Medical practitioners' awareness and practices regarding bisphosphonate therapy and oral health risks: a Malaysian cross‑sectional study.

Background

Bisphosphonates are synthetic analogues of pyrophosphate that were developed in the 1960s and introduced clinically in the 1970s for the treatment of bone-related conditions such as osteoporosis, Paget’s disease, multiple myeloma, and metastatic bone disease [ 1 – 4 ]. Their inhibitory effect on osteoclast-mediated resorption has made them the most widely prescribed antiresorptive therapy [ 5 , 6 ]. Both oral and intravenous formulations are used, with the intravenous route favoured in oncology because of its increased potency [ 7 , 8 ].

Despite their effectiveness, bisphosphonates are associated with adverse oral effects. Marx (2003) first described bisphosphonate-related osteonecrosis of the jaw (BRONJ), which was later broadened by the American Association of Oral and Maxillofacial Surgeons (AAOMS) to “medication-related osteonecrosis of the jaw” (MRONJ) in 2014, to include denosumab and antiangiogenic drugs [ 8 – 10 ]. MRONJ, although relatively uncommon, is associated with significant morbidity, including pain, infection, impaired mastication, and reduced quality of life [ 11 – 13 ]. Its prevalence varies, being higher among oncology patients on intravenous bisphosphonates than among osteoporosis patients on oral formulations [ 14 – 18 ].

Risk factors for MRONJ include systemic conditions such as advanced age, female sex, diabetes mellitus, malignancy, renal impairment, anaemia, corticosteroid or chemotherapy use, and prolonged bisphosphonate therapy, especially intravenous administration [ 7 , 14 , 16 ]. Local factors include dental extractions, periodontal or periapical disease, ill-fitting dentures, and poor oral hygiene [ 9 ]. Smoking, alcohol use, and antiangiogenic drugs further increase susceptibility [ 16 , 18 ]. A longer duration of bisphosphonate exposure, particularly beyond four years, markedly elevates MRONJ risk in both oncology and osteoporotic populations [ 15 , 17 ]. Preventive measures, particularly pretreatment dental evaluation and elimination of oral risk factors, remain the most effective strategies for reducing incidence [ 9 , 17 , 18 ].

However, studies internationally have shown variable levels of awareness among medical practitioners. In Korea, 78.1% of practitioners are familiar with MRONJ, but fewer than 10% have detailed knowledge [ 12 ]. In Japan, 94% of respondents recognized MRONJ, but only 24% were familiar with national guidelines [ 19 ]. In Saudi Arabia, 78.7% of practitioners were aware that preventive referrals remained uncommon [ 11 ]. In Pakistan, while general awareness exists, few practitioners follow protocols [ 20 ]. In India, 84.5% were aware, but fewer than 60% identified invasive dental procedures as risk factors [ 21 ]. Similarly, in Thailand, although 92.8% were aware of MRONJ, fewer than half consistently referred patients for dental evaluation [ 22 ]. Mutlu et al. (2025) further confirmed that although most specialists prescribing antiresorptive agents were aware of MRONJ, preventive referrals and collaboration with dental professionals were insufficient [ 23 ].

Medical practitioners play pivotal roles in MRONJ prevention, as they prescribe bisphosphonates, educate patients, and coordinate referrals. However, studies consistently reveal limited awareness of guidelines, insufficient collaboration with dentists, and inconsistent preventive practices [ 11 , 12 , 20 – 24 ]. In Malaysia, research on this topic is scarce. To our knowledge, this is the first study in Malaysia to examine medical practitioners’ awareness, prescribing practices, and perceived roles regarding the oral health effects of bisphosphonate therapy, providing locally relevant insights beyond existing international surveys. As university hospitals serve as multidisciplinary teaching institutions comprising specialists, clinical master trainees, and medical officers, they provide a representative context for assessing awareness and referral practices.

Therefore, this study aimed to assess the awareness, prescribing practices, and perceived roles of medical practitioners in a Malaysian university hospital regarding the oral health effects of bisphosphonate therapy. In addition, the study explored potential associations between awareness, role perception, and preventive practices to better understand factors influencing clinical behaviour. By identifying gaps and strengths, the study provides baseline data for targeted educational initiatives and the development of structured interprofessional collaboration to minimize the risk of MRONJ.

