A survey of ethical processes by the Regional Council of Dentistry of the Federal District in Brazil from 2009 to 2015 Contra Surgeon-Dentists A retrospective study

Introduction: The Dental Code of Ethics is the standard-setting instrument of the dental profession in Brazil. The Federal Council and the state councils of dentistry through this normative element, have in their competences, the duty to ensure the proper image and performance of the dental profession. Objective: This study was conducted in order to carry out a survey of ethical lawsuits filed against dentists in CRO / DF from 2009 to 2015 and thus draw the profile of the infringing professional, as well as their infractions. Methods: The data collection was performed by means of forms that contained information as: Gender, specialty, nature of the formation institution, scope of occurrence of the infringement, motivation of commencement of proceedings, among others. Results: During the period of six years covered by the ethical processes were 365 opened process, involving 479 dentists, which mostly (65%) were men. Problems related to treatment with implants and irregular advertising were the most occurring infractions, respectively. Instaurations motivated by patient dissatisfaction constitute the most of the ethical processes. Conclusion: Men are the most common infractions and most of the processes were performed in clinics or private practices. The marketization of the dental profession has a direct impaction in the establishment of these processes. In conclusion: a more appropriate communication by the professional is needed with regard to treatment, in order to avoid misunderstanding that may cause the patient dissatisfaction.


Introduction
The Federal Council of Dentistry (CRO), along with the 27 Regional Councils, established by Law No. 4324 of 14/04/1964 and regulated by Decree No. 68704 of 03.06.1971, aiming at the supervision of professional ethics and primacy for good ethical performance of Dentistry throughout the national territory. Among the duties of the CRO, is to prepare the professional Code of Ethics, which according to Garcia (2008) "establishes standards expected in the specific practice of each category, to disclosing the ethical nature of work and ensure relevant values for the society ". The Dental Code of Ethics is in its fifth edition, approved by Resolution CFO-118/2012 and in force since 01 January 2013. [1][2][3] Ethics in health professions is essential for an informed and fair implementation of the inherent professional duties. However, the model of teaching focused on the fragmentation of learning in subjects and the technique of recovery at the expense of full view of the individual, to see the patient as an individual rather than a mouth or dents. 4 The lack or deficit of bioethics study in academic professional training, brings a serious burden to the implementation of its social role, while health care professional. Gonçalves 5 checked that only 57 institutions, a total of 182 gifts Dental colleges in Brazil, had in their disciplines grid study of bioethics. According to the author, although the Bioethics awaken interest in academics, teachers recognize that this discipline is not treated as it should. Among the suggestions highlighted by the surveyed teachers, are: applicability and interdisciplinarity, increased working hours, compulsory in the curricula of undergraduate courses, as well as teacher training and upgrading teachers from other areas of knowledge.
An assessment of the moral development of graduates from dentistry courses, Freitas et al. 6 concluded that more than half of the evaluated did not have enough moral development for the profession. The moral level of development of most academics was below the population average, and comparable to that of children aged between 7 and 11 years. In moral development scale from 1 to 5, a total of 28 individuals of 42 respondents were within the stage 1 and 2, which are characterized by the inability to consider dilemmas and/or situations involving the moral and the tendency to resolve-them by an individualistic and personal perspective. This information indicated that the dentistry courses, mostly still fail to foster a sufficient moral development for the professional, Even in educational institutions, which should apply a strict ethical rules in serving the public, there is deviation, not the Code of Ethics, but the ethical consciousness itself. For instance, you can enter the information in the study Gonçalves,7 which shows the privilege in the care given to people known teachers or employees who were placed ahead of other patients, featuring unethical behavior on the part of these professionals.
Dentistry, having its origins in a market and technical model, is still treated as such. One fact that can corroborate this statement are the numerous cases brought against dentists, dental plans and clinics popular with consumer protection agencies. The profit of the unique vision has led professionals to overcome the dictates laid down in the Code of Ethics, and to ignore the proper performance of its services. Once enacted the Consumer Protection Code, the professional / patient relationship, allowing the dentist full control of the situation, as having the knowledge and power turning full on the mouth of the patient, has been replaced by the relationship supplier / consumer, granting rights to the patient on the service provide.
As service provider, the dentist clinic Owner or office makes use of advertising media to promote their services. However, advertising in violation of the expected normalization in the Dental Code of Ethics is constant and one of the main reasons for the establishment of ethical processes. Either for lack of knowledge on the subject, is purposeful, it is known that unethical advertising is an aspect that has grown significantly in all professional fields. [8][9][10] Therefore, this study aimed to quantify and qualify ethical brought proceedings before the Regional Council of Dentistry of the Federal District (CRO-DF) in a period of seven years, with the guiding element, the Code of Dental Ethics.

