Findings Of Fact Joseph L. Ratchford is a graduate of the University of Georgetown School of Dentistry and took the Florida dental exam in June, 1984. The clinical, or practical, portion of the dental exam consists of ten procedures and the examinee must obtain a total combined weighted grade of 3.0 to pass the clinical portion of the exam. Petitioner received a total overall grade of 2.96 and has questioned the grades he received on two of the ten procedures. In grading the clinical portion of the exam, three examiners separately review and grade each procedure performed by the examinees. At each examination, approximately twelve to thirty examiners are used, and three hundred to four hundred candidates are examined. Each examiner must successfully complete an eight to twelve hour standardization exercise during which they are trained on the grading scale, procedures, and the criteria to be used in grading the clinical portion of the exam. The Board of Dentistry determines the criteria to be used in grading the exams and the grading scale. A perfect score is a "5" and a complete failure is a "O". Examiners are chosen by the Board of Dentistry based upon their successful completion of the standardization exercise and must also have been licensed in Florida for at least five years. Petitioner received grades of 2, 3, and 5 from the three examiners grading the Periodontal procedure on his exam. This resulted in a grade of 3.33 on the Periodontal procedure. Petitioner objects to the grading of this procedure due to the wide disparity in the three examiners' grades. The periodontal procedure is performed on a live patient and is an evaluation of the patient's teeth, root structure, and supporting structures. In grading this procedure, five criteria are used: Presence of stain on assigned teeth. Presence of supra-gingival calculus on assigned teeth. Presence of sub-gingival calculus on assigned teeth. Root roughness on assigned teeth. Tissue management. While several of these criteria are easily observable, criteria (c) and (d) are not, and in fact are sometimes hard to distinguish from each other. The grading system requires two points to be taken off when sub-gingival calculus is present on the assigned teeth (criteria c), and allows one to four points to be deducted for root roughness on the assigned teeth (criteria d). Examiner 10 gave Petitioner a grade of 2 since the examiner found Petitioner was deficient on criteria (a), (c), (d) and (e). A grade of 2 is appropriate with these deficiencies, although such a grade may even be a bit high. Examiner 10 had participated in seven exams prior to the one in question and a post-exam evaluation of all examiners shows that Examiner 10 ranked 6th out of 18 examiners in terms of grading accuracy. Examiner 35 gave Petitioner a grade of 3 since the examiner found Petitioner was deficient on criteria (c). A grade of 3 is mandatory is this situation since the presence of subgingival calculus requires two points to be deducted from the grade. Examiner 35 had participated in no previous exams but ranked 7th out of 18 examiners in terms of grading accuracy, according to a post-exam evaluation of all examiners. Examiner 82 gave Petitioner a perfect score of 5, noting no deficiencies. This was the second exam Examiner 82 had participated in and he ranked 17th out of 18 examiners in terms of grading accuracy. Therefore, the perfect score which Petitioner received from Examiner 82 is the least reliable of the three grades on the Periodontal procedure since Examiner 82 had the worst ranking for accuracy among these three examiners, and was next to last among all examiners. On the Cast Class II Onlay Prep procedure, Petitioner received grades of 1, 0, and 1. This resulted in a grade of .66 on this procedure. Petitioner objects to the grading of this procedure. He states he performed this procedure the way he was taught in dental school, he alleges that the comments of the examiners conflict, and he feels it is impossible to measure tooth reduction without an opposing model. The Cast Class II Only Prep procedure is performed on a model, or mannequin, and consists of a restoration onlay wax-up on a posterior tooth. In grading this procedure five criteria are used: Outline form Depth Retention Gingival level Mutilation of opposing or adjacent teeth Examiners 6 and 37 gave Petitioner a grade of 1. Examiner 6 commented on his score sheet that "Distal box too deep and undercut; excess facial cusp reduction." Examiner 37 commented that outline form was poor and "no lingual cusp protection." Examiner 15 gave Petitioner a score of 0 and commented that there was insufficient reduction of the functional cusp. Each of these examiners had participated in at least two previous exams, and each had a high grading accuracy ranking according to a post-exam evaluation of all examiners. Specifically, Examiner 15 ranked 1st, Examiner 37 ranked 4th and Examiner 6 ranked 8th out of 18 examiners. The comments of the examiners do not conflict and, in fact, do support the grades given. An examination of the mannequin used by Petitioner to perform this procedure (Petitioner's Exhibit 1) by a dental consultant who has been a licensed dentist in Florida since 1971, and who was accepted as a expert on the technical aspects of the clinical portion of the dental exam, confirms and supports the grades given by the examiners on this procedure. The major and significant deficiency on this procedure was Petitioner's failure to adequately reduce the functional or lingual cusp, and excessive reduction of the facial cusp resulting in the subject tooth being almost level. Although it is difficult to determine the amount of tooth reduction without an opposing model, and no opposing model was used in the exam, the teeth used for the exam mannequin are manufactured in large quantities from the sane mold or form. Therefore, variations in these model teeth before the procedures are performed are not visible to the naked eye. Improper reductions on these teeth are visible to the examiners who have seen this procedure performed many times on these same models, both in exams and in the standardization procedure. According to an examination development specialist employed by Respondent who was accepted as an expert in testing and measurement, specifically for the dental exam, the grading of exams which involve hands-on, practical demonstrations of an examinee's skill level is not entirely objective. There is some subjectivity in assigning grades after criteria for each procedure are evaluated. This is why three examiners separately review each procedure, and the average of their grades is used. In addition, Respondent performs the standardization exercise prior to the exam and then evaluates each examiner's grades for accuracy after the exam in order to minimize disparity and the effects of subjectivity. Examiners who do not receive a good evaluation in the post-exam review are not used in subsequent exams. Proposed findings of fact and conclusions of law have been submitted by the parties pursuant to Section 120.57(1)(b)4, F.S. A ruling on each proposed finding of fact has been made either directly or indirectly in this Recommended Order, except where such proposed findings of fact have been rejected as subordinate, cumulative, immaterial or unnecessary. Specifically, Petitioner's proposed findings numbered 7, 10, 11 and 12 are rejected for these reasons, and also because they are not based upon competent substantial evidence.
Recommendation Based upon the foregoing, it is recommended that Respondent enter a Final Order upholding the grades given to Petitioner and denying the relief sought by Petitioner. DONE and ENTERED this 19th day of April, 1985 at Tallahassee, Florida. DONALD D. CONN, 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 19th day of April, 1985. COPIES FURNISHED: Drucilla E. Bell, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Michael S. Rywant, Esquire 240 Hyde Park Avenue Tampa, Florida 33606 Fred Roche, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Salvatore A. Carpino, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301
The Issue The ultimate issues to be decided in this proceeding are whether the Respondent has violated provisions of Florida Statutes pertaining to the practice of dentistry and, if so, whether his license should be revoked or suspended for a specified period, or whether other disciplinary action should be invoked. Petitioner contends that Respondent violated the provisions of Section 466.028(1)(y), Florida Statutes, in connection with his construction and adjustments of a set of upper and lower dentures for Sally Cohen, a former patient. Respondent disputes the allegation and contends that his diagnosis and treatment of Sally Cohen was proper.
