ALJDEC - Licensing

24F-202000111-DEN · Board of Dental Examiners · 2025-07-21

IN THE OFFICE OF ADMINISTRATIVE HEARINGS

In the Matter of:

Cheol Myeong Choi, DMD,

Holder of License No. D010028

For the Practice of Dentistry

In the State of Arizona

No. 24F-[number redacted]-DEN

ADMINISTRATIVE LAW JUDGE DECISION

HEARING: December 2, 2024

APPEARANCES: Cheol Myeong Choi, DMD, appeared and was represented by Amber Dresslar. The Arizona Board of Dental Examiners was represented by Assistant Attorney General Seamus Monaghan.

ADMINISTRATIVE LAW JUDGE: Tammy L. Eigenheer

EXHIBITS ADMITTED INTO EVIDENCE: Board Exhibits 1 through 7 and 9 through 19.

_____________________________________________________________________

FINDINGS OF FACT

Background and Procedure

The Board has the authority to regulate and control the practice of general dentistry in the State of Arizona.

Respondent Cheol Myeong Choi was the holder of License No. D010028 for the practice of dentistry in the State of Arizona. Respondent’s license was initially issued on May 23, 2018, and had been in a suspended status since June 3, 2021, because Respondent had been notified of the complaint in this matter before his license expired.

On or about April 8, 2021, the Board received a complaint against Respondent from the mother of a six-year-old patient, OSJ. The complaint alleged that Respondent performed 12 root canals and 12 caps on OSJ without informing the parents about the root canals; did not address the planned care with the patient’s mother; and would not allow the mother in the room during the procedure.

On or about August 28, 2024, the Board issued a Complaint and Notice of Hearing (“Complaint”) for Case No. [number redacted] alleging Respondent had engaged in unprofessional conduct pursuant Ariz. Rev. Stat. § 32-1201.01(14) (“Committing any conduct or practice that constitutes a danger to the health, welfare or safety of the patient or the public.”).

Respondent’s Answer to the Complaint was timely received by the Board.

Because Respondent contested the charges in the Complaint, the Board forwarded the matter to the Office of Administrative Hearings (“OAH”), an independent state agency, for hearing to determine whether Respondent violated Ariz. Rev. Stat. § 32-1201.01(14) as charged by the Board.

Hearing Evidence

At hearing, the Board presented witness testimony from April Romero, Chief Compliance Officer, and Julie Cutler, D.D.S., Board Consultant, and admitted 18 exhibits into the record. At hearing, Respondent testified on his own behalf.

The substantive evidence of record was as follows:

On or about March 4, 2020, OSJ presented to Respondent’s office with his father for a new patient examination. According to the father, the chief complaint was “cavities.” This was OSJ’s first visit to a dentist.

Respondent performed prophylaxis and fluoride treatment and discussed oral hygiene instructions.

Respondent attempted to obtain x-rays, but due to OSJ’s inability to tolerate the sensor, Respondent was only able to take two anterior periapicals (“PA”) of the maxillary and mandibular portions of the mount and one PA of the posterior area. Respondent was also able to obtain five clinical photographs of four posterior quadrants and one maxillary anterior quadrant.

Respondent’s oral examination demonstrated that all dentition had decalcifications and crowding as visible on the intraoral photographs. OSJ’s father was told that the child had multiple large caries, especially on the upper molars and the upper anterior dentition. Respondent recommended that they treat the whole mouth under general anesthesia for a safer and non-traumatic delivery of care for OSJ.

According to Respondent, he reviewed with OSJ’s father the need for additional x-rays, the possible treatment scenarios, and the various treatment of fillings, enameloplasty, pulpotomies, posterior stainless steel crowns, anterior porcelain veneered steel crowns, and possible extraction of some teeth depending on what the additional x-rays would show and what Respondent found at the time of treatment. Due to the generalized decalcification and multiple large caries, Respondent indicated that OSJ would likely need stainless steel crowns on all posterior teeth if confirmed with caries by the x-rays.

The estimated treatment plan was reviewed with the father. The treatment plan included 12 crowns, 12 pulpotomies, and 6 intracoronal composite restorations. The father was told the treatment plan may change at the time of the treatment depending on what conditions were found. The father signed an exam consent form acknowledging possible changes in the treatment.

