GREENSBORO, N.C. (WGHP) — A local dentist’s license was revoked by the North Carolina State Board of Dental Examiners due to multiple alleged violations of the Dental Practice Act.
The accused dentist, Andrew W. Kelly, DDS, of the Dental Center of the Carolinas, had been licensed to practice dentistry since 2001, according to the board’s findings.
Per the Dental Center of the Carolinas’ website, it has two locations, one at 4550 Country Club Road in Winston-Salem and one at 5509B West Friendly Avenue Suite 200.
The website describes the practice as “a cosmetic dentist that offers services like checkups, teeth cleaning, crowns, veneers and more.” Other services listed include “emergency dentist services that include bonding, root canals, crowns, and bridges.”
Due to multiple allegations of Dental Practice Act violations, Kelly’s license to practice dentistry in the state of North Carolina was revoked as well as his sedation permit in a decision made by the NCSBDE on April 22.
Initially, the decision to revoke Kelly’s license would have gone into effect on Wednesday, May 1. The board said that the time between the decision was to allow for Kelly “to complete patients in mid-treatment and refer all existing patients to another provider to ensure continuity of dental care.”
Kelly was not allowed to accept any new patients or begin any new treatments during that time.
On April 30, a temporary restraining order was filed in Davie County by Kelly. Kelly claimed that the May 1 date of the board’s final decision “would cause immediate and irreparable harm” to his dental practice.
Both parties agreed to push the date back of the final decision to May 8.
The decision to push back the date of the final decision has no bearing on the merits of the allegations made by NCSBDE.
FOX8 reached out to the Dental Center of the Carolinas for comment and a statement has not been returned as of the writing of this article.
Calls to both the Greensboro and Winston-Salem locations say they are “under new management” and that “Dr. Kelly is not available at this time.”
NCSBDE’s allegations
*Editors note: For the sake of the privacy of the patients involved placeholder names are used*
Patient A
The first of the allegations against Kelly involves a patient who came to Kelly for an implant consultation after getting a Groupon issued by Kelly in Oct. 2018.
The board claims that Kelly’s treatment notes for the patient contained “incomplete, contradictory and confusing entries,” which failed “to include an adequate description of treatment rendered, including when and by whom.”
One of the board’s examples of contradictory notes includes an instance where notes state that Kelly performed “a comprehensive examination” on Patient A. However, Kelly later stated he did not perform such an examination.
Despite the fact that Kelly claimed not to have performed a “comprehensive examination,” he still recommended an extensive treatment plan to Patient A.
Patient A later agreed to have a tooth extracted and impressions taken for study models at an appointment on Oct. 4, 2018.
The board says that Kelly’s treatment notes indicate he performed a simple extraction of the tooth. However, he billed Patient A for a surgical extraction.
An image that Kelly took on the day of the Oct. 4, 2018, appointment showed “an infection and significant bone loss” around the tooth that was extracted.
Later at a pre-hearing conference, the board states that Kelly stated he also “performed a bone graft for ridge preservation with osteogenic plugs” after extracting Patient A’s tooth. However, the aforementioned procedure was not included in the treatment note for the Oct. 4, 2018, appointment nor was Patient A billed for such a procedure.
Patient A returned to Kelly for the placement of the implant at the site of the removed tooth on Nov. 29, 2018.
The board says that Kelly’s notes for the Nov. 29, 2018 visit describe a surgical extraction of the tooth that was removed on Oct. 4, 2018. This contradicts the original notes that claim the Oct. 4, 2018 tooth removal was a simple extraction.
Kelly allegedly later claimed at a pre-hearing conference that the Nov. 29, 2018, note was an error.
The bone graft procedure that Kelly claims was performed during the Oct. 4, 2018, visit was not actually billed to Patient A until the Nov. 29, 2018 visit. The same visit where Kelly placed the implant.
Treatment notes for both of Patient A’s visits do not contain “a description of any technique used to perform a ridge preservation graft,” despite Kelly’s claims that he did perform such a procedure.
The board states that Kelly’s records do not contain a CT scan or radiograph of the area of Patient A’s extracted tooth before placing the implant. A radiograph of the area was later taken after the implant was placed and showed that the site “did not have sufficient bone to place an implant,” and that Kelly “placed the implant improperly.”
One set of the notes for the Nov. 29, 2018 visit is date-stamped as being entered on March 28, 2019, months after Patient A had been dismissed by Kelly.
NCSBDE says that Kelly’s treatment notes for the procedure are inadequate because they do not contain the following information:
- Whether a flap was made and, if so, the type and size of the incision and whether any releases were necessary;
- A description of the bone at the implant site;
- The size, lot number, expiration date, or platform size of the implant placed;
- Whether any bone graft material was used;
- The torque value of the implant; and
- The type of suturing technique used
Images taken during the Nov. 29, 2018, visit that were included in Kelly’s records indicate that they are for a different tooth than the one Patient A had removed. The board says Kelly claimed this was an error and the images were actually of the tooth that was removed.
The board claims that images taken of the extracted tooth site show a “clear bony defect in the area.”
