The Issue The issues are whether Respondent is guilty of recordkeeping violations of Section 466.028(1)(m), Florida Statutes, and standard-of-care violations of Section 466.028(1)(x), Florida Statutes, in connection with bridgework, implants, and root canals that he performed on a single dental patient.
Findings Of Fact Background At all material times, Respondent has been a licensed dentist, holding license number DN 11262. He is not Board- certified in any areas recognized by the American Dental Association, but he is a fellow, associate fellow, or diplomate with four associations, not recognized by the American Dental Association, devoted to dental implants. Respondent has been licensed to practice dentistry for over 20 years. At all material times, Respondent practiced in Port Charlotte. At one time, his practice grew to six offices employing 13 dentists and 80 employees. During that timeframe, Respondent performed about 100 crowns and bridges per month, endodontics (which includes root canals) on 7-10 teeth per month, and limited periodontics, including 20-30 implants and 2-3 sinus lifts per month. Respondent has been disciplined previously. In Nebraska, where he was licensed to practice dentistry, Respondent's license was suspended in 1989 upon his conviction for a felony for obtaining a controlled substance by fraud in writing one or more prescriptions, ostensibly for his father, so that Respondent could satisfy his chemical dependency. The Board of Dentistry consequently imposed discipline the following year for this offense (or the suspension arising from it), suspended Respondent's Florida license for one year, and required him to attend the PRN program for impaired practitioners. In February 1995, the Board of Dentistry imposed discipline against Respondent for his violation of the applicable standard of care by failing to diagnose periodontitis prior to seating crowns. The Board imposed a $3000 administrative fine and required Respondent to attend the PRN program and complete 35 remedial continuing education hours. Two years later, the Board of Dentistry imposed discipline against Respondent for his failure to pay the fine. The Board imposed a $500 administrative fine and issued a reprimand. In February 2002, the Board of Dentistry imposed discipline against Respondent for his violation of the applicable standard-of-care and recordkeeping requirements by failing to diagnose and treat periodontitis or recording required exams prior to seating a bridge and crowns and failing to document examinations and test results. The Board imposed a $6000 administrative fine and required Respondent to attend 60 hours of continuing education. In December 1993, evidently in connection with the acquisition of an existing practice, Respondent acquired W. C. as a patient. W. C. was a cost-conscious, aging man who wanted to preserve his natural teeth. Respondent treated him for about ten years and often acceded to W. C.'s requests for reduced pricing for specific procedures. The relationship ended only when Respondent insisted that W. C. pay off a balance that he had agreed to pay. Over the course of their professional relationship, which included about 120 visits, Respondent wrote off $10,000 in charges in an effort to help W. C. control costs. Likely due to pricing sensitivity, W. C. was an episodic patient, rather than a regular patient. This means that W. C. visited Respondent only for relief from particular problems, rather than appearing regularly for cleaning, x-rays, and maintenance. Sometimes W. C.'s refusal to visit the dentist except when he had a problem and his desire to control costs conflicted with his dental needs, which at times became fairly extensive. All of the issues in this case involve, directly or indirectly, Respondent's treatment of two bridges: one in the upper right quadrant and one in the lower left quadrant. The issues require findings addressing the endodontic (root canal) and implant issues, but these issues arose in the larger context of the bridgework issues that W. C. presented. When Respondent acquired W. C., he found bridges already in place in these two locations. A bridge is a fixed prosthesis that supports missing teeth between crowns. Abutment teeth are the retainers; missing teeth are the pontics (or false teeth). The bridge permits the patient to replace missing teeth without having to take them out overnight. Bridges are intended to remain in place for at least five years, although some may remain in place for 20 years. Bridges may be placed temporarily or "permanently." Although some dentists use plastic bridges for temporary placements, Respondent did not do so with W. C. References below to temporary bridges mean that Respondent used temporary cement with no intent, for various reasons, of "permanently" seating the bridge at that time. At the start of the operative timeframe, W. C.'s lower left bridge supplied a pontic for missing tooth number 19, tooth number 17 was missing, and tooth number 18 was a blade implant. On the other side of the pontic were teeth numbers 20 and 21. The presence of a blade implant confirms the age of the lower left bridge, as this type of implant was not typically in use after the 1980s. At the start of the operative timeframe, the upper right bridge supplied pontics for missing teeth numbers 3, 4, and 5. Prior to 1996, a predecessor to this bridge used natural teeth numbers 2 and 6 as abutments. However, in early 1996, Respondent extracted tooth number 2, replaced it with an implant, and installed a new bridge that used the implant at the site of tooth number 2 and teeth 6 and 7 as abutments. In May 1997, when W. C. returned with a loose upper right bridge, Respondent's notes state that he advised W. C. that he needed an implant and performed only palliative treatment. In June 1997, Respondent performed a root canal on tooth number 6, installed a temporary bridge, and later installed a new permanent bridge in the upper right quadrant. Petitioner's expert witness, Dr. Harold Haering, testified that, by July 24, 1997, Respondent extended this bridge to abutment tooth number 8. This is borne out by the note for that date, as well as the notes for October 27, 1997, and July 23, 1998. Some more remote history is available for both these bridges. The record contains dental records for W. C. as far back as September 1974, at which time he had periodontal surgery for teeth numbers 3 through 8. In November 1974, W. C. received a bridge for teeth numbers 4 through 7--a precursor of the upper right bridge at issue in this case. Five years later, the dentist treating W. C. recommended that the upper right bridge be remade after periodontal surgery to tooth number 5. He placed a new upper right bridge in August 1979 and performed a root canal on tooth number 4 in May 1980. In April and May 1981, the dentist placed another bridge, although his notes prevent identifying where. In June 1982, after performing the root canal on tooth number 21, as noted above, the dentist removed the lower left bridge due to decay in tooth number 18. The dentist continued to treat the teeth at the lower left bridge through 1982, removing and recementing the bridge as needed. In January 1983, the dentist discovered a cracked root in tooth number 4. He removed the upper right bridge and then extracted tooth number 4. Likely, dental records are missing from the record for the next five years because, in mid-1988, the records restart with the removal of sutures at teeth numbers 2-5. The records note that this bridge still suffers from mobility. A few months later, the dentist had to remove the upper right bridge again and take new impressions. In mid-1989, the lower left bridge failed, as pontics at sites 18 and 19 separated. At this time, the dentist replaced the lower left bridge. Respondent began to see W. C. in December 1993. Still prior to the operative timeframe, on February 15, 1995, after noting that the prognosis for tooth number 2 was guarded to hopeless, Respondent performed a root canal on this tooth. One year later, Respondent sectioned the upper right bridge and, as noted above, placed an implant at site number 2. In September 1996, Respondent prepared a bridge from teeth sites or numbers 2-7, using 2, 6, and 7 as abutments. After a couple of trials, Respondent cemented the permanent upper right bridge on November 5, 1996. The upper right bridge was rechecked for looseness in May and June 1997, at which time Respondent removed the bridge to perform a root canal on tooth number 6 and prepared a temporary upper right bridge. On July 24, 1997, Respondent prepared tooth number 8 for inclusion in the upper right bridge, which had previously stopped at tooth number 7. The temporary upper right bridge broke on August 6, 1997, at tooth number 6. A week later, Respondent tried in the permanent upper right bridge, but found it needed additional porcelain to the pontic area and took new bite impressions. His notes reflect that he would deliver the bridge after August 28, 1997. On September 3, 1997, Respondent had to send the upper right bridge back to the lab for more porcelain to the occlusal surface and recemented the temporary bridge, which had broken and presumably was repaired again. On October 10, 1997, Respondent cemented the permanent upper right bridge and adjusted it two weeks later. On October 27, 1997, Respondent again recemented the upper right bridge, noting that he was going to submit to W. C.'s insurer a request for pre-approval of a sinus lift in the upper right quadrant. This note states that Respondent was not going to permanently cement the upper right bridge (presumably, again) until he received a response from the insurer. On January 6, 1998, W. C.'s temporary upper right bridge was loose, and Respondent recemented it. For the first time in nearly nine years, based on the notes in the record, attention was also focused on the area of the lower left bridge. Respondent noted pockets of 4-5 mm at tooth number 20. Scaling removed a large seed hull from the vicinity of teeth numbers 20 and 21. On June 10, 1998, W. C. visited Respondent with complaints of sensitivity in the area of the lower left bridge. Respondent took periapical and bitewing x-rays of tooth number These x-rays, which are part of the dental records, justify the root canal for tooth number 20 that Respondent proposed, if the tooth were to be saved for use in the bridge, which was W. C.'s desire. Respondent's notes reflect that he scheduled a root canal for tooth number 20 on the next office visit. A root canal may be called for due to irritation or infection in the tooth's pulp. To perform a root canal, a dentist drills a hole through the crown to access the tooth's pulp and nerves, removes the pulp and nerves for disinfection, fills the resulting cavity, and reseals the tooth. The intent is to clean out the area to the far end of the root, which is called the apex. Overinstrumentation of the cavity or overfilling of the cleaned-out cavity may result in fill escaping beyond the tooth's