In the context of the rapid evolution of science and technology in the field of dentistry and the increase in patients’ demands and expectations, the dental profession is facing numerous challenges. In recent years, a significant increase in cases of malpractice in dentistry has been observed, encouraging doctors to adopt defensive measures to protect themselves against litigation and complaints [1,2]. However, this practice can lead to excessive treatments, erroneous diagnoses, and, implicitly, to increased costs and decreased patient satisfaction.

Defensive dentistry is defined as the set of practices and measures adopted by doctors to protect themselves against complaints and litigation, which has become an omnipresent reality.

Legal and economic pressures in the health system impose increased responsibility on dentists, forcing them to oscillate between legal protection and the provision of optimal treatment [3]. The importance of defensive dentistry is also underlined by the need to identify and implement strategies that minimize the risks of malpractice without compromising ethics and quality of medical practice [4,5]. Dentists face increased pressure to avoid medical errors, which leads to an increase in defensive practices and, implicitly, extra costs for patients and the health system [6]. Implementation of appropriate strategies and policies, based on recent research and statistical data, is essential to minimize the risks of malpractice without compromising ethics and quality of medical practice [7,8].

Internationally, there is an increasing incidence of defensive practices among dentists due to the fear of litigation and its consequences on the quality of patient care [9]. Global health organizations and professional associations promote policies and guidelines to reduce malpractice and improve standards of practice.

At the national level, in Romania, legislation on medical malpractice and its prevention measures are continuously developing, influenced by international practices and regulations. In recent years, the need to balance the legal protection of doctors with the provision of quality treatment for patients has been increasingly emphasized [10,11]. Educational institutions and professional communities in Romania play an essential role in the education and training of dentists, promoting research and the implementation of practices that minimize the risks of malpractice.

In Romania, medical malpractice, both in general medicine and in dentistry, is an increasingly frequent problem, reflecting both the increased awareness of patients’ rights and the challenges of the health system. The number of reported malpractice cases in Romania has been steadily increasing in recent years, necessitating a detailed analysis of the causes and consequences of this phenomenon. The most common forms of malpractice in Romanian dentistry include diagnostic errors, inadequate treatments, and failures to communicate the risks associated with the procedures [12,13]. Errors in prosthetic and implant treatments are particularly frequent, often caused by insufficient training and non-compliance with treatment protocols. In Romania, the determinants of malpractice include both structural problems of the health system and deficiencies in the training and practice of doctors. Overwork, lack of adequate resources and equipment, and financial pressures can contribute to medical errors. Another essential factor is the lack of effective communication with patients, which can lead to misunderstandings and unrealistic expectations on their part [14].

The consequences of malpractice in Romania are significant for both patients and healthcare professionals. Affected patients suffer not only physically and emotionally, but also financially due to the additional costs of corrective treatments. On the other hand, doctors face financial losses, reputational problems, and considerable professional stress. Also, the increase in the incidence of malpractice cases contributes to an atmosphere of distrust and a climate of fear, which can affect the quality of medical care.

In Romania, the legal institution of medical malpractice is regulated by Law no. 95/2006 [15] on healthcare reform, which includes in Title XVI provisions regarding the civil liability of medical personnel and service providers. This law was subsequently republished and updated, being completed by Order no. 482/2007 [16], which approves the methodological norms for the application of this title. Also, Law no. 46/2003 [17] on patient rights has made a significant contribution to regulating this area, establishing the legal framework of the patient–provider relationship and the fundamental rights of the patient. The Romanian legislative framework presents certain gaps and challenges, including the lack of resources and specialized personnel for the efficient investigation of cases, complicated bureaucratic procedures, and the long duration of trials in the courts. There is also a general perception of distrust in the justice system, which may discourage patients from reporting cases of malpractice [18,19].

In the context of medical malpractice, defensive practices in dentistry include frequent testing and investigations, avoidance of complicated procedures, unnecessary preventive treatments, and overly detailed documentation to cover potential legal risks. These behaviors are driven by dentists’ fear of being involved in malpractice litigation and by the increasing expectations of patients and the healthcare system [20,21].

