Medication-related osteonecrosis of the jaw: who knows more? A cross-sectional study of general dental practitioners and oral maxillofacial surgery assistants.

Introduction

Bisphosphonates are drugs used to treat and prevent various bone diseases such as osteoporosis, bone metastases, multiple myeloma, and metabolic bone disorders by inhibiting osteoclast-mediated bone resorption. These drugs, administered orally or intravenously, have a high affinity for hydroxyapatite crystals in bone, localizing particularly on bone surfaces with active osteoclastic activity. Their half-life in bone can extend up to 10 years [ 1 , 2 ]. Despite their benefits, bisphosphonate use has been associated with osteonecrosis of the jaw, first reported in 2003 in patients treated with pamidronate and zoledronate [ 3 ]. In addition to bisphosphonates, other anti-resorptive and anti-angiogenic medications have also been associated with osteonecrosis of the jaw. To reflect this broader range, the American Association of Oral and Maxillofacial Surgeons revised the terminology in 2014 to “medication-related osteonecrosis of the jaw” (MRONJ) [ 4 ].

Medication-related osteonecrosis of the jaw (MRONJ) is a condition characterized by the presence of exposed bone or the ability to probe through an intraoral or extraoral fistula for 8 weeks or longer, in patients who have received or are receiving anti-resorptive drug therapy, without a history of head and neck radiation therapy or metastatic disease [ 5 ].

The etiopathogenesis of MRONJ is still not fully understood, but hypotheses generally focus on the drug’s mechanism of action and risk factors that may contribute to osteonecrosis. There is no defined “gold standard” treatment in the literature, and MRONJ management is typically a challenging process for both the physician and the patient. Treatment strategies are individualized but primarily focus on minimizing the progression or development of bone necrosis, alleviating pain, controlling infection, and optimizing the patient’s quality of life [ 6 , 7 ].

It is essential for dental practitioners to be familiar with MRONJ risk factors, diagnosis, and evidence-based treatment strategies. This study aimed to assess and compare the level of knowledge and treatment approaches regarding MRONJ among general dental practitioners and OMFS trainees. These two groups were selected because they represent different levels of training and clinical exposure: general dentists often provide primary care and may encounter patients at risk for MRONJ without specialized training, whereas OMFS trainees typically receive more systematic and updated education on this topic. Comparing these groups helps identify knowledge gaps that could affect early diagnosis, appropriate referrals, treatment planning, and ultimately patient safety. Understanding these differences can guide curriculum improvements and targeted continuing education programs to enhance practice. This study hypothesized that significant differences exist between general dental practitioners and OMFS trainees in their awareness, knowledge of risk factors, and management strategies for MRONJ, which may influence their clinical decisions and affect patient outcomes.

Materials and methods

Study design and patients

This study was conducted at the Department of Oral, Dental, and Maxillofacial Surgery, Faculty of Dentistry, Ege University, following international ethical standards and the World Health Organization’s Helsinki Declaration. The study was approved by the Scientific Research and Publication Ethics Committee of Ege University with decision number 06 and protocol number 1764 at the meeting held on 29/12/2022.

A questionnaire was prepared to assess the knowledge, attitudes, and treatment approaches regarding MRONJ among OMFS assistants as well as general dental practitioners. The questionnaire was designed based on the AAOMS 2022 position statement, and was developed by three oral and maxillofacial surgeons with at least 10 years of experience. Care was taken to ensure the questions were relevant, purpose-oriented, and clearly stated. The questionnaire was reviewed and modified by faculty members of the Department of Oral, Dental, and Maxillofacial Surgery at Ege University.

The questionnaire, prepared in digital format, was delivered directly to dentists and sent via email through a web-based link, asking participants to complete it. Participation in the study was voluntary, and it was clearly stated that personal data would be protected and responses would remain confidential. The questionnaire was accessible between March 1, 2023, and August 14, 2023, and reached a total of 236 dentists, including 116 OMFS assistants and 120 independent general dental practitioners. No random sampling or power analysis was performed; instead, the study aimed to include all reachable OMFS assistants and general dental practitioners within the study period. This convenience sample design ensured that all participants who could be contacted were invited. All 236 invited participants completed the questionnaire, resulting in a 100% response rate, which is considered a strength of the study.