apex. Underinstrumentation of the cavity results in fill failing to reach to the tooth's apex. On July 1, 1998, Respondent performed a root canal on tooth number 20. Respondent cut a hole in the crown that had already been placed on the tooth and proceeded to clean out and disinfect the interior of the tooth. After he was finished, he placed composite fill to reseal the tooth. Respondent completed the root canal in this single visit. His records adequately record the procedure. Although Respondent had taken intraoperative x-rays that revealed the location of the endodontic cleaning instrument--a file--relative to the apex of tooth number 20, the post-operative x-ray revealed that the fill extended beyond the apex of the tooth almost 3 mm. This means that the fill extended beyond the tooth and into the bony area surrounding the tooth. Dr. Haering testified with evident conviction that the standard of care requires fill to the apex, but not beyond. Dr. Haering testified that the standard of care permits the fill to end 0.5 mm short of the apex. He noted that the standard of care is not violated by an apical puff, in which cement may spiral out during application beyond these limits, but added that this case is not an example of an apical puff. Dr. Haering explained that fill past the apex much more often than not will create sensitivity and will require correction. He testified that "every clinical exam" administered to dental students requires zero extrusion of fill past the apex. The dental records do not reveal any post-operative instructions. Dr. Haering stressed the importance of such instructions after this procedure, more than any other in this case, because of the likelihood of pain from the extrusion of the fill past the apex. Dr. Haering did not find fault with Respondent's practice of performing a root canal and "permanently" sealing it in a single visit. One week later, W. C. returned to the office, complaining of pain at the site of tooth number 20. Respondent reopened the root canal and recleaned the area, although nothing suggests that he found it necessary to readdress the extent of the fill. Respondent applied xylocaine in the cavity and temporarily resealed it until W. C. could return on July 15 for further treatment. He also prescribed an antibiotic and a painkiller. During this visit on July 8, Respondent noted that the upper right bridge was loose. On July 15, W. C. returned to the office and presented again with complaints of pain. However, the notes reveal a loosened lower left bridge, so it is unclear whether the recently treated tooth or the lower left bridge was causing the pain. Unable to remove the bridge, Respondent had to cut it out. He then removed the temporary fill for tooth number 20, rechecked the tooth, and completed the endodontic treatment of this tooth by placing permanent fill in the cavity. During the same visit, while the bridge was off, Respondent also retreated a root canal previously done on tooth number 21, which appears not to have been retreated since it was originally done in 1982. Respondent temporarily sealed the cavity in tooth number 21 and permanently resealed it during an office visit two weeks later. Respondent prescribed an antibiotic and Motrin. The Administrative Complaint alleges that Respondent inadequately shaped and improperly filled the cavity left after the root canal of tooth number 21. During the operative timeframe, Respondent did nothing more than clean out the existing cavity left by the previous root canal, and nothing suggests that Respondent extended the cavity in tooth number 21 beyond the tooth's apex or that he overfilled or underfilled this cavity. Dr. Haering testified that a postoperative x-ray of tooth number 21 revealed that the fill in that cavity did not extend to the apex, although he fails to specify by how much the fill was short. He testified that the applicable standard of care requires filling to the apex. However, as noted above, when testifying about the root canal of tooth number 20, Dr. Haering conceded that 0.5 mm short is acceptable, and a dentist would always want to be short rather than long with the fill. From an endodontic perspective, Petitioner has failed to make a standard-of-care case against Respondent for his retreatment of tooth number 21. Nothing suggests that he did any more than re-clean the preexisting cavity left after a root canal performed many years prior to the operative timeframe. Nothing suggests that Respondent underfilled the cavity, such as by leaving a gap, nor does clear and convincing evidence establish that leaving the fill short--by whatever amount it was short in tooth number 21--would violate the applicable standard of care. From an endodontic perspective, the standard-of-care case as to tooth number 20 is closer. Respondent probably overinstrumented the cavity and clearly overfilled the area past the apex. However, post-operatively, Respondent treated the pain at the site during the July 8 visit when he removed the permanent fill, injected a painkiller, and placed temporary fill in the cavity, as well as prescribing an antibiotic and painkiller. Although Respondent still complained of pain at the follow-up visit on July 15, it is at least as likely that the cause was the loosening of the lower left bridge, given the fact that Respondent did not retreat the endodontics and the records reveal no more complaints of pain in this area in the ensuing months. It appears that Respondent successfully treated tooth number 20, whose failure, years later, is more likely due to the failure of the blade implant at site 18 than to this root canal. In light of these developments, as well as Dr. Haering's inconsistency as to whether a short fill necessarily violates the standard of care, the testimony of Respondent's expert witness, Dr. Robert Fish, as to overfills is entitled to greater weight, at least as to whether an overfill or underfill is, in itself, a violation of the applicable standard of care. Dr. Fish properly stressed that teeth numbers 20 and 21 lasted for the duration of treatment and their ultimate failure was due to the loss of support of the aged blade implant at site number 18, not due to endodontic failure. This failure occurred two years and nine months after Respondent's endodontic work in July 1998. Dr. Fish's testimony is more persuasive as to the endodontics, although his testimony that tooth number 20 was not overfilled and that intentional overinstrumentation is sometimes required to ensure the removal of all infected material is not credited. For these reasons set forth above, Petitioner failed to prove that Respondent violated the applicable standard of care in the root canal that he performed on tooth number 20. Additionally, Petitioner has failed to prove a dental records violation with respect to these root canals. As Dr. Fish testified, the pre-operative x-rays themselves justify the course of treatment. Contrary to the allegations, Respondent recorded symptoms of pain with respect to both teeth. Contrary to Petitioner's contention, nothing in the record explains why Respondent would have to perform a periodontal exam before doing a root canal on tooth number 20 or revising a root canal on tooth number 21, especially when neither tooth failed until the old blade implant at site number 18--not, as alleged, placed by Respondent--failed nearly three years later. The preoperative x-rays showed adequate bone and no periodontal pathology to suggest any periodontal issues with these teeth prior to the endodontic work that Respondent did. The mobility that later developed in teeth numbers 20 and 21 was due to the ultimate failure of the blade implant at site number 18, which took place long after the endodontic work of Respondent on teeth numbers 20 and 21. The only remaining issue concerning the Root Canal Counts is tooth number 6. As noted above, the allegations pertain to root canal procedures performed on tooth number 6 from 1998 through 2001 or 2002. Respondent performed no such procedures on tooth number 6 during these timeframes. For these reasons, Petitioner has failed to prove the recordkeeping and standard-of-care Root Canal Counts. On July 23, 1998, W. C. presented for a repair of the porcelain on tooth site number 3 in the temporary upper right bridge. Respondent also scheduled W. C. for preparation of a new bridge to replace the lower left bridge that he had had to cut off. On the next office visit, which was July 29, Respondent took a final impression for a new lower left bridge. During this visit, he recemented the temporary bridge into place and, according to the notes, discussed shade and coping options with W. C. On August 4, Respondent recemented the temporary lower left bridge, but, on August 17, he had to return it to the lab after another try-in. Ten days later, Respondent had to recement the temporary lower left bridge. Three days later, on August 30, W. C. returned with the temporary bridge broken, and Respondent repaired it and recemented it. On September 15, 1998, the coping failed, and Respondent returned the lower left bridge with a new occlusal mounting. On October 9, 1998, Respondent cemented the permanent lower left bridge, which remained in place until its removal on February 19, 2001. Dr. Fish testified persuasively that there were no violations of the standard of care during this period. He testified that the notes were sufficient for what was essentially revisionary treatment of pre-existing dentistry in the form of the placement of both bridges. The sectioning of the lower left bridge at the time of the endodontics was merely reflective of the age of the bridge, according to Dr. Fish, and the sensitivity that required the root canal of 20 and retreatment of a pre-existing root canal in 21. For the upper right quadrant, where Respondent had placed a permanent bridge in October 1997, he had to recement the bridge in January and again in July and then repair it later in July when a pontic broke. But there were no more problems with this bridge in 1998. It is true that in 1997, prior to the operative timeframe, this bridge suffered more failures, but the first two loosenings--in May and June 1997--appear to be related to problems with tooth number 6, prior to its root canal. Later problems with loosening and breakage involved the temporary, except for one recementing of the new permanent on October 27, 1997. Significantly, Respondent attached to the notes for this visit the need to obtain pre-approval from W. C.'s insurer for a sinus lift, which, as described below, is necessary to permit the placement of implants in an area where the bony area was insufficient for implants. For the lower left quadrant, where Respondent had performed the root canal and root canal retreatment described above, there were two or three recementings of the temporary lower left bridge that Respondent placed after he had to remove the pre-existing lower left bridge to deal with teeth numbers 20 and 21. The additional work consisted of taking impressions for a new