Defensive dentistry can negatively impact the quality of patient care. Excessive testing and investigations can lead to patient discomfort and anxiety, and increased financial costs. In addition, overtreatment can expose patients to unnecessary risks, such as surgical complications or adverse reactions to treatments [22].

Defensive practices can have a direct impact on the effectiveness of treatments. Dentists who avoid complex cases out of fear of potential litigation may miss opportunities to provide optimal care to patients who need specialized interventions. Also, excessive or unjustified treatments are not only ineffective, but can also harm patients [23,24].

To reduce the negative impact of defensive medicine on the quality of care, it is necessary to implement effective strategies, including continuing education among dentists, improving communication, reforming the judicial system, and providing psychological support to them. Ensuring the continuous training of dentists should focus on updating knowledge and skills, and on managing risks without resorting to excessive defensive practices [25]. It is also necessary to develop training programs to improve the communication skills of dentists so that they can clearly explain the risks and benefits of treatments, contributing to increasing patient confidence. The implementation of legal reforms should provide dentists with adequate protection against abusive litigation, promoting a culture of learning from mistakes instead of punishing them.

Analyzing the collected data, a clear distribution of the respondents’ genders can be observed. Of the total number of respondents, 44% of the responding dentists belong to the female gender, and the remaining 56% belong to the male gender (Figure 1).

The distribution of the respondents by age group shows that the overwhelming majority, i.e., 58% of the respondents, are in the 26–40 age range. This is closely followed by the 41–55 age group, with a percentage of 21% of the respondents. A smaller, but still significant, percentage of 11% of the respondents falls into the 25 years of age or younger category, and a percentage of 10% of the respondents are over 56 years old (Figure 2).

Analyzing the distribution of respondents by years of dental practice, we observed that 4% of the total do not have one full year of experience. The best represented experience sample is 1–5 years: 20% of the total. 17% of the respondents have between 6 and 10 years of experience, 15% of them have between 11 and 15 years of experience, and 10% of the respondents have between 16 and 20 years of experience. The category of the most experienced doctors, with over 21 years of experience in dental practice, constitutes 15 percent of the total (Figure 3).

The distribution of the respondents according to the main environment of professional activity (Figure 4) shows that the majority of the respondents, more precisely 56%, work in private practice, without collaboration with CNAS (National Insurance Company). This is followed by the category of doctors who practice in private practice in collaboration with CNAS (29% of the respondents), respondents who practice dentistry in both the private and state environment (13%), and doctors who practice dentistry exclusively in the state clinic (2% of the respondents).

Analyzing the distribution of the respondents, it is found that the majority of dentists consider themselves to have legal knowledge in this field, with 44% stating that they are informed “to a large extent” and 27% “to a small extent”. Only 11% of respondents declare that they master the legislation “completely”, while a small percentage, 8%, admit that they do not know the legal provisions in force at all (Figure 5). These results indicate a general degree of familiarity with the legislation on malpractice, although the completeness of knowledge varies significantly between respondents.

The results show that of all the dentists, the overwhelming majority (43 respondents) declare that they have never been accused of malpractice, while 7 state that they have been accused, but without being found guilty. Only 2 respondents preferred not to answer this question. These data suggest that the incidence of malpractice accusations among the participants is relatively low, and the registered cases did not result in the establishment of guilt (Figure 6).

According to the data obtained (Figure 7), of the total number of dentists, the majority (52%) admit that they rarely avoid working with patients for this reason, while 31% declare that they never avoid working with patients for fear of malpractice. On the other hand, 17% of the respondents state that they do this frequently. These results indicate that, although fears related to possible accusations influence the professional behavior of many respondents, in most cases this influence is moderate.

Analyzing the impact of the fear of malpractice on the willingness of dentists to treat patients with complex dental problems (Figure 8), it can be said that, of the total number of respondents, the majority (69%) state that they never avoid such cases, while 31% state that they rarely avoid them. No respondent indicated that they would frequently avoid patients with complex dental conditions for fear of being accused of malpractice. These results suggest that, in general, the fear of malpractice does not represent a major obstacle in taking on complicated cases by the professionals interviewed.

