Sandra Whitley Ryals Director

COMMONWEALTH of VIRGINIA

Department of Health Professions Perimeter Center

9960 Mayland Drive, Suite 300 Richmond, Virginia 23233-1463

www.dhp.virginia.gov TEL (804) 367- 4400 FAX (804) 527- 4475

(804) 367-4538

Virginia Board of Dentistry

FAX (804) 527-4428 denbd @dhp.virginia.gov

July 15, 2008

Roy Silas Shelburne, D.D.S.

153 East Morgan Ave Pennington Gap, Virginia 24277

CERTIFIED MAIL:71960 3901 98451841 8414

Case #: 94842

Dear Dr. Shelburne:

Enclosed is a Copy Teste of the Consent Order that was entered by the Virginia Board of Dentistry on July 15, 2008.

Sincerely,

-.4~~~

Sandra K. Reen

Executive Director Virginia Board of Dentistry

SKRJtdp

Enclosure

cc: Conunittee Members

Sandra Whitley Ryals, Director, Department of Health Professions

Alan Heaberlin, Deputy Executive Director, Virginia Board of Dentistry Lorraine McGehee, Deputy Director, Administrative Proceedings Division Julia Bennett, Adjudication Specialist

Enforcement (#94892)

Board of Audiology & Speech - Language Pathology - Board of Counseling - Board of Dentistry - Board of Funeral Directors & Embalmers Board of Long-Term Care Administrators - Board of Medicine - Board of Nursing - Board of Optometry - Board of Pharmacy

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Board of Health Professions

VIRGINIA:

BEFORE TIIE BOARD OF DENTISTRY

INRE:

ROY S. SHELBURNE, D.D.S. License No. 0401-005798

CONSENT ORDER

By letter dated May 20, 2008, the Virginia Board of Dentistry ("Board") noticed Dr.

Shelburne for an informal conference to inquire into allegations that he may have violated certain

laws and regulations governing the practice of dentistry in the Commonwealth of Virginia.

In lieu of proceeding to this informal conference, the Board and Dr. Shelburne, as evidenced

by their signatures affixed below, agree to enter into this Consent Order affecting the license of Dr.

Shelburne to practice dentistry in Virginia.

FINDINGS OF FACT AND CONCLUSIONS OF LAW

1. Roy S. Shelburne, D.D.S., holds license number 0401-005798 issued by the Board

to practice dentistry in the Commonwealth of Virginia. Said license is currently active and will

expire on March 31, 2009, unless renewed or otherwise restricted.

2. Dr. Shelburne violated § 54.1-2706(5) and (11) of the Code in his care and treatment

of Patients A-J, in that these patients experienced significantly high rates of failed treatment and

i::::

were subject to diagnostically and clinically unwarranted dental procedures. Further, in Dr.

Shelburne's care and treatment of these patients, he demonstrated an inability to accurately diagnose

carious lesions and appropriately restore decay; to properly diagnose and treat endodontically

compromised teeth; to provide adequate periodontal treatment; to properly fit and place crowns; to

administer appropriate anesthesia; to adequately comprehend and treat pathology; andlor to

accurately diagnose the need for, and appropriately perform, pulpotomies. Specifically:

a. With respect to Patient A, whom Dr. Shelburne treated for fourteen years from

Consent Order - Roy S. Shelburne, D.D.S. Page 2 of IS

approximately January 1986 to April 2001:

1. On his first documented visit on January 23, 1986, Dr. Shelburne extracted

tooth #31. even though he noted no radiographic or clinical findings warranting such

action.

n. Dr. Shelburne performed the following amalgam restorations without noting

any radiographic or clinical findings warranting such action: tooth #4 on February

7, 1986; tooth #32 on February 27, 1986; tooth #2 on March 3, 1987; tooth #5 on

March 3, 1987; tooth #13 on October 3, 1987; tooth #15 on October 3, 1987; and

tooth #20 on October 3,1987.

111. Dr. Shelburne failed to perform or document a periodontal examination on

Patient A until October 18, 1994, over eight years from his initial visit to Dr.

Shelburne's office.