The questionnaire was divided into three sections. The first section included questions aimed at determining demographic information, such as age, gender, years of professional experience, and current workplace/institution. The second section contained questions addressing general information about anti-resorptive and anti-angiogenic drugs, their indications, and the development of MRONJ. The third section consisted of questions focusing on clinical attitudes and treatment approaches regarding MRONJ. These questions explored the prevention of MRONJ, dental procedures that can be performed in patients at risk of MRONJ, the feasibility of implant treatment in patients using anti-resorptive or anti-angiogenic drugs, and non-operative, operative, and adjunctive treatment approaches for MRONJ.

Statistical analysis

Statistical analysis of the data was performed using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, NY, USA) [ 8 ]. For statistical analysis, participants were divided into two groups: OMFS assistants and general dental practitioners. The relation between the groups was assessed using the Chi-square test (Fisher’s exact test). A significance level of p < 0.05 was considered statistically significant.

Results

The demographic characteristics of the participants are summarized in Table 1 , and additional detailed information is provided in Supplementary Table 1. The study included 236 participants, nearly half being OMFS assistants (49.1%) and the remainder independent general dental practitioners (50.9%). Gender distribution was balanced, with a slight male predominance among specialists (55.1%) and an equal split among general practitioners. Age and professional experience differed between groups: 69.2% of general practitioners were under 29 years old, compared to 41.4% of specialists, and 59.1% of general practitioners had 0–3 years of experience. All OMFS assistants were affiliated with university dental faculties, whereas general practitioners primarily worked in private practice or dental health centers.

The participants’ knowledge levels regarding anti-resorptive and anti-angiogenic drugs are presented in Table 2 , while extended response distributions are shown in Supplementary Table 2. Nearly all OMFS assistants were aware that these drugs can cause MRONJ, indicating a higher familiarity with current literature and clinical guidelines in this group. In contrast, a notable proportion of general dental practitioners lacked this knowledge, suggesting potential gaps in access to up-to-date information and clinical protocols related to MRONJ among this group.

The majority of participants in both groups reported consulting the prescribing physician before performing extractions on patients using these medications, reflecting an overall adherence to safe clinical practices. The notably higher consultation rate among OMFS assistants highlighted the positive impact of academic training on compliance with current guidelines.

OMFS assistants demonstrated consistent knowledge that the mandible is more commonly affected, which aligned well with existing literature. In contrast, general dental practitioners showed a notable lack of information on this topic, as reflected by the high number of “Don’t-know” responses. This suggested either limited clinical exposure or insufficient knowledge among general practitioners, emphasizing the greater anatomical awareness held by specialty-trained dentists [ 9 ].

The fact that most OMFS assistants correctly rejected the outdated view that “tooth extraction and alveolar bone interventions are contraindicated for patients using oral anti-resorptive drugs” indicated their adherence to current evidence-based practice. In contrast, the varying responses among general dental practitioners highlighted the need for targeted education and continuous professional development. The knowledge of the correct denosumab protocol—temporary discontinuation before planned dentoalveolar surgery—was significantly higher among OMFS assistants (about two-thirds) than general dental practitioners (about one-third). The high rate of “Don’t-know” answers among general practitioners indicates that this protocol is not yet well integrated into routine practice.

The level of knowledge about the indications of antiresorptive and antiangiogenic drugs was high in the OMFS assistant group, especially for malignancy-related conditions and osteoporosis. In contrast, awareness of less common indications such as Paget’s disease was notably lower among general dental practitioners, with many responding “Don’t-know.” This highlighted the need for ongoing education to support proper risk management, particularly in oncology cases. The results demonstrated that dentists undergoing specialty or doctoral training exhibited a significantly higher level of knowledge regarding medication-related osteonecrosis of the jaw MRONJ compared to general practitioners [ 4 ].

