Original Article

Awareness of Oral and Medical Healthcare Professionals in the Prevention, Diagnosis, and Management of Bisphosphonate-related Osteonecrosis of the Jaw


  • Yasemin Dedeoğlu
  • İlknur Özenci
  • Şebnem Dirikan İpçi
  • Gökser Çakar
  • Cavid Ahmedbeyli

Received Date: 03.11.2022 Accepted Date: 27.11.2023 Meandros Med Dent J 2023;24(4):349-356


The aim of this study was to evaluate the awareness and knowledge of oral and medical healthcare professionals regarding the prevention, diagnosis, and management of bisphosphonate-related osteonecrosis of the jaw (BRONJ).

Materials and Methods:

Two surveys were conducted with oral and medical healthcare professionals to evaluate their knowledge and attitude about bisphosphonates and their experiences with BRONJ.


A total of 385 oral and 119 medical healthcare responses were obtained. The level of knowledge of oral healthcare professionals who practiced for less than 10 years was significantly higher than that of those practicing for more than 10 years (p<0.05). Oral surgeons and periodontists had the highest level of knowledge (p<0.05). The knowledge level scores of the medical healthcare professionals exposed to the necrotic jaw during their careers were significantly higher than those who did not (p<0.05).


Within its limits, the knowledge of medical healthcare professionals was lower than expected. Knowledge of oral healthcare professionals was moderate, except for oral surgeons and periodontists. Multidisciplinary informative platforms between oral and medical healthcare professionals will benefit the management of potential risks and complications related to BPs.

Keywords: Bisphosphonate, bisphosphonate-related osteonecrosis of the jaw, awareness, survey


Bisphosphonates (BPs) are used to treat malignant bone diseases, prevent metastatic bone tumors, and prevent osteoporosis-related fractures in osteoporosis and osteopenia patients (1,2). Despite their beneficial effects, they have a severe side effect of bisphosphonate-related osteonecrosis of the jaw (BRONJ), defined as exposed necrotic bone at the maxillofacial region for more than 8 weeks (3). In 2014, as the second diagnostic criteria, bone that can be probed through an intraoral or extraoral fistula was also included (4). In recent years, due to the high number of osteonecrosis cases observed after the prescription of antiangiogenic and antiresorptive medications, the nomenclature was revised to medication-related osteonecrosis of the jaw (MRONJ) (2). A growing number of cancer and osteoporosis cases make this devastating clinical condition a potential complication for medical and oral healthcare professionals. Osteonecrosis lesions may occur spontaneously or after interventional approaches (5).

Medical healthcare professionals are the first link in the chain of events, and they should warn patients about BRONJ. Awareness of oral and medical healthcare professionals about BRONJ is paramount in the prevention, early detection, diagnosis, and management of these cases. Therefore, this study evaluated oral and medical healthcare professionals’ knowledge, awareness, and attitude regarding BPs and BRONJ.

Materials and Methods

This observational cross-sectional study was conducted between September 2018 and January 2019. Two different surveys were applied to oral and medical healthcare professionals. According to the sample size calculation, the estimated participation numbers were 379 and 110 for oral and medical healthcare professionals, respectively. A pilot study was performed to ensure the survey’s feasibility and validity. The questionnaire applied by Alhussain et al. (6) and El Osta et al. (7) was used for oral and medical healthcare professionals surveys, respectively.

The survey for oral healthcare professionals comprised three sections. The first section included questions about professional experience and demographic data, the second focused on perceptions about BRONJ, and the third assessed knowledge acquisition. The survey for medical healthcare professionals consisted of three sections and included 20 questions. The first section gathered data on demographic and professional characteristics; the second collected information about the number of BPs prescribed monthly and the name/form/duration of the recommended BPs; and the third comprised 30 sub-questions that evaluated the experience and knowledge of professionals. The highest score that could be obtained was 29 and 30 points in oral and medical healthcare professionals surveys, respectively. A higher score indicates a higher level of knowledge. Correct response rates of less than 25%, 25-50%, 50-75%, and more than 75% were considered weak, moderate, good, and excellent, respectively.

This study was approved by the Ethics Committee of İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine (decision no: A-19, date: 05.06.2018).