Findings Of Fact Petitioner holds license No. 1808 issued by Petitioner and has been licensed to practice dentistry in the State of Florida since 1953. Prior to his being licensed in Florida, the Respondent practiced dentistry in other locations beginning in 1940. Since approximately 1963, the Respondent's practice has been solely in the area of fabricating, constructing, fitting, and adjusting complete and partial dentures. Sally Cohen was formerly a patient of the Respondent. The Respondent first saw her during October, 1978, with a broken lower denture. The Respondent repaired it and refit it in her mouth. The Respondent saw Ms. Cohen in October, 1980. She was complaining of her old dentures. The Respondent observed her dentures and noted that they were slipping. He recommended that she get new dentures, and he told her that he would be able to make the dentures for her. He saw her again in April, 1981, observed the same conditions, and made the same recommendations. Ms. Cohen requested that he fit her for a new set of dentures. The Respondent took impressions, developed models, and sent the models to his laboratory for processing into dentures. When the laboratory completed the manufacture of the new dentures, Ms. Cohen returned to the Respondent's office to have the dentures fitted. The Respondent placed the dentures in her mouth, checked for "occlusion," and observed the fit of the dentures. The term "occlusion" pertains to the manner in which the upper and lower dentures touch. With dentures, it is important that the occlusion is as uniform as possible so as to assure a proper fit and prevent slippage of the denture plates within a patient's mouth. The occlusion and fit of Ms. Cohen's dentures appeared appropriate. The Respondent explained to Ms. Cohen at the fitting that there would be an adjustment period, and he explained good oral hygiene procedures to her. Ms. Cohen's upper ridge was anatomically good, but her lower ridge was in poor shape; and it was difficult to accomplish a fit of the lower plate without "overextending" the denture borders so as to make the lower denture as stable as possible in the patient's mouth. The Respondent ordinarily likes to wait for approximately one week after dentures are fitted to make an adjustment. Ms. Cohen, however, returned to his office on the first day after the fitting, complaining of pain. It appears that Ms. Cohen has a low pain threshold. Respondent again explained proper oral treatment to her. He observed no sore spots of significance in her mouth. He again checked the occlusion and fit of the dentures and observed no problems. Several times thereafter, Ms. Cohen returned to the Respondent's office complaining of pain from the new dentures. Each time, the Respondent checked the occlusion and fit of the dentures. He made minor adjustments. He properly observed the occlusion and observed no problems. The Respondent last observed Ms. Cohen on June 12, 1981. He felt at that time that she was in good condition. The Respondent was going on vacation, and he informed Ms. Cohen that Michael Overleese, the dentist who shared office space with the Respondent, would be handling any adjustments while the Respondent was away. While the Respondent was on vacation from his practice, Ms. Cohen made several appointments to see Dr. Overleese. She continued to complain that the dentures hurt her mouth. She complained of generalized discomfort, but was generally unable to pinpoint a specific area of pain. Dr. Overleese made four adjustments of the patient's dentures during June and July, 1981. He properly observed the occlusion and fit of the dentures. He observed no problems. He felt that Ms. Cohen was not keeping the dentures in her mouth long enough to adjust to them. He did not observe any ulceration or irritation in places where Ms. Cohen indicated she was experiencing pain. Dr. Overleese did grind some spots on the patient's dentures in order to improve occlusion, but this is not an unusual occurrence. Occlusion of dentures can typically always be improved at least slightly. Dr. Overleese was somewhat frustrated with the situation. On her last visit, Ms. Cohen felt that Dr. Overleese told her that she would not be able to return for further adjustments. Dr. Overleese did not give instructions of that sort, but was misunderstood by Ms. Cohen. After the last visit, Ms. Cohen visited a lawyer. The attorney assisted her in filing a complaint with the Petitioner. The Petitioner conducted an investigation and retained Richard A. Saal, D.D.S., to examine Ms. Cohen. Dr. Saal examined her in October, 1981, and observed that there was a premature occlusion. He observed that the first bicuspid on the upper and lower right dentures met prematurely. The premature occlusion was obvious to Dr. Saal. Such an occlusion would result in movement of the denture plates, resulting in pain. Dr. Saal concluded that the most logical explanation for the premature occlusion was improper manufacture and fitting of the dentures or an improper adjustment of the occlusion. While this may be the most common explanation, it is not the only one. Such a prematurity could result from structural problems in the patient's mouth and from changes in the structure. Tooth grinding on the part of the patient or any action that changes the contour of the lower ridge of a patient's mouth could result in such a prematurity. It is not uncommon for such prematurities to develop with dentures that displayed a proper occlusion and fit when first placed in the patient's mouth. Given the fact that the Respondent and Dr. Overleese properly observed the occlusion of Sally Cohen's dentures and observed no abnormalities of the sort observed by Dr. Saal, it is concluded that events which occurred after Ms. Cohen's last visit to Respondent's office resulted in the premature occlusion.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is, hereby, RECOMMENDED: That a final order be entered by the Department of Professional Regulation, Board of Dentistry, dismissing the Administrative Complaint that has been filed against the Respondent, Leonard Foley, D.D.S. RECOMMENDED this 1st day of November, 1982, in Tallahassee, Florida. G. STEVEN PFEIFFER Assistant Director 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 1st day of November, 1982. COPIES FURNISHED: Theodore R. Gay, Esquire Mr. Samuel R. Shorstein Department of Professional Secretary, Department of Regulation Professional Regulation 130 North Monroe Street 130 North Monroe Street Tallahassee, Florida 32301 Tallahassee, Florida 32301 Patrick L. Bailey, Esquire Mr. Fred Varn Sullivan, Ranaghan, Bailey Executive Director & Gleason, P.A. Board of Dentistry 2335 East Atlantic Boulevard Department of Professional Post Office Box 549 Regulation Pompano Beach, Florida 33061 130 North Monroe Street Tallahassee, Florida 32301
The Issue Whether Respondent Tessler has violated Florida Statute Section 466.24(3)(a), (c) and (d) and is guilty of misconduct, malpractice, or willful negligence in the practice of dentistry. Whether Respondent is guilty of receiving compensation because of a false claim intentionally submitted. Whether Respondent has failed to treat a patient according to acceptable dental standards and procedures.
Findings Of Fact Dr. Stephen W. Tessler, the Respondent, is a dentist licensed to practice dentistry under the laws of the State of Florida, Chapter 466, Florida Statutes, engaged in the practice of dentistry in his office located at 1245 NW 190th Street, North Miami, Florida. The Petitioner, State Board of Dentistry, filed an administrative accusation against Respondent Tessler, which was sworn to and subscribed in July, 1978. The accusation contained two counts, and the Respondent requested an administrative hearing. The hearing was first scheduled for October 20, 1978, but was continued upon motion of the Petitioner to January 10, 1979, and rescheduled upon motion of the Respondent to March 8, 1979. During the months of January, 1977, through mid-June, 1977, Ms. Rachel Dixon was a dental patient of Respondent Tessler. Ms. Dixon is a 32-year-old woman with a history of severe tooth and gum problems. She had prosthetic appliances and six (6) anterior crowns placed in her mouth ten (10) to fifteen (15) years ago in Pennsylvania. She had engaged a dentist, a Dr. Snyder in Hollywood, Florida, but had not seen him for some two (2) years prior to making an appointment with the Respondent for relief from pain and gum irritation, and for cosmetic improvement. Ms. Dixon is an unhappy dental patient with an inordinate fear of dentists, and her home dental hygiene care is inadequate. At the time