bridge, trying it on for size, and fixing breaks in the temporary lower left bridge--all ending with the placement of the permanent lower left bridge on October 9, 1998. After delivering the permanent lower left bridge, the next time that W. C. visited Respondent's office was on February 19, 1999, for full-mouth x-rays and, three days later, for a periodontal screening. The x-rays revealed some caries under the upper right bridge. During the cleaning that took place on February 22, W. C. declined Perioguard, a medicated rinse for gum health. This is a relatively inexpensive way to facilitate healthy gums and suggests that W. C. may have been reluctant to assume his share of the responsibility for maintaining good dental health. A note on March 23, 1999, states that W. C.'s physician recommends postponing treatment due to a heart problem. The postponed dental treatment is not specified, but it is the sinus lift, for which Respondent had sought pre- approval from the insurer. The sinus lift would require intravenous sedation, which, due to W. C.'s health problems, required clearance from his physician. Thus, this note implies that Respondent continued to recognize that the status quo was not sustainable for the upper right quadrant and that a more- lasting solution required a bone augmentation in order to permit the placement of implants to better secure a fixture in the upper right area. Almost as important as Respondent's recognition of the need for a sinus lift is the timing of it: it does not accompany any failure of the permanent upper right bridge that Respondent had seated in October 1997. Instead, the note confirms that Respondent was aware that the upper right bridge was precarious and needed to be readdressed. Consistent with Respondent's recognition of the need to proceed with a bone augmentation and implants in the upper right quadrant, on June 9, 1999, W. C. returned to the office because the upper right bridge had fallen out of his mouth while brushing his teeth. The dental note for this visit states that W. C.'s physician advises that the patient cannot undergo intravenous sedation until early September at the earliest. The note concludes with the tentative scheduling of a pre-operative sinus lift followed by an implant. During the operative timeframe, the instability of the upper right bridge was not due, as Petitioner contends, to Respondent's placement of an excessively long and wide post when doing the root canal in tooth number 6 prior to the operative timeframe; the upper right bridge had had problems before that root canal was performed, and the evidence is mixed as to whether this tooth even had an excessively long post--an issue outside of the scope of this case due to the pre-1998 date of service for this procedure. Nor does there seem to have been a problem with the implant at site number 2 that Respondent had placed prior to the operative timeframe. Respondent's expert, Dr. Carl Misch, testified persuasively that the implant served as an acceptable abutment. (Misch deposition, p. 35.) Also, Respondent's placement of an implant at site number 2 is an issue outside the scope of this case due to the pre-1998 date of service for this procedure. During the operative timeframe, the immediate need-- given W. C.'s rejection of removable dentures--was the placement of multiple implants in the upper right area, as Respondent recognized at the time. This is a fact agreed to by Petitioner's expert, Dr. David Clary, (Clary deposition, p. 19.), and Dr. Misch, who succinctly explained: between tooth number two and tooth number six there are no teeth. [B]etween those two teeth, which is basically the last molar on the upper right and the eye tooth on the upper right, this patient is missing three teeth. And as a consequence of that span a good option . . . is to put some implants in that span. However, if you don't have any bone you can't place implants. (Misch deposition, pp. 32-33.) On August 30, 1999, Respondent took another x-ray of W. C.'s mouth. This is the x-ray that Dr. Haering testified was necessary, before undertaking a sinus lift, to determine the thickness of the bone at the intended site of the implant. During this visit, Respondent scheduled W. C. for intravenous sedation and a sinus lift between September 9 and October 19. A sinus lift is a not-uncommon procedure that may be performed by a general dentist to augment bone in preparation for implant surgery. If the patient's sinus drops down too far, it leaves insufficient bony structure to secure the implant, so the dentist moves the membrane of the maxillary sinus and applies a paste derived from freeze-dried bone. The new material is then sutured into place. Eventually, the new material integrates into the adjacent bone, essentially augmenting the available bone to allow, in this case, the successful placement of implants. On October 4, 1999, Respondent removed the upper right bridge and performed a sinus lift in the area of the upper right quadrant. As conceded by Petitioner's expert, Dr. Gerald Laboda, an oral and maxillofacial surgeon, Respondent's notes adequately detail the sinus lift procedure and materials used, although they omit mention of the fact that W. C. bled heavily and had to go to the emergency room for treatment. However, a note one week later states that W. C. was doing well and not in any pain. Obviously, the bleeding that necessitated a visit to the emergency room is a serious matter. Dr. Laboda testified that the medial wall of the sinus is the lateral wall of the nasal cavity, and Respondent "may" have penetrated this wall accidentally during the procedure. Dr. Laboda was ambivalent in opining whether the applicable standard of care requires a general practitioner to conduct a CT scan prior to a sinus lift in order to identify the anatomy of the patient and reduce the chances of an incident during surgery. On direct examination, Dr. Laboda was unable to say unequivocally that the incident would have been avoided with the anatomical information that a CT scan would have yielded. At one point, Dr. Laboda testified that a general dentist must always obtain a CT scan, in addition to x-rays, prior to performing a sinus lift, but then he quickly characterized this statement merely as a recommendation. Some of Dr. Laboda's ambivalence may be explained by the testimony of Dr. Misch on this point. He testified that x-rays alone met the standard of care and a CT scan exceeded the standard of care, (Misch deposition, p. 66.), but he stated that he has used a CT scan prior to sinus lifts since 2005, even though this practice is still not the standard of care. (Misch deposition, p. 289.) Considering the testimony of both dentists, it appears that the standard of care may be evolving toward the requirement of a CT scan prior to a sinus lift, but did not so require when Respondent performed the sinus lift in 1999. Additionally, Petitioner's proof on this issue was not helped by the refusal of Dr. Laboda to accept Respondent as his peer in implants, suggesting that Dr. Laboda may not be an especially good source of generally prevailing peer performance, and the refusal of Dr. Haering, Petitioner's lone witness who was a general dentist, to opine as to the sinus lift. Likewise, the records justify the course of the treatment in terms of the sinus lift. The need for this procedure is reflected in the records, including the x-rays, which revealed that implants could not be placed unless the bone was augmented. The other notes justifying this course of treatment have already been detailed above. On February 7, 2000, after giving the bone augmentation time to stabilize, Respondent placed an implant in site 3 and an implant in site 4, according to Dr. Clary's interpretation of the record, which is credited. There does not appear to be any real issue with the placement of these implants, which, surprisingly, works somewhat to the disadvantage of Respondent as to recordkeeping, for the reasons set forth below. Dr. Misch testified that, judging from the x-rays, the placement of the implants was acceptable. (Misch deposition, p. 294.) Dr. Laboda testified that the placement of the implants did not violate the applicable standard of care, and he could not opine as to why any implants failed (if, in fact, they did), although he attributed his inability partly due to Respondent's records, which he deemed inadequate. Respondent also replaced the temporary upper right bridge at this time, but his main focus was, of course, on the two new implants. An x-ray on February 29 disclosed that "everything [was] healing well." However, on March 23, a note written by someone other than Respondent states that x-rays were taken and tissue was growing around the bridge, but W. C. needed to return to the office to see Respondent "to have removed"-- apparently, referring to the implants, but possibly the bridge. Four days later, the same person wrote that the bridge was removed, revealing 6 mm pockets around the "implant," although the pockets were around both implants. Without further analysis in the records, Respondent removed the implants. Based on the dental records, the removal of the implants seems to have simply happened. The finding of 6 mm pockets, without more, explains nothing. The placement of the implants was, as noted above, unremarkable. Dr. Laboda explained that 6 mm pockets are not necessarily pathological, and the sole reason for removing the implants is mobility, about which Respondent's notes state nothing. Dr. Laboda added that six-week implants are still integrating into the bone, so concern with these pockets should dictate nothing more than a trimming of the gum around the implants, a procedure known as a gingivalplasty. When asked why a dentist would remove implants with 6 mm pockets, Dr. Misch, acknowledging that some dentists would repair them, never addressed why this condition would justify removal; he merely addressed what other dentists would do. (Misch deposition, p. 296.) Dr. Fish's testimony is unpersuasive on this point. He testified that diagnosis was ongoing--evidently confusing findings of pockets with the diagnosis of a problem requiring the removal of the implants and, more importantly, with careful analysis of the course that the patient was taking with the implants. Dr. Fish also tried to justify the scant records concerning the removal of the implants based on the "fact" that the treatment plan was based on the presentation of an episodic problem. This clearly misses the mark: Respondent had been trying to initiate a treatment plan for the upper right bridge for two years and finally, with the clearance obtained from W. C.'s physician, was able to execute the plan. The best that Dr. Fish could offer, after looking at an x-ray, was that one implant "might" start to travel--hardly justification for the removal of the two implants after only six weeks. Dr. Fish's testimony that Respondent was diagnosing W. C. continuously following the implants, implying some insight on Respondent's part as to why he thought that