Statistical Analysis

The data were collected via a web-based program (Survey Monkey, US). Normality was checked with the Shapiro-Wilks test. Intergroup differences were evaluated by Kruskal-Wallis, One-Way ANOVA, and Student’s t-test. Mann-Whitney was used to determine the groups that caused the difference, and significance was assessed at p<0.05. Statistical analyses were conducted using SPSS Statistics 22 software (SPSS IBM, Turkey).


A total of 485 dentists registered with the Turkish Dental Association responded to the survey. Due to missing answers and abandoning the test, 100 participants were excluded. A total of 200 medical health professionals working at the İstanbul University Institute of Oncology and Cerrahpaşa Medical Faculty participated in the survey and related to the abovementioned problems; 119 responded to surveys included in the study.

The average knowledge score for oral healthcare professionals was 14.25±6.39. The knowledge of oral healthcare professionals is presented in Table 1, and the knowledge score by gender, age, specialization status, type of specialty, and duration of work in Table 2. General dentists had significantly lower total knowledge scores than specialists (p=0.000; p<0.05). Among the specialties, oral and maxillofacial surgeons had significantly higher total knowledge scores than others (p<0.05). Additionally, the total knowledge scores of the group with a professional practice duration of 1-5 years were significantly higher than those of groups with a longer duration of work (p<0.05) (Table 2).

The average knowledge score for medical healthcare professionals was 19.29±6.83. Correct response rates related to BRONJ are presented in Table 3. Medical healthcare professionals’ knowledge score according to demographic and professional characteristics is shown in Table 4. The knowledge level scores of the medical healthcare professionals who spent more than 51% of the day on academic work were found to have significantly higher scores than those who spent less than 25% (p=0.025; p<0.05). Medical healthcare professionals’ knowledge scores according to the answers given to the questions about the use of BPs are shown in Table 5. The knowledge scores of medical healthcare professionals who prescribed BPs were found to be significantly higher than those who did not (p=0.009; p<0.05).


The present study aimed to evaluate the knowledge of oral and medical healthcare professionals about BP usage and BRONJ as its side effect. The oral healthcare professionals survey aimed at assessing the knowledge about BRONJ covered several key aspects. Most oral healthcare professionals know that BP is prescribed for osteoporosis and bone metastases but less for other indications. Similar results were observed in literature (8-10). Besides, in a study, 65.4% of oral healthcare professionals could not define the indications of BPs (11). Similar to the literature, the most familiar BP was alendronate, followed by zoledronic acid and ibandronate, and the least was pamidronate in this study (12). On the contrary, in another study, most responders were unaware of alendronate, zoledronic acid, and risedronate sodium (13). Obtaining a complete medical history of the patient and knowing about the information received is undeniably essential to prevent BRONJ. To date, limited data is available for suggesting C-terminal telopeptide (CTX) as a diagnostic marker for high-risk group definition of BRONJ before invasive dental treatments (14,15). Since there is no clear-cut consensus about the topic, 58.4% of participants considered obtaining CTX levels.

In this study, similar to the literature, specialists had higher knowledge scores than general dentists, and oral and maxillofacial surgeons demonstrated significantly higher knowledge than other specialty groups (16,17). The Korean group associated their result with the greater experience of oral and maxillofacial surgeons face with BRONJ and their further rate of medication history taking (16). On the contrary, in a survey any differences were not observed in the total knowledge score of responders depending on their area of expertise, which was attributed to the low turnout among specialists (18). In this study, oral healthcare professionals with more than 10 years of experience had a lower level of knowledge score when compared to less experience. Similarly, oral healthcare professionals under 30 years of age and recent graduates elucidated better knowledge scores reported about bone resorption inhibitors and BRONJ (18).

In the medical healthcare professionals survey, 76.1% mentioned osteoporosis in terms of therapeutic indication of BP, similar to other studies (19,20). The specialty of the medical healthcare professionals included in the studies can be considered as the reason for these results. As stated in the literature, although the osteoporosis indication is known to be high by medical healthcare professionals working in general clinical areas, specialties such as oncology and radiotherapy, responsible for the follow-up of cancer patients, had more knowledge about other indications.