Ms. Dixon engaged Respondent Tessler, she was in need of dental treatment for full-mouth gross peridontal inflammation and infected root canals in tooth number 30. She employed the Respondent for the purpose of providing dental treatment for peridontal disease, endodonic care of tooth number 30, recapping to the anterior teeth, and restoration of an upper right bridge on teeth number 3, 4 and 5. Ms. Dixon was referred to Dr. Hirschfield, an orthodontist in Respondent's office, for x-rays. Costs were discussed, a payment made, and a schedule of appointments planned. Thereafter, Ms. Dixon kept numerous scheduled and unscheduled appointments with the Respondent. Respondent Tessler replaced existing crowns on six (6) anterior teeth (number 6, 7, 8, 9, 10 and 11) with six (6) anterior foil porcelain jackets. In the presence of peridontal disease, Respondent attempted to replace an upper right bridge on teeth number 3, 4 and 5. Respondent was dissatisfied with the "final restoration" but used it instead of making a temporary one. He placed it in Ms. Dixon's mouth because it was better than a temporary restoration. Respondent had told Ms. Dixon that he would satisfy her and would redo the temporary restoration on her front teeth. He did the restoration a second time. Initially, Ms. Dixon was pleased, but later she was not satisfied because she felt pain upon contact with food, drink, or air that was either hot or cold. At the time of hearing no further work had been done in this area of her mouth, and she still complained of pain. On the second or third visit, within two (2) weeks of Ms. Dixon's initial visit, Respondent treated tooth number 30 by performing three (3) root canal treatments. After a number of weeks, Ms. Dixon continued to experience pain in this tooth. Respondent treated tooth number 30 again, reopening two (2) root canals to permit drainage and prescribing an antibiotic. During the course of the endodonic treatment on tooth number 30 an existing lower right bridge on teeth number 28, 29, 30 and 31 was damaged. Ms. Dixon did not return to Respondent for treatment, although she was in pain and attempted for two (2) or three (3) days to reach Respondent by telephone calls to his office. Thereafter, a week or ten (10) days later, Ms. Dixon sought the services of Dr. Marvin Levinson. She indicated to Dr. Levinson that she was not going to return to Respondent Tessler, that she suffered from pain, and that she was concerned about her appearance. Dr. Levinson examined her and referred her to Dr. Satovsky, an endodontist, for immediate relief of pain for a dental abscess, and to Dr. Garfinkle, a peridontist, for a complete peridontal work-up. It was Dr. Garfinkle's opinion that the caps placed by Respondent Tessler in the mouth of Ms. Dixon were placed in the presence of peridontal disease or that the caps caused the disease. He could not determine which came first. Dr. Garfinkle stated that Ms. Dixon was prone to peridontal disease and that she was an unhappy dental patient. Dr. Garfinkle could not comment on the condition of Ms. Dixon's mouth at the time of the treatment given by Respondent, inasmuch as he had not seen her until some eight (8) months had passed. Dr. Satovsky stated that on tooth number 30, which he treated subsequent to the root canal treatment done by Respondent Tessler, the canals were inadequately cleaned and enlarged. He stated that there were three (3) canals on the tooth, two (2) of which had the rods removed, and that he removed the third. He retreated the three (3) canals and alleviated the pain of Ms. Dixon. Dr. Satovsky could not state whether he thought the work of Respondent was negligent, inasmuch as he could not state what the tooth looked like when Respondent first saw it. Dr. Marshall Brothers, the Secretary/Treasurer of the State Board of Dentistry, found that the permanent type of restoration was adequate but not good for a temporary restoration. Upon his examination of Ms. Dixon's mouth, he found her general peridontal condition to be poor. Dr. Brothers could not determine whether her condition was a result of the restoration or existed prior to the restoration. He assumed the condition to be the one or the other because of the recency of the restoration. Respondent Tessler is a licensed dentist and a general practitioner, and is licensed to perform the dental work involved in this case. His charges for this work were substantial, but there was no evidence submitted that said charges were excessive or that Ms. Dixon misunderstood them. Alternative methods of treatment were discussed. The testimony and the evidence in this case show that Respondent worked within his ability as an average dentist. There was no showing of willful negligence, although Respondent's judgment may have been poor, and probably he should have referred Ms. Dixon to specialists. Affixing a bridge and crown work in the presence of gum disease is not the acceptable standard of care within the dental profession, and Respondent admits to that fact; however, he felt that it would improve the overall condition, and he had not released Ms. Dixon as a patient. Ms. Dixon was not pleased with Respondent's work or his charges ad, after attempting to make an appointment, left Respondent Tessler for another dentist. Ms. Dixon was insured through her husband's employer by a policy issued by Aetna Casualty and Surety Company. On January 31, 1977, Respondent Tessler submitted a pre-treatment estimate for work to be done consisting of porcelain-to-gold restorations on anterior teeth number 7, 8, 9, 10 and 11, and for a fixed bridge on teeth number 28, 29, 30 and 31, plus additional treatment in the amount of $2,420.00. The insurance company refused to pay for all treatment except for the fixed bridge on teeth number 28 through 31. On April 27, 1977, Respondent submitted the customary insurance treatment form to Aetna certifying that the bridgework had been performed and completed on April 27, 1977. Based on Respondent's representation, Aetna paid Respondent $649.50. The bridgework had in fact not been done, nor were the anterior crowns porcelain-to-gold restorations. Approximately one year later, Respondent refunded the overage to Aetna upon the request of the insurance company. Both parties submitted proposed findings of fact and memoranda of law, and Respondent submitted a proposed order. These instruments were considered in the writing of this Order. To the extent the proposed findings of fact have not been adopted in, or are inconsistent with, factual findings in this Order, they have been specifically rejected as being irrelevant or not having boon supported by the evidence.
Recommendation Based upon the violation as established, it is recommended that the license of Stephen W. Tessler, D.D.S., be suspended for a period of time not exceeding one year from the date of the Final Order. DONE and ORDERED this 12th day of June, 1979, in Tallahassee, Leon County, Florida. DELPHENE C. STRICKLAND Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: L. Haldane Taylor, Esquire 2516 Gulf Life Tower Jacksonville, Florida 32207 Stephen Mechanic, Esquire Suite 200 1125 NE 125th Street North Miami, Florida 33161
The Issue The issues presented herein are: (1) whether or not the Respondent, Kenneth T. Risco, D.D.S., permitted an unlicensed dental employee (Wilbert E. Bolyea) to examine and diagnose the mouth of Dr. Erwin Ochs for treatment or treatment planning in violation of Chapters 466.024(4)(b) and 455.026(1)(c), Florida Statutes (1979); whether Respondent, thereby aided, assisted, procured or advised an unlicensed person to practice dentistry or dental hygiene contrary to Chapter 466.028(1)(g), Florida Statutes (1979); whether Respondent knowingly permitted Bolyea to take an impression for the purpose of fabricating an intra- oral restoration, to wit: upper and lower dentures, in violation Chapter 466.024(1)(a) and (c), Florida Statutes (1979); whether Respondent thereby delegated professional responsibilities to a person with knowledge or reason to know that such person did not qualify by licensure to perform such tasks in violation of Section 466.028(1)(aa), Florida Statutes (1979); whether Respondent permitted Bolyea to engage in the examination, diagnosis and treatment planning of conditions within the human oral cavity audits adjacent tissues in conjunction with the supplying of dentures to patients in Respondent's office in violation of Chapter 466.026(1)(c), Florida Statutes (1979), and thereby knowingly employed a person to perform duties outside the scope allowed such persons in violation of Chapter 466.024(4)(b), Florida Statutes (1979).
