Findings Of Fact During the summer of 1982, Petitioner, Habib H. Ghahremannezhad, of Thibodaux, Louisiana, sent a letter to the Respondent requesting information on the requirements to take the Florida dental examination. He had been advised by a representative of the American Dental Association that foreign dentists could take the examination. 1/ In response to his letter, the Respondent sent him the required application forms, which had a submission deadline in late September, 1982. Petitioner submitted them on time as required; and just a few weeks before the examination, in November, 1982, he received further instructions from Respondent which included the requirement that he, the candidate, bring with him to the examination a stipulated number of real human teeth in what could be described as perfect shape. Teeth of this nature are difficult to get; and though Petitioner called many practicing dentists in the area where he lived and also contacted the local dental school, he was unable to procure the appropriately preserved teeth within the short period of time between his receipt of notification of the requirement and the test. As a result, he was required to purchase a human skull from a medical supply house, from which he extracted the required teeth. These skulls are prepared for use by medical students and are dried out. The teeth in them, therefore, are brittle and fragile. Though he stored them in a glycerine/water solution up to the examination, this could not and did not restore already dehydrated, dead, brittle teeth to their former condition. The appropriate teeth would have been freshly extracted and thereafter stored in a mixture of glycerine and water which would have preserved their resiliency and rendered them not brittle and subject to easy breakage. There was no evidence presented, however, to show that Petitioner received his instructions any later than other candidates who suffered under the same handicaps as he in procuring appropriate teeth. In fact, he admits he was not singled out for late instructions, and the other candidates had the same problems. The mannequin examination consisted of at least nine different procedures. Each procedure was performed by the candidate with a monitor in the area. When the procedures were completed, they were thereafter graded anonymously (each procedure model was marked only with the candidate's examination number, not the name) by three separate examiners who independently, out of the presence of each other (and who were also identified only by a number), assigned a numerical grade to each procedure based on criteria set out on a prepared grading sheet. Under the rules for this examination, a grade of 3.0 out of a range from 0 to 5 is required to achieve a passing score. Respondent achieved a grade of 2.71, which was a failing grade and which was arrived at by averaging the three grades for each procedure, adding these nine averages and dividing by nine. Petitioner scored, as follows: (a) Procedure 01 Examiner 003 - 2 Examiner 071 - 3 average 2.67 Examiner 072 - 3 (b) Procedure 02 Examiner 072 - 3 Examiner 071 - 3 average 3.0 Examiner 008 - 3 (c) Procedure 03 Examiner 072 - 1 Examiner 071 - 1 average 0.67 Examiner 008 - 0 (d) Procedure 04 Examiner 008 - 2 Examiner 071 - 1 average 2.0 Examiner 072 - 3 (e) Procedure 05 Examiner 072 - 4 Examiner ,071 - 4 average 4.0 Examiner 008 - 4 (f) Procedure 06 Examiner 059 - 5 Examiner 066 - 3 average 4.33 Examiner 037 - 5 (g) Procedure 07 Examiner 059 - 3 Examiner 066 - 3 average 3.67 Examiner 037 - 5 (h) Procedure 08 Examiner 059 - 3 Examiner 066 - 4 average 4.0 Examiner 037 - 5 (i) Procedure 09 Examiner 059 - 0 Examiner 066 - 0 average 0.33 Examiner 037 - 1 Petitioner makes numerous allegations regarding the fairness of the examination and what he considers to be discrimination against foreign dental students. He produced, however, no evidence save his own opinion to support these claims except in the case of the instructions (Petitioner's Exhibit 1), which, on Page 3 at Paragraph 7, state that a candidate who fails this examination two times will not be eligible to take the remaining examinations for licensure "except for a candidate who graduated from the University of Havana prior to 1962, who may take [this] examination an unlimited number of times." Petitioner claims this provision discriminates against foreign dentists. If any discrimination is shown, it is clearly reverse discrimination in favor of older Cuban dentists, a decision which is an approved policy of the Respondent. Consequently, there is no showing whatever that Petitioner was in any way discriminated against. Petitioner also contests, however, the grades given him on Procedures 3 and 9. Procedure 3 was a "Dental Class III preparation for a composite restoration on a maxillary central incisor." Here, the tooth Petitioner had for preparation was one of those fragile teeth which had dried out and was brittle. As a result, the tooth broke as he was working on it. At this point, he showed his problem to the monitor, who advised him to include that area in the preparation. He did that, as instructed, and received a low grade on his procedure, which he contends was the fault of the instructions given him by the examiner. Procedure 3 was designed to test the candidate's ability to demonstrate an acceptable preparation to Respondent's standards. This preparation would be a minimal preparation which would be for a very small cavity. Petitioner was graded low on this procedure by all three examiners, who each made additional handwritten