Patient A came back to Kelly for a post-operative appointment on Dec. 13, 2018, and images were taken at the site of the extraction and implant. Notes from that visit indicate Patient A had no pain and was healing well.
Once again, Kelly’s records state the image is for a different tooth than the one Patient A had removed. The board says Kell claimed this was also an error and the image was actually of the tooth that was removed.
The board claims that the image shows that the implant was “placed in insufficient bone and was starting to fail.”
The board says that Kelly contradicted his notes that the area was healing well when he noted that there was “‘still’ infection around the apex of the implant” and prescribed Clindamycin to attempt to clear the infection.” Kelly told Patient A to come back in 7-10 days.
Clindamycin is an antibiotic used to treat infections.
On Dec. 20, 2018, Patient A returned to Kelly’s office and told him that the implant had fallen out since his last visit. During that visit, Kelly told Patient A to return in a few weeks to have the implant replaced.
The board claims that the initial note for the Dec. 20, 2018 visit makes no mention of a bone graft.
The board says Kelly advised that Patient A have the implant replaced despite the fact the image taken of the extracted tooth area showed Patient A “still had a huge bony defect.” Thus, making it not “an appropriate site to place a new implant in a few weeks.”
According to Kelly’s treatment records, he dismissed Patient A from his practice on Jan. 25, 2019, due to “derogatory emails and threats from patient.”
NCSBDE says that an additional note indicating that the area of the tooth extraction was grafted at the Dec. 20, 2018 appointment is date-stamped as being entered on March 27, 2019. Which was several months after Patient A was dismissed from Kelly’s practice.
Allegedly, Kelly’s additional treatment note for the Dec. 20, 2018 appointment does not accurately reflect what occurred on that date and is not credible.
Violations
The board says that Kelly failed to apply the standard of care for dentists licensed to practice in North Carolina by failing to:
- Adequately assess Patient A’s periodontal condition and bone loss to determine if he was an appropriate candidate for implant treatment;
- Take diagnostic radiographs to assess Patient A’s condition both pre-and post-treatment;
- Maintain adequate patient records that accurately documented the diagnosis and treatment performed for Patient A, including teeth extractions and implant surgical techniques and the dates they were actually performed;
- Stage and sequence treatment appropriately for Patient A and use appropriate implant surgical techniques;
- Use adequate procedures to eliminate any infection Patient A had prior to placing implants; and
- Manage Patient A’s complications.
Witness testimony
The expert testimony of another dentist and his related written report also concluded that Kelly violated the standard of care in his treatment of Patient A.
The dentist provided evidence that:
- Kelly’s records for Patient A included conflicting and contradictory information regarding the treatment provided;
- After Patient A initially presented with a periapical infection and extensive bone loss around the apex of tooth #5, Kelly placed an implant approximately two months later at the next office visit without taking an image to determine if the area had healed and the bone was ready for placement of an implant;
- The implant at tooth #5 was improperly placed where there was still a bony defect and only the apical third of the implant engaged bone;
- The implant at tooth #5 began to fail and became infected but Kelly did not inform Patient A that the implant should be removed; and
- The implant ultimately failed and Kelly advised Patient A that he could come back to his office in a few weeks to have the implant replaced.
The board concluded the dentist’s testimony was credible and said that Kelly’s violations of the standard of care caused harm or injury to Patient A.
Kelly did not offer expert testimony or other evidence regarding his treatment of Patient A.
Patient B
On Nov. 23, 2020, Patient B came to Kelly’s office for an implant consultation. The board says Kelly developed a treatment plan that included “extracting her remaining teeth, placing implants and performing a sinus lift of the upper right and upper left.”
On May 19, 2021, Patient B came for a pre-operative appointment. Kelly prescribed antibiotics and Patient B signed all necessary consent forms. However, Kelly did not make a conventional denture to assist him in determining where to place the implants.
The board says Patient B’s health history included that she is allergic to penicillin and has “sinus problems”. However, Kelly either failed to ask necessary follow-up questions on those issues or failed to record her responses in treatment notes.
On June 7, 2021, Patient B came to Kelly’s office to complete the procedures outlined in the treatment plan. Kelly’s notes indicated that eight of Patient B’s teeth were extracted and implants were placed in those areas.
Kelly’s notes also state that there were no complications in the procedure and that no pain medication was prescribed for Patient B.
NCSBDE says that Kelly’s treatment notes for Patient B contained “incomplete, contradictory and confusing entries,” which failed “to include an adequate description of treatment rendered, including when and by whom.”
One example included notes from the June 7 visit which state that Patient B presented “for ext and implants.” However, another dentist extracted Patient B’s teeth after the Nov. 23, 2020 consultation and before the May 19, 2021, pre-operative appointment with Kelly.
Also, the board claims that the local anesthetic recorded in Kelly’s treatment note contradicts his sedation record which indicates he administered more anesthetic than indicated in his notes.