Materials and methods

Study design and setting

This was a cross-sectional study conducted at the University of Malaya Medical Centre (UMMC), aimed at assessing the awareness, practices, and roles of medical practitioners regarding the oral health effects of bisphosphonate therapy. The design enabled the collection of quantitative data through structured electronic questionnaires adapted from a validated instrument used in a previous study of healthcare professionals in Victoria, Australia [ 24 ]. Data were collected between 15 February 2025 and 15 May 2025. Following ethical approval, permission was obtained from the respective heads of departments to approach eligible participants within their units. The questionnaires were disseminated via departmental mailing lists. To increase response rates, face-to-face administration was also carried out, typically after departmental teaching or clinical sessions.

A convenient sampling technique was employed to recruit eligible participants. The sample size was determined using the Krejcie and Morgan Table, which estimates the number of respondents needed to achieve a 95% confidence level with a ± 5% margin of error. Considering an anticipated 30% dropout rate, a final sample size of approximately 130 was targeted. This approach is consistent with similar studies, such as those conducted by Kim et al. (2016) and Supanumpar et al. (2024) [ 12 , 22 ].

Eligible participants were medical practitioners from medicine, orthopedics, and primary care at UMMC who were actively involved in prescribing or managing bisphosphonate therapy. Practitioners from other specialties not directly involved in bisphosphonate prescribing (e.g., pediatrics, psychiatry, dermatology), dental practitioners, pharmacists, nurses, allied health professionals, temporary staff, and visiting clinicians were excluded. Incomplete or duplicate responses were also removed from the final analysis.

Structured questionnaire and validation

The primary instrument was a structured questionnaire adapted from a previously published and validated survey by Raj et al. (2016), which assessed healthcare professionals’ awareness of bisphosphonates and their effects on oral health [ 24 ]. The adapted version was used with permission and further validated for content and face validity for use in the Malaysian context. It consists of six sections: (i) a participant information sheet and implied consent; (ii) sociodemographic details; (iii) awareness of the effects of bisphosphonates on oral health; (iv) practices in prescribing bisphosphonates; and (v) the role of medical practitioners. Both closed- and open-ended items were included, and Likert scales were used to assess levels of agreement. Both closed‑ and open‑ended items were included, and Likert scales were used to assess levels of agreement. For certain items (e.g., indications for bisphosphonate use and reasons for discontinuation), participants were permitted to select more than one response option.

Validation of the instrument involved both content and face validity procedures. Two expert reviewers with clinical and academic backgrounds evaluated the relevance of each item via a 4‑point Likert scale, and the item‑level content validity index (I‑CVI) was computed for all the items. All the items achieved an I‑CVI of 1.00, with an overall scale‑level CVI (S‑CVI/Ave) of 1.00, indicating excellent content validity [ 25 , 26 ]. While these perfect values reflect unanimous agreement among the expert reviewers, such results may appear over‑optimistic and are influenced by the small number of experts and the subjective nature of content validation. Facial validity was assessed by ten medical practitioners representing the target population, who rated the clarity of the items on a 4‑point scale. The scale‑level facial validity index (S‑FVI/Ave) was 0.98, confirming that the questionnaire was clear and understandable [ 27 , 28 ] (Table 1 ).

Table 1 Content and face validity of questionnaire items Validation type Index range Scale average Interpretation Content Validity (I-CVI) 1.00 – All items retained Content Validity (S-CVI/Ave) – 1.00 Excellent validity Face Validity (S-FVI/Ave) 0.90–1.00 0.98 Highly clear items

Data collection

The questionnaire was distributed electronically via Google Forms and as printed copies where necessary. The participants received an invitation explaining the study objectives, with completion of the form indicating consent. The questionnaire required approximately 10–15 min to complete. To improve the response rate, reminders were sent through departmental communication platforms, and investigators conducted in-person distribution sessions at departmental meetings. Only fully completed questionnaires were included in the analysis.

Statistical analysis

The data were exported into IBM SPSS Statistics version 28.0 for analysis. Descriptive statistics, including frequency distributions and percentages, were used to summarize sociodemographic information and responses on awareness, practices, and roles. Associations between sociodemographic variables and awareness or practices were analysed via chi-square tests. A p value < 0.05 was considered statistically significant.