Analyzing the behavior of the dentists in relation to requesting additional investigations out of fear of medical malpractice (Figure 9), it can be said that, of the total number of participants, 65% state that they never recommend such unnecessary investigations, while 21% admit that they rarely do so, and 14% say that they do so frequently. These data indicate that although the majority of doctors do not modify their medical practice out of legal precaution, there is still a significant segment that occasionally or frequently resorts to additional investigations as a measure of protection against possible accusations.

The distribution of dentists reflects how the fear of malpractice influences the medical decisions of dentists regarding the application of treatment protocols with a higher risk of complications (Figure 10). Of the total number of respondents, 58% state that they never avoid these protocols if they are indicated to the patient, which suggests a professional approach focused on medical needs. However, 33% state that they rarely avoid them, and 9% admit that they do so frequently, indicating an influence, albeit minor, of legal risk on therapeutic choices. These data suggest that, although clinical conduct guided by medical indications prevails, in some cases, fears related to malpractice can affect therapeutic decisions.

The distribution of dentists highlights the influence of the fear of malpractice on communication with the patient (Figure 11), especially regarding the provision of detailed explanations about the diagnosis and treatment plan. Of the total number of respondents, a significant majority (48%) state that they frequently provide additional explanations for this reason, and another 33% do so rarely, which indicates a clear trend towards extensive communication as a form of legal protection. Only 19% of dentists claim that they do not change their communication style for fear of malpractice. These data suggest that legal pressure determines, in most cases, a more cautious and detailed approach in the relationship with patients, reflecting the concern of doctors for clarity and transparency for preventive purposes.

The distribution of dentists according to the assessment of the risk of being accused of medical malpractice (Figure 12) shows that the majority of the participants (52%) assess this risk as low, and 27% consider it moderate, which indicates a general perception of control and safety in practicing the medical act. However, 15% of the respondents perceive the risk as high, signaling a significant concern among a minority, and only 6% consider the risk to be non-existent. These data suggest that, although fears regarding malpractice are present, they are not dominant in the perception of the majority, who seem to feel protected in the current professional context.

Analyzing the degree of awareness and application of defensive dentistry concepts among dentists (Figure 13), it can be observed that a significant part (37%) declares that they do not know the concept, which suggests a need for more extensive information in this field. Of those familiar with the notion, 19% state that they frequently apply it in their practice, and 29% rarely, indicating a notable presence of defensive behavior, probably generated by the fear of malpractice. Only 15% of the respondents claim that they do not practice defensive dentistry at all. Overall, the results reflect both a partial application of this type of professional behavior and a lack of familiarity with the term itself, which may indirectly influence the way of relating to forensic risk.

The data collected show the perception of dentists on the negative impact that the fear of medical malpractice can have on their practice, especially to the detriment of patients (Figure 14). Many respondents (56%) consider that this fear does not affect their medical activity, suggesting a balance between legal protection and the provision of adequate care. However, 34% admit that the fear of malpractice influences their practice to a small extent, and 10% declare that it largely has an impact. These results indicate that, although for some the legal risk generates more cautious behavior, for the majority, it does not significantly reflect on the quality of the medical act or the relationship with the patient.

Analyzing the perception of dentists on the impact that the fear of medical malpractice has on the relationship with patients (Figure 15), it can be seen that, of the total number of participants, most (43%) consider that this fear affects their relationship with patients to a small extent, while 16% declare that the effect is largely negative. However, 41% of the respondents state that they are not affected at all from this point of view. These data suggest that, although a significant part of professionals feel legal pressure in their interaction with patients, for the majority, this impact is moderate or non-existent, reflecting a good capacity to maintain an effective and empathetic professional relationship despite fears related to malpractice.

The results of the study provide a relevant picture of how defensive dentistry is perceived and practiced among dentists in Romania. The detailed analysis of the response highlights both the awareness of legal risks among professionals and the existence of defensive behaviors that, although not dominant, are widespread enough to raise questions about their impact on the quality of the medical act and the doctor–patient relationship.