NCSBDE says that Kelly’s treatment notes for the procedure are inadequate because they do not contain the following information:
- Type of sinus lift performed;
- Method for lifting sinus membrane;
- Perforations or complications;
- Type, amount, and where graft material was used;
- Use of membranes;
- Residual bone height to stabilize the implant; and
- Method of placing implants, including the type of incision and sutures, bone quality and any reduction of bone, and use of a surgical guide.
Kelly claimed in his treatment notes for Patient B that the CT scan showed no complications. However, the board claims that the CT scan shows that the implants were placed incorrectly.
The board says that Kelly failed to place any of the implants in the correct position.
On June 16, 2021, Patient B came back to Kelly’s practice for a post-operative appointment. He took another CT scan and stated that the implants were doing great and requested Patient B return in a month.
The board says that the treatment notes contradict what the CT scan actually showed; which was inflammation of the sinus with the extrusion of graft material into the sinus and substandard placement of implants.
On July 14, 2021, Patient B presented for a soft reline. She stated that the temporary dentures “were horrible” and that she was not able to eat at all. During this visit, Kelly tried to trim off the excess and adjust the dentures to make them comfortable but was not able to do so. He added a permanent reline to Patient B’s treatment plan.
From Aug. 23, 2021, through March 2, 2022, the board claims that Kelly and the dental lab unsuccessfully worked with Patient B to try and fabricate dentures that would correctly seat with the improperly placed implants.
On March 2, 2022, Kelly advised that Patient B should have the implants removed and start over with a hybrid denture. Notes about the removal of the implants are date-stamped as being entered on Sept. 13, 2022, which is after Patient B left Kelly’s practice and another dentist requested her records from Kelly.
On March 15, 2022, Patient B told Kelly that she had a sore implant and Kelly took a CT scan to check the area. She came back on March 29, 2022, for a wax try-in and signed for dentures which were supposed to be delivered at the next appointment. However, the dentures were not delivered because Patient B wanted to be sedated for the procedure.
Patient B returned to Kelly’s office on May 10, 2022. Kelly’s notes state he sedated Patient B and removed the closure caps for all implants.
Also on May 10, 2022, Kelly documented that one of the implants “perforated the sinus.” The term perforation refers to something being pierced with a hole.
The board says Kelly’s treatment notes for the May 10, 2022, procedure failed “to include an adequate description of the treatment rendered and of Patient {B’s} dental condition.” For example, there is no description of how the surgery was performed or of the bone loss that is noticeable on CT scans.
Kelly then prescribed amoxicillin tablets to Patient B despite her prior reports of a penicillin allergy. Patient B says that her pharmacist noticed before it was filled. Kelly failed to file an antibiotic replacement until five days later.
Between May to July 2022, Patient B returned to Kelly’s office for impressions, try-ins and attempted delivery of her dentures.
On Aug. 9, 2022, Patient B came to Kelly’s office for what would ultimately be the final attempted try-in for the dentures.
Notes for that last visit are date-stamped as being entered on March 21, 2023, which is months after Patient B left Kelly’s practice but only a short time after the board told Kelly that Patient B had filed a complaint against him.
In the note entered on March 21, 2023, Kelly noted the following:
- Documented marked recession around multiple implants;
- Acknowledged in his treatment record for the first and only time the bone loss that could be seen on the prior CT scans;
- Stated that the patient purportedly advised him she was smoking during the treatment process;
- Claimed that he advised Patient B that she should have a medical evaluation and then he would make an upper and lower hybrid denture for her at a reduced cost or refund her money so she could seek care somewhere else; and
- Wrote that due to her “high esthetic demands,” she would need to have a fixed full-arch prosthesis similar to what was offered to her on her initial visit.
The board says that the note for the Aug. 9, 2022, visit does not accurately reflect what occurred on that date and is not credible and that Kelly never provided Patient B with a refund of the “substantial funds” paid to his office for her treatment.
On Sept. 1, 2022, Patient B went to another dentist for evaluation. The board claims that the new dentist tried several times, unsuccessfully, to get Patient B’s records from Kelly’s office. On Sept. 15, 2022, the new dentist noted that he received a blank disc from Kelly’s office.
The new dentist eventually received some images from Kelly’s office. However, he never received Patient B’s implant information.
On March 1, 2023, Patient B was referred to a periodontist who determined that the implants Kelly placed were not in the proper position and needed to be removed.
An oral surgeon removed Patient B’s implants on Nov. 28, 2023. However, the board claims that due to the “large amount of funds” that Patient B spent on having the implants placed by Kelly, none of which has been refunded, Patient B has been able to have implants replaced as of April 22, 2024, and is wearing interim dentures.
Violations
The board says that Kelly failed to apply the standard of care for dentists licensed to practice in North Carolina by failing to:
- Properly assess Patient B to determine whether she was an appropriate candidate for implants and snap-in dentures and did not obtain a detailed history, particularly concerning her allergy to penicillin;
- Perform appropriate treatment and pre-surgical planning, including taking diagnostic radiographs and fabricating a proper overdenture to use as a surgical guide for the appropriate placement of implants;
- Maintain adequate patient records, including accurately documenting Patient B’s diagnosis, dental condition, treatment rendered, and surgical techniques;
- Utilize proper surgical techniques in determining where implants should be placed and stage the sinus lift and implant procedures; and
- Communicate all complications to Patient B.