Findings Of Fact Based upon my observation of the witnesses and their demeanor while testifying, the documentary evidence received and the entire record complied herein, the following relevant facts are found. By its eight (8) count Administrative Complaint filed herein on November 6, 1980, the Petitioner seeks to revoke, suspend or take disciplinary action against Respondent as a licensee and his license as a dentist under the laws of Florida. Respondent, Kenneth T. Risco, is a licensed dentist having been issued license No. DN6971, since approximately August of 1975. On approximately January 7, 1980, Respondent because professional associated with Wilbert Bolyea (Bolyea) whom he employed as an expanded duty assistant. In summary fashion, the complaint allegations are that Respondent, during the period January 7 through 18, 1980, permitted Bolyea, his expanded duty assistant, to engage in the examination, diagnosis, treatment planning and the taking of impressions for the purpose of fabricating prosthetic dentures and the adjusting of such dentures in violation of Chapter 466, Florida Statutes (1979). Petitioner's proof herein consists of testimony adduced from a deposition of Respondent taken on January 18, 1980, in Collier County Circuit Court, Case No.79-1029 captioned Bolyea v. Wittenberg; Dr. Erwin Ochs, who is now deceased, testimony was received as an unavailable declarant pursuant to Chapter 90-803(18), Florida Statutes; and testimony taken during the hearing herein on February 24, 1981, in Naples, Florida. Ruppert Bliss, a licensed dentist and a member of Petitioner's Board, has been practicing dentistry since approximately 1956. Dr. Bliss is a member of several professional associations and expressed familiarity with the terms of art peculiar to the dental profession. Dr. Bliss was received as an expert in prosthetic dentistry in this proceeding. According to Dr. Bliss, the treatment and diagnosis of a patient with dental problems should proceed as follows. First, the patient is examined by a visual inspection of the patient's pathological signs. A working relationship is then developed with the patient and a study model is made to follow and coordinate subsequent diagnostic procedures. This includes a study of a patient's tissue contours which aids in making a model to trace registrations and to effect proper adjustments which affect a patient's ability to bite. Throughout the procedure, the patient is constantly examined and a final adjustment is made to ensure that the dentures, as constructed and fitted, enable the patient to bite properly and that the bone and tissue conditions are not adversely affected. Dr. Bliss described the difference between the terms of art in the dental profession known as a "remediable" versus nd "irremediable" task. A "remediable" task is one that can be reversed whereas an "irremediable' task can not be reversed. Dr. Bliss included in the list of irremediable tasks, the adjustment of prosthetic appliances since they affect a patient's bite; may worsen bone or tissue conditions and also impacts on a patient's mannerisms. The diagnosis of a denture problem and its adjustment is an irremediable task. (Tr. 41) Respondent's Defense Dr. Riso is a 1975 graduate of the University of Pennsylvania. Upon graduation, he became licensed to practice in the states of Florida, New Jersey and Pennsylvania. Respondent's spouse, Dr. Rebecca Weber, is also a dentist licensed to practice in Florida and practices jointly with Respondent. Respondent, during the instant hearing on February 24, 1981, denied permitting Bolyea or any unlicensed person employed by him to practice dentistry or to examine patients without any supervision by him. Respondent became professionally associated with Bolyea on January 7, 1980, as an expanded duty assistant. In keeping with this employment relationship, Respondent and Bolyea entered into an employment agreement which delineated the procedures under which Bolyea was authorized to carry out his employment functions. (See Respondent's Exhibit No. 1) According to Respondent, he first learned of the services performed for Dr. Ochs by Bolyea, at the contempt hearing on January 21, 1980. Pursuant to the employment agreement, Bolyea was authorized to greet patients; take patients' dental history; determine the need for dentures and report back to Respondent. (Tr. pp. 53 and 67) Respondent therefore claims that he was unaware of any dental adjustments by Bolyea during times material to the allegations herein. (Se Respondent's Exhibit No. 1 and Tr. p 69) When Dr. Ochs visited Respondent's office for treatment on January 11, 1980, the employment relationship in effect between Respondent and Bolyea had been effective approximately two days. Dr. Ochs was not seen or examined by Respondent. On January 11, 1980, Dr. Ochs, a former dentist for approximately 35 years, visited Respondent's denture clinic in Naples for an examination and, if necessary, to have dentures made. After being greeted by an office assistant, Bolyea began talking to Ochs about the price and quality or dentures. At the outset of the examination by Bolyea, Ochs explained that he only needed an upper denture made since his lower denture was all right. Bolyea donned a pair of rubber gloves; removed Ochs' upper denture and placed it on a try. Bolyea then examined Ochs' mouth; massaged his lower gum with his finger; remarked that his ridge was very flat and had been pounded to almost nothing. (Petitioner's Exhibit 7, pp 3 and 4) After a mirrored view of Ochs' oral cavity while in the protruding position, Bolyea remarked that "there is contact anteriorly and posteriorly, but in the space between there, you have quite a space. That is why you are pounding your ridge to pieces, because your bite is not right." Bolyea advised Ochs that he could not help him with only a lower denture and that his only solution was to construct a complete set of dentures to correct his bite. Thereafter, Bolyea took a wax bite of Ochs' mouth. According to Respondent, the study model is made by Bolyea after a patient is initially screened. Thereafter, examines the model and a custom tray is made from which a final impression is made by Respondent. Respondent physically delivers the appliance after the third appointment. At some point during the course of fabricating the dentures, Respondent examines the patient. This occurred, in the usual case, during the second or third visit. Respondent's testimony during the contempt hearing held on January 21, 1980, is as follows. Patients desiring dentures were required to make three visits and at some point during the diagnostic procedures of the patient (by Bolyea), Respondent diagnosed and examined the patient. Respondent considered that Bolyea's actions in feeling dr. Ochs' gums and advising him as to the condition of the ridges included the corrective measures he would employ to correct his bite were "physical observations" rather than an examination and diagnosis. Respondent authorized Bolyea to make those determinations. (Petitioner's Exhibit 6 at p 48) Respondent did not check to determine the corrections of Bolyea's judgment as to the necessity for a new set of dentures. (Petitioner's Exhibit 6 at p 48) Respondent also stated that a patient was free to, and in fact would, return to his office if he was dissatisfied with the dentures (as fitted or adjusted by Bolyea). However, Respondent agreed that an improperly adjusted denture could result in irreversible harm to the muscles and soft tissues of the mouth. In this regard, Respondent's and Ms. Chesser's testimony during the hearing, to the effect that he (Respondent) was unaware of Respondent making adjustments to patients' dentures is contrary to Respondent's testimony on January 21, 1980. Respondent's sworn statements, when he was not under the pressure of disciplinary sanction by the Petitioner is considered more credible than the subsequent testimony herein when the threat of disciplinary action existed. To the extent that his testimony herein differs from the version offered by him during the prior proceedings, the more recent testimony is rejected. Likewise, Ms. Chesser's testimony to the effect that Respondent was unaware of Bolyea's actions relative to the adjustments of dentures is contrary to Respondent's testimony on January 21, 1980, and is also rejected. Joyce Chesser was employed by Messr. Dolyea from approximately July 1979, through March of 1980. She was hired as an assistant and officer manager. Based on Bolyea's procedures, dentures were completed during a span of not less than four weeks subsequent to a patient's first visit. Bolyea made adjustments to patients' dentures without Respondent's knowledge, permission or authorization (Tr. 76 thru 82). Bolyea also examined patients and went behind Respondent's back to adjust dentures which were already prepared prior to any employment relationship with Respondent. 2/ Respondent's wife, Dr. Rebecca Weber, was also familiar with the employment relationship between Respondent and Bolyea. Dr. Weber denied that Respondent permitted Bolyea to examine or otherwise diagnose patients.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Petitioner, Board of dentistry, enter a final order herein finding the Respondent guilty of the allegations set forth in Counts 1 through 8 of the Administrative Complaint filed herein and suspending the Respondent's license to practice dentistry in the State of Florida for a period of six (6) months. RECOMMENDED this 1st day of May 1981, in Tallahassee, Florida. JAMES E. BRADWELL Hearing Officer Division of Administrative Hearings Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 1st day of May 1981.
The Issue Whether Respondent committed various violations of Chapter 466, Florida Statutes, as alleged in the Administrative Complaints.
Findings Of Fact That on or about July 18 1984, patient P.F. presented herself to Respondent's dental center for dental services. At all times material to the allegations contained in the Administrative Complaint, the Respondent was the dentist of record for the patient, P.F. On or about Jul ,8, 1984, Joan Chen, D.D.S., at the direction or request of Respondent, began crown preparation on patient P.F.'s teeth number 18, number 19, number 30 and number 1, during the initial visit. The treatment rendered by Respondent consisted of root canal therapy on teeth number 19 and number 30, and placement of crowns on teeth number 18, number 19, number 30 and number 31. Treatment provided P.F. by Respondent as the dentist of record failed to meet the minimum standards of diagnosis and treatment by failure to complete endodontic treatment on patient's teeth number 19 and number 30. The patient indicated that at the time of her initial visit she was told she would need two root canals, one on each side. Dr. Delk had told the patient of this need and gave the patient an estimate for services. A person with a "certificate" started the drilling for the root canal, and Dr. Delk completed it. After the teeth were drilled, Dr. Delk offered to extract the teeth for the stated reason that her mouth was too small to accommodate them. The endodontic treatment on teeth number 19 and number 30 were never completed. The failure to complete endodontic treatment was beneath the standard of care in the community. It enhanced the possibility of tooth loss due to the involvement of the bifurcation. A permanent crown was placed over tooth number 19, which was fractured. Tooth number 19 had a violation of the bifurcation which showed "absolutely no dental skill at all". There was junk "piled" down to the bifurcation and a permanent crown placed over it. Tooth number 30 was also perforated. According to the pre-operative x-ray, this was a good healthy tooth. No treatment called for a permanent crown to be placed, and the tooth was left in that condition. The chart did not reflect the patient was ever informed of the perforation and that the minimal acceptable practice would be to inform the patient. The capping of the tooth after perforation was beneath the minimal standard of care. The patient first learned of the perforation of the tooth from Dr. Buljevic, a subsequent treating dentist in Chile. There was a level of awareness by both the Respondent and his staff of the perforation of at least one of the teeth according to the testimony of Jacqueline Hansen on July 18, 1984. Dr. Delk was aware of the perforations which were done in this case. Dr. Delk did not note in his chart the perforations or any attempt to notify the patient of the perforations.