comments on the form. All comments related to excessive depth of the preparation, which is not related to the width and size of the preparation. These latter conditions could, indeed, be related to the instructions of the monitor and, if they were the only comments, might justify adjustment. However, Petitioner made his preparation too deep, in fact exposing the pulp (nerve) of the tooth. This defect is not related to the size of the preparation as increased by the instructions of the monitor to include the area in the preparation. By itself, pulpal exposure is sufficient to cause a grade of 0 for this procedure. Here, the groove was so deep and so grossly oversized it went beyond any tolerance which might be given for a situation where, like here, the examinee has no idea, because of the dead tooth and no X rays, how close to the surface the pulp is. Further, two of the three grade sheets bear the notation "SMN," which means "saw monitor's notes." This indicates that before awarding a grade, these two examiners were aware of the problem that Petitioner had and that the monitor had advised him to include the break area in the procedure. Even after making allowances for that, two of the examiners graded Petitioner's work as "1," and the other gave him "0." These grades are consistent and within normal deviation, and all are failing grades. In light of this, one cannot conclude the rating for this procedure was improper so as to merit upward adjustment. As to Procedure 9, this was to prepare a "wax-up for a cast-gold bridge on the above [formerly] prepared teeth. . ." Petitioner contends he did as directed, completed the procedure, and turned it in. In an actual clinical situation, this work would not be done in the mouth of the patient, but for examination purposes, the candidates were directed to make the wax pattern directly in the model-- a far more difficult and rarely done procedure. However, the grading criteria take into consideration the conditions under which the examinee has to work in determining a pass or fail grade. This procedure has been changed with the 1983 examination. Candidates will no longer be required to work under this previous, more difficult method. After Petitioner completed the procedure, he turned it in and left. When the first examiner looked at the device prepared by Petitioner and attempted to take it apart, he broke it. Petitioner was awarded a grade of 0 by two examiners and a "1" by the third. He contends that since his wax model was broken by the first examiner, this was not his fault, and he should not have been given failing grades. He states that when he handed the pattern in, it was intact and, contra to claims of the examiner, he does not believe the pattern broke as a result of the area of cohesion being too small, as this item was graded as passing in the prior procedure. In addition, Petitioner contends that even if the wax cohesion was insufficient, this still does not justify a "0," since there were at least three other major areas which should be considered. However, review of the grading sheets, at least for Examiners 059 and 037, shows that numerous other deficiencies were found in Petitioner's procedure here, aliunde the wax cohesion and breakage, and these other deficiencies would justify a failing grade--even a "0." In the area of the broken wax pattern, however, examiners are indoctrinated as to all procedures to be tested the day before the examination and go over them thoroughly in advance. As to wax patterns, they are told at this time that the pattern may be removed, but only using "utmost care." Here, the candidate is asked to make a wax pattern for a 3/4 crown for one tooth, the back attachment to be waxed to a full crown. The stability of the pattern to withstand withdrawal is related to how well the procedure is waxed. In the opinion of Dr. Agnini, the Respondent's expert, sufficient wax could have been inserted to strengthen the wax pattern as it was being built under exam conditions. The examiner's (059) comments were that he broke the pattern and that the attachment was poor. It was the poor attachment that caused the device to break. Review showed that it was insufficiently waxed (See sheet for 059, Comment 5d.), and this did not meet the criteria. Respondent's witness concedes the possibility that the wax pattern breaking influenced in a negative fashion the judgment of the graders. However, as previously found, there were several other identified deficiencies on this procedure, and the low grades awarded rate to the procedure in its entirety--not solely to the fracture. There is no showing this procedure was unfairly or improperly graded. Although the examiners are not told how to withdraw the pattern during the standardization briefing other than to do it carefully, all examiners are licensed dentists and should know how to remove a wax pattern.
Recommendation Based on the foregoing, it is, therefore, RECOMMENDED: That a final order be entered by the Board of Dentistry finding that Petitioner has failed to achieve a passing score on the December, 1982, Dental Mannequin Examination and upholding the grade awarded to him on that examination. RECOMMENDED this 8th day of November, 1983, in Tallahassee, Florida. ARNOLD H. POLLOCK, 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 8th day of November, 1983.
The Issue The issue is whether the score that Respondent assigned to the Patient Amalgam Preparation section of the clinical part of Petitioner's June 2003 Florida Dental License Examination was arbitrary or capricious.
