an abutment tooth and the subsequent development of periodontal disease. On these facts, Respondent's records fail to document a thorough evaluation of M. D.'s oral structures involved in the restorative work and his overall dental condition. In these respects, Petitioner proved by clear and convincing evidence that Respondent failed to keep adequate dental records in that they fail to justify the course of Respondent's treatment of M. D. On March 30, 1992, S. T. presented to the Fort Myers Dental Service for an abscessed tooth at tooth number 3. One of the dentists at the office, Dr. Rubin, saw S. T. He recommended full mouth x-rays and study models and prescribed pain medication and an antibiotic. The dental records contain no indication of periodontal disease at this time. The Fort Myers Dental Service maintained a system of patient referral in which Respondent or Dr. Johnson saw patients requiring endodontic treatment and other dentists saw patients requiring periodontic treatment. Following her visit, Dr. Rubin referred S. T. to Respondent for endodontic work on April 2, 1992. The x-rays had revealed lesions on teeth numbers 3 and 4, so the referral was for an evaluation for root canals. On April 3, Respondent examined S. T.'s mouth and noted buccal swelling around teeth numbers 3 and 4 and broken- down, decayed teeth at teeth numbers 3, 4, and 5. However, his examination did not reveal any periodontal disease. Respondent recommended root canals for teeth numbers 3 and 4 followed by casts, posts, and cores for teeth 3 and 4 and a porcelain fuse metal crown for tooth number 5. Respondent commenced this dental treatment on April 10, 1992. During this visit, Respondent began a root canal on tooth number 4. On April 17, Respondent completed the root canal on tooth number 4. On April 24, Respondent began a root canal on tooth number 3. On May 22, Respondent completed the root canal on tooth number 4. On September 24, 1992, Respondent prepared teeth numbers 3, 4, and 5 for crowns. On October 8, Respondent installed crowns on these teeth and posts and cores on teeth numbers 3 and 4. Fourteen months later, on December 7, 1993, S. T. was examined by Dr. William McKenzie, a periodontist who practiced 33 years, primarily in Fort Myers, until his retirement prior to the hearing in this case. A general dentist in Fort Myers had referred S. T. to him. At the time of his examination, Dr. McKenzie found poorly fitting crowns on teeth numbers 3, 4, and 5 and open contacts between teeth numbers 2 and 3, 3 and 4, 4 and 5, and 5 and 6. In general, S. T.'s dental health was good, except for the area in which Respondent had worked. In this area, S. T.'s gums bled profusely upon probing by Dr. McKenzie. In part, Petitioner tried to prove that Respondent improperly proceeded with endodontic treatment despite unresolved periodontic problems. However, the record fails to sustain this allegation. To the contrary, as Dr. McKenzie testified, the poor-fitting and gapped crowns caused the periodontal condition that Dr. McKenzie encountered. The open contacts, which allowed food to pack between the teeth, led to infection, which caused the inflammatory process in the gums and bone deterioration that Dr. McKenzie also discovered in this area of S. T.'s mouth. As to the fit of the crowns, Dr. McKenzie described it as "horrible" and work of which a "freshman dental student" was capable. Petitioner proved by clear and convincing evidence that Respondent failed to meet the minimum standards of performance and treatment when measured against generally prevailing peer performance in the treatment of S. T.
Recommendation It is RECOMMENDED that the Board of Dentistry enter a final order suspending Respondent's license for six months and, following the expiration of the suspension, placing the license on probation for a period of 12 months. DONE AND ENTERED this 29th day of March, 1999, in Tallahassee, Leon County, Florida. ___________________________________ ROBERT E. MEALE 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 29th day of March, 1999. COPIES FURNISHED: Thomas E. Wright Senior Attorney Agency for Health Care Administration Post Office Box 14229 Tallahassee, Florida 32317-4229 E. Raymond Shope, II 1404 Goodlette Road, North Naples, Florida 34102 Angela T. Hall, Agency Clerk Department of Health Bin A02 2020 Capital Circle, Southeast Tallahassee, Florida 32399-1701 Pete Peterson, General Counsel Department of Health Bin A02 2020 Capital Circle, Southeast Tallahassee, Florida 32399-1701 Bill Buckhalt, Executive Director Board of Dentistry Department of Health 1940 North Monroe Street Tallahassee, Florida 32399-0750
The Issue This is a license discipline case in which the Petitioner seeks to take disciplinary action against the Respondent on the grounds that the Respondent has violated several statutory provisions by repairing dentures in a licensed dental lab without having obtained the required work order from a licensed dentist.