In this study, a high percentage of awareness was observed about BRONJ as a side effect of BPs (82.4%) in medical healthcare professionals. Even though there seems to be a basic awareness of BRONJ, there are knowledge gaps and a need for additional education (21). Although in this study specialty of medical professionals was not significantly associated with a high knowledge score similar to Kim et al. (19), in other studies, specialty types, especially ear, nose, and throat specialists, oncologists, and physicians who counteracted with cancer patients had higher knowledge scores (7,20). Despite medical healthcare professionals’ experience not contributing to the knowledge scores in this study, the highest level of awareness was observed in the group with more than 20 years of work experience in Kim et al.’s (19) study. Miranda-Silva et al. (20) reported that professionals with 5-10 years and less than 5 years of training presented significantly higher knowledge scores. In recent years, medical healthcare professionals have encountered patients using BP and have BRONJ in increasing frequencies, which may affect the relationship between experience and knowledge. Accordingly, in this study, the knowledge level scores of the medical healthcare professionals exposed to the necrotic jaw during their career were significantly higher than those who did not face this clinical condition (p<0.05). Most medical healthcare professionals who participated in this study (82.1%) could not entirely identify the BRONJ with the defined clinical criteria. Since medical healthcare professionals are one part of the equilibrium for BRONJ management, emphasis should be given to continuous professional training strategies.

A possible limitation of this study is that only Turkish oral and medical healthcare professionals were included. Therefore, the conclusions drawn from this study can only be generalized to Turkey.

BPs were included in the core basic education of Dentistry a long time ago. For this reason, dentists are expected to graduate with knowledge about the subject. This may explain differences in the responses to knowledge questions among oral and medical healthcare professionals. With the increase in the use of BP, the incidence of its side effects has also increased, and oral and medical healthcare professionals now encounter BRONJ patients more often. Understandably, healthcare professionals are more likely to encounter this situation and know more about the subject.


The information gathered from this study highlights the approach of oral and medical healthcare professionals to BRONJ and the need for additional training or guidelines to ensure that patients receive scientifically evidence-based treatments. Prevention remains the most critical aspect of the management, and AAOMS re-emphasizes the importance of a multidisciplinary approach to treating patients receiving antiresorptive therapies. As stated, a continuous effort is needed to educate patients and oral and medical healthcare professionals and the coordinated work of the oral and medical healthcare professionals has the utmost importance.


Ethics Committee Approval: This study was approved by the Ethics Committee of İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine (decision no: A-19, date: 05.06.2018).

Informed Consent: Informed consent is not required.

Peer-review: Externally and internally peer-reviewed.

Authorship Contributions

Concept: Y.D., İ.Ö., Ş.D.İ., G.Ç., C.A., Design: Y.D., İ.Ö., Ş.D.İ., G.Ç., C.A., Data Collection or Processing: Y.D., Analysis or Interpretation: Y.D., G.Ç., C.A., Literature Search: İ.Ö., Ş.D.İ., Writing: İ.Ö., Ş.D.İ.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