Findings Of Fact Petitioner took the June 2003 Florida Dental License Examination. A passing score for the clinical part of the examination is 3.0. Petitioner received a score of 2.9, so he failed the clinical part of the examination. Petitioner has challenged the grade of 2.0 that he received on the Patient Amalgam Preparation of the clinical part of the examination. The score of 2.0 is derived from averaging the 3s that Petitioner received from two evaluators and the 0 that he received from one evaluator. Petitioner challenges only the score of 0, and he needs two additional points to pass the clinical part of the examination. The administration of the clinical part of the dental examination requires Respondent to recruit and train numerous examiners and monitors, all of whom are experienced, licensed dentists. The training process includes standardization exercises designed to ensure that all examiners are applying the same scoring criteria. The evaluation of specific procedures are double-blind, with scoring sheets that identify candidates by test numbers, so examiners do not know the identity of the candidate whose procedures they are scoring. The section that is the subject of this case requires the candidate to demonstrate certain skills on a live patient. While working with the patient, the candidate is supervised by a monitor. When the candidate has completed the required dental work to his satisfaction, he so advises the monitor, who sends the patient to the dental examiners. For the section that is the subject of this case, three dental examiners examine the patient and score the procedure. These examiners do not communicate with each other, and each performs his or her examinations and scores the procedure in isolation from the other examiners. Communications between examiners and candidates are exclusively through monitor notes. For the section that is the subject of this case, the maximum possible score that a candidate may receive is a 5. Passing grades are 3, 4, or 5. Nonpassing grades are 0, 1, or A score of 3 indicates minimal competence. The Patient Amalgam Preparation section of the clinical part of the examination required Petitioner to remove caries from one tooth and prepare the tooth for restoration. These procedures are of obvious importance to dental health. Poor preparation of the tooth surface will probably result in the premature failure of the restoration. A restoration following incomplete removal of caries will probably result in ongoing disease, possibly resulting in the loss of the tooth. Written materials, as well as Respondent's rules, which are discussed below, require a 0 if caries remain, after the candidate has presented the patient as ready for restoration. Other criteria apply to the Patient Amalgam Preparation procedure, but this criterion is the only one of importance in this case. Examiners 207 and 394 each assigned Petitioner a 3 for this procedure, but Examiner 417 assigned him a 0. Examiners 207 and 394 noted some problems with the preparation of the tooth, but neither detected any caries. Examiner 417 detected caries and documented her finding, as required to do when scoring a 0. Examiner 207 has served as an examiner for 10 years and has conducted 15-20 evaluation examinations during this time. Examiner 417 graduated from dental school in 1979. Examiner 394 has been licensed in Florida since 1995 and has served as an examiner only three years. The instructions to examiners emphasize that they are to detect caries "exclusively" tactilely, not visually. Tactile detection of the stickiness characteristic of caries is more reliable than visual detection. For example, caries assumes the color of dentin as the decay approaches the dentin. Despite the requirement to detect caries by touch, not sight, Examiner 417 initially testified that she detected the caries by sight. Later in her testimony, she backtracked and stated that she was not sure if she felt it or saw it. Her earlier, more definitive testimony is credited; Examiner 417 never found caries by touch, only by sight. In DOAH Case No. 03-3998, Examiner 417 readily conceded that she must have missed the caries that another examiner had detected, inspiring little confidence in her caries-detection ability. In that case, her value as one of two dentists in the majority was insignificant, even though the majority finding prevailed. In this case, Examiner 417's role as the lone dentist who found caries is too great an evidentiary burden for her to bear. The vagueness of her testimony and her reliance upon visual caries-detection preclude a finding of caries in this patient. Three other additional factors undermine Examiner 417's finding of caries. First, Examiners 207 and 394 found no caries. Examiner 207 has considerable experience. Examiner 394 has less experience, but he was the lone evaluator in DOAH Case No. 03-3998 to detect calculus deep below the gums, proving that he is both meticulous and a demanding grader. Together, then, the findings of Examiners 207 and 394 of no caries carry much greater weight than the contrary finding of Examiner 417. Nor was it likely that Examiner 417 accidentally dislodged the caries. No evidence suggest that she was the first examiner to examine the patient, and her means of detecting caries was visual, not tactile. Second, the location of the caries in this case was directly in the center of the tooth. So located, it was difficult for Petitioner and Examiners 207 and 394 to miss. Third, by two monitors' notes, Petitioner twice obtained the evaluators' permission to expand the drilled area, due to the extensiveness of the caries, suggesting that Petitioner was devoting careful attention to the removal of all caries, even if it meant an atypical site preparation.
Recommendation It is RECOMMENDED that the Department of Health enter a final order granting Petitioner an additional two points on the clinical part of the June 2003 Florida Dental License Examination and determining that he has passed this part of the dental examination. DONE AND ENTERED this 27th day of February, 2004, in Tallahassee, Leon County, Florida. S 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 27th day of February, 2004. COPIES FURNISHED: R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, BIN A02 Tallahassee, Florida 32399-1701 William H. Buckhalt, Executive Director Board of Dentistry Department of Health 4052 Bald Cypress Way, Bin C06 Tallahassee, Florida 32399-1701 James Randolph Quick Driftwood Plaza 2151 South U.S. Highway One Jupiter, Florida 33477 Cassandra Pasley Senior Attorney Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1703
The Issue Whether respondent should license petitioner as a dentist, despite the results of his manual skills examination, on account of the alleged unfairness of Examiner No. 170?
Findings Of Fact Petitioner Mohammed Hossein Teimourijam, who has practiced dentistry for five years and once taught dentistry at the National University of Iran, took the dental manual skills examination respondent administered in November of 1987. The examination consisted of nine procedures which each examinee performed on "dental mannequins." By reference to the number with which each applicant identified all of his procedures, examiners recorded their evaluations. Petitioner's Exhibit No. 1. Petitioner's original score was arrived at, as follows: PROCEDURE 006 154 170 AVERAGE 1 2 2 2 2.0 2 2 2 1 1.66 3 2 2 1 1.66 4 5 5 3 4.33 5 3 3 2 2.66 6 5 4 4 4.33 7 2 3 3 2.66 8 4 4 1 3.0 9 3 3 1 2.33 Respondent's Exhibit No. 3; Petitioner's Exhibit No. 3. Anonymous examiners, who did not see petitioner or any other examinee at work, began grading only after the applicants had finished the assigned procedures. The Board preserved the physical product of each procedure, along with the standardized rating sheets three examiners (Nos. 006, 154 and 170, in petitioner's case), filled out in evaluating each procedure. When respondent Board apprised Dr. Teimourijam that he had scored 2.71, below the 3.0 "necessary to achieve a passing status," Petitioner's Exhibit No. 3, he requested reconsideration. As a result, a consultant to respondent, who had attended the same standardization session as the original graders, reviewed the grading sheets and the procedures. With respect to procedures 8 and 9, the consultant concluded either that one of the original graders' comments was not physically verifiable or that one of the original grades was indefensible. Accordingly, three new graders evaluated petitioner's procedures 8 and 9. The results of the regrading were 3, 3 and 4 for each procedure, which brought petitioner's final grade to 2.84.
