With advances in medical sciences and the evolution of the legal system in modern society and patients' awareness of their rights, doctors and other health care workers are frequently caught in difficult predicaments arising from their daily practice, such as the duty to respect informed consent, telling the truth, breaches of confidentiality, biomedical research, etc. In addition, there has been growing public concern about the ethical conduct of health professionals, reflected in complaints about their poor ethical conduct and an increase in the resort to lawsuits against them (6). For all these reasons, they should be more familiar with current health legislation and regulations.
In addition, as Hariharan concludes in his article, "there is a need to identify those who appear uninterested in ethical or legal issues” (15). This study was therefore able to identify the background and objectively quantify the level of knowledge of the dentists and stomatologists registered in the Valencian Community on current health legislation and regulations, who obtained overall, a score of 6.34 out of 10.
Furthermore, the dentists surveyed in the Valencian Community obtained the lowest average number of correct answers, 61.9%, to the questions in the first section, which covered their level of ethical knowledge, demonstrating, as also stated in the study in Adhikari's article, "that a significant proportion of doctors were not aware of the universally recognised ethical principles, which are an essential part of their clinical practice" (16). It should also be remembered that it is sometimes difficult to dissociate the legal and ethical basis of dentists' professional duties, as a moderate general level of knowledge on the part of dentists and stomatologists about current health legislation and regulations may be insufficient to carry out their daily clinical practice safely for both themselves and their patients.
With regard to the level of education and level of knowledge, based on the 2017 article by Blau, I. and Levin L., in which they pointed out that dental care providers are obliged to deal with legal issues and therefore it is essential for doctors and dentists to recognise the basic legal concepts of medical malpractice (12), it was deduced that all dentists should have a minimum knowledge base of legal dentistry to carry out their work. On the other hand, a highly interesting article from 2006, "Knowledge, attitudes and practice of medical students at the Cave Hill Campus in relation to ethics and law in healthcare", concluded in its findings that in general, medical students recognised the importance of ethical knowledge, but felt that they knew little about law, and that they drew knowledge from multiple sources, especially from lectures and seminars, to improve their ethical knowledge (17).
Thus, at the beginning of this study, it was believed that dentists who had received more additional training, through completing various courses, would be more likely to have received more information in some of them about existing health legislation or regulations, and would be able to obtain better results in this test, as opposed to others who had received less additional training. But as shown by the results of this study, level of education did not strongly correlate with level of knowledge.
With regard to specialisation and level of knowledge, the article published by Bordonaba-Leiva S et al. regarding malpractice claims filed in the last 24 years in the field of Oral and Maxillofacial Surgery in Spain, highlight the growing trend of malpractice claims for adverse events, suggesting that professionals working in Oral and Maxillofacial Surgery are aware of the ongoing problem (11). This initially led us to believe that the dentists and stomatologists specialising in Oral Surgery and Implantology who responded to this survey would obtain better results, as they would likely have to be better informed. Furthermore, these statements are added to what the 2019 article by He P. et al. pointed out, stating that: "surgical specialisations in particular have been shown to carry the highest legal risk, encompassing some of the highest premiums for malpractice” (18), which again made us suspect that those specialising in Oral Surgery and Implantology would perform better, as dental extractions are often the main reason for malpractice claims against this group and hence they should be more aware of current legal knowledge, as it can more easily impact on them. However, although there were some differences according to the specialisation of each practitioner, respondents working in General Dentistry and Aesthetics were found to be the most knowledgeable about ethical issues.
With regard to years of work experience and level of knowledge, as observed from the findings of the 2014 article by Dhanappa et al., which stated the importance of and the need for adequate training among graduates to raise their awareness of aspects of legal education and maintaining professional ethical conduct in the field of health (6), it was thought that the newer dentists and stomatologists, having graduated recently, would remember better and thus obtain better results in the survey, having taken the subject responsible for training them in this field, "Legal and Forensic Dentistry", more recently in the Degree of Dentistry. However, after analysing the results of our study, we can conclude that there is no significant correlation between the amount of time spent on the job and the degree of knowledge of the subject.
When considering the relationship between workplace and degree of knowledge, those working as university teachers, who accounted for 26.1% of the total number of dentists surveyed in the Valencian Community, tended to stand out from the rest of the occupations. It may be because university teachers have the task of sharing their knowledge and teaching not only to future dentists, but also to students of other degrees, postgraduate courses, undergraduate courses, vocational training at different levels related to dentistry, and thus they should be more up to date in this matter. As Bhadauria, US, explains in his 2018 article, understanding the legal aspects not only provides protection against lawsuits, but also provides the practical implication of understanding the significance of dental history, radiographs, photos and dental models, because legally, the dentist's written records carry more weight than the patient's memories (13), and academics also have a moral obligation to know these facts in order to pass them on to their students.
Finally, with regard to the professional category and degree of knowledge, it was initially thought, after reading the article by Perea Pérez B., entitled "Professional liability in oral surgery", that it was evident that the legal pressure from patients was increasing, so we dentists must assume it and try to adopt measures that minimise this risk, or limit its consequences in the event that it should occur. Among the recommendations for minimising the risks of a dental professional liability claim or to limit its consequences were to have a minimum of medical-legal knowledge in order to practise, to know the casuistry of the procedures with the most claims and to take the utmost legal precautions with regard to patients who may be potential claimants (10), that dentists in positions of greater responsibility, being more likely to receive an initial claim or lawsuit, should perform better, being more up to date with health legislation and regulations, than, for example, another dentist or stomatologist who is only dedicated to teaching and who does not work with patients or does so infrequently. However, after conducting our study we were able to confirm that, although there were differences in specific questions regarding the role of the professional, only one background, the self-employed and the employed combined, demonstrated a lower level of knowledge than the overall sample.
Based on the conclusions obtained from this study, new lines of research have arisen in relation to current dental law and expertise. The next step should be to carry out the same survey in other Spanish provinces and thus verify whether the same results are obtained in the different regions, in order to be able to extrapolate the results on a larger scale.