Witness testimony
The expert testimony of another dentist and his related written report also concluded that Kelly violated the standard of care in his treatment of Patient B.
The dentist provided evidence that:
- Kelly’s records did not accurately document Patient B’s diagnosis, dental condition, treatment rendered, and surgical techniques, and failed to indicate a clear restorative plan;
- Kelly poorly planned Patient B’s treatment;
- Kelly did not perform a prosthetic work-up prior to the implant surgery on June 7, 2021, and did not use an appropriate surgical guide for the surgery;
- The post-operative CT scan taken on June 7, 2021, the same day the implants were placed, showed that none of the implants were placed in an acceptable position;
- The implant placed at tooth #3 perforated the sinus membrane with extrusion of material into the sinus;
- Performing a lateral window sinus lift while also attempting to stabilize implants at teeth #s 3 and 14 was risky and aggressive and should have been a staged procedure; vii. Implants placed at teeth #s 3 and 14 were placed in a very small amount of residual bone height and did not have primary stability;
- The implant at tooth #6 was angled too far to the buccal preventing the fabrication of a denture flange that fit correctly in the maxilla;
- The implant at tooth #1 was angled too far to the buccal and was sticking into the sinus with no associated graft;
- No bone was reduced prior to placing lower implants; xi. Lower implants were placed with a significant portion of the buccal aspect of the implant entirely outside of the bony housing, were not placed deep enough, and impeded the ability to place a denture due to lack of restorative space; and
- Kelly did not inform Patient B of complications as they arose during treatment.
The board concluded the dentist’s testimony was credible and said that Kelly’s violations of the standard of care caused harm or injury to Patient B.
Kelly did not offer expert testimony or other evidence regarding his treatment of Patient B.
Patient C
On March 15, 2021, Patient C came to Kelly’s office for an implant consultation and stated that he did not want removable dentures.
Kelly took a CT scan during the initial consultation and created a treatment plan that included placing six implants and an upper anterior hybrid.
On May 6, 2021, Patient C presented for the extraction of his remaining upper teeth and the placement of six implants and a hybrid prosthetic in the maxillary with IV sedation.
The board claims that Kelly’s notes are inadequate; partially because they did not contain the following necessary information:
- The type and size of the incision and whether any releases were necessary;
- Whether any bone graft material was used;
- The torque values of the implants; and
- The type of suturing technique used.
Patient C came back to Kelly’s office for a post-surgical follow-up appointment on May 12, 2021, and Kelly took a CT scan that noted that Patient C’s implant was “doing great.”
The board says Kelly did not indicate a reason for taking the scan and that despite taking the scan, Kelly either did not recognize or did not notify Patient C that a root fragment of one of the extracted teeth remained and the implant was placed up against the remaining infected root fragment from the May 6 extraction.
On May 17, 2021, Patient C came back to Kelly’s office because the temporary prosthetic for four of his teeth had broken. Kelly told Patient C that he would leave the broken part off and smoothed the edges where the hybrid had broken.
On June 1, 2021, Kelly took another CT scan during a follow-up appointment and did not indicate a reason for taking the scan or prescribing Augmentin in his treatment notes.
Augmentin is an antibiotic used to treat infections.
The board says that Kelly told Patient C that the hybrid was “doing great.” However, Kelly either failed to recognize or inform Patient C of the retained root fragment.
During the June 1, 2021, visit, Patient C complained about discomfort in his lip and tongue due to rough edges and food becoming stuck in the hybrid prosthetic. Kelly responded by adjusting the hybrid prosthetic with a handpiece.
On June 16, 2021, Patient C came back to Kelly’s office for another follow-up appointment. Kelly again took a CT scan and did not provide a reason for doing so in his treatment notes for doing so. The board says Kelly once again failed to recognize or inform Patient C of the retained root fragment.
The final upper hybrid prosthetic was delivered to Patient C on Dec. 21, 2021, after Kelly took impressions and performed a final try-in.
The board claims that Kelly’s treatment notes about the delivery of the final upper hybrid prosthetic did not include the following necessary information:
- The material of the hybrid;
- The occlusion and whether any adjustments were necessary;
- The torque applied to the abutment screws;
- Whether the multi-unit abutments were re-torqued to ensure implant integration;
- Whether radiographs were taken to ensure the prosthetic was fully seated;
- Whether instructions were provided to the patient regarding how to clean and care for the hybrid; and
- Whether the patient was provided with a recall schedule concerning when to return for follow-up care.
In Jan. and Feb. 2022, Patient C complained about his bite being “off” and Kelly sent the hybrid to the lab for repair. Patient C says that the bite was never correct on the hybrid prosthetic, even after Kelly attempted repairs.
A year later in Jan and Feb. 2023, Patient C came back to Kelly’s office because the anterior of the hybrid had chipped and broken. However, he was unable to be seen by Kelly.
