ALJDEC decisions subject to certification as final

FY18-201600113-MP-DEN · Board of Dental Examiners · 2018-04-12

IN THE OFFICE OF ADMINISTRATIVE HEARINGS

In the Matter of:

James R. Chaffin, D.D.S.,

Holder of License No. D6119

For the Practice of Dentistry

In the State of Arizona,

Respondent.

No. FY18-[number redacted]-MP-DEN

ADMINISTRATIVE LAW JUDGE DECISION

HEARING: March 5, 2018, at 9:00 a.m.; the record was held open until March 19, 2018, to allow the Administrative Law Judge to have the benefit of the court reporter’s transcript in making her recommended decision.

APPEARANCES: The Arizona State Board of Dental Examiners (“the Board”) was represented by Sabrina Khan, Esq., and Mary DeLaat Williams, Esq., Assistant Attorneys General; James R. Chaffin, D.D.S. (“Respondent”) was represented by Jeffrey J. Tonner, Esq.

ADMINISTRATIVE LAW JUDGE: Diane Mihalsky

_____________________________________________________________________

FINDINGS OF FACT

Background and Procedure

The Arizona Board of Dental Examiners (Board) has authority to regulate and control the practice of dentistry in the State of Arizona. The Board is charged with enforcing the provisions of the Dental Practice Act, A.R.S. § 32-1201 et seq.

Respondent holds License No. D6119 for the practice of dentistry in the State of Arizona.

On or about August 23, 2017, the Board issued a Complaint and Notice of Hearing that charged Respondent with four departures from the applicable standard of care in his treatment of patient JD:

That Respondent had failed to seat the anterior restorations on JD’s teeth nos. 8, 9, 10, 11, and 12;

That Respondent had failed to obtain adequate informed consent from JD by documenting in his treatment record a discussion of the risks, benefits, and alternatives before initiating root canal treatment on teeth nos. 9, 10, and 11;

That Respondent had taken a working length radiograph on June 25, 2015 during a root canal treatment that showed a perforated mesial root on JD’s tooth #9, but had failed to inform JD or to document the discussion and treatment options in JD’s treatment record, and failed to take immediate steps to diagnose the severity of the perforation and initiate treatment, if necessary; and

That radiographs taken by Respondent on May 7, 2015 and June 25, 2015, showed that Respondent had overfilled the canals during the root canal treatment of teeth #9, 10, and 11, but Respondent failed to document the overfills or to inform JD of the overfills and possible consequences.

As a result of Respondent’s alleged departures from the applicable standard of care, the Board charged him with having committed unprofessional conduct as defined by A.R.S. §§ 32-1201.01(14) and 32-1201(24), furnishing grounds to take disciplinary action against his license to practice dentistry under A.R.S. § 32-1263.01(A)(1).

After Respondent filed a timely written answer to the Complaint and Notice of Hearing, generally denying the alleged acts of unprofessional conduct, the Board referred the matter to the Office of Administrative Hearings, an independent state agency, for an evidentiary hearing.

A hearing was held on March 5, 2018. At the beginning of the hearing, Respondent admitted having committed the unprofessional conduct that the Board alleged in Findings of Fact Nos. 3.1 and 3.2 above. Respondent also admitted that he had failed to make adequate records for patient JD for the apparent perforation on tooth #9 and overfill on teeth #9, #10, and #11, as alleged in Finding of Fact Nos. 3.3 and 3.4 above.

The issues in dispute on which most of the evidence was presented was whether the root canals that Respondent performed on JD’s teeth nos. 9, 10, and 11 complied with the standard of care. The Board presented the testimony of Sam D. Palmer, D.M.D., its independent expert consultant and investigator, and submitted seven exhibits. Respondent testified on his own behalf, presented the testimony of Donna Kauble, his office manager, and Jeanie Lewis, his former dental assistant, and submitted two exhibits.

Additional Hearing Evidence

On or about July 18, 2016, after the Board received a report that Respondent’s malpractice insurer had made a payment on his behalf to JD regarding an inadequate bridge, it opened a complaint investigation.

The Board assigned the matter to Dr. Palmer for investigation. Dr. Palmer has been licensed to practice dentistry in Arizona since 1975 and had a general dentistry practice between 1975 and 2002. Dr. Palmer testified that he has extensive experience with endodontics and root canal treatments. He has testified numerous times as a dental expert for and against regulatory authorities and has supervised third- and fourth-year dentistry students’ clinical education.