The participants’ knowledge levels regarding the development of MRONJ were also compared (Table 3 ), and detailed item-by-item results are presented in Supplementary Table 3. The results regarding the view that oral hygiene before anti-resorptive treatment and dental prophylaxis can reduce the risk of MRONJ showed that the level of knowledge on the subject was quite high in the specialist/doctorate group. The higher rate of “Don’t-know” responses indicating a lack of knowledge on this subject in the general dental practitioners group indicated that the awareness of this group should be increased regarding preclinical precautions. This highlighted the need to improve education among general practitioners, as differences in knowledge may translate into variations in clinical practice. The statement that “MRONJ develops most frequently after tooth extraction and dentoalveolar surgery” was correctly recognized by the majority of OMFS assistants. However, a notable proportion of general dental practitioners responded with “Don’t know,” highlighting gaps in knowledge within this group. This finding underscored the critical need for targeted, continuous professional education to improve awareness and clinical decision-making regarding MRONJ.

When asked about the risk of MRONJ developing after implant placement in patients taking oral anti-resorptive medication, it was seen that the OMFS group had correct information. In contrast, many general dental practitioners stated that they were unsure, indicating that they may not have received enough training in this area. This difference showed why it was essential to base implant-related decisions on up-to-date, evidence-based knowledge. It is also worth noting that OMFS group correctly rejected the false belief that there is no MRONJ risk after placing implants in oncology patients receiving parenteral anti-resorptive drugs. On the other hand, the general dental practitioners were more likely to give wrong or uncertain answers, which could lead to risky decisions for these high-risk patients. This finding further stresses the need for proper knowledge and compliance with current guidelines to protect patient safety, especially for vulnerable groups.

Participants’ knowledge about MRONJ treatment was also compared (Table 4 ), with further details presented in Supplementary Table 4. Most OMFS assistants correctly marked “Incorrect” for the statement that hyperbaric oxygen and ozone therapy should be the main treatment for MRONJ, while general dental practitioners more often believed this to be true. This indicated that specialist trainees were more familiar with evidence-based treatment protocols.

Although most OMFS assistants answered correctly that teriparatide can be used in MRONJ treatment, the “Don’t know” rate was still high. Among general dental practitioners, the higher proportion of “Don’t know” responses highlighted an evident lack of awareness about this option. Overall, this shows that more updated information on MRONJ treatment should be shared with all practitioners.

While most OMFS assistants agreed that non-operative approaches can be useful in MRONJ management, the opinions of general dental practitioners were more diverse. This suggested that specialists had stronger theoretical knowledge and were more familiar with alternative non-surgical methods, whereas general practitioners may be less confident in applying them in practice [ 7 ].

There was a significant difference between the two groups regarding the statement “In case of failure of non-operative treatment in MRONJ patients, early operative intervention is contraindicated”. While most OMFS assistants correctly marked it as “Incorrect”, general dental practitioners showed more varied responses. This suggested that assistants had better theoretical knowledge but may differ in clinical confidence.

The fact that the statement “When non-operative approaches fail, the necrotic and/or exposed bone should be resected until the surrounding vital bone tissue is reached” was largely agreed upon by the OMFS group. In contrast, agreement was lower and “Don’t-know” answers were higher among general dental practitioners, highlighting a need for more practice-level training.

In the OMFS group, the majority correctly answered that in stage 1 MRONJ cases, maintenance treatment can be performed by reducing biofilm on the necrotic bone surface with antimicrobial mouthwashes. However, the lower rate of correct answers and higher “Don’t-know” responses among general dental practitioners indicated the need for more education on this treatment approach.

