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 1970.3 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

Saudi Dental Journal, Vol. 12, No. 2, May - August 2000

dentists in 1988 to 27 per 1000 dentists in 1992.4

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 1992.
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 1991.4 In Washington
state, parasthesia following surgical extraction of
mandibular third molars accounted for nearly 25%
of the claims in 1984.6
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

DENTAL MALPRACTICE CLAIMS IN RIYADH

96
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 1417-1418H
(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

15.6

Oral surgery
Endodontics
Restorative dentistry
Periodontics
Non clinical cases

6
4
4
1
12

18.8
12.5
12.5
3
37.5

Total

32

100%

The mean age was 25.7 years, with a range of 18-58

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

Men
Women

6
9

2
4

Total

15

Total
8
13
21

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.

Saudi Dental Journal, Vol. 12, No. 2, May - August 2000

AMMAR AND GUILE

97

In 25 cases, the ages of the dentists were

known. The mean age was 39 years (range 30-60
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 5. Types and frequency of decisions taken in

malpractice cases.
Sanction

No. of cases

Verbal warning

Written warning

Table 3. Dental practitioners affected in the claims.

No. of cases

Saudi

Non-Saudi

Total

Men

10

13

Women

12

12

Total

22

25

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.
Guilty

Not
guilty

Under
Investigation

Total

Consent
obtained

Consent not
obtained

28

31

Total

28

32

No. of cases

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.
Saudi Dental Journal, Vol. 12, No. 2, May - August 2000

%
0

8.6

Payment
Withdrawal of license
Termination of contract

18
4
0

51.5
11.4
0

Others*

12

28.6

Total

32

100%

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

98
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

DENTAL MALPRACTICE CLAIMS IN RIYADH

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.
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2. Gordon B. The dentists as a defendant. NY State Dent
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3. Rudov MH. Myers Tl and Mirabella A. Medical
malpractice insurance claims files closed in 1970. In:
Appendix, Report of the secretary's commission on
medical malpractice, Washington, D.C.: Department
of Health, Education and Welfare; 1973.
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AMMAR AND GUILE

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