On or about July 29, 2016, Dr. Palmer issued an initial report, concluding that Respondent had departed from the standard of care by failing to close and seal the margins on JD’s teeth #8, 9, 10, 11, and 12 on the upper anterior restorations. As noted above, Respondent at the hearing admitted that he departed from the standard of care in the ways that Dr. Palmer had opined in his initial report.

Dr. Palmer testified that the potential harm of a dentist failing to correctly seal the margins of crowns and bridges were that the patient would get recurrent decay and that, if the decay continued, would most likely lose the teeth and end up with dentures or implants.

Respondent testified when he initially seated the anterior restorations, he took x-rays that showed the restorations were adequately seated but that on JD’s post-op seats appointment with hygienists, Respondent noticed that “things were changing” and “opening up.”

Respondent noted that his office notes for JD on April 21, 2014, stated that he had permanently seated the crowns for teeth #8 through 13.

Dr. Palmer testified that he would not expect to see open margins on every crown on the day that they were delivered.

The Board subsequently requested that Dr. Palmer prepare a report of his opinion on whether the endodontics that Respondent performed on JD met the standard of care. On January 3, 2017, Dr. Palmer prepared a second report that concluded that Respondent had deviated from the standard of care in the root canals he performed on JD in the following respects:

[Respondent] failed to document a complete and thorough informed consent discussion. X-rays provided by [Respondent] indicated a perforation occurred on tooth 9 during the root canal treatment of that tooth and overfills present on teeth 9, 10, 11. There is no record of the patient being informed of the overfills or the perforation.

Dr. Palmer noted that belated intervention after a perforation substantially increased the risk of chronic infection and tooth failure and that overfilling and/or over-instrumentation of root ends can cause traumatic and/or chemical injury, although JD did not report symptoms related to overfilling.

Respondent testified that he graduated early from dental school, at the top of his class. He spent a year and a half in a prosthodontic residency. Prosthodontics is an advanced specialty program where dentists learn reconstruction, opening bites, and TMD, which is temporomandibular disorder and involves overclosed bites. In TMD, the jaw is not aligned or in proper harmony with the skull, which may result in grinding symptoms and myofascial pain. Respondent explained that a normal healthy bite generally has between 22 and 30 millimeters between gum lines and a bite. An overclosed bite has less than 22 millimeters between gumlines and the bite. Typically, the teeth are really short. Because the space to work in is smaller, rendering dental care to patients with overclosed bits may be challenging, especially if the patient requires revision.

Respondent noted that when he first started treatment on JD on September 5, 2012, he made a chart of the presence and condition of JD’s teeth. Although most people have 28 to 30 teeth, JD was missing all of his back teeth #1, 2, 14, 15, 16, 17, 8, 19, 20, 21-29, 30, 31, and 32, even though he was still in his 40’s at the time. Dental treatment of JD was challenging.

Dr. Palmer testified that according to Respondent’s record for JD, on February 21, 2014, JD arrived at Respondent’s office with an escort because JD would be sedated for a root canal on tooth #10. Respondent’s record did not note any overfill or advice to JD after the root canal.

According to Respondent’s records, on May 7, 2015, JD presented with a loose bridge and Respondent noted recurrent decay in teeth #9 and 11. Respondent’s note stated in relevant part as follows:

Ltd exam. Pt presents with loose bridge ph x-rays. Upon exam & review of xrays 9 & 11 have recurrent decay lingual. Also radiolucency on apex of 9 & 11. Rx Amoxicillin 500 mg Disp 24. Dr. C let pt know that restoratively & periodontally there are some options to restore him long term. Dr. C would like to consult w/Dr. Augustine about possible Implants. . . . Pt is devastated. Dr. C. assured him that they would come up with a good plan. . . .

Dr. Palmer testified that Respondent’s working link x-ray taken on May 7, 2015, showed an overextension in JD’s tooth #10 where the gutta-percha extended to the very tip of the root, or apex, and into the bone. Dr. Palmer testified that it appeared that Respondent had overfilled tooth #10 with gutta-percha when he performed a root canal in on February 21, 2014.