While the majority of the OMFS assistant group correctly acknowledged that concentrated growth factors and autologous biomaterials such as platelet-rich plasma/fibrin can be used in MRONJ treatment, more than half of the general dental practitioners responded with “Don’t-know.” This suggested that OMFS assistants had greater knowledge of innovative treatment methods, whereas general practitioners may lack familiarity and practical experience with these options. These findings indicated that dentists undergoing specialty training tended to stay more current with the literature and were more receptive to multidisciplinary treatment approaches for MRONJ [ 10 ]. Statistical analysis revealed this difference to be significant, underscoring the need for enhanced continuing education programs targeting general dental practitioners to bridge this knowledge gap.

It was determined that both groups largely agreed with the appropriateness of the treatment protocols regarding the statement “Treatment protocols involving reduction of dental biofilm and eradication of infection are appropriate alternatives for patients in whom surgical interventions such as debridement and resection are contraindicated,” while “Don’t-know” responses were more frequent among general dental practitioners than the OMFS assistant group. These findings suggested that specialist students had better access to academic information on non-surgical treatment alternatives, yet the application of this knowledge in clinical practice remains limited. Statistical analysis confirmed a significant difference between the groups, highlighting the need to improve the translation of academic knowledge into everyday clinical decision-making, particularly among general practitioners.

Overall, the statistical analysis results revealed that dentists in specialty training had significantly higher knowledge levels regarding MRONJ. This indicates that the specialty training process enhances physicians’ knowledge and skills in treatment protocols and makes them more inclined toward current treatment methods [ 11 ].

Discussion

Awareness of knowledge of MRONJ

Bisphosphonates have been used since the 1960 s to treat bone diseases such as osteoporosis and Paget’s disease [ 12 ], but can cause necrotic bone lesions [ 6 ]. BRONJ, first defined by Robert E. Marx, refers to jaw necrosis that fails to heal within eight weeks in bisphosphonate users without cancer or radiation history [ 3 ]. Later, drugs like denosumab, bevacizumab, sunitinib, and temsirolimus were added as risk factors, leading to the term MRONJ [ 4 ]. Knowledge of these drugs is crucial to reduce MRONJ risk and improve outcomes [ 13 ].

Etiology and clinical presentation

Conditions often mistaken for MRONJ include alveolar osteitis, sinusitis, periodontitis, atypical neuralgias, fibro-osseous lesions, sarcoma, chronic sclerosing osteomyelitis, and TMJ disorders. Additionally, delayed healing, exposed bone, or sequestrum formation may occur in patients not using anti-resorptive/anti-angiogenic drugs, making a detailed medical history essential for accurate diagnosis [ 14 ].

Comparison of knowledge between groups

Most dentists in this study were aware of MRONJ risk, with OMFS assistants showing higher knowledge than general practitioners. Previous studies similarly reported greater awareness among specialists or students compared to general practitioners [ 13 , 15 – 17 ]. The rising use of these drugs and increased MRONJ cases likely expose OMFS assistants more to academic discussions, seminars, and evidence-based education, enhancing their knowledge. In contrast, general practitioners may have limited access to structured learning due to heavy workloads, fewer institutional resources, and less continuing professional development participation. Differences in undergraduate curricula and the lack of standardized MRONJ training further contribute to this gap. Targeted continuing professional development programs and inclusion of MRONJ-focused modules in undergraduate education could help bridge this knowledge gap.

Knowledge about indications and risk factors

In this study, osteoporosis (90.7%) and Paget’s disease (55.1%) were the most commonly recognized indications for anti-resorptive and anti-angiogenic drugs, with OMFS assistants identifying all diseases more frequently than general practitioners. Consistent with previous studies [ 13 , 15 , 17 – 19 ], general practitioners showed lower knowledge about drug indications, particularly for hypercalcemia (specialists 81.9% vs. general practitioners 40.8%). These findings emphasize the importance of taking detailed medical histories to identify patients at risk of MRONJ and highlight the need for targeted educational interventions for general practitioners.