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
Findings Of Fact Dr. Roberts and His Background Dr. Steven Roberts is a dentist licensed to practice in the State of New York. He attended the United States Military Academy and received his undergraduate degree in 1970. He graduated from the New York University College of Dentistry in 1978, and practiced dentistry in New York, New York from 1978- 1987. To be licensed in New York, Dr. Roberts passed the national boards and the northeast regional board examination. During the course of his practice in New York, Dr. Roberts never received a complaint or had a claim for malpractice made or filed against him. Clinical Examinations Dr. Roberts took the Florida clinical dental examinations in June of 1986, January of 1987, and June of 1987. His grade on the June of 1987, examination is the subject of this proceeding. Dr. Roberts has successfully passed the written examination and the diagnostic examination required for licensure by Section 466.066(4)(a) and (c), Florida Statutes. Dr. Roberts' score for the June of 1987, clinical dental examination was 1.95; the minimum passing score is 3.00. The procedures tested during the June 1987, Clinical Dental Examination and Dr. Roberts' scores were as follows: The Procedure The Score The Revised Score Periodontal 1.67 Amalgam Cavity Preparation 1.67 Amalgam Cavity Restoration 3.00 Composite Preparation .67 Composite Restoration .33 Posterior Endodontics 2.00 3.66 Cast Preparation 2.67 3.00 Pin Amalgam Preparation 1.00 Pin Amalgam Restoration 1.67 Denture 3.63 Total Score 1.95 2.15 Dr. Roberts made a timely request to review his grade, and filed objections to his grades; a regrading procedure resulted in the regrading of his scores for posterior endodontics and cast restoration as set forth above. Each of the procedures tested in the clinical dental examination is scored by three different examiners. For each procedure examiners record their scores on separate 8 1/2" X 11" sheets. Each sheet has a matrix of circles which are blackened with a pencil so that they can be machine scored. On each sheet the candidate's identification number and the examiner's identification number are recorded along with the number for the procedure involved and the candidate's grade. On the sheet for each procedure the criteria for successful performance of the procedure are printed, along with preprinted comments which the examiners may use to explain the reason for the grade assigned. These comments relate to the criteria being examined. The following grades may be assigned by examiners: Complete failure Unacceptable dental procedure Below minimum acceptable dental procedure 3- Minimum acceptable dental procedure 4- Better than minimal acceptable dental procedure 5- Outstanding dental procedure An examiner is not required to mark a comment if the grade assigned is 5, a comment is marked for any grade below 5. Each procedure is graded in a holistic manner. Grades assigned by each of the three examiners for a procedure are averaged; the averaged scores for each procedure are then weighted and the weighted scores are summed to provide the overall clinical grade. By averaging the scores of three examiners for each procedure, variation from examiner to examiner is minimized. The examiners are experienced Florida dentists selected by the Board of Dentistry. An examiner must have at least five years of experience as a dentist and be an active practitioner. Potential examiners attend a standardization training exercise. This training is required by Section 466.006(4)(d), Florida Statutes. Its purpose is to instruct examiners in examination procedures and the criteria to be applied in grading. Through the training the examiner group as a whole arrives at a consensus opinion about the level of grading, so that candidates' scores on the examination will be valid and reliable. The training attempts to focus on each examiner's subjective, internalized evaluation criteria, so that they can be modified, as necessary, to reflect the consensus of all graders. A standardizer explains grading criteria to the potential examiners, and discusses various divisions among schools of thought and training on the procedures which will be the subject of the examination. The standardizer uses dental exhibits from prior dental exams as examples, and identifies grades and errors on the exhibits so that the graders learn and can adhere to uniform grading standards. The training focuses on three problems which professional literature has identified in evaluation: errors of central tendency, proximity errors, and bias a priori. Errors of central tendency result when graders are uncertain of criteria, hesitate to give extreme judgments, even in appropriate cases, and thus tend to improperly grade near the average. Proximity error is a type of halo effect which is applicable in grading of mannequin exhibits. The examiner grades all of the mannequin exhibits for each candidate at one time. If the first example of the candidate's work is especially good, and deserves a grade of 5, the grader may tend to transfer a generally positive attitude towards the next example of the candidate's work and assign a grade which may not be based solely upon the merits of that second piece of work. The same process can improperly depress the grades on subsequent mannequins if the first example of a candidate's work is poor. Bias a priori is the tendency to grade harshly or leniently based upon the examiner's knowledge of the use that will be made of the grade, rather than only on the quality of the work graded. After an 8 to 12 hour standardization training session, the Department administers an examination to those who have been trained. Those with the highest scores become the examiners, i.e., dentists who will grade candidates' work, while those with the lower scores in the training session become monitors, who supervise the candidates in their work on mannequins or on patients, but who do not actually grade student work. There is, however, no minimum score which a dentist who attends the standardization session must obtain in order to be an examiner rather than a monitor. This results, in part, from the limited pool of dentists who participate in the examination processes as