Dr. Palmer testified that the standard of care required the gutta-percha or other inert matter to be within the confines of the tooth, but that a slight overfill of half a millimeter or a millimeter was acceptable, but more than that created mechanical and chemical irritation of the bone that could result in infection and pain. Dr. Palmer testified that because a dentist cannot retrieve overfill once it occurs, the standard of care requires the dentist to inform the patient of the overfill and its possible consequences and to refer the patient to an endodontist if it looked like there was going to be an issue because the endodontist could do apical surgery to cut off the end of the root.

Dr. Palmer testified that the standard of care also requires a dentist to document in his records the overfill and that he has discussed with the patient the overfill and its possible consequences. Dr. Palmer testified that Respondent’s records for the February 21, 2014 root canal on tooth #10 did not show any of this information.

Respondent acknowledged that the May 7, 2015 working link x-ray showed that he had overfilled tooth #10 on February 21, 2014, and that neither his record of the February 21, 2014 office visit nor his record of the May 7, 2015 office visit documented the overfill or any advice to JD.

Ms. Lewis currently teaches a course for dental assistants at UEI College. She started her career while she was in the Navy. Ms. Lewis was Respondent’s dental assistant when he treated JD in 2015. Ms. Lewis testified Respondent’s record for JD on May 7, 2015, was in her handwriting and that she was present for the consultation. Ms. Lewis testified that JD came in with his wife on May 7, 2015 when he was seen for a large amount of decay. Ms. Lewis testified that JD and his wife were concerned about the cost of treatment and felt that all work should not need to be redone, since only three teeth were affected.

Respondent testified that JD required revision due to an overclosed bite and other dental issues. Respondent testified that he has worked with Jason J. Augustine, D.D.S., a periodontist or gum specialist, on approximately 10 to 12 cases a year on patients who presented with more complex dental issues. JD was one of these patients. Respondent testified that Dr. Augustine was in charge of the bone, including what teeth were kept and which ones were taken out and Respondent was in charge of prosthetics.

Respondent noted that on his May 7, 2015 record, he recommended that JD consult Dr. Augustine due to the decay in teeth #9, 10, and 11, which made it more likely that problems with the bridge would reoccur, because Dr. Augustine might decide to go with implants. Respondent explained that because the bridge was bouncing up and down, moving buccal lingual, and there was infection present, on May 7, 2015, he referred JD to Dr. Augustine.

Respondent submitted Dr. Augustine’s record of treatment for JD on June 10, 2015, which included the following notation:

[R]emaining upper teeth became non-restorable bc cavities

Details of CC What area/ tooth; #8,9,10,11,12,13

How long?; had restoration placed by Dr. Chaffin two yr and now recurrent caries and endo issues- pt frustrated and knows implants are ideal choice for upper replacements instead of redo on teeth.

Symptoms; none other [than] endo fistula on #9

Exam; completed localized emergency eval.

Significant Findings; endo issue [and] failing teeth #8-13

. . . .

Recommended Tx with ABC’s; phase one; temp on #8,10,12 and then ext [9],11,13 with grafting and sed/ wait 3months, phase two; place #9,11,13, and wait three months, phase three; tempimplants 9,11,13 and ext 8,10,12. Wait one month refer back

Coop and Consent.

NV;phase one coordinated with chaffin for temps

Respondent explained that Dr. Augustine’s note stated that JD had cooperated with and consented to the treatment plan and that “NV” meant “next visit.”

Respondent testified that “non-restorable” on Dr. Augustine’s June 10, 2015 treatment note meant that the teeth could not be fixed, regardless of whether JD had a root canal, posts, or crown length fitted. The teeth would have to be removed. Respondent testified that Dr. Augustine sent JD back to Respondent to coordinate treatment to keep the patient “together” pending the permanent solution of placement of implants.

Dr. Palmer acknowledged that on May 7, 2015, Respondent’s record for JD indicated that he would like to consult with Dr. Augustine, who may have placed implants for JD. Dr. Palmer acknowledged that he was not given and did not review Dr. Augustine’s records for JD.

Dr. Palmer also acknowledged that his initial report noted that on February 21, 2014, Respondent saw JD for a 5.5-hour appointment with Dr. Augustine present. Dr. Palmer also acknowledged that JD’s x-rays showed evidence of implants by another doctor.