Conclusions Petitioner has proven by clear and convincing evidence that the Respondent has violated Section 466.208(1)(y), Florida Statutes, by being guilty of incompetence by failing to meet the minimum standards of performance and diagnosis and treatment when measured against generally prevailing peer performance by: Failing to complete endodontic treatment on patient's tooth number 19. Failing to complete endodontic treatment on patient's tooth number 30. Placement of a permanent crown over fractured tooth number 19. Perforation of tooth number 30. By failing to inform the patient of the condition or to note it in his chart. It is further found that the Respondent cannot avoid responsibility for his actions in light of Section 466.018, Florida Statutes, which provides that each patient shall have a dentist of record. The dentist of record shall remain primarily responsible for all dental treatment on such patient regardless of whether the treatment is rendered by the dentist himself or by another dentist, dental hygienist, or dental auxiliary rendering such treatment at the direction or request of or under the supervision of such dentist of record. Dr. John W. Delk was the dentist of record for patient P.F. when the treatment was rendered. Any attempt to disclaim responsibility based on the performance of services by another dentist is unsupported by the record, but even if, assuming arguendo, it was supported by the record, it does not excuse Dr. Delk's actions based upon Section 466.018, Florida Statutes, which places responsibility on the dentist of record.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the, Department of Professional Regulation, Board of Dentistry, enter its final order finding Respondent guilty of Count I and not guilty of Count II as to Case Nos. 89-0646; guilty of the allegations contained in Case Nos. 89-0647 and 89-3313; imposing a fine of $500 each for Case Nos. 89- 0646 and 0647 and a fine of $1000 for Case No. 89-3313; suspending the Respondent's license for two years; and placing Respondent on probation for 24 months subsequent to the expiration of the suspension period, conditioning reinstatement of Respondent's license to practice dentistry to such reasonable conditions as the Board may require. The suspension period reflects the consideration of Rule 21G-13.005, Florida Administrative Code, which provides the following be considered: (a) the severity of the offense, (b) the danger to the public, (c) the number of repetitions of offenses or number of patients involved, (d) the length of time since the violation, (e) the number of times the licensee has been previously disciplined by the Board, (f) the length of time the licensee has practiced, (g) the actual damage, physical or otherwise caused by the violation and the irreversibility of the damage, (h) the deterrent effect of the penalty imposed, (i) the effect of the penalty upon the licensee's livelihood, (j) any efforts of any rehabilitation by the licensee, (k) the actual knowledge of the licensee pertaining to the violation, (l) the attempts by the licensee to stop or correct the violation or refusal by the licensee to correct or stop the violation, (m) related violations against licensee in another state, including findings of guilty or innocence penalties imposed and penalties served, (n) penalties imposed for related offenses under Sections 2 and 3 above, and (o) any other relevant mitigating or aggravating factor under the circumstances. The offenses are severe since they have harmed three different patients, and Dr. Delk has previously been disciplined for improper delegation. The record does not indicate any efforts of rehabilitation by the Respondent, and he denied actual knowledge of the damage caused to P.F. in spite of, the fact that it was apparent. DONE AND ENTERED this 26th day of September, 1990, in Tallahassee, Leon County, Florida. DANIEL M. KILBRIDE 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 26th day of September, 1990. APPENDIX TO RECOMMENDED ORDER The following constitutes my specific rulings, in accordance with section 120.59, Florida Statutes, on findings of fact submitted by the parties. Petitioner's Proposed Findings of Fact As to Case No. 89-0646 Accepted: Paragraphs 1,2,3,4,5 (in substance), 6 (in substance), 8, 9 (in substance), 10, 15 (in substance),17, 18, 19, 20, 21(1) (in part), 21(2)(in substance), 22 (in substance) ,23 (in substance), 24 (in substance), 26 (in substance), 27 (in substance), 28, 29 (in part) Rejected as not proven by clear and convincing evidence: paragraphs 7, 11, 12, 13, 14, 16 (argument), 21(1) (in part), 25 (in part) As to Case No. 89-0647 Accepted in substance: paragraphs 1, 2, 3, 4, 5, 6, 7 (in part), 9, 14, 15 (in substance) Rejected as not proven by clear and convincing evidence: paragraphs 8, 10, 11, 12, 13, 16 and 17, 18, 19, 20 and 21 (duplication) As to Case No. 89-3313 Accepted: 1, 2, 3, 4, 5, 6 (in substance), 7 (in substance), 8, 9, 10, 11, 12, 13, 14, 15, 16-34 (incorporated in substance), 35 (in substance), 36, 37, 38, 39, 40, 41, 42 (in substance), 43, 44, 45, 46, 47 Respondent's Proposed Findings of Fact As to Case No. 89-0646 Respondent's recommended findings contained in 169 numbered paragraphs have been carefully and incorporated where sustained by the evidence. However, the proposed findings are essentially a recitation of the testimony of the witnesses. Therefore, they cannot be individually ruled upon and, except where incorporated, are rejected. As to Case No. 89-0647 Respondent's recommended findings contained in 129 numbered paragraphs have been carefully and incorporated where sustained by the evidence. However, the proposed findings are essentially a recitation and commentary on the testimony of the witnesses. Therefore, they cannot be individually ruled upon and, except where incorporated, are rejected. As to Case No. 89-3313 Respondent's recommended findings contained in 248 numbered paragraphs (followed by a summary of the facts numbered A through Y) have been carefully reviewed and incorporated where sustained by the evidence. However, the proposed findings are essentially a recitation and commentary on the testimony of the witnesses. Therefore, they cannot be individually ruled upon and, except where incorporated, are rejected. COPIES FURNISHED: John Namey, Esquire 1520 Livingston Street Orlando, FL 32803 Thomas Gordon, Esquire 320 North Magnolia Avenue Suite 5-B Orlando, FL 32801 William Buckhalt Executive Director Department of Professional Regulation Northwood Centre 1940 North Monroe Street Suite 60 Tallahassee, FL 32399-0792 Kenneth E. Easley General Counsel Department of Professional Regulation Northwood Centre 1940 North Monroe Street Suite 60 Tallahassee, FL 32399-0792
The Issue Whether Respondent's license to practice dentistry in the State of Florida should be revoked, suspended or otherwise disciplined under the facts and circumstances of this case.