Ethical considerations

Ethical approval for this study was obtained from the Medical Ethics Committee, Faculty of Dentistry, University of Malaya (Reference Number: DF CD 2435/0101 (L)) and the Medical Research Ethics Committee, University Malaya Medical Centre (ID No: 20241111-14392). The study adhered to the principles of the Declaration of Helsinki on ethical standards for research involving human participants. Participation was voluntary, and implied consent was obtained through questionnaire completion. All the responses were anonymized and handled with strict confidentiality.

Results

Participant characteristics

A total of 130 medical practitioners completed the questionnaire, yielding a response rate of 65%. Females accounted for slightly more than half of the respondents (53.8%), and most were aged between 31 and 40 years (80.8%). With respect to years of practice, 61.5% reported 6–10 years of clinical experience. The distribution of participants by department included medicine, orthopedics and primary care medicine. The details are summarized in Table 2 .

Table 2 Participant characteristics ( n = 130) Variable n (%) Gender Male 60 46.2 Female 70 53.8 Age ≤ 30 years 13 10.0 31–40 years 105 80.8 > 40 years 12 9.2 Years in practice ≤ 5 years 16 12.3 6–10 years 80 61.5 > 10 years 34 26.2 Department Medicine 44 33.8 Orthopaedics 33 25.4 Primary care medicine 53 40.8

Awareness

Almost all medical practitioners (96.2%) were aware that bisphosphonates may cause oral complications, and 94.6% correctly identified medication-related osteonecrosis of the jaw (MRONJ) as a possible side effect. However, only 58.5% reported awareness of existing clinical guidelines, and only 23.8% felt that they were adequately informed (Table 3 ).

Table 3 Awareness of bisphosphonate-related oral complications ( n = 130) Item assessed n (%) Aware bisphosphonates may cause complications 125 96.2 Identified MRONJ as a complication 123 94.6 Aware of clinical guidelines 76 58.5 Felt adequately informed 31 23.8

Prescribing practice patterns

Bisphosphonates were prescribed predominantly on a monthly (41.5%) or weekly (40.8%) schedule, while daily prescriptions were the least common at 17.7%. The commonly prescribed form was oral (77.7%), though 18.5% reported prescribing both oral and intravenous formulations, and only 3.8% prescribed intravenous formulations exclusively. Osteoporosis was the primary indication for prescription, cited by 95.4% of practitioners. Other indications included oncology-related conditions (20.8%) and Paget’s disease (3.1%). Regarding treatment duration, 70.0% of practitioners reported having ever discontinued therapy for their patients. The most common reasons for cessation were the use of alternative therapy (24.6%), the medication no longer being required (23.8%), or a planned drug holiday (15.4%). Medication-Related Osteonecrosis of the Jaw (MRONJ) was a relatively rare reason for discontinuation, reported by only 3.1% of practitioners, followed by side effects factors at 1.5% each. Among those who considered alternative treatments, 60.0% specified monoclonal antibodies such as denosumab or romosozumab, followed by anabolic agents like teriparatide (14.6%). Other alternatives included strontium (0.8%), calcitonin (0.8%), and selective oestrogen receptor modulators (1.5%) (Table 4 ).

Table 4 Prescribing practice patterns of medical practitioners ( n = 130) Note: Multiple responses allowed for certain items Variable Category n % Frequency of prescribing bisphosphonates Daily 23 17.7 Weekly 53 40.8 Monthly 54 41.5 Form prescribed Oral 101 77.7 Intravenous 5 3.8 Both 24 18.5 Indications for use* Osteoporosis 124 95.4 Oncology 27 20.8 Paget’s disease 4 3.1 Ever discontinued therapy Yes 91 70.0 No 39 30.0 Reasons for discontinuation Alternative therapy 32 24.6 No longer required 31 23.8 Drug holiday 20 15.4 MRONJ 4 3.2 Side effects 2 1.5 All the above 2 1.5 Considered alternatives? Yes 88 67.7 No 42 32.3 Alternatives specified* Denosumab / Romosozumab (Monoclonal antibody) 78 60.0 Teriparatide / anabolic agents 19 14.6 Strontium 1 0.8 Calcitonin 1 0.8 Selective oestrogen receptor modulator (SERM) 2 1.53 * Indications for use and alternatives specified allowed multiple responses per participant. Percentages may exceed 100%

