A one-year survey of dental malpractice claims in Riyadh Wafa Al Ammar*, BDS E. Ernest Guile*, DMD, MPH

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1 95 A one-year survey of dental malpractice claims in Riyadh Wafa Al Ammar*, BDS E. Ernest Guile*, DMD, MPH Malpractice is an increasing problem related to dental treatment around the world. The present study examined malpractice litigation cases which occurred in Riyadh during a one-year period. The Dental Department in the Ministry of Health reponded to a questionnaire consisting of 18 questions on malpractice during 1417H (1997). The questionnaire search yielded thirty-two cases, twenty of which were clinical and 12 were non-clinical cases. The majority of clinical complaints, 18.8%, were in the specialty of oral surgery with 15.6% in fixed prosthodontics specialty. Mistakes made during treatment were reported as the most frequent allegation (43.8%). Patients who were Saudi, female and from young age groups reported more complaints. Most of the complaints were against non-saudi dentists who were employees in the private sector. In 87.5% of the cases, the dentist was found guilty, with payment being the most common sanction taken (51.5%). The total payment awarded reached SRI63,100 with a mean payment of SR.9,061 per case. It is concluded that malpractice is a problem that should be prevented through education and careful patient care. The dental profession should lead the way in preventive efforts. Introduction Patients are sometimes dissatisfied with the treatment they received from their dentists. In most cases, such dissatisfaction can be resolved between the patient and the dentist but sometimes the patient turns to a legally competent body which can judge whether the complaint is reasonable and, if necessary, take subsequent action against the dentist. Complaints from patients about dental treatment are on the increase internationally, especially in the USA. 12 Rudov and his colleagues found that dentists accounted for 6.9% of all medical malpractice claims closed in In a more recent study, Peter Milgrom et al found that the incidence rate of dentists with at least one claim filed between 1988 and 1992 was 73 per 1,000 dentists. The number of dentists reporting at least one filed claim ranged from 11 per 1000 Received 10 March 1999; Revised 28 July 1999; Accepted 10 August 1999 'Formerly Intern; ^Formerly Associate Professor Dept. of Preventive Dental Sciences College of Dentistry King Saud University, Riyadh, KSA dentists in 1988 to 27 per 1000 dentists in In UK, the situation is not different. The number of dentists reporting complaints has shown a gradual rise from 3.5% in 1989 to 10.7% in The majority of complaints (56.9%) came from the specialty of restorative dentistry. 5 The most common dental specialty that patients complain about differs from one country to another. In USA, oral surgery claims grew from 18.8% in 1988 to 31.8% in In Washington state, parasthesia following surgical extraction of mandibular third molars accounted for nearly 25% of the claims in On the other hand, prosthodontics was most frequently involved in malpractice cases in Sweden. In a study of all Swedish disciplinary cases on dental malpractice between 1947 and 1983, 54.5% concerned mainly prosthodontic treatment. 78 In Saudi Arabia, there had been no published reports on patients' complaints about dentists although it has been acknowledged that some Address reprint requests to: Dr. Wafa Al Ammar PO Box 8066 Riyadh 11482, KSA