the implants had failed or were failing, contradicts the more persuasive testimony of Dr. Misch, who stated that, typically, a dentist does not know why an implant fails. (Misch deposition, p. 68.) Respondent testified that he removed the implants due to the presence of the 6 mm pockets. He testified that the problem was not so much periodontal as that the surgical site needed more time to heal. (Respondent deposition, pp. 40-41.) This testimony suggests that the implants may have been placed prematurely, or at least that Respondent thought so. Either way, Petitioner has proved a standard-of-care violation as to the removal of the implants. If Dr. Laboda's testimony were credited over Respondent's testimony on the status of the implants at the time of their removal, and it is, Respondent violated the standard of care by removing these implants prematurely and subjecting an elderly patient unnecessarily to the trauma of the removal and, as noted below, replacement of these implants a short time later. If Respondent's testimony were credited on the status of the implants at the time of their removal, and it is not, Respondent violated the standard of care by placing the implants prematurely. In this instance, the records are silent as to the reason for the removal of these two implants because there was no good reason to do so at that time. Thus, Petitioner has proved the standard-of-care Implant Count. Petitioner has also proved the recordkeeping Implant Count in the removal of the implants. As Dr. Laboda testified, when admitting that he could not explain the failure of the implants, the problem lies in the scant information contained in Respondent's records. Records justifying the course of treatment would detail the case sufficiently so it would be clear whether the implants were placed prematurely or, as is found, they were removed prematurely. If the pockets alone warranted the removal of the implants, Respondent needed to document this fact to justify their removal, rather than treatment of the gums, and to guide his or another dentist's attempt to place implants in the upper right quadrant of W. C.'s mouth in the future. If the implants were mobile, Respondent needed to state this fact, again for the same purposes. On May 8, 2000, using local anaesthetic, Respondent added bone to the area where he had performed the sinus lift and had placed and later removed the two implants described above. Checking them for the first month at two-week intervals and then one month later, on July 5, 2000, Respondent noted that the tissue was healing fine. Later in July, as well as in August, September, and October, Respondent had to repair the temporary bridge, as the permanent bridge still awaited the successful seating of two implants at sites 3 and 4. On November 13, 2000, Respondent again placed implants at sites 3 and 4. He noted the procedure as he had the previous procedure. These implants performed fine and integrated into the surrounding bone as intended. After a series of fittings, Respondent delivered the permanent fixtures for the upper right quadrant on May 22, 2001. Acknowledging the stability problems with the upper right bridge in its past configuration--although failing to mention this analysis anywhere in his notes--Respondent chose not to try to use a single bridge. Toward the back, he splinted together implants at sites 2, 3, and 4. Toward the front, he cantilevered a pontic at site 5 off natural teeth 6, 7, and 8. Petitioner's expert, Dr. Clary testified that he was "very fine" with the design for 2, 3, and 4. (Clary deposition, p. 123.) Dr. Clary expressed concerns about the cantilever bridge that extended from abutment teeth numbers 6, 7, and 8 to the pontic at site number 5. (Clary deposition, p. 124.) In particular, Dr. Clary questioned the length of the post in tooth number 6, for which, as noted above, Respondent had performed a root canal prior to the operative timeframe. (Clary deposition, p. 125.) Ultimately, Dr. Clary's concerns about the cantilever bridge are unpersuasive. The contemporary reader of Respondent's notes probably would not have known that Respondent delivered two fixtures on May 22. Prior to May 22, the lone indication of two fixtures is a brief note, dated May 2, that states that Respondent repaired the broken upper right bridge by cementing 6-8 with one bond and 2-4 with a different bond. More significantly is the omission of any findings or analysis supporting the choice to divide the upper right bridge into two fixtures. The notes continue to refer to a single "1-8" structure on May 14 during a try-in, May 16 concerning a production process, and May 22 at the time delivery. After the hint contained in the May 2 note, the next mention of a shorter fixture is a note on June 4 referring to a "6-7" bridge, evidently for delivery by the next visit, at the end of a note describing a porcelain failure of the crown for tooth number 6. Also, on June 26, the notes state that a metal fracture--not the fault of Respondent--occurred on the "bridge" "2-4." Even after these references, a note on August 6 refers to the delivery of "2-8." The notes are consistent with one of two situations, both of which lead to a recordkeeping violation in terms of the bridgework. Perhaps Respondent delivered another iteration of the 2-8 bridge on May 22 and, after encountering one more failure of this design only a few days later, abruptly decided to go with two fixtures. More likely, Respondent actually delivered two fixtures on May 22, and the recordkeeping was slow to reflect this fact. Either way, the records are devoid of analysis supporting the treatment choice of two fixtures. After W. C. switched dentists, he visited Dr. William McKenzie, a periodontist, for a consultation in January 2003 after presenting for x-rays in December 2002. Called by Petitioner as a fact witness, Dr. McKenzie testified that he found that the upper right bridge was "hopeless," (McKenzie deposition, p. 8.), at least partly due to the fracturing of tooth number 6. (In subsequent questioning, Dr. McKenzie clarified that he was referring to the cantilever bridge on teeth numbers 6-8. (McKenzie deposition, p. 13.)) He added that he could recall no other problems in W. C.'s mouth, except for tooth number 16, which lacked bone around it. (McKenzie deposition, pp. 13 and 30.) In particular, Dr. McKenzie saw no problem with the implants. (McKenzie deposition, p. 34.) Dr. McKenzie testified that these problems could have arisen "very, very quickly." (McKenzie deposition, p. 15.) Dr. Misch testified that about ten percent of teeth that undergo root canals suffer problems within eight years (Misch deposition, p. 39), commonly in the form of fractures (Misch deposition, p. 40). When the tooth that has undergone a root canal is used as an abutment for a bridge, the fracture risk may increase four-fold. (Misch deposition, p. 40.) The performance of the upper right bridge and, later, the cantilever bridge, was probably undermined by several factors. First, W. C. would not accept a removable denture, and he may not have been willing to undertake the growing responsibilities that he would have to shoulder to maintain his remaining natural teeth in this area, as the incidence of certain dental problems, like caries, would suggest. Second, teeth numbers 6-8 may have had anomalies of crown height and root length, which combined with the next factor to cause problems. Third, W. C., a tooth grinder, likely placed large loads on the teeth at night, which would be especially problematic during the period, after work on the teeth, that they were to remain unloaded. On this record, though, any problems in the performance of the upper right bridge and, later, the cantilever bridge cannot be attributed to Respondent, so Petitioner has failed to prove the standard-of-care Bridgework Count, at least as to the upper right quadrant. However, Respondent's recordkeeping concerning the upper right bridge failed to justify the course of treatment in one respect: the decision to separate the single fixture into two. When considered from the perspective of Respondent's records, this action has the same deus-ex-machina quality to it as the removal of the implants from sites 3 and 4 in March 2000: without warning, a seemingly outside force implements surprise treatment choices. As was the case with the implant-removal decision, the decision to place an implant splint and a cantilever bridge cannot be inferred or justified from x-rays or other dental records. There are two distinctions between the abrupt decision to place two fixtures and the abrupt decision to remove the implants. First, the treatment regarding the design of the new fixtures for the upper right quadrant does not represent a standard-of-care violation, but actually reinforces the impression that Respondent had a treatment plan in mind--not on paper--from the start of the operative timeframe, if not before. Second, the notes, apart from x-rays, fail adequately to describe the implant splint and cantilever bridge and rely excessively on inference to establish even the existence of these fixtures. The remaining factual issues concern the lower left bridge. As noted above, Respondent delivered the permanent lower left bridge on October 9, 1998. According to the notes, the next time it was addressed was when it was removed on February 19, 2001, which coincides with the end of the most intensive treatment, described above, of the upper right quadrant and precedes the delivery of the two upper right fixtures, also described above, by three months. Although the handwritten dental records do not indicate why Respondent removed the lower left bridge, a note on January 29, 2001, states that W. C. presented with a tooth ache in the lower left quadrant, and an x-ray taken on the same date revealed an infection around the blade implant at site number (Respondent deposition, pp. 56 and 58.) (Respondent's response on page 58 that the blade implant was placed in 1998 was either inaccurate or inaccurately transcribed given the era in which blade implants were used and Respondent's interrupted testimony, on the next page, suggesting that another dentist placed this implant, which, if 1998, would have been when Respondent was treating W. C. and routinely doing implants.) On February 19, Respondent placed a temporary lower left bridge and prepared for the production of a new permanent bridge. He also prepared a post and core for tooth number 20. On March 20, Respondent cleaned up the area around the blade implant at site number 18 and placed some bone material in the area to build it up to better secure the blade implant. After doing this work, on the same day, Respondent cemented the temporary lower left bridge. Respondent recemented the temporary lower left bridge the day after W. C. was hospitalized for "lethargy," according to a note on March 27, 2001. On April 9, the records note that the tissue looked good. On April 23, Respondent again recemented the temporary lower left bridge. Initially misreading