Perceived role, referrals and collaboration

Preventive and referral practices were inconsistent among the respondents. While 73.8% provided patient education about MRONJ, fewer than half (49.2%) advised pretreatment dental evaluation. Just over half (52.3%) referred patients for dental screening prior to therapy, and 63.1% instructed patients to inform their dentist about bisphosphonate use. Despite these efforts, nearly three-quarters of practitioners felt that they lacked sufficient information to manage patients receiving bisphosphonate therapy. Nevertheless, most recognized the importance of interprofessional collaboration, and 89.2% supported a multidisciplinary approach to patient management (Table 5 ).

Table 5 Perceived role, referrals and collaboration ( n = 130) Perceived role, referral and collaboration item n (%) Educate patients about MRONJ 96 73.8 Advise pretreatment dental evaluation 64 49.2 Refer for dental screening before therapy 68 52.3 Advise patients to inform dentist of bisphosphonate therapy 82 63.1 Felt lacking sufficient information 97 74.6 Support multidisciplinary approach 116 89.2

Associations between awareness, practice, role and demographic factors

There was no significant association between awareness and the referral role or between the referral role and prescribing frequency, indicating that awareness alone did not influence preventive referral practices. However, several significant relationships were identified. Awareness was significantly associated with prescribing frequency ( p = 0.003), suggesting that practitioners who prescribed bisphosphonates more often were more aware of potential oral complications. Referral practices differed significantly by department ( p < 0.001), with medicine showing the highest referral rates, followed by primary care and orthopedics. Referral behavior was also significantly associated with professional position ( p = 0.039) and age group ( p = 0.045); medical officers and younger practitioners (21–30 years) were more likely to refer patients for dental evaluation. No significant associations were observed with sex, education level, years in practice, or country of graduation.

Discussion

Overall, the findings demonstrated that medical practitioners had high general awareness of bisphosphonate-related oral complications, but there were important deficiencies in awareness of clinical guidelines, preventive practices, and referral behaviours.

The findings of this study highlight several novel contributions. Unlike international surveys, which provide broad global trends, our results offer regionally specific evidence from Malaysia, where prescribing practices and awareness levels may differ due to local healthcare structures and patient populations. By identifying gaps in collaboration between medical and dental practitioners and highlighting discontinuation reasons unique to this setting, the study provides context‑specific insights that can inform national guidelines and targeted educational interventions.

Majority of respondents (96.2%) were aware that bisphosphonates could cause oral complications, and 94.6% identified medication-related osteonecrosis of the jaw (MRONJ) as one of them. This high level of awareness is consistent with studies from Korea, Japan, Thailand, Saudi Arabia, India, and Pakistan, where awareness ranged from 78% to 94% [ 11 , 12 , 19 – 22 ]. However, only 58.5% of medical practitioners in the present study were aware of existing clinical guidelines, and only 23.8% felt adequately informed to manage such patients. This sharp contrast between high general awareness (96.2%) and low perceived adequacy of information (23.8%) regarding bisphosphonate‑related complications highlights a critical gap. While most practitioners recognized the risk of MRONJ, few felt sufficiently informed about referral protocols, preventive practices, and clinical guidelines. Similar deficiencies in guideline awareness have been reported globally. In Japan, Yamori et al. reported that 94% of practitioners recognized MRONJ, but only 24% were aware of national guidelines [ 19 ]. In Korea, Kim et al. reported that 78.1% of medical practitioners were aware of MRONJ but lacked an in-depth understanding [ 12 ]. Similarly, Aljohani reported that Saudi physicians were generally aware but did not apply preventive protocols consistently [ 11 ]. These findings indicate that while awareness of MRONJ is generally high worldwide, awareness of preventive guidelines and management strategies remains limited. In the present study, awareness should be interpreted across three dimensions: recognition awareness (96.2% knew bisphosphonates could cause oral complications; 94.6% identified MRONJ), guideline literacy (58.5% were aware of existing clinical guidelines), and clinical confidence (only 23.8% felt adequately informed to manage such patients). This distinction highlights that while recognition awareness was high, guideline literacy and clinical confidence were substantially lower, underscoring the need for structured education and interprofessional training.