2 96 DENTAL MALPRACTICE CLAIMS IN RIYADH complaints and claims for negligence do exist. This paper describes the number and character of such complaints in Riyadh over a one-year period and establishes the dental specialties involved and the outcome of these complaints. Materials and Methods All decisions on alleged dental malpractice registered by the Ministry of Health, Dental Department in Riyadh city, from year H (1997G) were studied. A questionnaire consisting of 18 questions written in Arabic was designed to determine the incidence of patients' complaints, the area of dentistry involved as well as the reasons behind the complaint and the disciplinary committee's decisions. The remaining questions were constructed to collect data on the age, sex and nationality of the patient and the defendant (dentist), as well as the type of work of the defendant (general practitioner, specialist, technician, assistant). The Ministry of Health, Dental Department personnel, filled the questionnaire. The data were entered into a computer and analyzed using descriptive analysis. The claims were divided into two groups: clinical claims that took place in the clinic during treatment and non-clinical ones which involved administrative issues. If a patient reported several complaints, each one was classed as a separate case. Results For the year HUH (1997), 32 malpractice cases were identified in the Riyadh region. Clinical malpractice claims in relation to all complaints during this year accounted for 62.5% (n=20) as shown in Fig.1. The majority of clinical complaints were in oral surgery (n = 6; 18.8%) with fixed prosthodontics accounting for 5 complaints (15.6%). There were relatively few complaints in the following clinical disciplines: endodontics (n = 4; 12.5%), restorative dentistry (n = 4; 12.5%) and periodontics (n = 1; 3%) as shown in Table 1. The age of the patients was known in 21 cases. Table 1. Malpractice claims in clinical and non-clinical cases. Specialties No. of cases % Fixed prosthodontics Oral surgery Endodontics Restorative dentistry Periodontics 1 3 Non clinical cases Total % The mean age was 25.7 years, with a range of years. The patient's sex was also stated in 21 cases. Eight of the patients (38%) were men and 13 (62%) women. Fifteen (15) of the patients (71.4%) were Saudis while the remaining were non-saudis (Table 2). Table 2. Gender and nationality of patients No. of cases Saudi Non-Saudi Total Men Women Total Errors in treatment accounted for 43.8% of the reasons for complaints in the malpractice cases. Other complaints involved unethical actions such as sexual harassment and swindling (9.4%), unreasonably high treatment costs (6.3%), and excessive pain and discomfort (3.13%) (Fig.2). Non-clinical cases accounted for 37.5% of the malpractice claims which included practicing without a license, advertisement violations and one case of a general practitioner practicing as a specialist in orthodontics.

3 AMMAR AND GUILE 97 In 25 cases, the ages of the dentists were known. The mean age was 39 years (range years). Approximately 88% of the cases were against non-saudi dentists. Thirteen of the dentists (52%) were men and 12 (48%) women (Table 3). Table 3. Dental practitioners affected in the claims. No. of cases Saudi Non-Saudi Total Men Women Total Table 5. Types and frequency of decisions taken in malpractice cases. Sanction No. of cases % Verbal warning 0 0 Written warning Payment Withdrawal of license Termination of contract 0 0 Others* Total % All of the complaints (100%) concerned the private sector, with 71.5% of the cases against medical centers, 21.4% against polyclinics, and 7.14% against private solo-practice clinics. Most of the cases (92%) were against general practitioners, 4% against specialists, and another 4% against technicians. In 25% of the cases, the dentist was the owner of the practice while in the remaining cases (75%), the dentist was an employee. Of the 20 clinical cases involved, it was only in one case where informed consent and consultation was obtained prior to the treatment to the patient. In 28 of the cases (87.5%) the dentist was found guilty and it was only in one case that the dentist was found to be innocent. Three cases were still undecided during the time of the study (Table 4). Table 4. Verdict reached in relation to informed consent. No. of cases Guilty Not guilty Consent obtained Consent not obtained Under Investigation Total Total In some cases, more than one penalty or sanction was imposed, causing the total number of sanctions taken to exceed the number of cases (Table 5). A penalty fee was the most common sanction imposed (51.5%). The total payments reached SR163,100 with a mean payment around SR9,061. The most expensive claim was in a non-clinical case involving an unlicensed practitioner who had to pay SR2 5,000. The next highest claim was SR20,000 in a prosthodontics case. Discussion This study is the first to present information on patients' complaints against dentists practising in Saudi Arabia. In the past, the processing of patients' complaints was not well organized and the records of the cases were not kept. There were, therefore, no previous data to compare the finding in this study with. However, there is little doubt that litigation in Saudi Arabia is increasing. The most likely explanation is the increasing number of practicing dentists, which has resulted in an increase in the number of treatments provided. These increased treatments have increased the risk of malpractice especially from complex case situations. Also, the expanding patient population is becoming more knowledgeable and aware of their rights and are taking action by contacting the Ministry of Health to lodge their complaints. Different clinical dental services are involved in claims. The largest proportion of claims involved oral surgery and fixed prosthodontics. This was also found to be the most common in the USA. 4 The finding also corresponded to that of a Swedish study of malpractice where it was found that prosthodontics specialty had the highest rate of malpractice suits. 7 The reason for this is probably because prosthodontics treatment is an expensive and complex one where clinicians have to cooperate with dental technicians. This may introduce various risks for mistakes and high rate of complaints compared to other areas of dentistry. The high expectation by the patient for treatment results and the psychological factors may also explain the increase in formal complaints. There were fewer claims involving endodontics, restorative dentistry and periodontics. This low level of complaints from these specialties