On March 21, 2023, Patient C came to the office of another dentist for a second opinion about the broken hybrid. The testimony of that dentist and his treatment records about Patient C were presented to the investigative panel.
The other dentist had treated Patient C for unrelated issues since 2014.
During the March 21, 2023, visit, the new dentist took intraoral photographs of the hybrid. Those photos showed broken anterior teeth on the prosthesis and also took PAs of the implants. The dentist’s office requested implant information from Kelly and was told they would charge Patient C $8,000 to replace the broken prosthesis.
PAs refer to Periapical Film, a radiographic X-ray film that shows the whole tooth including the root and the area around it, according to Lee Dental Office.
On April 6, 2023, during a return visit, the new dentist took PAs with the prosthesis in place and after he removed it. Patient C felt significant pain on the upper left implant while the hybrid was being unscrewed and reported that the implant had always been painful when the prosthesis was attached or removed.
The dentist noted that one of the implants was mobile with necrotic-looking bone on the mesial and took a PA of the area.
Johns Hopkins University School of Medicine says that avascular necrosis is a disease that results from the temporary or permanent loss of blood supply to the bone. When the blood supply is cut off, the bone tissue dies and the bone collapses. If avascular necrosis happens near a joint, the joint surface may collapse.
During the April 6 visit, the new dentist removed the loose necrotic piece which was touching the implant and that piece was a tooth rot. He photographed the tooth rot and then reattached the prosthesis to give the area time to heal.
On April 24, 2023, the new dentist removed the prosthesis and the implant had not improved and was still painful. He then removed the implant and re-attached the prosthesis.
The dentist then conducted an analysis which demonstrated that the prosthesis placed by Kelly was not correct for Patient C’s bite, including at the locations where it had broken, which is why he determined it should be replaced rather than repaired.
Patient C chose to proceed with a new prosthesis from the new dentist on the remaining implants which were noted to be stable. On Aug. 25, 2023, the new upper prosthesis was delivered to Patient C and he has had no issues with breaking or chipping since.
Violations
The board says that Kelly failed to apply the standard of care for dentists licensed to practice in North Carolina because he:
- Failed to accurately document and list the materials used in the surgical techniques and treatment rendered to Patient C
- Took an excessive number of unnecessary images during Patient C’s treatment; and
- Failed to recognize or communicate complications to Patient C, specifically that a tooth root was left behind after a tooth was extracted, was adjacent to implant #13, was infected, and could be causing pain and other complications that Patient C experienced.
Witness testimony
The expert testimony of another dentist and his related written report also concluded that Kelly violated the standard of care in his treatment of Patient C.
The dentist provided evidence that Kelly:
- Failed to recognize and diagnose an infected root tip that was left behind at the area of tooth #13, near an implant;
- Failed to inform Patient C that an infected root tip was left behind at the area of tooth #13; and
- Took multiple CT scans without justification subjecting Patient C to unnecessary radiation.
The board concluded the dentist’s testimony was credible and said that Kelly’s violations of the standard of care caused harm or injury to Patient C.
Kelly did not offer expert testimony or other evidence regarding his treatment of Patient C.
Failure to produce timely records
While the board was investigating complaints made by Patients A, B and C, they claimed that Kelly “repeatedly failed to respond and provide complete treatment and other records,” in a timely manner and in response to the board’s multiple requests, despite submitting verification he had provided complete records.
False statements and evidence about expiration of permit
The board’s findings state that Kelly was first issued a moderate conscious sedation permit on Nov. 28, 2006.
Permits are required to be renewed on an annual basis and NCSBDE sends “emails, postcards and letters” to dentists reminding them that the renewal date is approaching each year.
Kelly’s renewal payment of $100 and application for the permit was due by Jan. 31, 2021, for the 2021 year. If the application and payment, including the $50 late fee, were not submitted by March 31, 2021, his permit would expire.
Once renewed, dentists are required to print their renewal permit and display it in their office along with their dental license.
The board says they did not receive Kelly’s renewal application and payment by March 31, 2021, and thus his permit expired.
On April 8, 2021, the board sent a certified letter to Kelly informing him of his permit’s expiration for nonpayment. The letter stated that an application for reinstatement and a check for $150 would need to be submitted to apply for reinstatement.
On April 29, 2021, Kelly emailed the board in response to the letter stating “I am certain that I paid my sedation renewal at the same time that I paid for my dental license renewal. As a matter of fact, I made a copy of the check before I mailed it.”
Kelly sent a second email on April 29, 2021, attaching a copy of a check which was dated Jan, 22. 2021, and represented that it was a copy of the check he sent the board for renewal in January. However, the check was written for $150 which was not the correct amount due at the time the check was allegedly dated.
Kelly renewed his dental license on Dec. 21, 2020, and did not renew his permit at the same time as he stated in his email.
The board claims that Kelly’s bank statements indicate that the check he sent in the email was not in sequence with checks written in Jan. 2021, but rather checks written in April and May 2021.
Kelly later submitted an application and payment to reinstate his permit which the board received on May 3, 2021. His permit was then reinstated on May 4, 2021.