his own notes, Respondent testified that he did the final impression for the lower left bridge on April 23 when he actually did the final impression for the upper right bridge/fixtures on that date. (Respondent deposition, pp. 61- 62.) When advised of this error, Respondent testified that he did eventually replace the lower left bridge with a permanent fixture, but it is not reflected in the notes. (Respondent deposition, p. 62.) This is an odd answer because the notes actually document the delivery of the permanent lower left bridge on July 8, 2002. After April 23, the next reference to the lower left quadrant in the notes is June 26, 2001, when Respondent had to recement the temporary lower left bridge. On August 20, 2001, the notes indicate that Respondent "attempted to restore 20, 21 guarded." Evidently, the attempt was short-lived and the deterioration from guarded to hopeless was quick because the same note--confirmed by Respondent as accurate (Respondent deposition, p. 63)--is that he extracted teeth numbers 20 and 21. On August 27, 2001, W. C. returned to the office. Respondent recommended a treatment plan to include the placement of four implants in the lower left quadrant. Due to cost considerations expressed by W. C., Respondent only placed three implants, which took place on October 31, 2001. The October 31 note adequately describes the procedure. The implants integrated into the surrounding bone after a brief infection shortly after their placement. On April 17, 2002, Respondent restored the implants and placed a temporary lower left bridge. On May 8, 2002, Respondent took a final impression for a bridge from site number 18 to site number On July 8, 2002, Respondent delivered the permanent lower left bridge. The professional relationship ended with a note on July 31 that W. C. agreed to pay the balance in three weeks; he later failed to appear for an appointment on January 30, 2003. Of course, by this time, he had presented for x-rays and been seen by Dr. McKenzie on a consultation in connection with dental work that W. C. was undertaking with another general dentist. The recordkeeping fails to justify the course of treatment as to the removal of teeth numbers 20 and 21. Respondent could explain orally that these two teeth became mobile when they lost the support they required from the blade implant at site 18, but nothing in the records mentions this fact, and, from the perspective of the records, these two extractions just seem to happen. However, Petitioner already proved the recordkeeping Bridgework Count in connection with the treatment decision to divide the single upper right bridge into two fixtures, so this additional violations may only have a bearing on the penalty. The lone count not yet proved, but still at issue in connection with the lower left bridge, is the standard-of-care Bridgework Count because Petitioner failed to prove this count in connection with the upper right bridge. Dr. Clary testified that he had no problem with the decision to place implants at site numbers 20 and 21; his lone criticism of this treatment is that it did not take place in 1998. (Clary deposition, p. 99.) Nor did he disagree with the placement of the third implant at site number 18. (Clary deposition, p. 100.) Questioning whether the standard of care permits the connection of implants to natural teeth (Clary deposition, p. 100), Dr. Clary conceded that this is a point of controversy within the dentistry profession (Clary deposition, p. 101), implicitly admitting that the standard of care does not prohibit this practice. Dr. Clary conceded that controversy also existed as to the type of connector--ridged or unridged-- that should be used for these implants and natural tooth. (Clary deposition, p. 102-03.) In sum, Dr. Clary did not try to make much of a case as to the standard of care concerning the lower left bridge, especially if one accepts the fact that patient resistance precluded the use of a removable denture in this area and that extensive work on the lower left bridge probably had to await completion of the extensive work on the upper right bridge, given W. C.'s financial constraints and the practical problem of ensuring that he could chew on at least one side of his mouth for weeks at a time. Likewise, Dr. Laboda did not fault the placement of any implants; his focus was on the sinus lift and recordkeeping. Thus, Petitioner has failed to prove a standard-of-care violation with respect to the bridgework in the lower left quadrant. Based on the foregoing, Petitioner has proved only the following violations. First, Petitioner proved the recordkeeping Bridgework Count (Count I) concerning Respondent's decision to replace the single upper right bridge with two fixtures in May 2001. This was a good treatment choice. However, Respondent not only failed to document the reasons for this choice or findings that would support this choice; he even failed to identify adequately the treatment choice. Second, Petitioner again proved the recordkeeping Bridgework Count (again, Count I) concerning Respondent's decision to extract teeth numbers 20 and 21 in August 2001. Relying on Dr. Clary's testimony, this was probably a good treatment choice, although Dr. Clary's testimony that this action should have been taken in 1998 is not credited, at least as to the implication that it violated the standard of care for Respondent not to have taken this action earlier. Third, Petitioner proved the recordkeeping Implant Count concerning the sudden removal of the recently placed implants at site numbers 3 and 4 in March 2000. Fourth, Petitioner proved the standard-of-care Implant Count concerning the premature removal in March 2000 of the recently placed implants at site numbers 3 and 4, although the consequences of this departure from the applicable standard of care are slight due to Respondent's immediate addition of more bone, using only local anaesthetic, and successful replacement of implants at these two locations. Aggravating factors are the number of times that the Board of Dentistry has disciplined Respondent, including one case involving a recordkeeping violation; and the presence of three separate recordkeeping violations in this case (although two of them are alleged in the same Bridgework count). Mitigating factors are the lack of danger to the lone patient from, and the lack of severity of, the proved violations; the reversibility of the limited damage that resulted from the lone standard-of-care violation (i.e., the premature removal of the two implants followed by the addition of more bone and successful replacement of two new implants); the number of years that Respondent has practiced; and the time that has elapsed-- eight years--since the last violation, during the last seven and one-half years of which Respondent has not been disciplined.
Recommendation Based on the foregoing, it is RECOMMENDED that the Board of Dentistry enter a final order finding Respondent guilty of Counts I, III, and IV of the Administrative Complaint and imposing the following discipline: $20,000 administrative fine; license suspension until the greatest of 30 days, full payment of fine, or posting of security adequate to the Board for the full payment of fine; passage of the Florida Rules and Laws exam within one year of the Final Order; probation for the greater of five years or until Respondent successfully completes the two-year remedial course described above; and audits every two years to ensure that Respondent is current on his continuing education. As noted above, a suitable restriction on practice would be an effective substitute for the minimum 30-day suspension described above, although the restriction on practice would need to extend longer than 30 days. DONE AND ENTERED this 17th day of June, 2009, 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 17th day of June, 2009. COPIES FURNISHED: H. Wayne Mitchell, Esquire Assistant General Counsel Department of Health 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Max R. Price, Esquire Law Offices of Max R. Price, P.A. 6701 Sunset Drive, Suite 104 Miami, Florida 33143 Susan Foster, Executive Director Board of Dentistry Department of Health 4052 Bald Cypress Way Tallahassee, Florida 32399-1701 R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Josefina M. Tamayo, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Dr. Ana M. Viamonte, Secretary State Surgeon General Department of Health 4052 Bald Cypress Way, Bin A00 Tallahassee, Florida 32399-1701
The Issue The central issue in this cause is whether the Respondent is guilty of the violation alleged in the Administrative Complaint dated June 10, 1987; and, if so, what penalty should be imposed.
Findings Of Fact Based upon the testimony of the witnesses and the documentary evidence received at the hearing, I make the following findings of fact: Petitioner, the Department of Professional Regulation, Board of Dentistry, is the appropriate state agency charged with regulating the practice of dentistry in Florida. Respondent, Norman A. Fenichel, D.D.S., is, and has been at all times material to this case, licensed to practice dentistry in Florida (license number 0008157). On or about March 5, 1985, Respondent treated a patient named Susan Klein. During the course of this treatment, Respondent inserted two fillings (teeth #12 and #13). Subsequently, Ms. Klein visited another dentist who advised her of "overhangs" on teeth #12 and #13. An "overhang" is caused by filling material which extends beyond the contour of the tooth. Instead of meeting the tooth surface evenly, the filling "overhangs" like the eaves of a roof. An "overhang" is not acceptable dental practice because it prohibits proper oral hygiene. Bacterial plague may collect under the overhang which may result in a new cavity or periodontal problems. On June 9, 1986, Ms. Klein was examined by Dr. John Jordan. Dr. Jordan's findings included the overhangs described above and also noted a void in one of the fillings. This void indicated a piece of filling material was missing either because it was not placed there originally or because it broke out. In order for a dentist to test the contact made between a new filling and other teeth, articulating paper is placed in the mouth with instruction given to close. During this procedure a patient may or may not close in true centric. The restoration (filling) may appear to be acceptable when, in fact, a closing in true centric results in traumatic occlusion. This traumatic occlusion may cause overhangs in a new restoration and, once the material sets, may cause the filling to break. Unfortunately, overhangs are not uncommon but should be, upon discovery, corrected. Ms. Klein has not, to her knowledge, experienced the problems associated with overhangs noted in paragraph 6. Ms. Klein has not had the overhangs corrected. Ms. Klein did not return to Dr. Fenichel for further dental treatment. Had he been aware of the overhang problem as a result of another examination, Dr. Fenichel stated he would have repaired it.