IV. Dr. Shelburne performed a root canal and amalgam restoration on tooth #5

on August 27, 1987, and performed another restoration on that tooth on September

4, 1996. However, a Panorex taken on June 29, 1999, revealed an incomplete

endodontic fill, which Dr. Shelburne did not treat or refer for treatment, thereby

jeopardizing the long-term viability of tooth #5. Further, on August 26, 2002,

Dentist V noted radiolucency at the apex of tooth #5.

v. On October 3, 1987, January 16, 1995, and May 26, 1995 Dr. Shelburne

performed restorations on tooth #13. On or about October 4, 2001, Dentist V

smoothed overhangs on tooth #13 that Dr. Shelburne had failed to remediate.

Consent Order - Roy S. Shelburne, D.D.S. Page 3 of15

VI. On March 2, 1992, Dr. Shelburne placed an amalgam restoration on Tooth

#18 and subsequently, on April 14, 1993, performed endodontics. On December 12,

2001, Dentist V noted tooth #18 had distal caries separating the distal root from the

crown and caries extending into the mesial root at the furcation, with purulent

drainage and infection present at the furcation, conditions Dr. Shelburne failed to

diagnose or treat at or prior to Patient A's last visit with him on April 10, 2001.

Dentist V determined tooth #18 was non-restorable and extracted it.

Vll. On January 31, 1989, July 1, 1993, May 26, 1995, and July 28, 1995 Dr.

Shelburne performed restorations on tooth #29, and, on July 23, 1996, he performed

an apicoectomy and retrofill on that tooth. An x-ray taken on June 29, 1999

revealed that the fill of the tooth went outside the end of the root and filled in the

bone area, rather than just the tip of the root, and indicated infection around the fill,

necessitating extraction of tooth #29 on September 1, 1999.

Vl1l. On October 4, 2001, Dentist V noted "rampant" caries and the need for

restorations on seven of Patient A's teeth (#1, 3, 4, 5, 15, 20, and 21), which Dr.

Shelburne had failed to diagnose or adequately treat at or prior to Patient A's last

visit to his office on or about April 10, 2001.

b. With respect to Patient B,whom Dr. Shelburne treated for approximately twelve

years from April 27, 1989 to June 18, 2001:

1. For the entire treatment period, Dr. Shelburne failed to perform or note

periodontal examination or treatment for Patient B, with the exception of one limited

Consent Order - Roy S. Shelburne, D.D.S. Page 4 of 15

periodontal score documented on February 23, 1994.

11. Dr. Shelburne failed to diagnose and treat the following conditions indicated

on a Panorex taken August 3, 1999: decay around teeth #4, 12, 14 and 27; poor

contacts on teeth #2 and 3; an abscess on tooth #18; and a root tip left from the distal

of extracted tooth #30.

lll. Dr. Shelburne failed to diagnose and treat the following conditions indicated

on bitewing x-rays taken on March 6, 2001: decay and a large overhang on tooth

#2; decay and an overhang on the distal of tooth # 3; decay and poor margins

around the crown on tooth #4; large caries on the distal of tooth #5; a poorly fitted

crown on tooth #13; an overhang and caries under the distal of the restoration on

tooth #14~ an overhang and caries under the mesial of the restoration ontooth #15;

and root caries on the distal of tooth #29.

iv. Dr. Shelburne performed amalgam restorations on tooth #31 on November

26, 1991, July 23, 1992, May 27, 1993, and October 4, 1993; placed a stainless steel

crown on October 29, 1993; performed endodontics on August 7, 1996 and October

2, 1996; and noted periapical pathology on December 18, 1996. Notwithstanding

radiographic indication of infection around the apex of tooth #31 on November 2,

2000, Dr. Shelburne performed crown preparation and seated a crown on November

7 and 21, 2000, respectively. When Patient B complained of pain and swelling near

tooth #31 on May 3, 2001, Dr. Shelburne noted infection around the apex of the

tooth and prescribed medication. On June 18, 2001, when Patient B again

Consent Order - Roy S. Shelburne, D.D.S. Page 5 er rs

complained that tooth #31 was very painful and a Panorex showed a dark area at the

apex, Dr. Shelburne instructed Patient B to continue taking Augrnentin and

prescribed an additional antibiotic, Tetracycline, but took no further action. On July

