Complaints against Dentists Working in Mashhad, Iran; 2012-2017

Abstract
Background: The analysis of complaints against health professionals assists in improving health care services. The objective of this study was to evaluate complaints against dentists working in Mashhad, Iran during 2012-2017.
Methods: In this study, all the available completed dental complaint cases from the archive of the Mashhad Medical Council addressed within a six-year time period (from 2012 through 2017) were reviewed. The required information was extracted based on a checklist including variables such as the gender of dentists and complainants, the age of dentists and complainants, dentists’ degree, the place of service provision, the type of services provided, the causes of complaints, and the sentences issued to dentists (conviction or non-conviction).
Results: A total of 208 cases were evaluated, and in 67 (32.2%) cases, dentists had been found guilty. Most cases involving convicted dentists were associated with male dentists, female complainants, general dentists, and in-office services. In the cases of convicted dentists, the most common service provided was endodontic treatment and the most common cause of complaint was failed or incomplete treatment.
Conclusion: To reduce the growing number of complaints against dentists, their skills should be improved, especially in endodontic treatment services. It is advisable for general dentists to consider referring patients to specialists either for more skilled treatments or to allow their patients’ expectations to be better met.
Keywords: Delivery of health care, Dentists, Iran, Malpractice, Patients 

Introduction
A simple search in each database reveals a large number of studies which have examined the various aspects of complaints against health professionals, including dentists. The quantity of these studies and the geographical distribution of countries in which these studies have been conducted show the importance and prevalence of this problem worldwide. Unfortunately, health professionals involved in complaint cases are affected emotionally and physically, and this is arguably one of the most stressful experiences of their careers (1).
In any society, the review of former complaints allows the possibility of increased familiarity with the characteristics of those complaints; therefore, making possible the elimination of health care system shortcomings to increase health care recipients’ satisfaction. To this end, numerous studies in different countries, including Iran, have reviewed past filed complaints (2-11).
Among complaints against health professionals, a significant share is allocated to dentists. In the United States, for instance, approximately 13% of all the reports of the National Practitioner Data Bank (NPDB) were associated with dentists (12). Due to the importance and relatively significant number of complaints against dentists, these complaints have been studied in Iran and many other countries over the past years (2,6,13-20). Of course, to the best of our knowledge, only one previous study has evaluated complaints against dentists working in Mashhad, the second most populous city in Iran, and the available data on these complaints have not been updated for almost 10 years (13).
The aim of the present study was to evaluate complaints against dentists working in Mashhad, Iran during 2012-2017.

Materials and Methods
In this study, all completed dental complaint cases available in the archive of the Mashhad Medical Council within a six-year time period (from 2012 through 2017) were reviewed. For purposes of protecting the rights and identities of individuals involved in these cases, the researchers were provided with the required information based on a checklist and extracted by a staff member of the Mashhad Medical Council. The checklist included variables such as the gender of dentists and complainants, the age of dentists and complainants, dentists’ degree (general dentist or dental specialist), the place of service provision (office or clinic), the type of services provided (tooth extraction, maxillofacial surgeries, periodontic treatments, dental implantation, endodontic treatments, tooth filling, prosthodontic treatments, orthodontic treatments, or pediatric dental treatments), the cause of complaints (failed or incomplete treatment, wrong diagnosis, damage to other tissues, high fee, bad infection control, or other causes such as dentists’ inappropriate interaction and lack of a medical license), and the sentences issued to dentists (conviction or non-conviction). Complaint cases with unavailable or incomplete information as well as complaint cases originating out of Mashhad were excluded from the study.

Statistical analysis
The data were analysed using SPSS for Windows, version 16 (SPSS Inc., Chicago, IL, USA). The chi-square test was utilized to assess the association between the gender of dentists and complainants, and the sentence issued to dentists. T-test was used to assess the association between the age of dentists and complainants, and the sentence issued to dentists. In all the statistical analyses, the statistical significance level was set at p<0.05.

Ethical approval
This study was approved by the Ethics Committee of School of Dentistry, Mashhad University of Medical Sciences (Approval code: IR.MUMS.DENTISTRY.REC.1398.004).

Table 1. Complainants’ age (n=184) and dentists’ age (n=207); among all cases, cases with convicted dentists, and cases with not convicted dentists