Globally, more than 190 million oral bisphosphonate prescriptions are issued annually, reflecting their widespread use in managing bone-related disorders [ 29 ]. In this study, oral formulations were the most frequently prescribed (77.7%), with weekly (40.8%) and monthly (41.5%) regimens predominating. Similar to other studies where most practitioners (75.4%) had prescribed bisphosphonates for more than five years, 24.6% reported using intravenous forms, which are known to carry a higher MRONJ risk than oral preparations [ 30 , 31 ]. However, this higher risk primarily reflects oncology dosing regimens. When IV zoledronate is administered annually at osteoporosis doses, the risk remains very low and is comparable to oral bisphosphonates which is < 0.1% [ 5 , 9 ]. In contrast, oncology regimens involving frequent IV dosing are linked to substantially higher MRONJ incidence due to cumulative exposure [ 9 , 14 , 32 ]. Osteoporosis was the leading indication (95.4%), followed by malignancy-related bone disease (20.8%), which is consistent with global prescribing patterns [ 33 , 34 ]. Similar trends were observed internationally, where oral bisphosphonates were commonly used [ 11 , 12 , 22 ].

The consideration of alternative therapies was also reported. A total of 67.7% of respondents in this study had considered alternatives to bisphosphonates, with denosumab (43.1%) and teriparatide (20.8%) being the most frequently mentioned. These findings are consistent with prescribing trends reported in Saudi Arabia, where both alendronate and denosumab were among the most frequently used antiresorptive agents [ 11 ]. In contrast, the study in Pakistan highlighted limited awareness of alternatives like denosumab or mTOR inhibitors, despite high rates of Bisphosphonates prescribing [ 20 ]. This highlights an evolving clinical awareness regarding the differential risk profiles of various antiresorptive agents and the potential for therapeutic substitution to mitigate MRONJ risk, particularly given that denosumab, while an alternative, also carries a recognized risk of osteonecrosis of the jaw [ 33 ].

Although most respondents were aware of MRONJ, their perceived role and referral practices were inconsistent. In this study, 73.8% reported educating patients about MRONJ, yet fewer than half (49.2%) advised pretreatment dental evaluation, and only 52.3% referred patients for dental screening before initiating bisphosphonate therapy. These results mirror international findings. In Thailand, although 92.8% of physicians are aware of MRONJ, fewer than half refer patients for dental assessment before therapy [ 22 ]. In Pakistan, Kazmi et al. similarly reported that preventive referrals were uncommon despite general awareness [ 20 ]. In India, Priyadarshini et al. reported that although 84.5% of practitioners were aware of MRONJ, only 56% identified dental procedures as risk factors [ 21 ]. The present study therefore supports previous observations that awareness alone does not necessarily translate into preventive behaviour.

Additionally, only 63.1% of the respondents advised patients to inform their dentist about bisphosphonate therapy, which suggests gaps in reinforcing patient education. Mutlu et al. (2025) also noted similar findings, where the majority of physicians were aware of MRONJ, but preventive referrals and collaborative actions with dentists were lacking [ 23 ]. These findings highlight the persistent gap between awareness and practice across various countries and healthcare settings.

Despite the relatively high awareness of MRONJ among medical practitioners, nearly three-quarters of the respondents in the present study perceived themselves as lacking sufficient information about bisphosphonate-related complications, indicating limited confidence in their current knowledge. Similar trends have been observed internationally. In Saudi Arabia, awareness is common, but overall knowledge and attitudes are poor due to limited educational exposure [ 11 ]. In Japan, persistent knowledge gaps remain despite high awareness and limited interdisciplinary discussion [ 19 ]. Likewise, studies in India and Thailand reported inadequate understanding and confidence among physicians, which was often linked to the absence of formal training [ 21 , 22 ]. This highlights the need for targeted educational interventions, as general awareness does not necessarily translate into clinical competence or effective patient counselling. In this study, 89.2% of the respondents supported a multidisciplinary approach to bisphosphonate therapy, which is consistent with findings from Thailand, where physicians recognized the value of collaboration with dental professionals in reducing MRONJ risk despite inconsistent practices [ 22 ]. Interdisciplinary management involving dental professionals allows for pretherapy risk assessment, removal of infection sources, and regular monitoring measures essential for prevention and optimal patient care [ 9 , 35 ].

