REVISTA MEDICINA LEGAL DE COSTA RICA Vol. 38 (2) September 2021 REVISTA MEDICINA LEGAL DE COSTA RICA ISSN 2215-5287 98 Dental malpractice lawsuits in Costa Rica: analysis of 124 cases in the period 2015-2020 José Manuel Fernández Chaves 1 1 Specialist in Legal & Forensic Dentistry. Oral Surgery & Pathology. MSc. Health Services Administration. School of Dentistry, University of Costa Rica. Forensic Dentistry Unit, Department of Legal Medicine, Judicial Investigation Agency. Costa Rica. ORCID ID: https://orcid.org/0000-0001-6478-5407 Correspondence: Dr. M.Sc. José Manuel Fernández Chaves ---jfernandezch@Poder-judicial.co.cr Received: 10-06-2021 Accepted: 20-08-2021 Abstract Introduction: In Costa Rica, dental malpractice lawsuits (professional liability) are classified under the crime of culpable injuries according to the Criminal Code of Costa Rica. The purpose of this study is to describe the characteristics of all the claims analyzed by the Forensic Dentistry Unit of the Department of Legal Medicine in a period of six years (2015-2020). Materials and methods: A detailed review was carried out in the database of the Legal Medicine System (SIMEL) of the Legal Medicine Department of the Organismo de Investigación Judicial (Judicial Investigation Agency) of all the complaints of dental "malpractice" filed since January 1, 2015 to December 31, 2020. The information collected was tabulated in Excel and classified by year, related dental discipline, sex of the complainant and the result of the expert analysis. Results: The data analysis determined a total of 124 complaints, the disciplines with the highest percentages were oral and maxillofacial surgery (39.52%), dental implants (16.94%) and orthodontics (12.9%). More than two thirds (66.12%) of the complaints correspond to women and within the results of the forensic report 10% of the cases were positive, 32% negative and 58% inconclusive. Conclusions: the complete dental record is essential to be able to determine a causal link between the investigated facts and the results of a treatment; in this study more than 50% of the files where incomplete, invasive procedures such as oral surgery generate a greater possibility of lawsuits that could be avoided through proper management of risks and complications, adequate patient-caregiver communication, and management of treatment expectations. Key words Malpractice, dentistry, lawsuit, professional liability Source: MeSH (Medical Subject Headings) REVISTA MEDICINA LEGAL DE COSTA RICA Vol. 38 (2) September 2021 REVISTA MEDICINA LEGAL DE COSTA RICA ISSN 2215-5287 99 Introduction Dental professional liability lawsuits are commonly known as dental malpractice lawsuits, historically they have been overshadowed by complaints filed against medical professionals, both for the frequency and amounts of compensation. (1) It is important to mention that complaints for dental treatments can involve serious situations such as fractures of the jaw or maxilla, less complex situations such as failure of fixed prostheses (bridges), crowns or dental implants to complaints of unadjusted dentures or aesthetic results that did not meet the expectations of the patients. (2) One of the main problems when performing the analysis of complaints is the lack of elements available in clinical records, according to a study carried out in 2019 in Costa Rica related to dental clinical records, it was determined that 53.3% of physical records and 33.3% of digital systems presented incomplete clinical examination and data. (3) A detailed file makes it possible to determine by means of evidence whether there is really a causal link between the facts investigated so that the judge has real criteria when it comes to dispensing justice. (4) Dentistry has had great technical scientific advances in all specialties, every day there are more procedures that involve examinations in three dimensions such as tomography(5) and intraoral scans,(6) additionally aesthetic procedures that were previously rare are increasingly used such as facial fillers that have increased during the last 10 years (7) as well as facial cosmetic surgery performed by specialists in maxillofacial surgery. (8) Materials and methods A detailed review of each of the cases analyzed by the Forensic Dentistry Unit of the Department of Legal Medicine registered in the SIMEL database (Legal Medicine System) was carried out in a six-year period from January 1, 2015 to December 31, 2020. A table was designed in Excel with the following characteristics of the cases: year, related discipline, sex of the complainant and result of the expert analysis that was classified as positive, negative and inconclusive. The classification of “inconclusive" was defined for those cases in which the lack of elements did not allow an objective criterion to be issued. Results Classification of lawsuits by dental discipline In the six-year period analyzed, a total of 124 complaints were recorded, the average was 20 cases per year. When classified by discipline, the oral and maxillofacial surgery procedures were the ones with the highest number of processes (49) representing 39.52% of the total. The second area with the most complaints is Dental Implants with 16.94% (21 cases), followed by Orthodontic procedures with 16 cases (12.9%), Prosthodontics 12.1% (15 cases), General Dentistry 13 cases (10.48%), Endodontics 7 cases (5.64%); Pediatric dentistry, Periodontics and other events (falls) had 1 case each respectively (0.80%). See Figure 1. REVISTA MEDICINA LEGAL DE COSTA RICA Vol. 38 (2) September 2021 REVISTA MEDICINA LEGAL DE COSTA RICA ISSN 2215-5287 100 Distribution by year and sex of the complainant The data analysis revealed that the year 2019 presented the highest number of complaints (27 cases), followed by 2016 (26 cases), the year 2020 (22 cases), 2018 (19 cases), 2015 (17 cases) and the year 2017 was the year with the fewest complaints (13 cases). Regarding to sex, the claims filed by women corresponded to 66.12% (82 cases) of the sample against 33.87% of men (42 cases) out of the total of 124 complaints, representing a ratio of 2 to 1 of cases of women and men. This behavior predominates in most years except for 2015 where the ratio is practically 1:1 as shown in Figure 2. 