monitors or examiners. For the 1987 clinical dental examination 31 dentists accepted selection by the Board and attended the standardization session, 20 were then selected as examiners and 11 became monitors for the examination. None of the dentists who attended the standardization session were dismissed by Department of Professional Regulation from further service at the examination session. The process by which the Department selected the examiners for the 1987 clinical dental exam was neither arbitrary nor capricious, but comports with Rule 21G- 2.020(4), Florida Administrative Code. The standardization training and examination of dentists to determine who will serve as examiners and monitors does not provide any bright line for distinguishing among potential examiners those who will make the most assiduous effort to apply the grading criteria explained in the training session versus those who retain an innate sense of a passing work based on what the examiner considers acceptable work in his own practice. The effort to convey to examiners the standard of "minimum competency" has imperfect success, but the Department's training is appropriate. Out-of-State Candidates' Scores 11. There is a substantial difference in the failure rates for out-of- state candidates and for in-state candidates on the clinical dental examinations. In the June of 1987, exam 82.5% of the candidates who graduated from the only in-state dental school, the University of Florida, passed the entire examination, while 54.2% of the out-of-state graduates passed, and only 37.8% of candidates from foreign schools were successful. Overall, 86.5% of the candidates passed the written portion of the examination, 93.5% the portion on oral diagnosis, but only 63.3% the clinical portion of the examination. Dr. Roberts has failed to prove that the lower pass rate for out-of- state candidates is the result of any sort of conscious effort on the part of examiners to be more stringent in grading out-of- state candidates. Dr. Kennedy's testimony indicated only that the data bear more analysis, not that they prove improper grading. Procedures Performed on Mannequins The Board of Dentistry tests between 600 and 700 dental candidates per year. It is extremely difficult for the candidates to find patients who have exactly the problem which is to be tested and bring them to the examination to work on. Some portions of the clinical dental examination, therefore, are not performed on patients, but on cast models of human teeth which resemble dentures, and which are known as mannequins. This is expressly authorized by Section 466.006(4)(a), Florida Statutes. The notice to appear which candidates receive approximately 30 days before the examination informs them of the types of mannequins which will be used in the examination. Before that time, however, dental supply companies obtain lists of those eligible to take the examination, and contact the candidates in an attempt to sell them the mannequins. Candidates must bring mannequins with them to the examination and can purchase additional mannequins for practice. Testing with mannequins is also more efficient because with live patients, the student must be graded at the time of the examination, while a model can be retained and graded a day or two later. The decision of the Board to have certain procedures performed on mannequins, so that each candidate would be graded on exactly the same procedure, is reasonable. The Board had also considered having students perform all test procedures on extracted human teeth, but there are not a sufficient number of all natural teeth available, given the number of students who are tested, both for the examination itself and for practice. The Board determined that it would be better to use mannequins for some of the procedures tested in the examination because they are readily available and students can purchase extra copies for practice. For certain procedures, such as endodontics, specific natural teeth (such as first bicuspids) are often extracted and so are generally available; for procedures performed on those teeth, it is possible to have candidates work on human teeth. By contrast, testing procedures performed on teeth such as incisors is not practicable. It is impossible to obtain enough incisors in good condition, without restorations and chips, for use during an examination. The statute governing the dental examination does require that one restoration performed by candidates must be done on a live patient, and for the June 1987, clinical dental examination that procedure was a class 2 amalgam restoration. The Board directed by rule that mannequins be utilized for five test procedures: the pin amalgam preparation and restoration, Rule 21G-2.013(3)(d), Florida Administrative Code; the endodontic procedure, Rule 21G-2.013(3)(e) Florida Administrative Code; the posterior tooth preparation for a cast restoration, Rule 21G-013(3)(f), Florida Administrative Code, the class III acid etch composite preparation and class IV acid etch composite restoration, Rule 21G-2.013(3)(g), Florida Administrative Code. Performing these procedures on mannequins is not exactly the same as performing procedures on human teeth in a patient. In view of the difficulty involved in finding patients whose teeth present virgin lesions, so that each candidate would be tested on exactly the same problem, the difficulty in grading a large number of procedures performed on live patients, and the difficulty in obtaining a large number of human teeth necessary for testing and for practice, the Board's decision to use the mannequins for these procedures is reasonable. The Legislature recognized this in Section 466.006(4)(b), Florida Statutes, which prescribes that the clinical dental examination shall include restorations "performed on mannequins, live patients, or both. At least one restoration shall be on a live patient." The Board was within its authority when it determined the procedures to be performed on mannequins. Violation of Blind Grading The dental examiners who grade the work of candidates grade blindly, i.e., they do not know which candidate's work they are grading. The Clinical Monitor and Examiner Instruction Manual for the June of 1987, examination makes this clear. At page 