In Malaysia, such collaboration is often informal and depends on individual initiatives rather than structured protocols. The results suggest that despite good intentions, the absence of standardized interprofessional systems continues to hinder optimal patient care. Similar conclusions were drawn by Mutlu et al. (2025), who reported that even among specialists familiar with MRONJ, collaboration between medical and dental professionals was inconsistent [ 23 ]. This highlights the universal need for structured communication and referral pathways between disciplines. Moreover, joint educational initiatives and integrated referral systems have been proposed as practical solutions to overcome the current implementation gap in many healthcare settings [ 36 , 37 ].

Further analysis revealed that awareness was significantly associated with prescribing frequency ( p = 0.003), indicating that medical practitioners who prescribed bisphosphonates more often had greater awareness of oral complications. This finding aligns with that of Raj et al., who reported that greater clinical exposure was associated with greater awareness among orthopedic surgeons [ 24 ].

Referral practices were also significantly associated with department ( p < 0.001), position ( p = 0.039), and age ( p = 0.045). The highest referral rates were recorded for Medicine, followed by Primary Care, whereas Orthopaedics presented the lowest referral rates. This pattern reflects the departments commonly involved in prescribing bisphosphonates, mainly internal medicine (including endocrinology and rheumatology). In contrast, Mutlu et al. involved different specialties, such as oncology, endocrinology, and primary care, reflecting variations in prescribing responsibilities across healthcare systems [ 23 ].

Referral behaviour varied significantly by professional position. Medical officers refer patients most frequently, followed by specialist and master’s trainees, which may reflect their direct involvement in patient management, although this represents an association rather than causation. Younger practitioners (aged 21–30 years) also demonstrated higher referral rates. This association may be related to more recent exposure to interprofessional education and guideline‑based care, but causation cannot be inferred. However, the predominance of respondents aged 31–40 years (80.8%) should be acknowledged, as this skewed age distribution may have influenced the overall findings on awareness and referral behaviour. Practitioners in this early‑ to mid‑career stage may differ in their clinical exposure and collaborative practices compared to younger or more senior colleagues, which limits the representativeness of the results. These findings collectively suggest that referral behaviour is influenced not only by awareness but also by professional context, clinical experience, and departmental responsibilities. The persistent lack of consistent dental referrals among medical specialists, including oncologists, underscores a significant disconnect between systemic therapeutic strategies and localized oral health considerations [ 38 ]. The lack of prioritization of dental referrals by medical specialists highlights the broader issue of inadequate interprofessional collaboration and a fragmented approach to patient care [ 22 ].

Implications and limitations

The findings of this study emphasize the need for greater integration of oral health into medical education and for institutional protocols that promote routine dental assessment before bisphosphonate therapy is initiated. Awareness programs and interdisciplinary workshops between medical and dental departments should be implemented to improve preventive collaboration.

This study is the first to evaluate the awareness, practices, and roles of medical practitioners regarding bisphosphonate therapy and oral health in Malaysia. The use of a validated questionnaire and the inclusion of multiple specialties strengthen its internal validity. Nevertheless, several limitations must be acknowledged.

First, the single‑center design restricts the generalizability of the findings. Data were collected from one academic hospital, which may not fully represent the diversity of prescribing practices, referral behaviours, and interprofessional collaboration across Malaysia. University hospitals often have greater access to specialists, trainees, and structured educational resources compared to district or private hospitals, meaning that awareness levels and referral practices observed here may differ from those in other healthcare settings. This institutional context may therefore introduce selection bias and limit the applicability of the results to broader national or international populations.

Second, reliance on self‑reported data introduces inherent biases. Respondents may have overestimated their awareness or preventive practices due to recall errors or social desirability bias, particularly when reporting behaviours such as patient education or referral to dental services. Self‑reporting cannot capture actual clinical behaviour, and discrepancies between stated practices and real‑world implementation are well documented in survey‑based research. This limitation raises the possibility that the true level of preventive collaboration may be lower than reported.