On or about April 2, 2020, Respondent’s lead dental assistant called OSJ’s father to review the planned treatment, preoperative instructions, and planned treatment time. The father informed Respondent’s dental assistant that OSJ’s mother would be accompanying OSJ for the visit, as the father and mother had separate custody of OSJ. Respondent’s dental assistant made a separate call to OSJ’s mother to review the same information that had been provided to the father.

On or about April 6, 2020, OSJ and his mother arrived for the treatment. The mother met with the anesthesiologist who obtained separate informed consent for the anesthesia portion of the procedure.

Respondent’s staff asked the mother to sign a standardized digital consent for the planned dental treatment. The informed consent document was presented to the mother by an administrative assistant after the care had begun. There was no indication on the consent form that any discussion regarding care was given. Though the form included descriptive paragraphs and check boxes to indicate the applicable procedures, none were checked to show the parent’s understanding or approval.

Respondent did not speak to OSJ or his mother prior to the treatment.

At the surgical visit, Respondent obtained preoperative radiographs, four posterior bitewings.

The bitewing x-rays taken at the surgical appointment revealed proximal decay and the extent of decay and proximity to the pulp.

There were no posterior periapical images taken which would be necessary to further diagnose pulpitis or necrosis by showing the furcation and periapical area as well as surrounding bone of teeth involved. The posterior films taken did not reveal severe carious lesion depth nor frank pulpal exposure of all the posterior teeth.

During the procedure, Respondent performed an interproximal reduction between the lower anterior teeth (Teeth N, O, P, and Q) to create space to remove the decay and to allow OSJ to be able to keep the teeth cleaner as the saliva would have a natural flow between the teeth.

The proximal reduction of the mandibular incisors was not part of the treatment plan and was done without preoperative knowledge or consent of the parents.

At the appointment on April 6, 2020, Respondent also performed the following procedures/treatments:

Teeth A, B, I, J, K, L, S, and T each received a stainless steel crown and cervical pulpotomy based on Respondent’s clinical note.

Teeth D, E, F, and G each received a stainless steel crown with cosmetic veneer and pulpotomy based on Respondent’s clinical note.

Teeth C, H, M, N, Q, and R each received multiple surface resin restorations.

Teeth N, O, P, and Q each had proximal reduction though this was not reflected in the clinical note.

Respondent’s plan to do 12 pulpotomies was based on limited information as he had not taken all the needed x-rays, and thus, was just an anticipation of worst case findings in the future x-rays. Once the x-rays were taken, a final decision could be made on the best option for pulp therapy of all teeth. Any pulp therapy could be limited to vital choices such as indirect pulp cap, direct pulp cap, or pulpotomy as there was no evidence of necrosis or suspected irreversible pulpitis.

Respondent’s plan regarding pulpotomies did not change during the treatment and 12 pulpotomies were completed. The x-rays obtained at the time of treatment showed caries, but few posterior lesions were near the pulp.

On or about April 8, 2020, the Board received a complaint from OSJ’s mother. In the complaint, OSJ’s mother stated that neither she nor OSJ’s father were informed OSJ would have root canals, but were only told he would have 8 caps. The mother denied anyone discussing the treatment plan with her that day, but maintained she was only directed to “sign the pin pad.” The mother stated she was not informed of the change in treatment plan after the x-rays were taken and was hurried out after the procedure was completed. The mother asserted that Respondent “went in a drilled every tooth in my six year old boys head.”

On or about April 13, 2020, the Board advised Respondent of the complaint and issued a subpoena to Respondent. Respondent was required to submit the relevant records and information with a narrative response no later than May 18, 2020.

On or about May 4, 2020, Respondent, through his counsel, submitted the required response to the Board.

On or about May 21, 2021, the Board’s Consultant submitted their report to the Board after reviewing the records and Respondent’s narrative.

On or about August 6, 2021, the Board reviewed Respondent’s case and voted to offer Respondent a consent agreement requiring 10 additional hours of continuing education (“CE”).

On or about September 10, 2021, the Board again reviewed Respondent’s case and voted to offer the consent agreement as proposed and, if not accepted, invite Respondent to a formal interview.

On or about December 3, 2021, the Board again reviewed Respondent’s case and voted to amend the language of the proposed consent agreement.

On or about January 14, 2022, the Board received Respondent’s request for a Formal Interview.

On or about January 27, 2022, the Board invited Respondent to participate in a formal interview to occur on March 4, 2022.