Findings Of Fact Based on the stipulations of the parties, on the exhibits received in evidence, and on the testimony of the witnesses at hearing, the following facts are found: At all times relevant and material to this case, the Respondent, Magnolia Iole, held license number DL 0002153 issued by the Department of Professional Regulation, which licensed her to operate as a dental laboratory in the State of Florida. At all times relevant and material to this case, the Respondent's dental laboratory was operated at 201 East Oakland Park Boulevard, Fort Lauderdale, Florida, under the business name of All Emergency Denture Service. On April 11, 1990, an investigator with the Department of Professional Regulation took a broken denture to the Respondent's dental laboratory and asked to have it repaired. The broken denture was a woman's denture that had been obtained by one of the other Department investigators from a local dentist's office. The investigator who presented the broken denture for repair had not seen any dentist regarding the broken denture, nor did the investigator have any work order from a dentist for the repair. On April 11, 1990, an employee of the Respondent's dental laboratory agreed to repair the broken denture that was brought in by the Department investigator. The employee said that the repair would cost $50.00, and that the denture would be ready later than same day. Later that same day two Department investigators returned to the Respondent's dental laboratory, where they met the same employee who had agreed to repair the broken denture. The employee told the investigator who had brought the denture that it would be ready in a few minutes. A few minutes later the employee of Respondent's dental laboratory handed the repaired denture to the investigator who had brought it in earlier the same day. At that time the previously broken denture was completely repaired. Although the Respondent, Magnolia Iole, was not observed on the dental laboratory premises during the events of April 11, 1990, described above, she was aware that such events were taking place, because during a telephone conversation on April 12, 1990, Magnolia Iole admitted to a Department investigator that she had been taking repair work without work orders because she needed the money. A work order for denture repair is an order from a licensed dentist to a dental laboratory directing that certain repair services be performed. The work order is, essentially, a prescription for the performance of specific services. A dental laboratory is not permitted to perform a repair of an intra- oral dental appliance without a work order signed by a licensed dentist. A dental laboratory that repairs a denture without a work order issued by a licensed dentist is engaged in the unauthorized practice of dentistry. Denture repair under such circumstances also constitutes the acceptance and performance of professional responsibilities which the dental laboratory licensee is not competent to perform. Denture repair without a work order issued by a licensed dentist, even when the repairs are excellently accomplished, can prevent the discovery of emerging dental problems and cause them to go untreated to the harm of the patient.
Recommendation For all of the foregoing reasons, it is recommended that the Board of Dentistry enter a final order in this case concluding that the Respondent has violated Sections 466.028(1)(z) and 466.028(1)(bb), Florida Statutes, and imposing an administrative penalty consisting of a six month suspension of the Respondent's license, to be followed by a one year period of probation during which the Respondent shall be required to advise the Board quarterly of all work performed by the Respondent's dental laboratory and shall comply with all statutory and rule provisions governing the activities of dental laboratories. DONE AND ENTERED at Tallahassee, Leon Coun~y, Florida, this 21st day of May, 1991. MICHAEL M. PARRISH Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 904/488-9675 Filed with the Clerk of the Division of Administrative Hearings this 21st day of May, 1991. COPIES FURNISHED: Albert Peacock, Esquire Department of Professional Regulation Northwood Centre 1940 North Monroe Street Tallahassee, FL 32399-0792 Ms. Magnolia T. Iole 531 Northwest 39th Street Oakland Park, Florida 33309 Mr. William Buckhalt, Executive Director Florida Board of Dentistry Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, FL 32399-0792 Jack McRay, Esquire General Counsel Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, FL 32399-0792