24 paragraph 3 the Manual states Examiners are requested to disqualify themselves at anytime they are presented with models or patients treated by a dentist who they know personally or with whom they have had professional contact. All examiners are requested to give department staff the name of any examination candidate who is personally known to them to be taking the exam. The department staff will assist the examiners in avoiding any work performed by the candidates they know. Rationale: Allegations have been made about examiners who knew candidates taking the exam even though the examiners only see candidate numbers. Monitors and Examiners are strongly urged to avoid discussion with candidates about the examination. Even conversation about non-examination related matters can be misinterpreted by other candidates as an unfair privileged communication. Despite this admonition, one of the examiners, Dr. Cohen, who knew Dr. Roberts, graded the work of Dr. Roberts. Dr. Cohen met Dr. Roberts the first time Dr. Roberts took the Florida Clinical Dental Examination in June of 1986. Dr. Roberts had with him a bag which would have identified him as a student from New York University, where Dr. Cohen had taught. Dr. Cohen came over to Dr. Roberts, introduced himself, gave Dr. Roberts his card, (exhibit 44) and invited Dr. Cohen to his hotel room where they discussed practicing dentistry in Florida. In 1986 Dr. Cohen was associated with another dentist, Gerald P. Gultz, who had recently moved to Florida from New York. Dr. Gultz had also been a part-time clinical assistant professor of dentistry at New York University College of Dentistry. After Dr. Cohen returned from the June 1986, administration of the clinical dental examination, he had a conversation with Dr. Gultz in which Dr. Cohen asked Gultz if he knew Dr. Roberts, and commented on Dr. Roberts performance on the clinical examination. Dr. Cohen said Dr. Roberts had done terribly, and Dr. Cohen believed that Dr. Roberts would never get his license to practice in Florida. (Tr. 5/26/88 at 73). Dr. Roberts saw Dr. Cohen at the January of 1987, clinical dental examination, but they did not speak. In June of 1987, Dr. Cohen also spoke briefly to the wife of Dr. Gerald Gultz, Lauren Gultz, saying that he would be seeing Dr. Roberts at the June of 1987, clinical dental examination, which was coming up. He told Mrs. Gultz that Dr. Roberts was a poor practitioner, and that he did not think he would pass the examination. At the June 1987, exam, Dr. Roberts' periodontal patient was his uncle, Mr. Finkelstein. Dr. Cohen was one of the examiners who reviewed Mr. Finkelstein to determine whether his condition was appropriate to serve as a patient for Dr. Roberts on the periodontal portion of the examination. Dr. Cohen had a conversation with Mr. Finkelstein in which he told him "tell your dentist to do a good job". Because Mr. Finkelstein had stated that his dentist was a graduate from N. Y. U. Dental School, Mr. Finkelstein was convinced that Dr. Cohen knew exactly who the dental candidate who would work on Dr. Finkelstein was -- Dr. Roberts. After accepting Mr. Finkelstein as an appropriate periodontal patient, Dr. Cohen also served as a grader on the periodontal procedure performed on Mr. Finkelstein. After grading the work which Dr. Roberts had done, Dr. Cohen told Mr. Finkelstein to tell his dentist that Dr. Cohen would see him later in the hotel where they were staying. At the hotel, Dr. Cohen talked to Dr. Roberts about the dental examination, that he himself had to take the examination three times, although he considered himself to be a superior dentist, and that Dr. Cohen could help Dr. Roberts with his grades but that he could never grade Dr. Roberts more that one grade higher than any of the other examiners. Dr. Cohen served as an examiner (i.e. grader) for Dr. Roberts on six of the nine procedures tested. There were: procedure number 1, the periodontal evaluation where he assigned a failing grade of 2; procedure number 4, the class III composite preparation, where he assigned a failing grade of 1; procedure number 5, the class IV composite restoration, where he assigned a failing grade of 1; procedure number 6, the endodontic evaluation, where he assigned a passing grade of 3; procedure number 7, the preparation for a cast restoration, where he assigned a passing grade of 3; and procedure number 8, the pin amalgam preparation, where he assigned a failing grade of 1. This failure of blind grading is a serious irregularity in the evaluation of Dr. Roberts' performance on the 1987 clinical dental examination, given his prior negative comments about Dr. Roberts before the examination. By ignoring those scores, Dr. Roberts would be evaluated only by two examiners, on all the procedures for which Dr. Cohen gave a grade. This would mean that his scores would not be comparable with those of any other candidate, for his grade on each procedure would not be the result of blind grading by three independent examiners. Dr. Roberts' Challenges to Grades Assigned by Other Examiners The full nine procedures evaluated in the 1987 dental clinical examination and Dr. Roberts' grades were: A periodontal exercise performed on a live patient, Mr. Finkelstein, which involved the scaling of five teeth both above and below the gum and stain removal. Dr. Roberts was assigned scores of 1, 2, and 2 by the examiners (one grade of 2 was assigned by Dr. Cohen) An amalgam cavity preparation, performed on a live patient, Elizabeth Cox, which is the preparation of a tooth for filling. When the preparation is completed a proctor escorts the patient to the three examiners who independently grade this part. After grading, the patient returns to the candidate who completes the filling of the tooth (the restoration) which is subsequently graded independently by three examiners. Dr. Roberts was assigned grades of 1, 1, and 3 for the preparation (none of these grades were assigned by Dr. Cohen). A final amalgam restoration, which is the filling of the tooth prepared in the prior procedure. Dr. Roberts received grades of 3, 3, and 3 on this procedure (none of the grades were assigned by Dr. Cohen). A class III composite preparation, which is preformed on a model, not a live patient. This involves