SD = Standard deviation

* T-test

Results
A total of 208 cases (7.9% of 2628 complaint cases against all health professionals) were evaluated, and in 67 (32.2%) cases, dentists had been found guilty. In 42.3% of all cases and 25.4% of cases with guilty verdicts, complainants were male. The gender of complainants was statistically significantly associated with the conviction of dentists; most of guilty verdict cases were related to female complainants (p=0.001). In 79.8% of all cases and 79.1% of guilty verdict cases, dentists were male. The gender of dentists had no statistically significant association with the conviction of dentists (p=0.862). As table 1 presents, neither complainants’ age (p=0.748) nor dentists’ age (p=0.100) was statistically significantly associated with the conviction of dentists as well.
Among all cases, most dental services related to complaints (52.4% of 208 cases) had been provided in clinics, while among cases with convicted dentists, most services (53.7% of 67 cases) had been provided in offices. Among cases with convicted dentists, most cases (88.1%) were associated with general dentists, followed by oral and maxillofacial surgery specialists (6.0%), cosmetic and restorative dentistry specialists (3.0%), endodontists (1.5%) and orthodontists (1.5%), respectively.
Among all cases, tooth extraction was the most common type of received dental services. However, among cases with convicted dentists, the most frequent type of received dental services was endodontic treatment (Figure 1). Figure 2 shows the frequency of the six causes of complaints among all cases, and among cases with convicted dentists. The frequency of the causes of complaints among cases with convicted dentists has been presented in figure 3, categorized by the type of received dental services.

Discussion
This study aimed to update available information on complaints against dentists working in Mashhad. All completed dental complaint cases available in the archive of the Mashhad Medical Council from 2012 through 2017 were reviewed.
According to our findings, dentists were convicted in a third of the reviewed cases, and most cases with convicted dentists were related to male dentists, female complainants, general dentists, and in-office services. In cases with convicted dentists, the most common service provided was endodontic treatment and the most common cause of complaint was failed or incomplete treatment. The results of this study in combination with results presented by Movahhed et al (13) revealed a relatively increasing trend in the annual total number of complaints against dentists working in Mashhad, Iran from 2001 through 2017 (Figure 4).
The results of the present study showed that most complainants were female. Our findings, in this regard, are in line with the results of some other studies (2,13,14,19). The higher proportion of female complainants may be due to women being more sensitive to their own health and beauty, or due to having more free time to pursue legal action. However, Pukk et al in their study, as one of the reasons for the higher proportion of female complainants, also pointed out that medical errors are more common in the treatment of female patients as compared to male patients (21).
In the current study, it was also found that most complaints were associated with male dentists. Our findings, in this regard, are similar to the results of a large number of previous studies (6,13,15-20). The fact that most complaints were related to male dentists might be due to the greater number of male dentists, more professional activity by men, more aggressive work of male dentists, or female dentists’ better communication skills (22-24).
In this study, almost half of all complaint cases and the majority of cases with convicted dentists were related to services provided in offices. Some other studies reported that most complaints were attributed to private sector services (13,17,18,20). In this regard, the results of the present study are consistent with the results of the mentioned studies since most private sector services are provided in offices. The relation between the majority of guilty cases and in-office services may be due to the fact that dentists may act more aggressively in in-office situations where they feel more independent. Another possibility is that dentists in their own offices prefer not to refer cases to more skilled dentists, but instead attempt to meet all or most of their patients’ treatment needs themselves.
This study showed that the majority of all complaint cases, as well as the majority of cases with convicted dentists were related to general dentists. In this respect, the results are similar to the results of some previous studies (13,15,17,18). Due to the greater number of general dentists, most oral health services are provided by them which leads to their higher proportion of complaints. But it is also possible that general dentists, despite being less skilled than specialists, tend to perform a wide range of treatments.
Based on the results of this study, the three most common dental services related to complaints were tooth extraction, endodontic treatment, and prosthodontic treatment, in respective frequency. It is noteworthy that in many similar previous studies, despite the differences in service categorization, endodontic treatment and prosthodontic treatment were also among the three most common services related to complaints (13,15-20). Examination of the results of the present study showed that the most common cause of complaints regarding both of these treatments was failed or incomplete treatment.
In this study, all completed complaint cases against dentists working in Mashhad over a period of six years (from 2012 through 2017) were reviewed. The selected time period and also the similarity of the study method enabled us to combine our results with those of Movahhed et al’s study (13). This combination provided a more complete picture of the changes in the number of complaints over a 17-year period. A limitation existed as no interviews were held with either complainants or dentists for this study, thus the results were based solely on information recorded in archived cases. Comparison of the results of this study with those of the previous similar studies has also been limited due to differences in the categorization of services and causes of complaints.

Conclusion
According to the results of this study, the involved dentists in almost one third of the reviewed complaint cases had been found guilty, and the majority of them were male general dentists. It can be deduced that to reduce the increasing number of complaints against dentists, their skills should be improved, especially in services such as endodontic and prosthodontic treatment. It is advisable for general dentists to consider referring patients to specialists either for more skilled treatments or to allow their patients’ expectations to be better met.

Acknowledgements
We sincerely thank the Mashhad Medical Council for assisting in the implementation of this study. This article was originated from a graduate thesis registered under #3112 at the Academic Affairs Office of School of Dentistry, Mashhad University of Medical Sciences. The study was approved by the Ethics Committee of School of Dentistry, Mashhad University of Medical Sciences (Approval code: IR.MUMS.DENTISTRY.REC.1398.004). This work was financially supported by the Mashhad University of Medical Sciences [grant number: 971434].

Conflict of Interest
None.