Respondent established that the Board had subpoenaed Dr. Augustine’s records for JD and had received the records on August 29, 2016. Dr. Palmer noted that he prepared his initial report on July 29, 2016. Dr. Palmer testified that because the Board’s second complaint involved inadequate endodontics, he had no reason to review Dr. Augustine’s records before he prepared his January 3, 2017 report.

Respondent next saw JD on June 19, 2015. His record of the visit provided in relevant part as follows:

Consult with [Respondent, JD, and JD’s spouse]. Pt and wife are concerned & not happy that [JD] is facing redoing some work and the expenses of it. Dr. explained that the initial tx from last year was right on. Now we are dealing with recurrent decay. Dr. is comfortable to section bridge & access teeth 9-11 and do RCT. [JD’s wife] is very upset they wouldn’t have spent the money last year knowing they would have to spend more. Dr. explained that they are not redoing all of his mouth only 3 teeth because he has recurrent decay. . . . Dr. explained that he has a 5 year warranty. Dr. will 1st try to do 3 unit bridge & RCTS-spice the 5 unit bridge, Dr will charge only lab fees. 1st step is to remove 9-11 address decay, place temps, redo bridge . . . .

NV: RCT/Bridge 9-11 1crt/Sept.

Respondent testified that on June 19, 2015, JD and his wife came in for a consult and informed him that they were scheduled to leave for a 30-day trip to Europe in a short time, even though JD’s teeth were infected and the bridge was moving. Respondent testified that he tried to convince JD not to go on the trip to allow time to at least pull the teeth and put in a “flipper” to cover the loss of JD’s non-restorable front teeth. Respondent explained that a flipper is a removable piece that is quickly made but, aesthetically, is “horrible.” JD was vain about his smile and a flipper likely would have broken JD’s teeth #12 and 13 while he was in Europe. Respondent testified that, in addition, removable prosthetics were not advisable for JD because he was a gagger and did not want anything removable.

Respondent testified that after Dr. Augustine saw JD on June 10, 2015, Dr. Augustine would have called Respondent. Respondent testified that according to JD’s record for June 19, 2015, he discussed trying to do a three-unit bridge and root canal treatment and to splice the five-unit bridge that was already in JD’s mouth. Respondent acknowledged that his record did not indicate that he discussed implants or Dr. Augustine’s recommendations with JD.

Respondent acknowledged that on June 19, 2015, when his record stated that “1st step is to remove 9-11 address decay, place temps redo bridge,” he meant that he would remove the crowns and place temporary crowns on the teeth.

JD’s next visit to Respondent was on June 25, 2015. Respondent’s record of the visit provided in relevant part as follows:

9 RCT – post bu

11 RCT—post bu

#9 & #11 accessed nerve chamber, removed gross decay with SS/#6 bur. Filed to 20 mm. Irrigated w/ SHC and water dried canals, filled with gutta percha [illegible] .06 & sealer. Placed fiber post, built it; etch, brush on bond. Dr. felt it would be best to stabilize pt before splicing bridge since pt was leaving country for 2 wks. Dr. feels that #9 is fractured, not sure if it is savable. Dr. will see how infection clears up and teeth stabilize before splicing bridge and removing the rest of the decay. Rx Amox 500 mg.

Dr. Palmer testified that if tooth #9 could not be saved, it would have to be extracted and that Respondent prescribed an antibiotic to JD to help clear up the infection. Dr. Palmer explained that during a root canal, the dentist cleans out the pulp from the tooth and fills it with an inert material such as gutta-percha. A periapical radiograph, or working link x-ray, is taken to show the end of the roots. Dr. Palmer testified that when a dentist takes the working link x-ray, he hopes to see how long and how far down his instrument is going into the center of the tooth where the pulp is.

Dr. Palmer testified that the working link x-ray that Respondent took of JD’s teeth #9, #10, and #11 on June 25, 2015, showed that the instrument was not in the pulp of tooth #9 at all; it was running out the side of the root. Dr. Palmer testified that the x-ray showed a perforation on tooth #9.

Dr. Palmer testified that if a perforation is not addressed, it likely will result in the loss of the tooth. A perforation needed to be addressed within 24 to 72 hours using a material that was called NTA in endodontics to seal a perforation. The standard of care requires a dentist to both inform the patient of the perforation and to document the perforation and the discussion in the record. Respondent did neither with respect to the perforation in JD’s tooth #9. Dr. Palmer testified that Respondent’s records also did not show that the perforation in JD’s tooth #9 was ever subsequently addressed.