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 a Final Order dismissing the Administrative Complaint dated June 10, 1987, against the Respondent. DONE and ORDERED this 11th day of December, 1987, in Tallahassee, Florida. JOYOUS D. PARRISH 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 11th day of December, 1987. APPENDIX TO RECOMMENDED ORDER, CASE NO. 87-3292 Rulings on Proposed Findings of Fact submitted by Petitioner: Accepted. Finding of Fact, paragraph 1 Accepted. Finding of Fact, paragraph 2. Accepted. Finding of Fact, paragraph 3. Accepted to the extent addressed in findings of fact paragraphs 4, 5, & 6 otherwise rejected. COPIES FURNISHED: William P. Doney, Esquire 1615 Forum Place, Suite 200 West Palm Beach, Florida 33401 Norman A. Fenichel, 7544 Lake Worth Road Lake Worth, Florida 33463 Pat Guilford, Executive Director Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Tom Gallagher, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 William O'Neill, General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301
Findings Of Fact By application dated March 3, 1983, Respondent ITT Community Development Corporation (ITT) requested a permit from Respondent Department of Environmental Regulation (DER) to dredge 815 cubic yards of material from the Intracoastal Waterway In Flagler County, Florida, as part of the construction of a high-level concrete highway bridge over the intracoastal Waterway. The proposed bridge project will extend Palm Coast Parkway from the end of existing pavement to State Road A1A east of the Intracoastal Waterway, and thus complete the Interstate 95 connector link with coastal State Road A1A. At the present tine, there are two drawbridges across the Intracoastal Waterway some ten miles south at Flagler Beach. and approximately 15 miles north at Crescent Beach. Existing high bridges across the Intracoastal Waterway are further north and south of the proposed bridge project. (Testimony of Smith, ITT Exhibits 1, 9- 12) The proposed bridge is a fixed concrete bridge approximately 2,598 feet long and 52 feet, 7 inches in width. The bridge will have a minimum vertical clearance of 65 feet above mean high water and 66.4 feet above mean low water, with a horizontal clearance of 90 feet between fenders. It will involve a cast- in-place concrete deck set upon prestressed concrete columns. The bridge will be supported by sets of concrete beams and placed on top of pilings, which will be driven into the surface to a depth of approximately 80 feet. The center two support piers, which are the subject of the requested permit, will be set upon concrete seals constructed inside of cofferdams, which will be located within the right-of-way of the Intracoastal Waterway. It is the construction of these two piers within the limits of the cofferdam that involves the removal of material which is considered dredging pursuant to DER rules. (Stipulation) The cofferdams will be made of steel and will be driven into place to encompass the pier foundations, with the 815 cubic yards of material excavated from inside the cofferdams being placed on a barge and transported to the adjacent uplands as part of the bridge approach construction. During construction of each support pier, a turbidity curtain will be placed around the cofferdams and the barge. Bridge deck drains will be omitted over the Intracoastal Waterway, and first flush storm water runoff will be retained in a stormwater management system which meets the requirements of Chapter 17-25, Florida Administrative Code. Piles used in the construction of the two fenders shall be made of concrete rather than treated timber. Treated timber may be used for the horizontal wales, the catwalks, and other components of the fender system which do not extend below M.S.L. Reasonable assurance has been provided by ITT that the release of preserving chemicals by the timber components of the fender system will not adversely affect the waters of the Intracoastal Waterway in violation of Chapter 17-3, Florida Administrative Code. Turbidity controls will be used during the the construction of the two piers in the Intracoastal Waterway if the level of turbidity produced exceeds 29 NTUs. (Stipulation, Greene) The bridge will connect two parcels of land under the ownership of ITT, and will facilitate access between Palm Coast Parkway and the State Road A1A. (Stipulation, ITT Exhibits 1, 9-12) After receiving the ITT application, DER solicited comments from adjoining landowners, the Flagler County Board of Commissioners, and the Florida Game and Fresh Water Fish Commission, but none were received. By letter dated April 13, 1983, the Department of Natural Resources gave its authority for the project under Section 253.77, Florida Statutes. An onsite inspection of the proposed site was made by DER in June 1982 and March 1983, who found that the project site was devoid of literal vegetation and that minimal impact could be expected from the project provided that turbidity is contained during construction. They further determined that the bridge pilings would not eliminate valuable habitat or alter the natural flow of the Intracoastal Waterway, a Class III body of water. Further, in view of the fact that the dredging activities would be isolated by the cofferdams, no turbidity problems re expected. On May 18, 1983, the DER District Manager issued a notice of its intent to issue the requested permit for the reason that reasonable assurance had been provided that the short-term and long-term effects of the proposed activity would not result in violation of water quality criteria under Chapter 17-3, Florida Administrative Cede, and that the proposed activity would not interfere with the conservation of fish, marine and wildlife or other natural resources to such an extent as to be contrary to the public interests, or create an navigational hazard or impediment, or alter or impede the natural flow of navigable waters so as to be contrary to the public interests. The intent to issue provided that the permit would be subject to the condition that turbidity controls would be used during construction if the level of turbidity produced exceeds 50 JTU above background. (Testimony of Tyler, ITT Exhibits 2-5, 7) By Resolution No. 83-13, dated August 18, 1983, the Flagler County Board of County Commissioners expressed its support of the concept of the proposed project as long as the cost of construction is funded through ITT funds or bridge tolls. (ITT Exhibit 13) In their prehearing and posthearing stipulations, the parties agreed to the following: That reasonable assurance has been provided by ITT that the short-and long-term effects of the bridge construction will not adversely affect the surficial aquifer to such an extent that it will cause harm to its use by Petitioners as a potable water supply. That the construction and operation of the proposed bridge will not interfere with the conservation of the Florida Scrub Jay, the Gopher Tortoise, or the Indigo Snake. Reasonable assurance has been provided by ITT that the release of preserving chemicals by the timber components of the fender system will not adversely affect the waters of the Intracoastal Waterway in violation of Chapter 17-3, Florida Administrative Code. Reasonable assurance has been provided by ITT that the short-term effects of turbidity will not adversely affect the waters of the Intracoastal Waterway in violation of Chapter 17-3, Florida Administrative Code. The proposed bridge will not create a navigational hazard or a serious impediment to navigation, or substantially alter or impede the natural flow of navigable waters so as to be contrary to the public interests, and the proposed bridge will not result in the destruc- tion of oyster beds, clam beds, or marine productivity, including but not limited to destruction of natural marine habitats, grass- flats suitable as nursery or feeding grounds for marine life, and establish[ed] marine soil(s] suitable for producing plant growth of the type useful as nursery or feeding grounds for marine life or natural shoreline processes to such an extent as to be contrary to the public interests. If the permit is issued, it shall be issued with the following conditions: Turbidity controls will be used during construction of the two piers in the Intracoastal Waterway if the level of turbidity produced exceeds 29 NTUs above background. Piles used in the construction of the two fenders shall be made of concrete rather than treated timber. Treated timber may be used for the horizontal wales, the catwalks, and other components of the fender system which do not extend below M.S.L. In view of the above stipulations by the parties, the only remaining disputed issues of material fact are whether the proposed project will interfere with the conservation of the Florida panther and Florida black bear to such an extent as to be contrary to the public interests. The black bear is considered to be a "threatened" species of wildlife by the State of Florida. A wildlife survey of some 2,000 acres of land surrounding and including the project area during the period 1979-82 by an expert in the field of wildlife ecology revealed traces indicating the presence of the black bear on two occasions in a location east of the proposed project area. On those occasions, bear tracks were found east of State Highway A1A in a hammock area north of the bridge corridor in 1979. However, the signs were insufficient to indicate that there was a resident bear population in the area. Signs of the black bear are fairly common on the west side of the Intracoastal Waterway in swampy wilderness areas, such as Long's Creek area and Graham's Swamp. It is possible that, on occasion, a black bear may wander into or cross the bridge area; however, construction and operation of the bridge should have little or no adverse impact on any black bear population which is located either several miles south or north of the proposed bridge area. (Testimony of Brown) The Florida panther is classified as an "endangered" species by the State of Florida. The four-year survey of wildlife undertaken by ITT during the period 1979-82 failed to disclose any traces of the panther in the area surrounding the proposed project site. There are only approximately 20 to 30 Florida panthers in the state, and all are located to the south and west of Lake Okeechobee in the Everglades. The Florida panther requires a vast area of undisturbed habitat. Approximately 400 square miles are necessary for males and some 50 to 100 square miles for a female. They avoid populate areas. Several state personnel saw a tan catlike animal near the entrance to Washington Oaks State Gardens which is located a number of miles north of the proposed bridge site, on May 13, 1983. They reported to the Florida Game and Fresh Water Fish Commission that the animal was a Florida panther, and plaster casts of the animal's tracks were submitted to that agency for verification. However, the casts were insufficient upon which to base an identification of the animal as a Florida panther, and the park personnel admittedly lacked sufficient qualifications to determine if the animal was, in fact, a Florida panther. There have been other purported sightings of panthers in the general area during past and recent years by Petitioner Gerald D. Schatz and others who reported such sightings to him for investigation. However, it has never been confirmed that the said sightings were of the Florida panther. Although a suitable habitat for the panther is the Graham Swamp, that area is not large enough to be sustain the Florida panther, and It is unlikely that any of that species are present in the area of the proposed bridge. It is accordingly found that construction of the bridge would have no impact on the Florida panther. (Testimony of Brown, Wood, Ganson, Nichols, Schatz; Petitioner's Exhibits 3-5)
Recommendation That the Department of Environmental Regulation issue the requested permit pursuant to Chapter 253 and 403, Florida Statutes, and Public Law 92-580, subject to standard conditions, and the special conditions set forth in paragraph 6 above of the Conclusions of Law herein. DONE and ENTERED this 30th day of November, 1983, in Tallahassee, Florida. THOMAS C. OLDHAM Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 30th day of November, 1983.
The Issue Whether Petitioner should receive a refund for an alleged overpayment of dental insurance premiums.