  1. Russell RG. Bisphosphonates: the first 40 years. Bone 2011; 49: 2-19.
  2. Ruggiero SL, Dodson TB, Aghaloo T, Carlson ER, Ward BB, Kademani D. American Association of Oral and Maxillofacial Surgeons' Position Paper on Medication-Related Osteonecrosis of the Jaws-2022 Update. J Oral Maxillofac Surg 2022; 80: 920-43.
  3. Ruggiero SL, Dodson TB, Assael LA, Landesberg R, Marx RE, Mehrotra Bet al. American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaw - 2009 update. Aust Endod J 2009; 35: 119-30.
  4. Ruggiero SL, Dodson TB, Fantasia J, Goodday R, Aghaloo T, Mehrotra B, et al. American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw--2014 update. J Oral Maxillofac Surg 2014; 72: 1938-56.
  5. Hellstein JW, Adler RA, Edwards B, Jacobsen PL, Kalmar JR, Koka S, et al. Managing the care of patients receiving antiresorptive therapy for prevention and treatment of osteoporosis: executive summary of recommendations from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2011; 142: 1243-51.
  6. Alhussain A, Peel S, Dempster L, Clokie C, Azarpazhooh A. Knowledge, practices, and opinions of ontario dentists when treating patients receiving bisphosphonates. J Oral Maxillofac Surg 2015; 73: 1095-105.
  7. El Osta L, El Osta B, Lakiss S, Hennequin M, El Osta N. Bisphosphonate-related osteonecrosis of the jaw: awareness and level of knowledge of Lebanese physicians. Support Care Cancer 2015; 23: 2825-31.
  8. Ahmadov R, Karacaoğlu F, Akkaya M. Knowledge, opinions and behaviors of dentists regarding bisphosphonates and bisphosphonate-related osteonecrosis of jaw. Turkiye Klinikleri J Dental Sci 2018; 24: 114-22.
  9. López-Jornet P, Camacho-Alonso F, Molina-Miñano F, Gomez-Garcia F. Bisphosphonate-associated osteonecrosis of the jaw. Knowledge and attitudes of dentists and dental students: a preliminary study. J Eval Clin Pract 2010; 16: 878-82.
  10. Hajmohammadi E, Sattarzadeh S, Amani F. Knowledge rate of dentists regarding dental consideration of bisphosphonate drug user patients. J Res Med Den Sci 2015; 3: 194-8.
  11. de Lima PB, Brasil VL, de Castro JF, de Moraes Ramos-Perez FM, Alves FA, dos Anjos Pontual ML, et al. Knowledge and attitudes of Brazilian dental students and dentists regarding bisphosphonate-related osteonecrosis of the jaw. Support Care Cancer 2015; 23: 3421-6.
  12. Escobedo MF, García-Consuegra L, Gay S, Álvarez L, Olay S, Ascani G, et al. Influence of the teaching program on the learning in knowledge and practice of osteonecrosis of the jaws produced by antireasorptives in dental students of the Principality of Asturias (Spain). J Clin Exp Dent 2017; 9: e1402-7.
  13. Gaballah K, Hassan M. Knowledge and attitude of dentists on bisphosphonates use in the UAE: a descriptive cross-sectional study. Int Surg 2017; 4: 1398-404.
  14. AAOM clinical practice statement: Subject: The use of serum C-terminal telopeptide cross-link of type 1 collagen (CTX) testing in predicting risk of osteonecrosis of the jaw (ONJ). Oral Surg Oral Med Oral Pathol Oral Radiol 2017; 124: 367-8.
  15. Marx RE. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 2003; 61: 1115-7.
  16. Yoo JY, Park YD, Kwon YD, Kim DY, Ohe JY. Survey of Korean dentists on the awareness on bisphosphonate-related osteonecrosis of the jaws. J Investig Clin Dent 2010; 1: 90-5.
  17. Hristamyan-Cilev MA, Pechalova PP, Raycheva RD, Hristamyan VP, Kevorkyan AK, Stoilova YD. Bisphosphonate-associated Osteonecrosis of the Jaws: a Survey of the Level of Knowledge of Dentists about the Risks of Bisphosphonate Therapy. Folia Med (Plovdiv) 2019; 61: 303-11.
  18. Arnaud MP, Talibi S, Lejeune-Cairon S. Knowledge and attitudes of French dentists on bone resorption inhibitors (bisphosphonates and denosumab): A cross-sectional study. J Stomatol Oral Maxillofac Surg 2022; 123: 163-70.
  19. Kim JW, Jeong SR, Kim SJ, Kim Y. Perceptions of medical doctors on bisphosphonate-related osteonecrosis of the jaw. BMC Oral Health. 2016; 16: 92.
  20. Miranda-Silva W, Montezuma MA, Benites BM, Bruno JS, Fonseca FP, Fregnani ER. Current knowledge regarding medication-related osteonecrosis of the jaw among different health professionals. Support Care Cancer 2020; 28: 5397-404.
  21. Al-Mohaya MA, Al-Khashan HI, Mishriky AM, Al-Otaibi LM. Physicians' awareness of bisphosphonates-related osteonecrosis of the jaw. Saudi Med J 2011;32:830-5.