Dr. Palmer testified that a working link x-ray taken on June 25, 2015, showed that the gutta-percha extended beyond the apex of tooth #9 into the bone, indicating that Respondent had overfilled JD’s tooth #9 during the root canal. Dr. Palmer noted that Respondent’s records did not note the overfill of tooth #9 or any discussion with JD about the overfill.

Dr. Palmer testified that Respondent’s working link x-ray for JD also showed that Respondent had overfilled tooth #11 during the June 25, 2015 root canal procedure. Respondent’s record of the root canal also did not note the overfill or that JD was informed of the overfill and possible consequences.

Respondent testified that his primary concern on June 25, 2015, was to protect the bone in JD’s mouth so that Dr. Augustine would be able to place implants on JD’s return from Europe because JD refused to have the teeth pulled on June 25, 2015. Unless the source of infection was removed from the nerves in teeth #9 and 11, “the bone over a 30-day course would become mush.” Because teeth #9, 10, and 11 would eventually be removed and replaced by implants, Respondent testified that he did not intend for the June 25, 2015 root canals to be permanent.

Ms. Kauble testified that on June 25, 2015, while she was employed by Respondent as his office manager, she overheard a conversation between Respondent and JD during which Respondent informed JD that he was going to “patch up” and get JD’s dental problems stable as a temporary fix to buy time because JD was going to Europe. Ms. Kauble acknowledged that she did not make any notes of the conversation.

Ms. Lewis testified that she was present on June 25, 2015, when Respondent performed root canals on JD’s teeth #9 and 11. Ms. Lewis testified that on that date, Respondent removed decay because JD was going out-of-town. Ms. Lewis testified that Respondent told JD that the teeth would have to be removed and implants placed because the teeth had so much decay and broken roots, they were not restorable. Although Respondent had hoped to do root canals, the treatment that he performed was intended only to get JD out of pain and stabilize his condition before he went to Europe.

Ms. Lewis acknowledged that the record only noted that tooth #9 was not savable and did not mention tooth #11. Ms. Lewis acknowledged that she had heard that the standard for dental records was that if something was not in the record, it did not happen.

Respondent acknowledged that the working link x-ray that he took of JD’s tooth #9 on June 25, 2015, showed that the file he used for the root canal was outside the canal. Respondent explained that the file went beyond the canal due tooth #9 being fractured. Respondent testified that because tooth #9 was non-restorable and would be taken out in less than 30 days, the perforation did not matter.

Respondent testified that he did not sedate JD on June 25, 2015, in contrast to February 21, 2014, when he performed a root canal on tooth #10, and that he did not charge JD for the June 25, 2015 office visit.

Respondent acknowledged that when his June 19, 2015 treatment note stated “NV: RCT/Bridge 9-11,” one seat, one septo, he meant that JD would have anesthetic on his next visit.

Respondent acknowledged that the working x-ray that he took of JD on June 25, 2015, showed that he had overfilled the canal on teeth #9 and 11, but that his record did not reflect the overfills or any advice to JD.

Respondent testified that gutta-percha is meant to seal the apex of the tooth in a root canal. Respondent testified that he only used a file, not a rotary on JD’s teeth #9 and 11.

Respondent testified that although he felt that JD’s tooth #9 had a fracture, he did not remove the portion of the tooth that was fractured on June 25, 2015, because “[y]ou can’t remove fracture . . . from a bridge that you are accessing. You can’t see what . . . you are doing when you are going through and accessing on the lingual – which is the back side of the tooth – when the bridge is intact.”

Respondent testified that when JD returned from Europe, he went to Dr. Augustine and had teeth #9, 10, and 11 pulled and replaced by implants. Respondent testified that Dr. Augustine did not say that the overfills caused any problem with the implants. Because implants go into the bone beyond the apex of the teeth, all the gutta-percha was removed when the implants were placed.

Dr. Palmer testified that a dentist cannot perform a temporary root canal. Once he takes out the pulp and seals the tooth, the gutta-percha cannot be taken out. Dr. Palmer testified that “[a]ny treatment performed, whether it’s temporary or for free, must be within the standard of care.”