Findings Of Fact The Division of State Group Insurance (Division) is the executive agency within the Department of Management Services (Department) that is responsible for the administration of the State Group Insurance Program (Program). Isaacs was first employed with the State of Florida in 1993, and remained employed with the State until March 2011, when he retired. According to Isaacs, when he originally signed up for dental insurance, there were only two options available for employees; an employee could sign up either for “employee” coverage or for “employee plus family” coverage. Isaacs chose “employee plus family” dental coverage, so that he and his spouse would have coverage. During his tenure as a State employee, Isaacs was married and had no children. At all times material to the instant case, Isaacs resided, and received his mail, at 13021 S.W. 116th Street, Miami, Florida, 33186. On January 1, 2005, the State of Florida started using an online system called “People First” to manage State of Florida employee payroll and benefit packages. Every employee and retiree was given a username and password to access the online system. Each employee’s payroll information, leave balances, and benefits information could be seen online. Pursuant to section 110.123(3)(h), every year there is a finite period of time during which State employees can sign up for benefit plans, or change their existing benefit plans, for the upcoming calendar year. This period is called “open enrollment.” Prior to open enrollment every year, People First mails out, to every State employee, a package which contains a personalized benefits statement and a Benefits Guide, which contains information as to all the benefit plans that are being offered for the upcoming calendar year. The benefits statement informs employees of the benefits they currently have and will continue to have during the upcoming calendar year, unless they make changes to their insurance or coverage level. On September 7, 2007, the Division mailed each participant in the dental insurance program a letter explaining significant changes to the dental program. This letter was mailed by first class mail to the address of record for each employee who was then enrolled in the dental program. Isaacs' address of record in People First was his mailing address: 13021 S.W. 116th Street, Miami, Florida, 33186. Isaacs claims that he never received this letter. The undersigned finds this testimony to not be credible, given that Isaacs' address has not changed in 33 years, and he was unaware of any other problems with delivery to this address. The September 2007 letter advised employees that there would be new coverage levels offered in 2008. It stated, in pertinent part: There will be new coverage levels offered in 2008. You may currently be enrolled in a coverage level that will not be offered. The new coverage levels are: ° Employee Only ° Employee + Spouse ° Employee + Child(ren) ° Family You will have the opportunity during the upcoming Open Enrollment to cancel coverage, change your coverage level, or switch to another dental plan. Any change you make will be effective on January 1, 2008. If you take no action, your dental coverage may be changed automatically for 2008. If you are currently enrolled in a coverage level that will not be offered in 2008, you will be enrolled in Family coverage. People First sent Isaacs open enrollment packages in 2007, 2008, 2009, and 2010. The 2008 package, sent on September 17, 2007, included a Benefits Guide which contained all the information as to the change in the dental insurance program. Employees were placed on notice that except for employees who had previously been enrolled for “Employee” coverage, all coverage levels would be moved to “Family” coverage unless the employees made changes during open enrollment. The package included instructions on how to make the coverage changes, and how to verify that those changes had been properly made. Isaacs never changed his dental plan coverage; therefore, he was defaulted to the “Family” coverage as of January 1, 2008. Due to his failure to act, he remained in that coverage until he retired. The open enrollment packages sent to Isaacs for years 2009, 2010, and 2011 included information as to the dental coverage tiers, and a personalized Benefits Statement which indicated which benefit plans Isaacs was enrolled in, and his coverage level. Every year, he could have made changes to his dental insurance coverage, but failed to do so. As of People First going “live” in 2005, all State employees could review their benefits and coverage levels online. Thus, Isaacs, on his state-issued desktop computer, had access to People First, and could have reviewed his coverage levels and benefit plans. Isaacs admitted at hearing that he did not review the open enrollment packages he received every year because he was under the impression, based on advice he was given, that he need not review the information if he was not making any changes to his coverage levels or benefit plans. He added that he was not sure if he even opened all the open enrollment packages that were sent through the years. Isaacs had the responsibility to open, review, and carefully read the open enrollment packages and all correspondence sent to him by his employer. Isaacs was advised of the changes to the dental plan, but did not review the information sent to him. He had ample notice of the change to the dental plan coverage levels, but failed to review the information, and failed to avail himself of the many opportunities he had to adjust the coverage level. He paid for more coverage than he needed because he ignored all the information sent to him, which gave him specific instructions on how to avoid that exact circumstance.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Department of Management Services enter an order denying Isaacs' request for a refund for his overpayment of dental insurance premiums. DONE AND ENTERED this 15th day of November, 2011, in Tallahassee, Leon County, Florida. S JESSICA E. VARN Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 15th day of November, 2011.
Findings Of Fact On January 20, 1988 the City made application to the Department for issuance of a dredge and fill permit to replace an existing wooden bridge known as the Lynnhaven Terrace Bridge which crosses Deep Bottom Creek in Duval County, Florida. At that time the existing bridge was a two lane timber bridge measuring approximately 20 feet wide, having two spans of 19 feet and 14 feet respectively with associated guardrails. The replacement bridge was to be 44 feet wide and 37 feet long. Subsequently, a revision was made to the permit application which called for reduction in the width of the bridge to 39 feet. A copy of the original application may be found as City's Exhibit 2 admitted into evidence and the revision was received as City's Exhibit 3. The bridge in its revised format would include two paved lane and two sidewalks on the outside of those lanes. This bridge too would have guardrails. The bridge replacement project would involve the dredging of approximately 122 cubic yards of material from the creek bottom and the installation of 12 concrete pilings along the riverbank. Approximately 4.75 cubic yards of fill will be placed below the mean high waterline and 690 cubic yards above that line. Stabilization of the north and south banks of the side of the bridge will be accomplished with 160 linear feet of sheet pile wall. The total acreage to be filled is approximately 1.1 acres with 0.002 acres being in wetlands or open waters within the Deep Bottom Creek. By this arrangement, part of the activities are within waters of the state and the upward extent of those waters and confer jurisdiction on the Department to require a dredge and fill permit and water quality certification. The jurisdiction of the Department extends to the mean high waterline of the creek in accordance with Section 403.913(2), Florida Statutes, and this takes into account the opportunity to examine the implications of dredging and filling associated with the project. The waters at issue are Class III waters. Black Bottom Creek is part of a drainage basin leading to the St. Johns River, a major water body. The reason for this project concerns the present bridge's deteriorating condition as shown in the City's Composite Exhibit 1, a series of photos. The bridge is in such disrepair that it has been downgraded in its load rating to three (3) tons, which is inadequate to support heavy vehicles, to include emergency vehicles such as firetrucks. With the advent of the concrete bridge, this problem would be rectified. An attempt to effect repairs on the existing bridge is not a reasonable choice for the City. The Department, in response to the application, conducted an assessment of that application or appraisal to include biological and water quality concerns. A copy of the report rendered in response to the application may be found as the Department's Exhibit 1. That report favors the grant of a permit in water quality certification and at the date of hearing that opinion was still held by the Department. The report points out that the project would straighten out a problem with a curve in the creek course by the choice of location for the new bridge. This arrangement will assist in the flow pattern and give a positive influence in preventing shoaling underneath the existing bridge. It will also positively affect the problem of the erosion in the upland area of the existing bridge which causes deposition of material into the creek bottom. The report describes the fact that steps to contain turbidity during the construction phase can be achieved. Having been satisfied concerning this application, an Intent to Issue a Permit and water quality certification was stated on April 15, 1988. A copy of the Intent to Issue may be found as Department's Exhibit 2 admitted into evidence. The permit was to be issued on condition concerning the question of authority to operate in waters of the state as contemplated by Chapter 253, Florida Statutes. That matter is not one for consideration in the present dispute. It also refers to preservation of historical and archeological artifacts. There has been no demonstration that such artifacts exist in the area of this project. The turbidity control mechanisms were mentioned as a special condition and as suggested before, those matters can be attended by this applicant and are expected to be. There is reference to doing the work at periods of average or low water, and there was no indication that this could not be accomplished by the applicant. On April 19, 1988 the actual permit was rendered and had attached letters of April 18, 1988 advising the City that it could contest the permit terms and the fact that others might promote objections to the permit and water quality certification. In fact, a number of land owners in the general vicinity of the project have contested this permit application leading to the present hearing. The petition and challenge to the intention to grant a permit was timely made. The Petitioners are Mr. and Mrs. John Jordan, Mr. and Mrs. Ian Ablett, Mr. Keith Kelly, Ms. Dorothy Brown, Mr. Hal Moyle, Ms. Holly Baker, Ms. Beatrice Diomont, J. H. Cater, Mr. and Mrs. W. Reed, Mr. and Mrs. H. Carrell, Mr. Harvey Jay, Ms. K. C. Walsh and Donald Braddock. Only Mr. and Mrs. Ablett, Mr. Kelly, and the Carrell's attended the hearing and established their standing to challenge the intended agency action. Moreover, the nature of their challenge as set forth in their petition has been restricted by a ruling which struck reference to the alleged influence which this project has on property values associated with a lack of sensitivity for aesthetics in exchanging the wooden bridge for a concrete pile bridge. Otherwise, the Petitioners through the presentation at hearing spoke in terms of shoaling at the site as a matter of their concern. This problem is not one which is attributable to the City and its activities, it is related to commercial activities upstream from the project site. As described, if anything, the project will alleviate those problems to some extent. Additional reasons which the Petitioners advanced in opposition concern the belief that they did not need a new bridge, that the bridge was too wide and that they did not need sidewalks and guardrails. Notwithstanding their perceptions, the overall public needs would favor the replacement of the bridge to include wider lanes and sidewalks for safe pedestrian passage. Again, at present, there are no sidewalks with the existing bridge. The expression of opposition by the Petitioners beyond the reference to the shoaling problem and the effects on water levels is not a matter of environmental concern contemplated by the permit application review process under consideration here. On May 13, 1988, the Department of the Army issued a permit for this project, a copy of which may be found as City's Exhibit 4 admitted into evidence. In addition, the Coast Guard has no opposition to this project and has said as much in its correspondence of May 2, 1988, a copy of which may be found as City's Exhibit 5 admitted into evidence. The immediate and long term impacts of this project are not violative of applicable state water quality standards, in that reasonable assurances have been given that those standards will not be exceeded. This project is not contrary to the public interest. It is not adverse to public health, safety or welfare or property of others. The project will not adversely affect the conservation of fish and wildlife, to include endangered or threatened species or other habitats. The project will not adversely affect navigation or the flow of water which will cause harmful erosion or shoaling. The project will not adversely affect the fishing or recreational values or marine productivity in the vicinity of the project. The project is permanent in nature but over time it will not have adverse impacts on the environment. Considering the current conditions and diminished value of environmental functions being performed by the area, they are not particularly significant at present and the project will not change that posture, in fact it may improve the circumstance. Specifically, at present no endangered or threatened species are found within the creek. There had been some wildlife activity, but continuing problems with silting or shoaling have occurred since the homeowners in the area dredged the creek bottom, and wildlife has decreased as a result. This relates to the upstream activities which continue to promote problems in the creek bottom. On the subject of navigation, limited navigation is available by small boats or canoes at present, and the elevations of the replacement bridge are such as to not interfere with that activity.