0 0 2 1 3 2 1 8 0 1 1 4 3 3 5 4 5 0 0 0 0 0 4 1 1 7 0 0 0 1 1 1 5 3 9 0 0 0 2 0 7 1 4 11 1 0 0 4 2 3 2 2 9 0 1 1 13 7 21 16 15 49 1 0 10 20 30 40 50 60 Periodontics Pediatric dentistry General Dentistry Endodontics Implants Orthodontics Prosthodontics Oral & Maxillofacial Surgery Other events Classification of lawsuits by dental discipline Total 2020 2019 2018 2017 2016 2015 Figure 1. Complaints classified by discipline in the period 2015-2020. REVISTA MEDICINA LEGAL DE COSTA RICA Vol. 38 (2) September 2021 REVISTA MEDICINA LEGAL DE COSTA RICA ISSN 2215-5287 101 Figure 2. Distribution by sex of the complainant. Result of the forensic analysis As a result of the expert analysis carried out by the Forensic Dentistry Unit, it is observed that 12 cases were positive, representing 9.7% of the total, 40 cases were concluded as negative, that is 32.25% and finally 72 cases were classified as "inconclusive" that constitute 58.05% of all cases. See Figure 3. 17 26 13 19 27 22 124 9 6 4 4 10 9 42 8 20 9 15 17 13 82 0 20 40 60 80 100 120 140 2015 2016 2017 2018 2019 2020 Total Distribution by year and sex of the complainant Total Men Women REVISTA MEDICINA LEGAL DE COSTA RICA Vol. 38 (2) September 2021 REVISTA MEDICINA LEGAL DE COSTA RICA ISSN 2215-5287 102 Figure 3. Result of the forensic analysis 2015-2020 Discussion From the analysis of the data, it is observed that the behavior of complaints by discipline practically half of the cases are related to the most invasive procedures such as oral and maxillofacial surgery and dental implants. This behavior is similar in studies carried out in countries such as Chile,(9) Brazil,(10) and Spain. (11). In relation to the result of the forensic analysis, less than 10% of the cases were positive, 32% are negative and 58% are inconclusive, which makes it indisputable that the absence of material evidence in the clinical file influences the results. From the expert analysis, these findings are compatible with those found in investigations carried out in Costa Rica regarding the performance of dental clinical records.(3)(12) Regarding the sex of the complainants, women had a 2: 1 relationship with men, this percentage according to the literature may correspond to the fact that women use health services more frequently than men, these numbers are similar in studies carried out in countries such as Brazil, (10) Chile,(13) Mexico,(14) Italy,(15) and Spain. (16) Within the complaints there is the classification of "other events", this was used specifically for the case of a user who suffered a precipitation (fall) after undergoing a surgical procedure. 2015 2016 2017 2018 2019 2020 Total Gral Positive 2 3 2 2 2 1 12 Negative 5 9 9 6 7 4 40 Inconclusive 10 14 2 11 18 17 72 0 10 20 30 40 50 60 70 80 Am ou nt o f c as es Result of the forensic analysis REVISTA MEDICINA LEGAL DE COSTA RICA Vol. 38 (2) September 2021 REVISTA MEDICINA LEGAL DE COSTA RICA ISSN 2215-5287 103 It is important to mention that in many of the complaints filed, the lack of communication with the treating person is mentioned within the narrations and complaints, where no attempt was made to solve the main complaint or that the resolution time was not as expected, additionally another of the points described are the expectations prior to treatment that were not met, which highlights the importance of measuring the perception of user satisfaction.(17) Conclusions Within the legal processes for professional liability there is a common element that must be demonstrated to established if there is an omission of the duty of care and therefore determine if it is positive, this element is the so-called “causal link”. (4) Regarding the expert report, it requires all the elements available in a clinical file to issue a scientific technical criterion in an objective manner, the lack of a complete clinical file makes it difficult to analyze cases and can leave both patients and professionals without tools for defense. Previous studies developed in Costa Rica have determined that the clinical record is not always carried out correctly. (12) One of the facets to take into account within the professional practice of dentistry is the reduction of risks, since the literature establishes that practically half of the demands occur for events that are considered foreseeable and avoidable,(11) they must be previously explained and discussed during the realization of informed consent. A good history and a good diagnosis, a detailed analysis of the main complaint and the expectations of the user are sine qua non requirements to achieve predictable treatments and reduce the possibility of lawsuits. 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