removing decay and shaping a tooth to hold a class III filling, i.e., one located on the side surface of an incisor. Dr. Roberts received scores of 1, 0, and 1 (Dr. Cohen assigned one of the grades of 1) A class IV composite restoration, which is performed on a model, not a live patient. This involves restoring a fractured tooth with a composite restoration material. On this procedure Dr. Roberts received scores of 0, 0, and 1 (Dr. Cohen assigned the grade of 1). An endodontic evaluation performed on a posterior tooth, which is performed on a mannequin, and involves the opening of a molar, and identification of the canals in the tooth in preparation for a root canal procedure. Originally Dr. Roberts received grades of 3, 3, and 0 (one of the grades of 3 was assigned by Dr. Cohen). Dr. Roberts work was regraded by three new examiners and the grades of the original examiners were discarded. Dr. Roberts ultimately received a grade of 3.67 on the endodontic portion of the examination A preparation of a posterior tooth for a cast restoration, which is performed on a mannequin. It involves preparing a tooth to receive a crown. Dr. Roberts' original grades were 2, 3, and 3 (Dr. Cohen had assigned a grade of 3 on this procedure). On review, Dr. Roberts' was regraded by three new examiners, and the original grades were discarded. Dr. Roberts received a final grade of 3 on this portion of the examination. A pin amalgam preparation, which is performed on a model, not on a live patient. This involves the preparation of a tooth to hold an amalgam filling by inserting a pin into a portion of the tooth, which serves to anchor the filling. Dr. Roberts was assigned grades of 2, 0, and 1 on this procedure (Dr. Cohen assigned the grade of 1). Pin amalgam final restoration, which is performed on a model. It involves filling a tooth with amalgam filling material. Dr. Roberts was assigned grades of 2, 1, and 2 on this procedure (Dr. Cohen assigned one of the grades of 2). Due to the involvement of Dr. Cohen in so many of the procedures involved here, Dr. Roberts performance on the June of 1987, clinical dental examination was not fairly evaluated. A fair evaluation cannot be provided after the fact by merely dropping Dr. Cohen's grades, because Dr. Roberts' performance would not be subject to the independent evaluation of three examiners. Dr. Roberts relies, to a large extent, on the testimony of Dr. Gultz as the basis for regrading his procedures to a passing grade of 3, or better. The testimony of Dr. Gultz does not, however, show that he has ever participated in the standardization exercises for examiners at Florida clinical dental examinations. Dr. Gultz experience as a clinical professor of dentistry at New York University provides a substantial basis for his evaluation of dental procedures. The difficulty, however, is that as with any qualified examiner, his evaluations will be based on internalized standards which are personal to him. There is no way to know whether Dr. Gultz standards for adequate performance are equivalent to those which the standardization training produces among examiners at the standardization exercise before a clinical dental examination. The standardization process "attempts to bring all examiners to the same level of grading, so that each [examiner] is grading in a valid and reliable manner." Clinical Monitor and Examiner Instruction Manual, June of 1987, at page 42. The Florida dental clinical examination uses a holistic grading method. Each score sheet which an examiner fills out has on it the criteria to be applied in evaluating the candidates performance on that procedure. They all contain a statement which reads: It is the intent of the Board that each of the criteria are to be accorded equal importance in grading. Equal importance does not mean that each criteria has a numerical or point value, but means that any one of the criteria, if missed to a severe enough degree so as to render the completed procedure potentially useless or harmful to the patient in the judgment of the examiner, could result in a failing grade on the procedure. The criteria do not have any assigned numerical or point value, but are to be utilized in making a holistic evaluation of the procedure. Each grading sheet also points out to the examiner certain critical factors which, if present, require a grade of 0 for the procedure. The standardization in grading which the Board diligently attempts to achieve through the standardization training and the standardization testing of examiners done at the close of the training is elusive at best. Nonetheless, in the absence of showing that Dr. Gultz standards of evaluation are equivalent to those of an examiner trained at a standardization session, it is impossible to know whether his standards of evaluation are more rigorous or less rigorous than those reflected by the grades assigned to other candidates by the corps of examiners which evaluated the work of candidates at the June of 1987, clinical dental examination. The same is true with respect to the testimony of Dr. Simkins, the expert for the Board in this proceeding. No useful purpose would be served in attempting to choose between the testimony of Dr. Gultz, on the one hand, and the testimony of Dr. Simkins and of the other examiners who testified by deposition in this proceeding. If this were to be done, all the hearing officer would have determined is whose testimony about the appropriate grade to be assigned for each procedure is more believable. On this record it would be impossible to make a further finding about whether that more believable testimony reflects a scoring standard more stringent, less stringent or the same as that generally applied to all candidates by the corps of examiners in the June of 1987, clinical dental examination.
Recommendation It is recommended that the results of the clinical dental examination which Dr. Roberts took in June of 1987, be found invalid, and that he be permitted to take the next clinical dental examination offered by the Department of Professional Regulation at no cost to him. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 8th day of December, 1989. WILLIAM R. DORSEY, JR. 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 8th day of December, 1989.