The Issue The issue is the appropriate penalty to be imposed upon Dr. Carroll for two admitted violations of the Dental Practice Act: (1) performing root canal treatment which was below acceptable standards, and (2) practicing beyond the scope of dentistry.
Findings Of Fact Findings Concerning Liability The following findings of fact are based upon the paragraphs or subparagraphs of the Administrative Complaint which Dr. Carroll admits: Inadequate Root Canal Therapy Dr. Carroll treated Sylvia Lankheim. He performed root canal therapy on Ms. Lankheim's lower left second bicuspid (tooth #20) and provided a post and crown for the tooth. Dr. Carroll's endodontic treatment and post and crown restoration of tooth #20 were inadequate, and subsequently failed. Practicing Beyond the Scope of Dentistry Dr. Carroll neither admits nor denies the following allegations found in the Administrative Complaint, but agrees that they make out a prima facie case for the charge of practicing beyond the scope of dentistry: On or about October 31, 1983, Dr. Carroll made a presentation at a local condominium association concerning the purported hazards of mercury poisoning resulting from amalgam restorations in teeth. His presentation included films, testimonies by two former patients, and paraphernalia used to test for mercury toxicity. As the result of this presentation, Ms. Sylvia Lankheim scheduled an appointment with him on about November 3, 1983. When Dr. Carroll saw Ms. Lankheim on November 3, he took full mouth x-rays and made an impression of her teeth for study models. On or about November 8, 1983, Dr. Carroll's dental assistant conducted a Mercury Patch Test on Ms. Lankheim to determine her sensitivity to mercury. The test involves placing a solution of mercury chloride on a band- aid, placing the band-aid on the forearm, removing the band-aid 24 hours later and interpreting the patient's dermatological response to the test. Use of a patch test to determine an allergic response or sensitivity to mercury is not within the scope of the practice of dentistry as defined in Section 466.003, Florida Statutes (1985). The patch test used by Dr. Carroll to determine an allergic response or sensitivity to mercury is not reliable and its use is unproven. Based upon these facts, Dr. Carroll has agreed he is guilty of the charge of practicing beyond the scope of dentistry, in violation of Section 466.028(1)(z), Florida Statutes (1985), as alleged in paragraph 13(d) of the Administrative Complaint. Findings Pertaining to Penalty Penalty guidelines have been adopted by the Board of Dentistry in Rule 21G-13.005, Florida Administrative Code. The penalty for incompetence in the practice of dentistry is prescribed under Rule 21G-13.005(2)(bb) as follows: Being guilty of incompetence. The usual action of the Board shall be to impose a period of probation, restriction of practice, suspension and/or revocation. The usual penalty for practicing beyond the scope of dentistry is stated in Rule 21G-13.005(2)(dd) as follows: Practicing or offering to practice beyond the scope permitted by law or accepting and performing professional responsibilities which the licensee knows or has reason to know that he is not competent to perform. The usual action of the Board is to impose a period of probation, restriction of practice, and/or suspension. The Board may deviate from these penalties in an individual case based upon the following aggravating or mitigating factors: The severity of the offense; The danger to the public; The number of repetitions of offenses or number of patients involved; The length of time since the violation; The number of times the licensee has been previously disciplined by the Board; The length of time the licensee has practiced; The actual damage, physical or otherwise, caused by the violation and the reversibility of the damage; The deterrent effect of the penalty imposed; The effect of the penalty upon the licensee's livelihood; Any efforts of rehabilitation by the licensee; The actual knowledge of the licensee pertaining to the violation; Attempts by the licensee to correct or stop the violation or refusal by the licensee to correct or stop violation; Related violations against the licensee in another state including findings of guilt or innocence, penalties imposed and penalties served; Penalties imposed for related offenses... Rule 21G-13.005(4)(a)-(n), Florida Administrative Code. Dr. Carroll relies on a number of recent cases decided by the Board of Dentistry to argue that the appropriate penalty in this case is a fine of no more than $1,000, and a requirement that he attend 20 to 25 hours of additional training in endodontics in addition to the continuing education required of dentists to maintain their licensure. He maintains that no probation is necessary, as rehabilitation or as punishment. In the case of Board of Dentistry v. Norman A. Fenichel, reported at 10 FALR 6745 (Board of Dentistry, 1988) the Board imposed an administrative fine of $1,500 and placed the dentist on probation for two years, with a requirement that he attend 36 hours of continuing education in crown and bridge work, 36 hours in endodontics and 12 hours in the laws and rules relating to the practice of dentistry or ethics. The penalty was based upon findings made after a formal hearing that the dentist had performed inadequate root canal therapy, and that after the patient had stopped payment on the check for that dental work due to pain and the improper seating of the crown. Fenichel had failed to forward her file to a subsequent treating dentist. Dr. Carroll also relies on other discipline cases of the Board of Dentistry to support the penalty he advocates, where there were stipulated dispositions in somewhat similar circumstances. The case of Board of Dentistry v. Daniel B. Baldridge, DPR Case 0066648 (Board of Dentistry 1987) involved a charge of a feeble attempt to perform endodontic therapy on tooth #3. The stipulated disposition was a fine of $1,000, a reprimand, and probation far one year during which Dr. Baldridge was required to complete 20 hours of continuing education in endodontics. No portion of the Baldridge stipulation included an agreement that Baldridge was guilty of any violation, which is a significant difference from the present case. In the case of Board of Dentistry v. Vance Bishop, Case 0068343 (Board of Dentistry 1988), Dr. Bishop neither admitted nor denied the allegations of an Administrative Complaint which charged that he had provided incomplete endodontic filling of a tooth on which he placed a crown and that two other crowns were poorly done. A fine of $1,500 was imposed, Dr. Bishop was reprimanded, placed on probation for a year and required to complete 15 hours of continuing education in endodontics and another 15 hours in the area of crown and bridge work, endodontics and another 15 hours in the area of crown and bridge work. In the case of Board of Dentistry v. David Murrin, Board of Dentistry Case 0066593 (Board of Dentistry 1988), Dr. Murrin entered into a stipulation without admitting any of the facts in the Administrative Complaint. According toe the complaint, Murrin had performed a root canal and installed a crown on a mandibular left first molar (tooth #19), but subsequent examination showed that the root canal procedure had never been concluded because there was only partial removal of pulp tissue from the tooth, and no filling material had been used. His records failed to show any therapy had been attempted. Murrin was charged with making untrue representations in the practice of dentistry in violation of 466.028(1)(l), Florida Statutes; malpractice, in violation of 466.028(1)(y), Florida Statutes; exploiting a patient for financial gain in violation of 466.028(1)(m), Florida Statutes; and fraud and deceit in the practice of dentistry, in violation of Section 466.028(1)(u), Florida Statutes. According to the stipulation he paid administrative costs of $1,000, and received a reprimand but no period of probation. In the case of Board of Dentistry v. Frederick Newton, Board of Dentistry Case 0070984 (Board of Dentistry 1988), Dr. Newton entered into a settlement stipulation in which he admitted the allegations of fact contained in the Administrative Complaint (with a small correction of those facts). According to the admitted facts, Dr. Newton provided root canal therapy on tooth #3 and amalgam restorations on teeth #3, 14, 19 and 30. The root canal therapy on tooth #3 was inadequately filled and sealed, Johnson did not record on the patient's chart the use of a rubber dam, did not record the canal length of tooth #3, chart the measurements for the endodontic files he used, or take a post-operative x-ray showing the completed root canal therapy. He was therefore charged with malpractice in violation of Section 466.028(1)(y), Florida Statutes, and failing to keep records justifying the course of treatment in violation of section 466.028(1)(m), Florida Statutes. The Board's final order imposed an administrative fine of $1,500, reprimanded him and placed him on probation for a period of twelve months, in which time he was required to complete 20 hours of endodontic continuing education and one course in recordkeeping.
Recommendation Based upon the foregoing, it is RECOMMENDED that a Final order be entered by the Board of Dentistry finding Dr. Carroll guilty of violation of Sections 466.028(1)(y), Florida Statutes (1985) and 466.028(1)(z), Florida Statutes (1985), that an administrative fine in the amount of $1,500 be imposed, that he be reprimanded, and that his license be placed on probation for a period of one year, during which he shall complete 25 hours of continuing education in endodontics in addition to any other education required to keep his licensure current. DONE and ORDERED this 9th day of May, 1989, in Tallahassee, Leon County, Florida. 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 9th day of May, 1989. COPIES FURNISHED: Nancy M. Snurkowski, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Michael J. Cohen, Esquire 517 Southwest First Avenue Fort Lauderdale, Florida 33301 Salvatore A. Carpino, Esquire One Urban Centre, Suite 750 4830 West Kennedy Boulevard Tampa, Florida 33609 Kenneth E. Easley, Esquire General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 William Buckhalt, Executive Director Board of Dentistry 130 North Monroe Street Tallahassee, Florida 32399 =================================================================