5, 2001, Patient B presented to Dentist V, who diagnosed tooth #31 with short

endodontic fills of the mesial canals and a large radiolucency encircling both root

apices. Tooth #31 was extracted on July 13, 2001, revealing a large cyst at the

bottom of the socket.

v. On October 4, 2001, Dentist V noted "rampant" caries and the need for

restorations on thirteen of Patient B's teeth (#2,3, 7, 8,10, 12, 14, 18,20,21,22,28,

and 29), which Dr. Shelburne had failed to diagnose or adequately treat at or prior to

Patient B's last visit to his office on or about June 28,2001.

c. With respect to Patient C, whom Dr. Shelburne treated for approximately twelve

years from March 22, 1988 to December 23, 2002:

1. On November 15, 1999, Dr. Shelburne performed a root canal on tooth #30

and seated a temporary crown. The next day, the temporary crown came off and Dr.

Shelburne was unable to re-cement it, thus leaving the tooth exposed until the

__ ,f"

permanent crown was seated on December 19, 1999.

11. On April 20, 2000, Dr. Shelburne performed a root canal and placed a

temporary crown on tooth #9, followed by the seating of the permanent crown on

May 10, 2000. On January 3, 2002, Patient C presented to Dentist W on an

emergency basis for treatment of severe pain in tooth #9. Dentist W noted that the

Consent Order - Roy S. Shelburne, D.D.S. Page 6 of IS

root canal fill in tooth #9 was 3 millimeters short of the apex, the canal exhibited

ledging, and an open margin existed on the mesial surface of the crown. Patient C

was referred for an apicoectomy.

111. On November 8, 1999, Dr. Shelburne performed a root canal and placed a

temporary crown on tooth #14, followed by the seating of the permanent crown on

December 13, 1999. On April 11, 2003, Patient C presented to Dentist W on an

emergency basis with complaints of sporadic pain in the upper left posterior tooth

for approximately two months. A radiograph revealed radiolucency at the apex of

the palatal root of tooth #14, and Patient C was referred for extraction of tooth #14.

IV. On May 6, 2002, Dr. Shelburne performed a root canal and placed a

temporary crown on tooth #8. On November 18, 2002, Dr. Shelburne seated a

permanent crown on tooth #8 without investigating or treating Patient C' s

complaints of severe pain in that tooth.

d. On August 28, 2002, Dr. Shelburne administered 4% Septocaine x 5 prior to

performing pulpotomies and placing stainless steel crowns on seven-year-old Patient D's

teeth #J, K, and L, a quantity of Septocaine in''excess of safe levels.

e. On December 18, 2002, Dr. Shelburne administered 4% Septocaine x 6 and 2%

Lidocaine x 2 to 16-year-old Patient E prior to performing seven restorations on teeth #2,

20,21,22,27,28, and 31, quantities ofSeptocaine and Lidocaine that were excessive.

f Dr. Shelburne treated Patient F, who was fifteen years old at her first visit, from

approximately July 11,2000 to May 23,2003. During that treatment period, Dr. Shelburne

Consent Order - Roy S. Shelburne, D.D.S. Page 7 of15

performed numerous dental procedures on Patient F that failed, had to be redone, were

inadequate, or ultimately resulted in extraction of the treated tooth, as noted by follow-on

Dentist X, to whom Patient F presented on January 18,2005. Specifically:

Tooth Treatment Procedures Performed by Dr. Diagnosistrreatment Observations
Dates Shelburne By Dentist X
On or after January 18, 2005
#2 8/7100 Endodontics, crown preparation, and Overhang on the crown.
core build-up
8124/00 Crown seated
#3 7/17/00 Restoration Open margin on the crown, caries under
1114/02 Seen for toothache the margin of the restoration, and, upon
1116/03 Endodontics, crown preparation, core extraction, gutta percha observed
build-up, and temporary crown extending out of the root approximately 2
2/5/03 Seated permanent crown millimeters; abscess on gum between tooth
#3 and d.
#4 8/7/00 Endodontics, crown preparation, and Crown on tooth #4 was bulky with large
core build-up overhangs and decay present under the
8/24/00 Crown seated crown; parulis located between tooth #4 and
5.
#5 7117/00 Restoration Severe caries under the restoration and
necrotic pulp with chronic apical
periodontitis. Tooth required extraction.
#6 1/16/03 Restoration Severe caries under the restoration and
necrotic pulp with chronic apical
periodontitis. Tooth required extraction.
#15 10/4/00 Endodontics, crown preparation, and Periapical radiolucency around the roots,
1!~ temporary crown placed 1-2 millimeters of gutta percha extending
5/24/01 Permanent crown seated beyond the apex of each root, and an open
margin on the crown. Tooth required
extraction.
#18 8/24/00 Endodontics, crown preparation, and Parulis present on buccal tissues,
core build-up symptoms of necrotic pulp with chronic
9119/00 Permanent crown seated apical periodontitis, short root canal filling,
crown was too big, and an overhang
present. When tooth # 18 was extracted, a
cyst of abscess was noted and root canal
filling material was observed ill the
transportation of the canal, through the root
into the ligament space. Consent Order - Roy S. Shelburne, D.D.S. Page 8 of 15

#19 7/20/00 Restoration Recurrent decay present in the distal
5/7/03 X-ray showed tooth to be broken occlusal and symptoms of necrotic pulp
5/22/03 Patient complains tooth still hurting with chronic apical periodontitis. Tooth
required extraction.
#20 8/24/00 Endodontics, crown preparation, and Abscessed with gross overhangs.
core build-up
9119100 Permanent crown seated
#24 7/20/00 Restoration Open margins with overhangs.
8/24/00 Tooth starting to abscess and patient
complaints of pain
9/19/00 Endodontics and crown preparation
10/4/00 Permanent crown seated
#25 7/20/00 Restoration Open margins with overhangs.
8/24/00 Tooth starting to abscess and patient
complaints of pain
9119/00 Endodontics and crown preparation
1014/00 Permanent crown seated
#28 7/17/00 Restoration Abscessed with caries under restoration.
#29 7117/00 Restoration Abscessed with caries under restoration.
6/21101 Amalgam restoration
#30 7/17/00 Restoration Abscessed with overhangs.
6/21100 Amalgam restoration
2/18/03 Noted to be abscessing and in need of
endodontics and crown
5/7103 Endodontics, crown preparation, core
build-up, and temporary crown seated
5/22/03 Permanent crown seated
#31 7/17/00 Restoration Abscessed with overhangs.
1114102 Seen for toothache ~.
2/5/03 Apical lesion on radiograph and tooth
noted to be painful; endodontics,
crown preparation, and core build-up
2/18/03 Seated permanent crown and adjusted
occlusion in response to patient
complaints of pain at new crown g. Dr. Shelburne treated Patient G, who was thirteen years old at her initial visit from

January 19, 2000 to January 24, 2002. On February 29, 2000, Dr. Shelburne performed

Consent Order - Roy S. Shelburne, D.D.S. Page 9 of 15

endodontics and crown preparation for teeth #8 and 9, and seated the permanent crowns on

those teeth on March 15,2000. Patient G complained of pain where the crowns were done

on March 30, 2000. On April 3, 2000, Dr. Shelburne noted an infection on tooth #9, wrote a

prescription for Keflex, and told Patient G to return if she continued to experience pain. On

June 20,2001 and December 12, 2001, Patient G reported continuing pain in teeth #8 and 9,

for which no treatment or treatment plan was noted. On January 7, 2004, Dentist Y saw

Patient G for pain in teeth #8, 9, and 19. Radiographic and clinical examination revealed

apical radiolucencies on both teeth #8 and 9, inflamed gums, and a large marginal

discrepancy on the facial of tooth #8. Patient G was referred to an endodontist to redo the

root canals on teeth #8 and 9. On January 16, 2004, Patient G sought a second opinion

regarding teeth #8 and 9 from Dentist V, who noted that the Panorex revealed apical

radiolucencies on teeth #8 and 9 and that there were several areas of open margins

associated with the crowns on teeth #8 and 9. Subsequently, teeth #8 and 9 were extracted.

h. Dr. Shelburne treated Patient H, a five-year-old, on three occasions from July 25,

2002 to August 22, 2002. At his August 22, 2002 visit, Dr. Shelburne's treatment plan for

Patient H was to performpulpotomies and place stainless steel crowns on teeth #A, B, S,

and T. On February 24, 2003, Patient H presented to Dentist Z, who found no decay or

other indications that would justify Dr. Shelburne's planned treatment of pulpotomies and

crowns on teeth #A, B, S, and T.