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant findings of fact are made. At all times material to this proceeding, the Respondent was a licensed dentist in the State of Florida, having been issued license number DN 0005429. The patient, R.M., first presented herself to the American Dental Center (Center), a dental business owned and operated by Respondent, around July 7, 1987, and was seen by a dentist, other than the Respondent, employed by the Center. This dentist examined R.M. and recommended a new upper denture and lower partial. R.M. was seen again on December 7, 1987, by a dentist, other than the Respondent, at the Center who repaired tooth number 7 on her upper denture. This dentist also advised R.M. that she needed a new upper denture and a lower partial. On June 13, 1989, R.M. was seen by the Respondent at the Center, and the Respondent refused to reline R.M.'s upper denture. Respondent advised R.M. that she needed a new upper denture and a lower partial. On July 12, 1989, R.M. saw another dentist, other than Respondent, at the Center who replaced tooth number 7 in her upper denture, and this dentist advised R.M. that she needed a new upper denture and a full lower denture. On September 8, 1989, R.M. visited the Center and was seen by the Respondent. R.M. agreed to Respondent's treatment proposal of June 13, 1989, for a new full upper denture and a new lower partial. During this visit, the Respondent drilled two holes in the back of two of the lower teeth, numbers 22 and 27, in preparation for a cingulum rest. This procedure was not discussed with R.M. at that time. R.M. did not complain to the Respondent that there was sensitivity as a result of these holes. Also, on this same visit, the Respondent made lower partial impressions and full upper denture impressions. The Respondent properly performed a periodontal probing which was properly recorded in the records, notwithstanding the conflict in the testimony regarding R.M.'s records as to which dentist performed the periodontal probing. Likewise, the Respondent properly performed a soft tissue examination which was properly recorded in the records. On September 25, 1989, the Respondent checked the vertical dimensions of occlusion (VDO) with the full upper dentures and lower partial in place, and found both the vertical dimensions and the occlusion (bite) to be within reasonable bounds. Dr. Marshall performed the vertical dimensions and found them to be outside reasonable bounds. However, when Dr. Marshall performed this test, R.M. did not have the lower partial in place because the holes in teeth numbers 22 and 27 had been bonded by Dr. Odegaard. Because the lower partial could not be in place, the occlusion could not be checked. Also, not having the lower partial in place could have accounted for the difference in the vertical dimensions observed by Dr. Marshall and the Respondent. R.M. was apparently satisfied at this time with Respondent's work since she voiced no complaint. Respondent also selected shade of teeth at this appointment. At R.M.'s next visit, sometime between September 25, 1989, and October 6, 1989 (possibly October 1, 1989), the Respondent made a full upper denture impression in rubber base. R.M. was allowed a look at the full upper denture and the lower partial in place. When in place, the upper denture and lower partial did not interfere with Respondent's enunciation of certain words or certain numbers which would indicate that the upper denture and lower partial fit properly. R.M. initialed her chart indicating that she approved the shape, shade, color, size and arrangement of teeth. There is insufficient evidence to show that the patient knew what she was initialing, and at this point had no complaints, or if she had, she did not voice them. R.M.'s next visit was October 6, 1989, and at this visit the full upper denture and lower partial were delivered to her, placed in her mouth and she was allowed to look at them with a mirror. R.M. voiced no complaints, other than a minor sore spot which Respondent corrected, and she paid the balance of her bill and left. At this same visit, both Respondent and R.M. realized that after a period of time certain adjustment would be needed. On October 16, 1989, R.M. called Respondent's office complaining that her dentures and lower partial were hurting. R.M. was advised that her chart would be pulled for the Respondent to review and that the office would call back. Upon being called back, R.M. was advised by Respondent's staff that Respondent wanted her to come in to the office for adjustments. However, R.M. refused to come back in for any adjustments and advised Respondent's staff that she wanted her money back or she was going to the Better Business Bureau or get a lawyer. Around November 24, 1989, R.M. visited Dr. Odegaard's office complaining of sensitivity on lower teeth numbers 22 and 27. Upon examination, Dr. Odegaard determined that the hole drilled in those teeth by Respondent had gone through the enamel into the dentin which was the apparent cause of the sensitivity. Dr. Odegaard bonded the holes in teeth numbers 22 and 27 which relieved the sensitivity. At that visit, Dr. Odegaard was aware of Petitioner's involvement in this case. Based on the testimony of the experts, it is apparent that drilling through the enamel of a tooth into the dentin is not an uncommon occurrence, and that, in itself, would not necessarily be practice below the standard of care. Notwithstanding the testimony of Dr. Odegaard and Dr. Marshall, there is competent substantial evidence, including Dr. Reichgott's testimony, to establish facts to show that the placing of the lingual rest on teeth numbers 22 and 27 was a treatment of choice and not any riskier than other procedures performed by dentists. Notwithstanding the testimony of Dr. Odegaard and Dr. Marshall, there is competent substantial evidence, including the testimony of Dr. Reichgott, to establish facts to show that: (a) a soft tissue and periodontal examination was performed and recorded in the patient's records; (b) the preparation of the lower lingual surface of the lower canine for the lingual rests was not practice below the standard of care, or (c) the failure to record in the patient's chart the possible sequela of sensitivity from lingual rests and alternate methods of treatment was not practice below the standard of care. While the Respondent's plan of treatment was brief, it was not inadequate record keeping or practice below the standard of care. On each visit where R.M. saw the Respondent in a professional capacity, the Respondent made certain notations in the record concerning what he had accomplished during each visit, and while these notations are brief they do adequately describe what Respondent had accomplished. There is competent substantial evidence to establish facts to show that Respondent's dental records and medical history records justified the course of treatment for R.M. There is competent substantial evidence to establish facts to show that Respondent's treatment of R.M. met the minimum standards of performance in diagnosis and treatment when measured against the generally prevailing peer performance.
Recommendation Having considered the foregoing Findings Of Fact and Conclusions Of Law, it is, accordingly, Recommended that the Board enter a Final Order dismissing the Administrative Complaint filed in this case. DONE and ORDERED this 27th day of May, 1992, in Tallahassee, Florida. WILLIAM R. CAVE Hearing Officer Division of Administrative Hearings The Desoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 27th day of May, 1992. APPENDIX TO THE RECOMMENDED ORDER The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on the Proposed Findings Of Fact submitted by the Parties in this case. Specific Rulings On Proposed Findings Of Fact Submitted By The Petitioner 1. Adopted in Finding of Fact 1. 2-4. Adopted in Finding of Fact 2, except for the date June 7, 1987, which is rejected in that it was July 7, 1987. Adopted in Finding of Fact 4. Rejected as not being supported by competent substantial evidence in the record. 7(a)(b). Adopted in Finding of Fact 6. 7(c). Adopted in substance in Finding of Fact 13, as modified, except for being "performed in a non-traditional area" which is rejected as not being supported by competent substantial evidence in the record. 7(d). Other than being asked to sign chart signifying approval which is adopted in Finding of Fact 9, this proposed finding of fact is rejected as not being supported by competent substantial evidence in the record. 7(e). Adopted in Finding of Fact 10. 7(f)-(i). Rejected as not being supported by competent substantial evidence in the record. 7(j)-(k). Adopted in Finding of Fact 13. 7(l). Neither material or relevant to the conclusion reached in the Recommended Order. 8-9. Rejected as making a conclusion without making a finding of fact that there was in fact a failure on the part of the Respondent, but in any case these are not supported by competent substantial evidence in the record. 10-11. Rejected as not being supported by competent substantial evidence in the record. Specific Rulings On Proposed Findings Of Fact Submitted By The Respondent The Respondent's "Findings Of Fact" are in part argument and part restatement of testimony rather than proposed findings of fact. However, for those that are truly findings of fact, I have adopted in Findings Of Fact 1-19. Copies furnished to: Albert Peacock, Esquire Department of Professional Regulation 1940 N. Monroe Street Tallahassee, FL 32399-0792 Peter Kurachek, D.D.S. 395 Sugar Mill Drive Osprey, FL 34229 William Buckhalt Executive Director Department of Professional Regulation Northwood Centre 1940 North Monroe Street Suite 60 Tallahassee, FL 32399-0792 Jack McRay General Counsel Department of Professional Regulation Northwood Centre 1940 North Monroe Street Suite 60 Tallahassee, FL 32399-0792