Third, the age distribution of respondents was skewed, with 80.8% falling within the 31–40-year age group. This predominance may have influenced the findings on awareness and referral behaviour, as practitioners in this early‑ to mid‑career stage may differ in their clinical exposure, confidence, and collaborative practices compared to younger or more senior colleagues. The lack of balanced representation across age groups limits the generalizability of the results and should be considered when interpreting the findings.

Together, these limitations highlight the need for future multicentre studies involving larger and more diverse samples across Malaysia, including district hospitals, private practices, and different healthcare systems. Incorporating objective measures of practice such as audits of referral records, prescription data, or direct observation would reduce reliance on self‑reporting and provide a more accurate picture of clinical behaviour. Such studies would also allow evaluation of the effectiveness of interprofessional education initiatives and structured referral systems in reducing MRONJ risk, thereby strengthening external validity and ensuring findings are more representative of national practice.

Another limitation relates to the validation of the questionnaire. Although content and face validity procedures yielded high I‑CVI, S‑CVI, and S‑FVI values, these perfect or near‑perfect scores may appear over‑optimistic. Such results are influenced by the small number of experts involved and the subjective nature of content validation. Future studies should therefore complement content and face validity with broader psychometric testing, including construct validity and reliability analysis, to strengthen the robustness of the instrument.

Conclusion

This study provides the first Malaysian evidence on medical practitioners’ awareness, prescribing practices, and referral behaviours related to bisphosphonate therapy and its oral health implications. Although most practitioners recognized that bisphosphonates could cause oral complications and identified MRONJ, awareness of clinical guidelines, preventive practices, and referral behaviours was limited. Oral bisphosphonates were the most prescribed, with osteoporosis as the leading indication, while intravenous forms were less frequent and carried a very low MRONJ risk at osteoporosis dosing compared to oncology regimens. Many patients receiving bisphosphonates are likely to encounter dental issues, and inadequate preventive referrals or counselling may increase the need for invasive dental procedures, thereby elevating MRONJ risk. To enhance prevention, a multidisciplinary approach should be adopted between medical and dental disciplines, supported by structured referral systems and pre‑treatment dental consultation. Educational strategies such as academic publications, seminars, and joint training programs will be essential to raise awareness, strengthen interprofessional collaboration, and ensure early prevention and optimal patient care in Malaysia and beyond.

Clinical trial number

Not applicable.

Supplementary Information

Supplementary Material 1

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Acknowledgements

The authors have nothing to report.

Authors’ contributions

F.C.R. conceived the study, designed the methodology, performed the data collection and analysis, and drafted the manuscript. J.F., C.W.L. and L.S.M.P. supervised the research process and critically reviewed the manuscript. All the authors read and approved the final manuscript.

Funding

This research was funded by a Dental Postgraduate Research Grant (UMG001E-2025) from the Faculty of Dentistry, Universiti Malaya.

Data availability

The datasets generated and analysed during the current study are available from the corresponding author upon reasonable request. The questionnaire used in this study was adapted from Raj et al. (2016). The adapted English-language version used in this study is provided as Supplementary File 1.

Declarations

Ethics approval and consent to participate

This study received ethical approval from the Medical Ethics Committee, Faculty of Dentistry, University of Malaya (Reference Number: DF CD 2435/0101 (L)) and the Medical Research Ethics Committee, University Malaya Medical Centre (ID No: 20241111–14392). All participants were informed about the study objectives, procedures, and confidentiality of their responses. Written informed consent was obtained prior to participation.

Consent for publication

Not applicable. This study did not involve any individual person’s data, images, or identifiable information.

Competing interests

The authors declare no competing interests.

Abbreviations

American Association of Oral and Maxillofacial Surgeons

Bisphosphonate-Related Osteonecrosis of the Jaw

Medication-Related Osteonecrosis of the Jaw

University of Malaya Medical Centre

Universiti Malaya

Diabetes Mellitus

Content Validity Index

Item-Level Content Validity Index

Scale-Level Content Validity Index (Average)

Face Validity Index

Scale-Level Face Validity Index (Average)

International Business Machines Statistical Package for the Social Sciences

National Osteoporosis Guideline Group

Scottish Dental Clinical Effectiveness Programme

Probability Value

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