1. Dr. Shelburne treated Patient I, a four-year-old, on May 3, 17, and 23, 2001. At the

second visit, Dr. Shelburne performed pulpotomies and placed stainless steel crowns on

Consent Order - Roy S. Shelburne, D.D.S. Page 10 of IS

teeth #A, B, S, and T, and planned pulpotomies for teeth #D, E, F, G, I, J, K, and L. During

treatment on May 23, 2001, Patient 1 became upset, a temporary was placed on tooth #L,

and the child was referred to another dentist for treatment. On May 28, 2002, Patient 1 was

seen by Dentist Y, who found no need for pulpotomies on teeth #D, J, and K in the absence

of decay into the pulp of those teeth. Dentist V also noted that, in reviewing Dr. Shelburne's

pre-operative x-rays from May 3, 2001, she saw no radiographic indication for pulpotomies

on teeth #A, J, or T. Further, Dentist V did not treat teeth #F and G since Patient 1 would be

expected to loose those teeth within approximately a year.

J. Dr. Shelburne treated Patient J, who was four years old at her initial visit, from July

20,2000 to July 25, 2001. On August 7,2000, Dr. Shelburne performed pulpotomies and

placed stainless steel crowns on teeth #A, B, S, and T, and performed pulpotomies and

placed composite restorations on teeth #D and E. On August 14, 2000, Dr. Shelburne

performed pulpotomies and placed stainless steel crowns on teeth #1, J, K, and L, and

performed a pulpotomy and composite restoration on tooth #M. Three days later, the

restoration on tooth #M fell out, and was replaced on September 26,2000. On January 24,

2001, Dr. Shelburne noted that part of the filling on tooth #M was missing, and on February

,.~ ..

12, 2001, he performed a pulpotomy and placed a stainless steel crown on that tooth. On

July 25, 2001, Patient J presented with the crown off of tooth #L, which Dr. Shelburne re-

cemented. Follow-on Dentist V, who began treating Patient J on February 12,2002, noted

that Dr. Shelburne's radiographs dated July 29,2000 showed no indication for pulpotomies

and stainless steel crowns on teeth #A or B or for a pulpotomy on tooth #E.

Consent Order - Roy S. Shelburne, D.D.S. Page 11 oIl5

3. Dr. Shelburne § 54.1-2706(4) and (10) of the Code, and 18 VAC 60-20-170(1) of

the Board Regulations, in that, on numerous occasions he performed and billed for unnecessary or

contraindicated dental procedures on Patients A, B, D, I, and J, as follows:

a. At Patient A's April 10, 2001 visit, Dr. Shelburne noted that tooth #31 had lost a

temporary crown and another temporary crown was seated; however, Dr. Shelburne

documented the extraction of tooth #31 at Patient A's initial visit on January 23, 1986.

b. On or about November 21,2000, Dr. Shelburne seated a crown on Patient B's tooth

#31, even though such action was contraindicated due to the fact that the tooth was noted to

have periapical pathology as early as December 18, 1996.

c. Dr. Shelburne billed for performing a pulpotomy and placement of a stainless steel

crown on Patient D's tooth #B on February 21, 2002, when he actually performed an

extraction, as evidenced by his treatment note on August 1, 2002 that he seated a unilateral

spacer on that date to replace tooth #B.

d. On May 17, 2001, Dr. Shelburne performed pulpotomies and placed stainless steel

crowns on Patient I's teeth #A and T; however, based on Dr. Shelburne's radiograph from

May 3,2001, pulpotomies for these teeth were not illdicated.

e. On August 8, 2000, Dr. Shelburne performed pulpotomies on Patient J's teeth #A,

B, D, and E, placed stainless steel crowns on teeth #A and B, and performed composite

restorations on teeth #D and E. Follow-on Dentist V, who began treating Patient J on

February 12,2002, noted that Dr. Shelburne's radiographs dated July 29, 2000 showed no

Consent Order - Roy S. Shelburne, D.D.S. Page 12 of1S

indication for pulpotomies on teeth #A, B, or E. or for stainless steel crowns on teeth #A or

B.