NCSBDE claims that Kelly did not issue or sign the check in the April 29, 2021, email at the same time he paid for his dental license renewal and that he did not issue or sign that check on or about Jan. 22, 2021.
Instead, the board claims that Kelly fabricated the check after he got the board’s notice in an attempt to conceal that he had failed to renew his permit before its expiration and thus his April 29, 2021 statement was “a false and material misrepresentation.”
Administration of sedation while permit was expired
The board claims that Kelly administered moderate conscious sedation to numerous patients between April 1, 2021, and May 3, 2021, while his permit was expired.
In the board’s findings, nine patients are listed as having been sedated during that time frame.
NCSBDE claims that Kelly should have known his permit was expired while administering those sedations.
Inspection and fabricated drug labels
After Kelly failed to have his permit reinstated, an NCSBDE investigator inspected his office on June 20, 2022. Kelly gave the investigator his sedation drug logs.
The board claims that when he presented the sedation logs to them, he failed to disclose that the logs had:
- Had not been maintained contemporaneously,
- Had been created after getting notice of the upcoming inspection, and
- Were not an accurate representation of the drugs Respondent or others working in his office administered to patients.
Both of the random sedation records chosen by the board investigator failed to appear in the sedation drug logs, including for two of the patients who were sedated while Kelly’s license was expired.
The board says that Kelly later admitted the following about the drug logs he gave to the board at the June 20, 2022, inspection:
- They were not maintained contemporaneously;
- He had staff members create the drug logs prior to and in anticipation of the Board inspection;
- He did not see the drug logs until the date of the Board inspection; and
- The drug logs are inaccurate and do not reflect the type and amounts of controlled substances administered to patients.
NCSBDE says that Kelly failed to maintain accurate drug logs for controlled substances as required by the United States Drug Enforcement Administration (DEA) and that the logs he provided at the June 20, 2022 inspection were created “after the fact” and “did not accurately represent the controlled substances administered to patients.”
Conclusions of Law
The board concluded that Kelly:
- Violated the applicable standard of care for dentists practicing in North Carolina in his assessment and treatment of Patient A
- Violated the applicable standard of care for dentists practicing in North Carolina in maintaining inadequate patient treatment records for Patient A
- Was negligent in the practice of dentistry in violation of N.C. Gen. Stat. S 90-41 committed acts constituting malpractice in the practice of dentistry in violation of N.C. Gen. Stat. S 90-41(a)(19), and engaged in acts violating Article 2 of Chapter 90 of the North Carolina General Statutes in violation of N.C. Gen. Stat. S 90-41 (a)(6) and 21 NCAC 16T .0101 in his treatment and care of Patient A, as set forth in Conclusions of Law 2 and 3 and Findings of Fact 6-43
- Violated the applicable standard of care for dentists practicing in North Carolina in his assessment and treatment of Patient B
- Respondent violated the applicable standard of care for dentists practicing in North Carolina in maintaining inadequate patient treatment records and failing to promptly provide or transfer records for Patient B
- Respondent was negligent in the practice of dentistry in violation of N.C. Gen. Stat. S 90-41(a)(12), committed acts constituting malpractice in the practice of dentistry in violation of N.C. Gen. Stat. 5 90-41(a)(19), and engaged in acts violating Article 2 of Chapter 90 of the North Carolina General Statutes in violation of N.C. Gen. Stat. S 90-41 (a)(6) and 21 NCAC 16T .0101 and .0102 in his treatment and care of Patient B, as set forth in Conclusions of Law 5 and 6 and Findings of Fact 44-102
- Violated the applicable standard of care for dentists practicing in North Carolina in his assessment and treatment of Patient C
- Violated the applicable standard of care for dentists practicing in North Carolina in maintaining inadequate patient treatment records for Patient C
- Was negligent in the practice of dentistry in violation of N.C. Gen. Stat. S 90-41 (a)(12), committed acts constituting malpractice in the practice of dentistry in violation of N.C. Gen. Stat. S 90-41 (a)(19), and engaged in acts violating Article 2 of Chapter 90 of the North Carolina General Statutes in violation of N.C. Gen. Stat. S 90-41 (a)(6) and 21 NCAC 16T .0101 in his treatment and care of Patient C., as set forth in Conclusions of Law 8 and 9 and Findings of Fact 103-133
- Committed unprofessional conduct in violation of N.C. Gen. Stat. S 90-41 (a)(6) and 21 NCAC 16V .0101(2), (14), and (17) by repeatedly failing to respond and provide complete treatment and other records in a timely manner and by verifying that he had provided all records when he had not done so, as set forth in Findings of Fact 134-144
- Violated N.C. Gen. Stat. S 90-41 (a)(26) by presenting false or misleading statements or records when communicating with the board or its agents, pursuant to 21 NCAC 16V .0101 (2), as set forth in Findings of Fact 145-160