4 98 DENTAL MALPRACTICE CLAIMS IN RIYADH may reflect the patients' lack of knowledge about these areas and may reflect the limited scope of specialty treatment available in these specialties. The total penalty payment for oral surgery cases was SR6300 (two cases were still under investigation). For fixed prosthodontics, the payment was SR2880 (one case was still under investigation and in another case, no sanction was given). These settlements are low by American standards but will probable increase in the future. The mean age of the patients was 25.7 years. This is expected because most of the population in Saudi Arabia is below 30 years of age. It has been found that women complained more than men (62%: 38%). This is probably explained by the fact that Saudi women utilize dental services more than men. Therefore, they face a greater risk of treatment failure or negligence. In some cases, more than one complaint was filed. Patients probably tended to include more faults in their reports than their main complaint, in order to increase their credibility and draw attention to their suffering. Mistakes made during treatment were reported as the most frequent allegation in dental claims. However, high cost, unethical behavior and excessive pain and discomfort were additional concerns. There was no relationship in the prevalence of complaints and the gender of the dentist. All of the cases were against private practitioners, which might be related to the higher social-economic level of the patients seeking treatment from this sector. Also it is possible that complaints in government clinics were settled internally and didnt reach the level of a formal review by the Board. Most of the cases were against non-saudi dentists, which is expected since most of the employees in the private clinics are non-saudis. Dental employees and not dental practice owners may have greater probability of failed claim because they may have less reason to be cautious with patients. They may feel that their employer's reputation is at stake and the costs associated with the claims will be covered by the owner. It is only in one case that the dentist was found not guilty. This was the only case in which the dentist obtained informed consent from the patient prior to treatment. This indicates the importance of getting a patient's agreement on the treatment plan before delivering the treatment. Payment (fine) was the most common sanction given. It is anticipated that these penalties will increase as more cases occur. It is especially important that the dental profession minimizes malpractice claims and develops legally defensive measures to prevent their occurrence. Conclusion In the rapidly modernizing country of Saudi Arabia, the incidence of dental malpractice claims seems to be increasing. This does not contribute to advancement of the aims of optimal dental care. A reduction in the quality of dental care available should be prevented. Knowledge of this problem as presented in this paper could possibly have a positive effect upon the quality of dental care provided by some dentists. This will alert them to the need for greater care and ethical professionalism when treating their patients. Two obvious limitations of this (pilot) study were: a) The validity of the data could not be checked. b) The study covers a short period of time with a small number of cases. A nationwide study on a representative sample is needed to provide more information on this field. Our results showed an increase in the proportion of claims resulting in payment as a settlement with the patient. Few dental service areas were involved in dental malpractice claims. Oral surgery and fixed prosthodontics had the most claims. Considering the current environment of health system changes, careful attention should be paid to malpractice liability, insurance issues and legal developments within dental services in Saudi Arabia. Preventive efforts should be stressed. References 1. Griangrego E, Johnson B and Dwyer B. Emphasis: the liability issue. Protecting the profession. J Am Dent ASSOC 1986; 112: Gordon B. The dentists as a defendant. NY State Dent J. 1986; 6: Rudov MH. Myers Tl and Mirabella A. Medical malpractice insurance claims files closed in In: Appendix, Report of the secretary's commission on medical malpractice, Washington, D.C.: Department of Health, Education and Welfare; 1973.

5 AMMAR AND GUILE 99 Peter Milgrom et al. Malpractice claims during A national survey of dentists. J Am Dent Assoc 1994; 125(4): A.C. Mellor and P. Milgrom. Prevalence of complaints by patients against general dental practitioners in Greater Manchester. Br Dent J1995; 178(7): A.E.Swanson. Removing the mandibular third molar: neurosensory deficits and consequent litigation. J Can Dent ASSOC 1989; 55(5): Nils Rene and Bengt Owall. Malpractice reports in prosthodontics in Sweden. Swed Dent J 1991; 15(5) Ove Sjostron. No-fault-compensation, patient guarantee, peer review committees: the Swedish experience. Int Dent J1990; 40(2):