Materials and methods
Through a documentary descriptive research, carried out by the CRO / DF, one was madesurvey of cases recorded in this federal agency. Data were collected for each case individually and inserted into specific records that were developed based on the structure of the ethical processes, in order to cover the maximum possible information to perform the search. The sample consisted of all dentists who responded ethical procedures in the CRO / DF sphere of action, from 2009 to 2013. Were collected from the following process variables: number of applied punishments, number of acquittals, the number of experts, registration time on the board, graduation time, operational area, nature of the training institution, the nature of the place where the professional has undergone the process (public or private service), the current process situation, sex offenders and professional recurrence of historical processes. In order to protect the confidentiality of the professional, the researchers did not have access to name and other information that could identify the same, except in cases of punishment with disclosure in the official gazette. the assumptions of Resolution 196/96 were respected, in its version of 2012 and the work was properly submitted to the Research Ethics Committee of the University Center UNIEURO and approved with the opinion number 468 404. The collected data were submitted to descriptive analysis percentage (simple rule of three) and stored in an Excel application system in the Windows XP® operating system the researchers did not have access to name and other information that could identify the same, except in cases of punishment with disclosure in the official gazette. the assumptions of Resolution 196/96 were respected, in its version of 2012 and the work was properly submitted to the Research Ethics Committee of the University Center UNIEURO and approved with the opinion number 468 404. The collected data were submitted to descriptive analysis percentage (simple rule of three) and stored in an Excel application system in the Windows XP® operating system the researchers did not have access to name and other information that could identify the same, except in cases of punishment with disclosure in the official gazette. the assumptions of Resolution 196/96 were respected, in its version of 2012 and the work was properly submitted to the Research Ethics Committee of the University Center UNIEURO and approved with the opinion number 468 404. The collected data were submitted to descriptive analysis percentage (simple rule of three) and stored in an Excel application system in the Windows XP® operating system

Results
A total of 365 procedures were initiated in ethical CRO / DF between 2009 and 2015, and against 357 processes dentists ( Figure 1). Of the remaining eight, three covered only dental technicians, three covered clinics, one included an auxiliary oral health and another filed and reopened in another year, for reasons not informed. Since these processes can include more than one professional in your body, the total number of professionals enrolled in them was 479 total. Of the offenders professionals, 240 (50%) had some specialty registered in the CRO / DF. The other 239 (50%) did not have specialized registration with the CRO / DF. The number of offenders was 310 men, while the women was 169. These professionals 71% (339) were from private educational institutions and 29% of public institutions (Table 1). Of the 79 dentists who responded were processed 467 cases for actions committed in clinics or private offices, and 142 of these were technical experts. The discrete number of 12 offenses was committed in institutions belonging to the National Health System. For processes, the observed rate of recurrence was 16% among dentists processed, which corresponds to the number of 80 professionals. Most of the cases (233) were initiated by the complaint. On the trial process, 156 of the total of professionals had already been tried, 152 professionals had their process osarquivados, the number of professionals with ongoing process was 47, one process was canceled and one case was referred to the Council of the offender occupational given that it did not have registration in the CRO / DF. Table 2, note that about 18% of instaurations against professionals were not judged consistent with the complaint at the time of initiation of the proceeding and that there was no case of revocation of professional registration in this period. The data described as "Other" refers mostly to filings processes. These filings, the agreements proposed by the Council in an attempt to reconcile the parties, is the most significant number, corresponding to 86 cases or percentage data about 18% of the total number of sentences that is 479. Among professionals found guilty 38 suffered the imposition of financial penalties.  Table 1 Number of professionals and infringement procedures, taking into account the nature of the educational institution in which they have completed graduation as reason pointed out by the CRO