Clinical procedures and treatment awareness

Dentoalveolar procedures are the main cause of MRONJ in patients using anti-resorptive and anti-angiogenic drugs [ 6 ]. In this study, 93.1% of OMFS assistants and 79.2% of general practitioners recognized this risk, consistent with prior reports [ 20 , 21 ]. The discontinuation of medications before procedures remain controversial [ 4 , 5 , 7 , 9 ]. Denosumab, with a shorter half-life than bisphosphonates (26–32 days), is recommended to be stopped 3–4 months before and resumed 6–8 weeks after surgery [ 5 , 22 , 23 ], although cessation may increase vertebral fracture risk [ 24 , 25 ]. Awareness of drug holidays varied: 66.4% of specialists and 31.7% of general practitioners answered correctly, highlighting a significant knowledge gap. Enhancing postgraduate and doctoral education and staying current with literature is critical for specialists managing MRONJ [ 26 , 27 ].

Education, development and systemic interventions

The knowledge gap among general dentists may result from limited access to updated clinical guidelines and continuing professional development (CPD) opportunities. Unlike residents or doctoral students, general practitioners often have less exposure to academic discussions, seminars, and evidence-based education due to heavy workloads, limited support, or lack of awareness of CPD resources. Variations in undergraduate curricula and absence of standardized MRONJ-focused training may further widen this gap.

This study emphasizes the need to strengthen MRONJ education in dental faculties and implement targeted CPD programs for general dentists. Encouraging practitioners to stay updated through literature, symposia, and conferences, along with promoting interdisciplinary collaboration, can improve patient management and MRONJ prevention. Incorporating MRONJ-focused modules in undergraduate curricula and developing CPD initiatives may address existing knowledge gaps. Future research should assess the long-term impact of educational interventions on clinical practice and patient outcomes. Additionally, national or regional awareness campaigns and a national registry for medication-related complications could guide research and clinical protocols.

This study has several limitations. A limitation of this study is that no a priori sample size calculation or statistical power analysis was conducted, as all reachable eligible participants were included. Additionally, the use of self-reported data may introduce response bias, and the cross-sectional design prevents establishing causal relationships. The sample was also limited geographically to dentists practicing in Turkey, which may restrict the generalizability of the findings to other regions or healthcare systems. Future research should consider longitudinal designs, broader populations, and power-based sample calculations to validate and extend these results.

Conclusions

This study compared the knowledge levels and treatment approaches regarding MRONJ between general dentists and dentists undertaking residency or doctoral training in oral and maxillofacial surgery. The findings revealed that dentists in specialist training had greater awareness and knowledge of MRONJ etiology, risk factors, diagnosis, and treatment methods compared to general dentists. These findings highlight the importance of guideline-based clinical practice and continuing professional development (CPD) programs for general dentists to enhance patient safety and treatment outcomes.

Supplementary Information

Supplementary Material 1.

Supplementary Material 2.

Acknowledgements

Not applicable.

Abbreviations

American association of oral and maxillofacial surgeons

Bisphosphonate-related osteonecrosis of the jaw

Continuing professional development

International business machines corporation

Medication-related osteonecrosis of the jaw

Oral and maxillofacial surgery

Statistical package for the social sciences

Temporomandibular joint

Authors’ contributions

Conceptualization, M.Z. and O.Ö.; methodology, M.Z. and O.Ö.; formal analysis, M.Z. and O.Ö.; data curation, M.Z. and O.Ö.; writing—original draft preparation, M.Z. and O.Ö.; writing—review and editing, M.Z.; visualization, M.Z.; supervision, M.Z. All authors have read and approved the final manuscript.

Funding

This research received no external funding.

Data availability

Not applicable.

Declarations

Ethics approval and consent to participate

The study was conducted according to the principles of the Declaration of Helsinki and was approved by the Scientific Research and Publication Ethics Committee of Ege University (protocol code 1764 and date of approval 29/12/2022). Informed consent was obtained from all participants involved in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

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

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Associated Data

Supplementary Materials

Supplementary Material 1.

Supplementary Material 2.

Data Availability Statement

Not applicable.