- Violated the board regulations in violation of N.C. Gen. Stat. S 90-41(a)(6) and 21 N.C.A.C. 16Q .0301 (a) and .0305(a) by administering moderate conscious sedation when he did not have a Permit, as set forth in Findings of Fact 161163
- Violations of 21 N.C.A.C. 16Q .0301 (a) and .0305(a) may result in suspension or revocation of Respondent’s Permit or license to practice dentistry in accordance with N.C. Gen. Stat. S 90-41 and 21 NCAC 16Q .0701
- Violated N.C. Gen. Stat. S 9041 and (26) and 21 NCAC 16V .0101 (28) by committing an act that violated state or federal statutes or regulations governing controlled substances, as set forth in Finding of Fact 168-169
- Violated N.C. Gen. Stat. S 90-41 and (26) and 21 NCAC 16V .0101 (2) by providing inaccurate drug logs that he had fabricated prior to the Board inspection, as set forth in Findings of Fact 164-172
- Violated N.C. Gen. Stat. S 90-41 (a)(6), by violating the Rules and Statues set forth in Conclusions of Law 1-16 and Findings of Fact 6-172 above
Additional findings and disciplinary conclusions
The board also concluded that:
- Kelly committed multiple instances of negligence or malpractice in treating Patients A, B and C
- Kelly intended to treat Patients A and B in a manner where the potential harm was foreseeable
- Kelly’s violations resulted in harm to Patients A, B and C, and potentially serious or catastrophic harm to the patients sedated while Respondent’s Permit was expired and his violations also resulted in harm to the dental profession
- Kelly’s violations adversely affected Patients A, B and C because they received negligent treatment and suffered resulting harm. As a result of Kelly’s negligent treatment of them, Patients A, B and C were required to have additional treatment at their own expense
- Kelly’s actions have had a negative impact on Patients A, B and C’s perception of the dental profession
- Kelly did not make restitution to Patients A, B and C for his negligent dental treatment or attempt to rectify the consequences of his negligent treatment of them
- Kelly elevated his interest above that of his patients or the public and demonstrated a selfish motive by negligently performing dental services and failing to refund fees for services he performed in a negligent manner
- Kelly failed to respond or provide responsive documents or information upon request and in a timely manner during the Board’s investigation of his treatment of Patients A, B and C
- Kelly demonstrated a dishonest motive by providing false information to the Board regarding the purported renewal of his sedation permit for 2021
- Kelly submitted false evidence, statements, or engaged in other deceptive practices during the Board’s investigation or disciplinary proceedings, including:
- Creating false verifications stating he had submitted all treatment records for Patients A, B and C when he had not done so;
- Fabricating or creating after-the-fact controlled substance drug logs prior to the Board inspection; and
- Submitting false or inaccurate drug logs at the inspection and failing to disclose or inform Board Investigators that the drug logs he presented to them were not maintained contemporaneously
- Kelly engaged in fraud, dishonesty, misrepresentation, deceit, or fabrication related to the practice of dentistry, including by:
- Making false statements regarding the purported renewal of his Permit for 2021;
- Fabricating or creating after-the-fact controlled substance drug logs prior to the Board inspection; and
- Fabricating or creating after-the-fact false or inaccurate and self-serving entries in his patient treatment record that did not accurately describe what occurred and doing so after he was no longer treating the patient and, in at least one instance, after he was notified that the patient had filed a complaint with the Board
- Kelly’s violations, including the false statements and other misconduct indicated in Nos. 9-11 above, demonstrate a lack of honesty, trustworthiness, or integrity
- On August 18, 2011, Kelly voluntarily signed a Consent Order with the Board (“2011 CO”). The 2011 CO found that Respondent violated the standard of care in his treatment of three (3) patients in several respects spanning from 2005-2009, including:
- Perforating a patient’s tooth and failing to inform the patient;
- Failing to manage a patient’s sequence of treatment; and
- Failing to provide a patient with a proper denture and obtain adequate informed consent before placing implants
- On April 9, 2013, Kelly was issued a Reprimand for causing a left lingual nerve injury during the extraction of a patient’s tooth and then failing to refer the patient to a specialist to address her resulting paresthesia in 2010-1 1 (“2013 Reprimand”)
- On December 11, 2015, Kelly voluntarily entered into a Consent Order with the Board (“2015 CO”). The 2015 CO found that Respondent violated the 201 1 CO and violated the standard of care in his treatment of three (3) patients in several respects spanning from 2009-12, including by failing to:
- Appropriately select patients for sedation and implants;
- Obtain informed patient consent for sedation and placement of implants;
- Administer the appropriate dosage of sedation medication to patients;
- Perform appropriate pre-operative planning and proper monitoring and airway management of patients during procedures;
- Maintain proper recordkeeping during procedures;
- Promptly recognize when a patient is in distress or danger and take appropriate action, including involving emergency services; and
- Select appropriate abutments with which to restore implants.