4. Dr. Shelburne violated § 54.1-2706(5), (9) and (11) of the Code, and 18 VAC 60-20-

15 of the Board Regulations, in that his records for Patients A-J do not consistently include the

following required information: updated health histories; diagnosis and treatment rendered; and a

list of drugs prescribed, administered, dispensed and the quantity, including levels of nitrous oxide

administered to minor Patients D (on March 4, 2002 and August 28,2002), E (on December 18,

2002), and G (on February 28, 2000).

5. Dr. Shelburne has provided the Board with revised consent forms for treatment, root

canals, crowns, and extractions as examples of his efforts to remediate past deficiencies and

improve his practice of obtaining informed consent.

6. Since approximately 1999, Dr. Shelburne has completed 256.25 continuing

education hours, to include the following subjects: endodontics, fixed prosthetics, oral surgery,

infection control, and recordkeepinglrisk management.

CONSENT

Roy S.'Shelburne, D.D.S., by affixing his signature hereon, agrees to the following:

1. He has been advised specifically to seek the advice of counsel prior to signing this

document;

2. He is :fully aware that without his consent, no legal action can be taken against him

except pursuant to the Virginia Administrative Process Act, § 2.2-4000.A et seq of the Code of

Virginia;

Consent Order - Roy S. Shelburne, D.D.S. Page 13 of 15

3. He has the following rights, among others:

a. the right to an informal conference before the Board; and

b. the right to appear in person or by counsel, or other qualified representative

before the agency.

4. He waives all rights to an informal conference;

5. He neither admits nor denies the truth of the above Findings of Fact, but he agrees

not to contest them in any future administrative proceeding before the Board; and

6. He consents to the following Order affecting his license to practice dentistry in the

Commonwealth of Virginia.

ORDER

WHEREFORE, on the basis of the foregoing Findings of Fact and Conclusions of Law, and

with the consent of the licensee, it is hereby ORDERED that the Board accepts the surrender for

REVOCATION of the license of Roy S. Shelburne, D.D.S.

Upon entry of this Consent Order, the license of Roy S. Shelburne, D.D.S., will be

recorded as REVOKED and no longer current.

Should Dr. Shelburne seek reinstatement of his license, he shall be noticed to appear

before the Board, in accordance with the Administrative Process Act. As petitioner, Dr.

Shelburne has the burden of proving his competency and fitness to practice dentistry in the

Commonwealth of Virginia in a safe and competent manner.

Consent Order - Roy S. Shelburne, D.D.S. Page 14 of IS

Pursuant to § 2.2-4023 and § 54.1-2400.2 of the Code of Virginia, the signed original of this

Consent Order shall remain in the custody of the Department of Health Professions as a public

record and shall be made available for public release, inspection and copying upon request.

FOR THE BOARD:

Sandra K. Reen

Executive Director Virginia Board of Dentistry

ENTERED: ::r::Lr 15; 200Y

SEEN AND AGREED TO:

._"'-:\/-~"I -rt\ r:

r.~ ~(1JMJL."--"tZq_;::J

Roy S. Shelburne, D.D.S.

ST/JIG v r- fe /l/l cS.I c. _.

C(JMMONWEALTH E)Vu."'vR'1:lt9.,(JF.!;n'fll:\f'M'"IAn-~'

CITY/COUNTY OF tv' AS( .... I ~ '/J;:--

Subscribed and sworn to before me, a NQllizy Public in and for the city/county of

WAsb;()jld . .-'\.. ,this 3 day of Ut.I(,j ,2008, by Roy

S. Shelburne, D.D.S.

Consent Order - Roy S. Shelburne, D.D.S. Page 15 of 15

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