On or about October 13, 2023, the Board again considered Respondent’s case. Respondent’s counsel asserted that Respondent had not been practicing in Arizona and proposed working with the Board’s attorney to draft an agreement. The Board voted to rescind the previous motion for a formal interview and remand the matter to investigative review.

On or about May 31, 2024, the Board again considered Respondent’s case. The Board voted to offer the most recent disciplinary consent agreement drafted by the assistant attorney general, and if it was not signed within 30 days, move the matter to a formal interview.

Respondent declined to participate in a formal interview and requested that the matter be referred for a formal hearing.

On or about August 28, 2024, the Board issued the Complaint alleging Respondent had engaged in unprofessional conduct pursuant Ariz. Rev. Stat. § 32-1201.01(14). Specifically, the Board asserted that Respondent’s failure to take posterior periapical images necessary to diagnose pulpitis or necrosis and Respondent’s completion of 12 pulpotomies, some of which were not necessary, were deviations from the standard of care. Further, the Board maintained that Respondent deviated from the standard of care when he performed a proximal reduction between OSJ’s lower anterior teeth without discussing and receiving informed consent from OSJ’s mother and father. Additionally, Respondent deviated from the standard of care when he failed to discuss the planned treatment with OSJ’s mother despite knowing OSJ’s mother and father were separated, mother was not present for the April 2, 2020 appointment, and mother was presenting for the first time the day of the treatment.

At hearing, the Board pointed out that Respondent failed to meet with OSJ or his mother prior to the procedure despite having had no previous conversations with the mother regarding the treatment plan. Respondent admitted that the interproximal reduction was not in the treatment plan and was not discussed with OSJ’s mother prior to it being completed. Respondent stated he discussed it with OSJ’s father, but it was not in the treatment plan because he was going to treat it as a free service, so it did not need to be included in the financial agreement or the treatment plan.

Respondent stated that it was appropriate to let his dental assistant, who was neither regulated nor a health professional in Arizona, explain the treatment plan to OSJ’s mother and obtain her informed consent, even though he proposed extensive dental work during the treatment.

Respondent indicated that the treatment plan could change depending on what was observed during the treatment, so the treatment plan was not finalized until the procedure was complete. Respondent stated that, in the event major changes to the treatment plan were needed, such as extraction, those changes would be communicated to the parent prior to proceeding, but small changes would not be addressed until the treatment concluded.

At hearing, Julie Cutler, D.M.D., testified that the x-rays obtained did not support the original treatment plan. In some of the x-rays, the top teeth were cut off, so it would not be possible to diagnose anything with respect to those teeth. Dr. Cutler stated that it was possible Respondent’s treatment was appropriate, but the records supplied could not establish that.

Dr. Cutler testified that overtreatment is a harm to a patient and without evidence to support the treatment provided, it was possible OSJ was overtreated. Dr. Cutler stated that it was possible the treatment provided was appropriate, but she did not have enough information to conclude that was the case.

In closing, the Board argued that it wanted to rehabilitate Respondent and requested Respondent be required to complete 10 additional hours of CE with 4 hours in risk management and 6 hours in treatment and diagnosis.

CONCLUSIONS OF LAW

The Board has jurisdiction over Respondent and the subject matter in this case. The matter was properly brought before OAH pursuant to ARIZ. REV. STAT. §§ 41-1092 et seq.

All licensees must apprise themselves of, and be held responsible to, the State’s Dental Practice Act.

The Board bears the burden of proof to establish that Respondent committed unprofessional conduct that furnishes cause to discipline his license to practice dentistry in the State of Arizona by a preponderance of the evidence. Respondent bears the burden to establish affirmative defenses and factors in mitigation of the penalty by the same evidentiary standard.

“A preponderance of the evidence is such proof as convinces the trier of fact that the contention is more probably true than not.” A preponderance of the evidence is “evidence which is of greater weight or more convincing than evidence which is offered in opposition to it; that is, evidence which as a whole shows that the fact sought to be proved is more probable than not.”

Pursuant to Ariz. Rev. Stat. § 32-1201(13), “disciplinary action” means regulatory sanctions that are imposed by the Board in combination with, or as an alternative to, revocation or suspension of a license and that may include:

(a) Imposition of an administrative penalty in an amount not to exceed $2,000 for each violation of this chapter or rules adopted under this chapter.

(b) Imposition of restrictions on the scope of practice.

(d) Imposition of censure or probation requirements best adapted to protect the public welfare, which may include a requirement for restitution to the patient resulting from violations of this chapter or rules adopted under this chapter.