- The 2015 CO also found violations of the standard of care for an additional nine (9) patients up through 2015, including that Kelly:
- Repeatedly used an anesthesia medication, propofol, that is contraindicated and unsafe for general practitioners with a moderate conscious sedation permit, risking unanticipated deep sedation, general anesthesia, and significant respiratory depression;
- Administered propofol to patients while also performing procedures on those patients;
- Administered excessive amounts of local anesthetics;
- Sedated patients to a level of deep sedation or general anesthesia resulting in apnea or significant respiratory depression and hypoxemia;
- Used a monitor on sedation patients that was subject to interference by his electrical handpiece;
- Failed to recognize and adequately treat patients for hyper- and hypotension and respiratory depression when immediate treatment was indicated;
- Failed to properly select and evaluate patients to undergo sedation procedures;
- Failed to evaluate the airway prior to sedation procedures;
- Failed to obtain a comprehensive medical history for patients;
- Failed to consult with patients’ treating physicians when indicated by their disclosed medical histories; and
- Failed to maintain adequate recordkeeping
Over the past at least 18 years since 2005, Kelly has provided negligent dental care in the following clinical practice areas:
- Pre-operative planning;
- Pre-sedation patient assessment, evaluation, and selection
- Informed consent;
- Sequence of treatment, addressing periodontal disease;
- Dentures, partials, and other restorations, including a tooth perforation not disclosed to the patient;
- Extractions resulting in nerve injury and paresthesia,
- Referral to specialists when clinically necessary;
Kelly has been repeatedly negligent, committed malpractice, violated the standard of care, and committed numerous other violations in the past as set forth in the 201 1 CO, 2013 Reprimand, and 2015 CO.
Kelly engaged in a lengthy and extensive pattern of violations, as demonstrated by the standard of care violations in this matter and the prior disciplinary actions issued by the board in the 2011 CO, 2013 Reprimand, and 2015 CO. (21 NCAC 16N .0607(3)
Kelly’s violations in his prior discipline through the current matter span from 2005 through 2023 and are not remote in time. (21 NCAC 16N .0607(3)(s))
The probationary period in Kelly’s 2015 CO was still in effect when he began treating Patient A and committed negligence. The 2015 CO prohibited Kelly from violating any of the Board’s statutes or rules for a five-year probationary term. Kelly failed to comply with the 2015 CO in his negligent treatment of Patient A from Oct.4, 2018, through Dec. 20, 2018.
When combined with the numerous violations in this matter, the extensive pattern of providing negligent care and committing malpractice for numerous patients over the past 1 8 years in a wide range of practice areas spanning most aspects of dental care with failed attempts at remediation demonstrates that Kelly is incompetent in the practice of dentistry.
Kelly has refused to acknowledge the wrongful nature of any of the violations included in the Notice of Hearing and found in this matter.
Kelly has practiced dentistry in North Carolina for more than twenty (20) years and numerous attempts to rehabilitate Kelly through remediation measures contained in prior discipline have been ineffective because the same or similar pattern of violations or misconduct has continued to recur.
The Hearing Panel individually considered all remaining factors set forth in 21 NCAC 16N .0607 and determined that the following factors are not applicable or relevant to the discipline in this case: I(a), (b), 2(a), (b), (g), and (3)(g), (i), (n) (p)(r), (u), and (v).
The conclusion that Kelly is incompetent in the practice of dentistry noted above independently and separately warrants revocation of his dental license and Permit to protect the public, even without any evidence, findings, and conclusions on unrelated issues set forth in the Final Agency Decision.
Kelly’s compounded acts of dishonesty and misrepresentation demonstrating a lack of honesty, trustworthiness or integrity warrant revocation of his dental license and Permit to protect the public, even without any evidence, findings, and conclusions on unrelated issues set forth in the Final Agency Decision.
Kelly’s conduct and violations for administering sedation to patients without a valid Permit, combined with his extensive and significant past violations involving sedation established in the 2015 Consent Order, and the serious potential harm to patients and others, independently warrants the revocation of his dental license and Permit to protect the public, even without any evidence, findings, and conclusions on unrelated issues set forth in the Final Agency Decision.
The board has attempted without success to address Kelly’s lengthy history of prior violations through the other disciplinary options available to it under N.C. Gen. Stat. S 90-41 (a). Attempts at remediating past violations while under probation, and even an active suspension, were unsuccessful in preventing further violations and thereby failed to adequately protect the public.
Kelly’s numerous, compounded acts of negligence, malpractice, and other violations cannot be adequately remediated as prior attempts at remediation ordered by the Board were unsuccessful.
Kelly’s numerous, compounded violations and other conduct demonstrate that if Respondent is permitted to continue practicing dentistry, there is a substantial risk that he will engage in further misconduct and violations and pose a significant risk to public safety and well-being.
All lesser discipline and other options authorized by N.C. Gen. Stat. S 9041 (a) were considered but all are insufficient to protect the public pursuant to 21 NCAC 16N .0607.
Respondent’s misconduct and violations, along with his lengthy and extensive disciplinary history involve such serious, numerous violations of the Dental Practice Act that revocation of his dental license and Permit is the only discipline or disciplinary measure sufficient to protect the public.
- Placement of implants on numerous occasions;
- Administering and monitoring sedation on numerous occasions;
- Recognizing and treating clinical emergencies; and
- Sedation and treatment records
As a result, Kelly’s license to practice dentistry in the state of North Carolina as well as his sedation permit have been revoked.