Findings Of Fact At all times pertinent to the allegations in the Administrative Complaint, the Respondent was licensed as a dentist in Florida and the Petitioner was the state agency charged with regulating the practice of dentistry in this state. In June, 1984, Morris W. Kemmerer went to the Respondent, Peter M. Kurachek's, dental office because he needed dental work done and Respondent's office was handy. He was examined on this first visit by the Respondent and told Respondent what he wanted. Respondent went to work right away and within a few minutes of the patient's sitting in the chair, pulled a tooth which had broken and had to come out. Though Mr. Kemmerer had asked Respondent to put him to sleep for the extraction, Respondent did not do so. Respondent told Mr. Kemmerer what he planned to do as a course of treatment, and advised him of the expected cost and how it could be paid. Mr. Kemmerer claims he did not take a dental history nor did he, at any time, either before or after the work was done, discuss the patient's oral hygiene which was, supposedly, poor. The chart prepared by Respondent on Mr. Kemmerer contains, aside from notations as to work done, only the most basic information, such as allergies and prior medical condition, as well as current status of the mouth. Though minimal, it can be considered a dental history. After the initial procedure done the first day, Mr. Kemmerer returned to Respondent's office every day for awhile. On his second visit, the Respondent told him he needed a bridge and, though Mr. Kemmerer's memory on the matter is poor, probably told him of the remainder of the course of treatment. The bridge in question was necessary because the tooth Respondent pulled on the first visit was the one to which Mr. Kemmerer's existing bridge was anchored, and extraction of that anchor tooth required Respondent to make another bridge to be affixed to the next sound natural tooth. However, Mr. Kemmerer recalls that the bridge made for him by the Respondent did not fit correctly from the beginning and Respondent had to make several for him before a reasonably comfortable fit was finally achieved. This was done by grinding down Mr. Kemmerer's opposing natural teeth. Even with that measure, however, the fit was never completely correct. Respondent also made an additional partial denture for Mr. Kemmerer which could never be worn because it didn't fit. When Mr. Kemmerer told Respondent about this, he tried to fix it but was not able to do so satisfactorily and Mr. Kemmerer suffered an extended period of pain as a result. Mr. Kemmerer paid Respondent approximately $1,700.00 for the work done and did not see him again after August 9, 1984. Even though the work done was not to his satisfaction, Mr. Kemmerer did not see another dentist because he could not afford to do so. However, at the suggestion of his coworkers, he agreed to see Dr. Philip M. Davis, II, another dentist in Sarasota who, after an examination, told him the work Respondent had done had to be done over. Mr. Kemmerer ultimately contacted the Department of Professional Regulation about the treatment he received from the Respondent and filed a civil suit against Respondent, settling without trial for $3,000.00. The fact that the suit was settled in Mr. Kemmerer's favor has no bearing on the issue of care involved in this hearing and is not considered. Dr. Davis first saw Mr. Kemmerer as a patient on June 11, 1986 when Mr. Kemmerer presented himself complaining of swelling and pain in a right upper molar, (tooth 4). Upon examination, Dr. Davis found the patient had a partial bridge with crown and observed that the crown margins did not touch the prepared edge of the supporting tooth as they should. His x-rays taken at the time showed Mr. Kemmerer had an infection in the tooth and when he opened it through the crown, he found a space filled with cement, food, and waste, and that the tooth tissue was leathery. All that indicated to him that decay had gotten up under the crown and the base of the tooth had rotted because, in his opinion, the crown edge, (margin), did not properly fit to the tooth base. Dr. Davis noted that the margins of several crowns prepared by the Respondent several years earlier, were not good fits. Photographs of Mr. Kemmerer's mouth made in August, 1987 and October, 1988, as much as 3 and 4 years after completion of Respondent's work, reveal that at that time the margins on several teeth were substantially open. When Dr. Davis saw Mr. Kemmerer in 1986, he noted that the bridge constructed by the Respondent had been cemented to the abutment teeth which also had open margins. Regarding the specific teeth in question, photos of tooth 4 show a failure of the margin of the crown to touch the tooth and the preparation thereof. This indicates the crown was not properly fitted to the prepared tooth. It had never fully seated on the tooth and appeared to have been cemented in a suspended position above the tooth instead of being seated down on it. Insertion of a crown such as this one is a routing procedure and is not particularly complex. By not properly seating the crown, the installer, (Respondent), left an open space for saliva to enter and wash out the cement. Acceptable tolerance for a margin of this nature is 40 microns, (40/10,000 in.). On tooth 4, the margin was 2 mm short on the cheek side and 3 mm short on the tongue side. This led to the cement being washed out and to the entry of food and bacteria resulting in decay and infection of the bone. Had the crown been seated properly, it should have lasted for 10 - 20 years or more, absent trauma. As to tooth 11, examined by Dr. Davis on July 21, 1986, again, the crown margin was found to be well shy of the preparation margin on the tooth. On the tongue side, the crown was 1 mm short of full seating and was pulled away from the tissue. On the cheek side, the crown was too bulky for the preparation and did not match with a smooth, continuing surface. When Dr. Davis examined tooth 6 that same day, he found that here, too, the crown was too bulky and the margin did not fit. On the tongue side, it was 1/2 mm short and allowed food and bacteria to get up into an area of the tooth where the patient could not get it out. Dr. Davis did not measure the degree of separation, if any, on the cheek side. He did, however, find that on tooth 10, the margin was at one point 1/2 mm off and allowed food and bacteria retention. With regard to tooth 7, Dr. Davis found the margin on the lip side to be excessively heavy, (overbuilt), and on the tongue side, to be 1/2 mm short. In none of these cases were the margins acceptable as they far exceeded the 40 micron tolerance. These observations were confirmed by an examination of Mr. Kemmerer conducted at the request of the Board of Dentistry on May 13, 1987 by Dr. Davis R. Smith, an expert in general dentistry and the Board's consultant. Dr. Smith found the bridge built by Respondent to be poorly fitted around the preparation line of the teeth to which it related. Decay was present in every tooth to which Respondent had fitted a crown. The bridge had come loose, the crowns were not fitted properly, and the margin lines were short, open, and/or overcontoured. On each tooth involved, there was some combination of all those defects. When describing the margin shortage on some of Respondent's work on Mr. Kemmerer, Dr. Smith characterized it as, "ridiculously far off minimum standards." Dr. Smith's measurements were made visually and consisted of his running a probe over the margin seam which, in each case, he found to be excessive. A space of 50 microns can barely be felt with a probe and a space of 30 to 40 microns can barely be seen with the naked eye. Here, the margins were so poor that the space could be visually seen and entered with a probe. Both the experts opinioned that Respondent's seating of the crowns in question, so as to leave extensive gaps at the margins, was below standards. Respondent contends that at the time of installation, the crowns fit properly, and his expert, Dr. Carter, urges that a 1987 review of work done in 1984 cannot determine whether the margins at the time of installation were correct. This is because: Many things could have transpired in the patient's mouth in the interim such as changes in bone and tissue structure or a natural alteration of the appliance; Chemical changes in the mouth can erode tooth structure from beneath the margin, and tooth structure can be removed by cleaning. Respondent also contends that if the margins had been as poor from the beginning as indicated, the patient would have suffered pain and sensitivity associated with them. The evidence clearly demonstrates he did. Both Drs. Davis and Smith were of the opinion that, aliunde the margins, Respondent's office practice and record keeping were poor. In Dr. Davis' opinion, when a patient such as Mr. Kemmerer, of advanced age and obviously poor dental hygiene, comes in, the dentist must do a complete examination and charting to look for gum disease, cavities, occlusion and malocclusion, and evidence of cancer, and the examination should include full mouth x-rays. He must also talk with the patient and see what the patient perceives as his needs. If these are not great, the preliminaries need not be extensive, but in his opinion, to start work immediately, as Respondent did here, was improper since there was no emergency to justify disregard of a full work-up. Under the circumstances, he feels Respondent should have done a complete examination, determined what the patient needed, explained it all to the patient, and lectured on proper oral hygiene instead of jumping right in to do the crown and bridge work. It is found that would be the appropriate course for him to have followed. It must be noted that Mr. Kemmerer came in to Respondent's office indicating he was in pain. Respondent examined him and identified the cause of the pain. He corrected that problem and, in addition, began additional crown and bridge work which, while profitable, was not shown to be unnecessary. The procedures described by Drs. Smith and Davis are unquestionably the clinically appropriate things to do. While Respondent did not do all the things described as appropriate, he did identify his patient's immediate problem and correct it. Either he or his assistant advised the patient to practice better dental hygiene. He also incorporated his findings into his records on this patient. In that regard, the charting practices taught in school are appropriate for a school environment, but what is considered acceptable in private practice is not necessarily as detailed as in school. Respondent's expert is of the opinion that a dentist should advise his patient thoroughly on home care but that advice need not be noted in the records. He has found that records have become verbose, time consuming, and generally a pain in the neck, and, more importantly, record keeping such as is suggested, takes time away from caring for the patient. Legal action requires the dentist to protect himself, but in