The first important aspect is related to the level of knowledge of the legislation on medical malpractice. The data show that the majority of dentists consider themselves to have “a great deal” (44%) or “a little” (27%) legal knowledge, with only 11% declaring that they fully master the legislation. This distribution underlines the existence of a general legal basis among the doctors but also highlights the lack of a deep level of understanding, which can generate uncertainties and, implicitly, protective behaviors in the face of perceived risks. It is noteworthy that four respondents admit that they do not know the legislation in force, which draws attention to the need for continuous training in this area. In the context of a legislation that is still evolving, insufficiently clarified, and often difficult to apply in practice, the fear of accusations becomes a significant factor in clinical decision-making.

Defensive dentistry, in its broadest sense, involves making therapeutic decisions not necessarily for the direct benefit of the patient, but for the legal protection of the doctor. From the data collected, most of the respondents state that they provide detailed explanations to patients in order to prevent accusations of malpractice. This approach, although apparently positive in terms of communication, can become excessive or artificial, especially when it is dictated by fear rather than a real desire to inform the patient. In some cases, patients may interpret this formalized communication as a lack of empathy, which can affect mutual trust.

Also included in the register of defensive behaviors is requesting additional investigations. Although 65% of the respondents claim that they never request unnecessary investigations, some admit that they resort to this practice either frequently (21%) or occasionally (14%). These decisions are motivated by the desire to document the case as completely as possible in order to have legal coverage in the event of a dispute. In reality, this attitude can lead to unjustified costs for the patient. From an ethical point of view, treatments or investigations without a solid clinical foundation can compromise the principle of patient benefit.

An interesting element revealed by the study is the relationship between the fear of malpractice and the attitude towards difficult patients. Approximately 70% of the respondents state that they frequently or rarely avoid collaborating with patients who display a hostile attitude. This behavior is a clear example of defensive medicine with implications for equity in the provision of medical care. Avoiding patients perceived as conflicting can lead to the marginalization of vulnerable categories, but also to a polarization of the doctor–patient relationship, in which the essence of empathy and responsibility towards all patients is lost, regardless of their behavior. Therapeutic decisions are also directly affected by the fear of making mistakes. In approximately 40% of cases, doctors may opt for therapeutic options that are less risky but also less effective for the patient. This form of professional self-censorship, in which legal certainty prevails over clinical interest, is an essential feature of defensive medicine and can have long-term negative effects on the quality of medical practice. The perception of the risk of malpractice is another significant indicator. Most dentists consider it low (52%) or moderate (27%), with only 15% stating that it is high, and 6% that it is non-existent. However, the behaviors adopted show that, despite the perception of a moderate risk, the psychological pressure is high enough to actively influence professional decisions and interactions. This phenomenon suggests the existence of a tense professional climate, in which risks, although perceived as low, are treated as constant threats.

Another crucial point is the direct recognition of the practice of defensive dentistry. A total of 19% say they practice it frequently, 29% rarely, and 37% are not familiar with the concept. Only 15% say they do not practice it at all. These data confirm that defensive medicine is present in the daily reality of dental offices, even if not all doctors identify or name it as such. The fact that a large number of professionals do not know the terminology, but adopt behaviors associated with it, suggests an acute need for continuing professional education to clarify, define, and regulate these practices.

Regarding the impact on the patient, approximately 45% of the respondents believe that the fear of malpractice affects their medical practice to the detriment of the patient, either to a small or large extent. This perception confirms the working hypothesis according to which defensive dentistry has negative effects not only on the doctor (through stress and anxiety), but also on the patient (by reducing the quality and personalization of care).

When it comes to the relationship between dentists and patients, the data highlight that, in many cases, it is negatively influenced by fears of malpractice. Communication often becomes overly formalized, sometimes rigid, and the degree of trust and empathy can decrease. These consequences are alarm bells about how the current legal climate influences medical practices and the quality of services provided to patients.