Dr. Palmer acknowledged that the Board’s Internal Investigational Review Committee (“IIRC”) had recommended non-disciplinary sanctions be placed on Respondent’s license as a result of the complaint and the Board’s follow-up complaint and investigation. Dr. Palmer acknowledged that he was a member of the IIRC and that the Board had not accepted the IIRC’s recommendation and, instead, had determined to impose discipline. Dr. Palmer testified that the IIRC conducts an investigation, but the Board makes the final decision. In this case, the Board determined to impose discipline on Respondent’s license.

CONCLUSIONS OF LAW

The Board has jurisdiction over Respondent and the subject matter in this case.

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 “[t]he greater weight of the evidence, not necessarily established by the greater number of witnesses testifying to a fact but by evidence that has the most convincing force; superior evidentiary weight that, though not sufficient to free the mind wholly from all reasonable doubt, is still sufficient to incline a fair and impartial mind to one side of the issue rather than the other.”

Pursuant to A.R.S. § 32-1263(A)(1), the Board may impose disciplinary action against a dentist for any unprofessional conduct as defined in section 32-1201.01. “Unprofessional conduct” includes “[a]ny conduct or practice that constitutes a danger to the health, welfare or safety of the patient or the public” and “[f]ailing or refusing to maintain adequate patient records.”

Respondent admitted that he had failed to close and seal the margins on JD’s teeth #8, 9, 10, 11, and 12 on the upper anterior restorations and that his failure violated the applicable standard of care. The Board established that Respondent’s failure could have harmed JD by causing or contributing to decay. Therefore, the Board established that Respondent committed unprofessional conduct as defined by A.R.S. § 32-1201.01(14).

The Board established that overfilling or perforating root canals violates the applicable standards of care for dentistry in Arizona. Respondent presented evidence to attempt to establish that his departure did not constitute unprofessional conduct because, in any event, JD teeth #9, 10, and 11 could not be saved and that his only purpose in rendering treatment was to provide a stop gap measure that would protect the bone for eventual implants. None of Respondent’s records for JD reveals this intent. When Respondent performed the February 21, 2014 root canal on JD, no evidence showed that tooth #10 could not be saved. Finally, a patient may or may not follow up on treatment recommendations. A failure to follow the standard of care because the dentist believes that future treatment will render moot any departure from the standard is speculative and exposes the patient to an unacceptable possibility of harm in the event that the anticipated follow-up care does not occur. The fact that JD did not apparently experience any harm is considered as a factor in mitigation of the penalty. Nonetheless, the Board established that Respondent committed unprofessional conduct as defined by A.R.S. § 32-1201.01(14) by overfilling JD’s teeth #9, 10, and 11 and perforating tooth #9.

Respondent admitted and the Board established that Respondent’s February 21, 2014 record did not note that an overfill of JD’s tooth #10 or any advice to JD about the possible consequences of the overfill, that Respondent’s May 7, 2015 record also did not note the overfill of JD’s tooth #10 or any advice to JD about the possible consequences of the overfill, that Respondent’s June 25, 2015 record did not note a perforation on tooth #9 or any advice to JD about the possible consequences of the perforation, and that Respondent’s June 25, 2015 record did not note the overfills of JD’s teeth #9 and 11 or any advice to JD about the possible consequences of the overfills. The Board also established that the standard of care required this information to be included in Respondent’s records. Therefore, the Board established that Respondent committed unprofessional conduct as defined by A.R.S. § 32-1201.01(24).

RECOMMENDED ORDER

Therefore, pursuant to A.R.S. § 32-1263.01, IT IS ORDERED that on the effective date of the final order in this matter, a decree of censure shall be entered against Respondent James R. Chaffin, D.D.S.’s License No. D6119.

IT IS FURTHER ORDERED that within six months of the effective date of the final order, Respondent shall be required to provide to the Board acceptable written proof that he has completed ten hours of continuing education in record keeping, in addition to the hours required to keep his license in good standing, and that his failure to complete these additional hours shall provide a basis for additional discipline against his license.

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 five days from the date of that certification.

Done this day, April 12, 2018.

/s/ Diane Mihalsky

Administrative Law Judge

Transmitted electronically to:

Elaine Hugunin, Executive Director

Arizona State Board of Dental Examiners