Discussion
Because of the mercantilist expansion of the profession and to the breakdown of the professional-patient relationship, the number of instaurations of caused processes dissatisfaction between the parties appears to be high, constituting approximately 53% of the cases initiated in the CRO-DF against dentists, given this corroborating the assertions made by Cavalcanti and Zimmermann. 9,11 The market for the provision of health-related services before seen as something difficult to access, with regard to the patient's coparticipation in the health / disease process, after the advent of the modern model of capitalism and the constant changes in social thinking profile resulted in a legal expansion, more precisely, a more efficient legal apparatus control service in odontologia. 11,12 Garcia, 8 when performing similar collection to this, held in the state of Santa Catarina in 2006, found as more frequent causative factor of opening processes irregular advertising, with a possible technical error, the third question and the percentage of only 12%. Such data can corroborate the assertions present in the work Pereira11que affirms the popular clinics facilitate the emergence of new cases brought against dental professionals. Still common science that this clinical modality is based on productivity and that this, in turn, hamper crucial stages of treatment, like a correct history or the proper explanation of the prognosis for the professional, it must be considered that professionals serving in their own offices may also allow such actions to thus meet a greater number of patients. This way, there are the popular clinics, but the competitive conditions of the labor market as a whole that can be displayed as key influencers Trail ethical standard expected by the dentists. When related to poorly designed and / or planned treatments can bring major complications, given the technological advances that can both facilitate the procedure, how to detect possible errors technicians. 9 One can make a comparison with the data obtained by the introduction Garcia 10 in the growing number of ethical proceedings which corresponded to 154 over a period of 12 years. This study covered the years 2009 to 2015 and you can find more than twice as many cases against dentists. Such data can illustrate the fact that professionals are constantly entering the labor market, but it also illustrates that Oliveira 13 stated in his research, concluded that both professionals inserted in the market, as academics did not have adequate knowledge about the assumptions contained in the Code Dental Ethics. This data becomes more alarming when one notes that only medical professionals, or those who just played clinical practice. Irregular advertising, another important factor in the emergence of new processes, should be approached with substantial attention. Since advertising is based on the popularization of something and the more usual marketing model on the market is the external, the surgeon dentist disclosures external marketing is based on showing the existence of that professional in a particular place and also their professional duties in regard to specialties. Such disclosure is through cards, brochures, advertisements in communication media, magazines, the most diverse publications, among others. 10 In addition, the Dental Ethics Code is very specific in relation to dental advertising standards, and many forms of disclosure.
Regarding the sanctions after the entire course of the process, we can mention the acquittal as the decision to a higher occurrence. This finding is confirmed in research Garcia. 10 We suggest this because, although this heightened awareness of patients regarding their rights, sometimes is confused with a utopian vision of the end result of dental treatment that sometimes has a more aesthetic connotation that functional by those. However, this data underscores the need for professional dialogue / patient, making the service something dynamic and requires the participation of both sides, so that the treatment plan is sufficiently clear to the patient and that it can share responsibility success throughout the course of this treatment. 9 In the context of the fact that most of the ethical processes against dentists are opened due to a possible technical error, Benedicto (2010) states that the complexity involved in dental care is not limited only to technical aspects, but also to administrative, legal, ethics and good relationship with the patient. Therefore, due to the existence of legal mechanisms such as the Criminal Code, the Civil Code and the Code of Ethical Dentistry, which have punishment for those who, in the exercise of their profession, may commit harmful acts against patients, the proper maintenance of medical records dentistry guarantees to the professional the protection against possible. 14 Therefore, within the current social reality, ethics has been the subject of constant discussions and has had unique significance within these. The word ethics can be associated with the conduct of human beings. However, it does not define standards for these behaviors, being this attribution inherent in the area of law. Based on this assumption, it can be affirmed that the right is the element computer, being guided by the ethics and the moral. By definition, a code of ethics can be understood as a set of legal norms delimited by ethical precepts. 15,16 Nascimento (2014) pointed out that of the total number of offending professionals prosecuted by the Regional Dental Council of the Federal District, approximately 27% were technically responsible, a fact probably explained by the assumptions contained in article 33, which places the supervise the clinic it signs, as well as other professionals who work there. Faced with this and the knowledge of many of these students in relation to this precept, greater care is expected from them when, in the future, as responsible, since it is possible to infer that they fully understand the responsibility of the function. 16,17

Conclusion
The growing awareness of patients about their right, together with the dissatisfaction of a poorly cleared procedure has been a major cause of establishment of ethical processes, which highlights the need for greater communication between professionals and patients, thus resulting in a co-participation treatment.

Research funding statement
The author of the paper entitled "Assessment of ethical process at the cro/df and profile of surgeons-dentists" involved states that it was done with own funds.

Dating and signing
Declaration of Conflict of Interest