Dr. Carter's opinion, one cannot put everything on a chart; only those things which support patient care. While perhaps not conforming to optimum standards of practice, Respondent's actions in regard to record keeping and procedure choice cannot be said to be materially below standards. The formulation of the treatment plan is the primary responsibility of the dentist. During their examinations, both Drs. Davis and Smith noted that Mr. Kemmerer had lost a lot of enamel from the teeth occluding with the bridge. It appeared this was caused by Respondent's extensive grinding of the natural tooth material down to the dent in in order to get a proper occlusion with the bridgework he had installed, instead of removing the bridge and adjusting it to properly meet the natural teeth, or making another which did fit. Neither expert considered the worn condition of Mr. Kemmerer's teeth to be the result of natural grinding or bruxism. In any case, Respondent could have polished the rough enamel so as to reduce the resultant abrasion and he failed to do so. Respondent's actions here were, in the opinion of the Board's experts, below practice standards, and it is so found, notwithstanding Dr. Carter's testimony tending to exculpate Respondent's actions. Dr. Carter claims that Respondent's use of porcelain in the bridge, which, since it is harder that normal tooth tissue, will wear it down, was appropriate. He also asserts that if the patient did not wear his tooth 2 - 4 partial, he would still have had the abrasion problem because all chewing force being applied on the front teeth would wear them down. On balance, however, the evidence supports more clearly a finding that Respondent knowingly ground Mr. Kemmerer's natural teeth down to achieve the fit rather than taking appropriate corrective action when he found the bridge did not fit properly and he admits to this. The bridge in issue was made of metal and porcelain. When Respondent inserted the upper bridge, it was necessary for him to adjust the occlusions and to do so, he ground down the opposing lower natural teeth so the uppers and lowers would fit harmoniously. He denies that his placing of the upper teeth caused excessive wear on the lower teeth. The reduction in mass of the lower teeth was the direct result of Respondent's grinding down the natural teeth to fit to the false teeth on the bridge. Respondent presented the testimony by deposition of Dr. Hemerick, accepted as an expert in general dentistry. Dr. Hemerick was also offered as an expert in the field of prosthodontics. Petitioner accepted the witness as an expert in general dentistry but objected to him being classified as an expert in the field of prosthodontics. The objection is well taken. Though the witness is retained as an expert to evaluate dental performance for an insurance company which provides malpractice insurance to many dentists, his stated educational background and experience in the specialized field do not qualify him as "expert" in that specialty. He can, however, appropriately state his opinion as to the Respondent's treatment of Mr. Kemmerer in its totality and concluded that Respondent's treatment met accepted standards. Specifically, he stated that margins, as here, which fit acceptably when installed, can spread and open due to mouth activity over a period of years. What this witness, as well as Dr. Carter overlooks, however, is the excessive thickness of the device at the margin where it abuts the actual tooth. While the margin may open with time, construction material cannot grow on the appliance to make it thicker than when installed, and this, according to Petitioner's experts, was a basis for claiming Respondent's work was below standard in addition to the open margins. However, it is found that the likelihood of the margins opening as much as appears here, by normal mouth activity, is remote. Respondent has been a practicing dentist since 1966 when he got his degree in Kentucky. Over two separate periods, he has practiced in Florida for approximately 14 years. Mr. Kemmerer came to him initially for repair or replacement of a very old, (1943), denture which replaced front teeth 8 and 9 and which was not reparable. Respondent and Mr. Kemmerer discussed possible alternative treatments but both agreed treatment could not be postponed for this demanding cosmetic problem. It seems Mr. Kemmerer was in the real estate profession and needed teeth, and according to Respondent, wanted to leave Respondent's office that day with replacement teeth in his mouth. Respondent agreed to provide them. However, before starting treatment, Respondent determined from his examination of Mr. Kemmerer that due to long neglect of his dental hygiene, major treatment was necessary. Mr. Kemmerer wanted a patch job, Respondent alleges, and he refused to do that. Before work was started, however, Respondent left the room, leaving to his dental assistant the task of advising Mr. Kemmerer of the proposed treatment plan. Respondent had charted Mr. Kemmerer's mouth and instructed his assistant to go over the proposed work with him and give him a price for the work to be done. The assistant was to answer any questions Mr. Kemmerer might have. When Respondent returned to the treatment room, Mr. Kemmerer had a lot of questions to ask. His main concern was whether a new bridge would last. Respondent went over the proposed procedures with him and told him that with good home care, the appliance should last for the rest of Mr. Kemmerer's life. After Mr. Kemmerer met with Respondent's assistant, he elected to have the bridge made. Thereafter, Respondent had his assistant take impressions of Mr. Kemmerer's upper and lower jaw. Respondent anesthetized the upper area to be worked on and began the crown preparation on teeth 4, 6, 7, 10, and 11. He also adjusted the incisal edges on the abutting lower teeth, poured the upper and lower models, made a plastic temporary device for the upper area, and inserted it. There appears to be some dispute over whether Respondent made and utilized study models in the preparation of Mr. Kemmerer's appliance. He claims he did and there is little evidence to the contrary. Certainly, models were made and whether these constitute the required models has not been defined. It was obvious to Respondent early on that Mr. Kemmerer did not practice good dental hygiene. When Mr. Kemmerer returned to the office with stains on the temporary after only a short period of insertion, Respondent became concerned over his dental practices. However, it was not so bad a situation as to cause the needed repairs to be deferred and in Respondent's opinion, it was safe to begin the restorative treatment regardless of the fact that Mr. Kemmerer required periodontal treatment as well. It also appeared to Respondent that Mr. Kemmerer was an individual who was very susceptible to pain. It is because of this he believes that if all the margins had been open from the beginning, as alleged in the Complaint, Mr. Kemmerer would have sustained a lot of pain right away. At no time, however, during treatment, and after insertion of the permanent appliance did Mr. Kemmerer complain to him of pain. Respondent also contends that according to the records kept by Dr. Davis, when Mr. Kemmerer went to him in 1986, he complained of suffering pain for only 2 days. Respondent claims to have constructed in excess of 1,000 partial bridges in his 20 year career. He agrees that the margins as they now exist in Mr. Kemmerer's mouth are not acceptable and are excessive. However, he contends, these conditions did not exist when he placed the bridge and there were no open margins. It is his practice, he alleges, to return for reconstruction any bridge which does not fit properly and if at insertion this bridge had had the margins it now has, he would have done it over at no charge. He claims he saw Mr. Kemmerer's bridge on five separate occasions after it was inserted and claims never to have seen any open margins. However, Mr. Kemmerer's record shows that he only came back twice after the bridge was inserted and Respondent, commenting on the alleged lack of "follow-up" stated that after the bridge was completed and inserted, Mr. Kemmerer didn't come back. It would appear Respondent's memory is somewhat less than complete. Respondent also sees no problem in his ability to complete Mr. Kemmerer's work within 4 weeks from initial visit. When comparing that with the other expert's estimate of 6 to 9 months for completion of a proper treatment for this patient, Respondent claims the longer period is for rehabilitation of the entire mouth which, he asserts, he did not propose or agree to do. It is found that Respondent's operation is one of direct response to a particular problem, and he is not a provider of broad scale dental care.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore: RECOMMENDED that Respondent's license to practice dentistry in Florida be suspended for a period of six months and he be fined $3,000.00, and that when reinstated, he be placed on probation, under such terms and conditions as the Board may prescribe, for a period of three additional years, these actions to run concurrently with the penalty, if any , imposed by the Board in its action, when taken, in its allied cases involving Respondent, heard under DOAH case numbers 89-1240 and 89-1241. RECOMMENDED this 21st day of November, 1989, in Tallahassee, Florida. ARNOLD H. POLLOCK, Hearing Officer Division of Administrative Hearing The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearing this 21st day of November, 1989. APPENDIX TO RECOMMENDED ORDER IN CASE NO. 89-5544 The following constitutes my specific rulings pursuant to S 120.59(2), Florida Statutes, on all of the proposed Findings of Fact submitted by Petitioner in this case. 1. & 2. Accepted and incorporated herein. 3. & 4. Accepted and incorporated herein. 5. & 6. Accepted and incorporated herein. & 8. Accepted and incorporated herein. COPIES FURNISHED: David Bryant, Esquire 13015 North Dale Mabry Highway Suite 315 Tampa, Florida 33618 Salvatore A. Carpino, Esquire One Urban Centre, Suite 750 4830 West Kennedy Blvd. Tampa, Florida 33609 Kenneth E. Easley, Esquire General Counsel DPR 1940 North Monroe Street Tallahassee, Florida 32399-0792 William Buckhalt Executive Director Board of Dentistry 1940 North Monroe Street Tallahassee, Florida 32399-0792 =================================================================
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