Ariz. Rev. Stat. § 32-1263.01(A) provides that the Board may take any one or a combination of the following disciplinary actions against any person licensed under the chapter:

1. Revocation of license to practice.

2. Suspension of license to practice.

3. Entering a decree of censure, which may require that restitution be made to an aggrieved party.

4. Issuance of an order fixing a period and terms of probation best adapted to protect the public health and safety and to rehabilitate the licensed person. The order fixing a period and terms of probation may require that restitution be made to the aggrieved party.

5. Imposition of an administrative penalty in an amount not to exceed two thousand dollars for each violation of this chapter or rules adopted under this chapter.

6. Imposition of a requirement for restitution of fees to the aggrieved party.

7. Imposition of restrictions on the scope of practice.

8. Imposition of peer review and professional education requirements.

9. Imposition of community service.

Pursuant to Ariz. Rev. Stat. § 32-1263(A)(1), the Board may impose disciplinary action against a dentist for any unprofessional conduct as defined in Ariz. Rev. Stat. § 32-1201.01.

Pursuant to Ariz. Rev. Stat. § 32-1201.01(14), “unprofessional conduct” includes committing any conduct or practice that constitutes a danger to the health, welfare, or safety of the patient or the public

The record established by a preponderance of the evidence that Respondent failed to obtain sufficient images to diagnose pulpitis or necrosis prior to planning treatment for 12 pulpotomies.

The record failed to establish by a preponderance of the evidence that Respondent overtreated OSJ. Respondent was credible in his testimony that his observations of the teeth during the treatment necessitated the treatment provided even though sufficient images were not obtained to document that fact.

The record established by a preponderance of the evidence that Respondent failed to obtain informed consent from OSJ’s mother or father for the interproximal reduction between the lower anterior teeth and did not obtain informed consent from OSJ’s mother for any of the treatment prior to the procedure. While Respondent delegated the task of reviewing the treatment plan with OSJ’s mother to different staff members and assumed that OSJ’s father had communicated the treatment plan to her, such conduct was not appropriate in light of the situation. Respondent knew OSJ’s mother and father were separated and he did not speak directly to OSJ’s mother prior to the procedure day. OSJ’s mother was not presented with the informed consent document until after the procedure had started and the boxes on the form were not checked to denote which procedures were being done and approved. Respondent had a responsibility to ensure that OSJ’s mother understood the treatment plan and consented to the same in advance of performing any treatment.

Here, the Board has established that Respondent committed acts of unprofessional conduct pursuant to Ariz. Rev. Stat. § 32-1201.01(14). As such, grounds exist for the Board to take disciplinary action pursuant to Ariz. Rev. Stat. § 32-1263.01(A).

Weighing the gravity of Respondent’s above-captioned conduct against the Board’s interest in protecting the public, the undersigned Administrative Law Judge finds that it is appropriate for Respondent to complete additional CE in the areas of risk management and treatment and diagnosis.

RECOMMENDED ORDER

Based on the foregoing,

IT IS RECOMMENDED that within twelve (12) months of the effective date of the Final Order in this matter, Respondent Cheol Myeong Choi shall be required to provide to the Board acceptable written proof that he has completed four (4) hours of continuing education in risk management and six (6) hours of continuing education in treatment and diagnosis. Respondent’s failure to timely provide the Board with proof of completion regarding the above-captioned hours of education instruction shall result in the revocation of Respondent’s license.

Pursuant to A.R.S. § 41-1092.08(I), the licensee may accept the Administrative Law Judge Decision by advising the Office of Administrative Hearings in writing not more than ten (10) days after receiving the decision. If the licensee accepts the Administrative Law Judge Decision, the decision shall be certified as the final decision by the Office of Administrative Hearings.

In the event of certification of the Administrative Law Judge Decision by the Director of the Office of Administrative Hearings, the effective date of the Order will be forty (40) days from the date of that certification.

Done this day, July 21, 2025.

/s/ Tammy L. Eigenheer

Administrative Law Judge

Transmitted by either mail, e-mail, or facsimile to:

Ryan Edmonson,

Board of Dental Examiners

Amber Dresslar

Quintairos, Prieto, Wood & Boyer, P.A.

[email redacted]

Cheol Myeong Choi, DMD

[email redacted]

Seamus Monaghan

Office of the Attorney General

[email redacted]

By: OAH Staff