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
The Issue At issue in this proceeding is whether petitioner's challenge to the grading of his dental manual skills examination should be sustained.
Findings Of Fact Background Petitioner, Jorge Jose Velis, sat for the dentistry manual skills examination pursuant to Section 466.006(3)(c)3, Florida Statutes (1991), in November 1991. After receiving notification that he failed to achieve a passing score on the examination, petitioner challenged respondent's grading of three procedures, number 2, 7 and 8. The respondent sustained petitioner's challenge to the grading of procedure number 7 and had such procedure regraded, but such regrading failed to raise the overall grade awarded for the procedure. Respondent denied petitioner's challenge to the grading of procedures 2 and 8. In turn, petitioner filed a timely request for a formal hearing pursuant to Section 120.57(1), Florida Statutes, to contest the respondent's grading of procedures number 7 and 8. The examination procedure During the course of the examination at issue in this proceeding, the candidates were called upon to exhibit manual skills by performing various procedures on a laboratory model. The quality of the candidate's performance was then graded by three examiners who assigned grades of 0 to 5 based on their assessment of the candidate's performance. The scores assigned were then averaged to derive the score achieved by the candidate on the particular procedure. In scoring, a grade of "0" represented a complete failure, a grade of "3" represented a minimally acceptable dental procedure, and a grade of "5" represented outstanding dental procedure. See Rule 21G-2.013, Florida Administrative Code. Each of the examiners who participated in both the original grading of petitioner's model and the regrade had been licensed by the Florida Board of Dentistry for at least five years, and had participated in a day-long standardization training session the day before the examination was offered. Based on their previous performance as graders and their performance at the November 1991 examination, these examiners demonstrated a statistically acceptable grade variation range. Petitioner's examination results and review. Petitioner received a final grade of 2.97 on the examination, which was below the minimum passing grade of 3.0. Pertinent to this case, respondent received a grade of 2.66 for procedure 7, based on scores of 1, 3 and 4 from the individual examiners, and a grade of 2.66 for procedures 8, based on scores of 3, 1 and 4 from the individual examiners. Dr. Theodor Simkin, the respondent's consultant, upon petitioner's request for a regrade, examined petitioner's models and the evaluations of the examiners with regard to procedures number 7 and 8. In Dr. Simkin's opinion, which is credited, the original grade of 1 assigned to procedure 7 did not conform with the grading criteria since petitioner's error was not serious enough to warrant a grade of one. Accordingly, Dr. Simkin recommended a regrade of procedure number 7. With regard to procedure number 8, Dr. Simkin did not recommend a regrade because in his opinion, which is credited, the low grade of 1 was warranted because of a sever undercut made by petitioner on the tooth which would prevent any crown made up for the tooth from fitting properly. Accordingly, the assignment of a failing grade of 1 for procedure number 8 was appropriate under the grading criteria. Based on Dr. Simkin's conclusions, petitioner's procedure number 7 was regraded. In such regrading, petitioner's model was hand-delivered by a Department of Professional Regulations representative to three examiners, different from the original examiners, but all of whom participated in the standardization and grading of the November 1991 examination. In the regrade, petitioner received scores of 3, 3 and 2, for an average or final grade of 2.66, the same failing score he had previously received. The scores assigned by the examiners on regrading were, however, rendered in conformance with the grading criteria, and were an appropriate reflection of petitioner's performance. Here, the proof demonstrates that the regrade of procedure number 7 and the original grading of procedure number 8 were rendered in accordance with the grading criteria, and that petitioner's final grade of 2.97 was appropriately derived. Accordingly, petitioner failed to attain a minimum passing grade on the examination.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that a final order be rendered dismissing the subject petition. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 23rd day of December 1992. WILLIAM J. KENDRICK 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 23rd day of December 1992. APPENDIX Petitioner's proposed findings of fact are addressed as follows: 1 & 2. Unnecessary detail. Addressed in paragraph 5. Addressed in paragraph 10. Addressed in paragraphs 2 and 5-8. Rejected as argument or addressed in paragraph 12. Respondent's proposed findings of fact are addressed as follows: 1 & 2. Addressed in paragraphs 1 and 10. 3. Addressed in paragraphs 3 and 5. 4-9. Addressed in paragraphs 5-8, otherwise unnecessary detail. 11-12. Addressed in paragraphs 3 & 4, otherwise unnecessary detail. 13. Addressed in paragraph 8. COPIES FURNISHED: Jose I. Perez, Esquire Grove 2000 Building Suite 100-D 2000 South Dixie Highway Miami, Florida 33133 Vytas J. Urba, Esquire Assistant General Counsel Department of Professional Regulation Northwood Centre, Suite 60 1940 North Monroe Street Tallahassee, Florida 32399-0792 William Buckhalt Executive Director Board of Dentistry Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792 Jack McRay General Counsel Department of Professional Regulation 1940 North Monroe Street Suite 60 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
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that Respondent regrade Petitioner's examination and give equal numerical value to each criterion; all other requests for relief should be DENIED. DONE and ENTERED this 9th day of December, 1982, in Tallahassee, Florida. DONALD R. ALEXANDER 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 9th day of December, 1982.
