Introduction
Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse event primarily associated with antiresorptive agents, such as bisphosphonates and denosumab, as well as certain antiangiogenic drugs. Since its first recognition in 2003 [ 1 ], MRONJ has posed considerable and persistent clinical challenges owing to its detrimental impact on patient quality of life and the complexity of its prevention and management. The pathogenesis of MRONJ is multifactorial; however, some contributing factors include the suppression of osteoclast-mediated bone remodeling, oral infections, and inflammation. MRONJ occurs in 4.9% of patients with cancer treated with denosumab [ 2 ]. Therefore, completing dental treatment before initiating bisphosphonates or denosumab and regular dental follow-up are essential preventive strategies.
In Japan, the number of patients with osteoporosis is increasing owing to the aging population. Furthermore, bone-modifying agents (BMAs) are widely used to manage skeletal-related events, including bone pain, hypercalcemia, spinal cord compression, and pathological fractures in patients with solid tumors and multiple myeloma. A recent survey revealed that 9.8% of long-term care-facility residents were being treated with bisphosphonates or denosumab for osteoporosis, with one case of MRONJ observed in a resident receiving injectable bisphosphonates [ 3 ]. Given the increasing population receiving these agents, the number of MRONJ cases is also expected to rise, highlighting the need for comprehensive, multidisciplinary prevention strategies involving dentists and medical and pharmaceutical professionals.
Several studies have reported the awareness and knowledge of MRONJ among dentists and dental students, consistently reporting insufficient understanding, particularly among general practitioners and those with limited experience [ 4 - 6 ]. Similarly, the lack of MRONJ knowledge has been reported among medical students [ 7 ]. Furthermore, dental hygienists working in private dental clinics in Japan showed limited awareness and clinical experience with MRONJ, underscoring the need for broader educational interventions across dental professions [ 8 ]. To address these educational gaps, researchers have proposed targeted educational programs, enhancement of interprofessional collaboration, and meticulous documentation of patient medication histories [ 9 , 10 ]. Additionally, the MRONJ-Quality of Life Questionnaire was developed to assess the effect of MRONJ on the daily functioning of patients [ 11 ]. Despite the central role of pharmacists in managing medications associated with MRONJ, their awareness and active participation in preventing MRONJ remain undetermined. Pharmacists, especially those in oncology settings, are frequently involved in initiating and monitoring antiresorptive therapies and are therefore in a unique position to identify patients at risk for MRONJ, provide patient education, and serve as a bridge between medical and dental care. However, data regarding pharmacist knowledge, their attitudes toward MRONJ, and the extent of their involvement in interdisciplinary preventive measures remain scarce.
This study aimed to assess the awareness, knowledge, and attitudes of pharmacists working in a designated community cancer care hospital in Japan regarding MRONJ, while also evaluating their engagement in dental-related practices with attention to potential gaps between theoretical understanding and clinical application. Furthermore, we sought to identify systemic barriers and propose strategies to enhance interprofessional collaboration and educational support systems for the early diagnosis and prevention of MRONJ.
Materials and methods
Survey method
Saitama Medical Center, Saitama Medical University, a regional core hospital and designated cancer center, provides surgery, chemotherapy, and radiotherapy for various types of cancer. Pharmacists working in the hospital pharmacy department (n=65) were surveyed based on their awareness, knowledge, and clinical engagement related to MRONJ using an anonymous questionnaire created with Google Forms (Google LLC, California, US). Concurrently, a survey on the involvement of pharmacists in dental care was conducted. The survey period was one month, between February 19 and March 18, 2024. To enhance the response rate, a reminder email was sent two weeks after the initial distribution of the questionnaires.
Five sections of the questionnaire
The first section included three items about demographic characteristics: sex, age, and years of pharmacist experience. The second section included four items related to oral cavity checks during medication counseling and suggestions for oral care interventions to other healthcare providers. The third section contained nine items concerning experience with dispensing BMAs (bisphosphonates, zoledronic acid, and denosumab), medication counseling, and knowledge of associated adverse events. The fourth section included seven items to assess pharmacists’ knowledge of MRONJ and their experience with consultations for suspected cases. The fifth section comprised seven items addressing collaboration with other professions and community healthcare, including providing information to dental clinics outside the hospital and strategies for interprofessional collaboration between pharmacists and dentists. This questionnaire was developed based on previous literature and existing research on MRONJ. Its content validity was reviewed by an oncology pharmacist, a dentist specializing in oral surgery, and a faculty member from a school of pharmacy. A pilot test was subsequently conducted with two pharmacy students to confirm clarity, comprehensibility, and feasibility prior to distribution.
Ethical considerations
This study was approved by the Ethics Committee of the Center for Medical Science of Saitama University (Application No.: 2023-032). Data was anonymized and the study was conducted under the ethical standards of the Declaration of Helsinki (1964 and later amendments). Participants provided informed consent using the Google Forms platform.
Results
Table 1 shows the participant demographic characteristics.
Table 1
Demographic characteristics and basic information regarding the study participants
| First section | n | % |
| Sex | ||
| Male | 27 | 52.9 |
| Female | 24 | 47.1 |
| Age (years) | ||
| 50-59 | 2 | 3.9 |
| 40-49 | 11 | 21.6 |
| 30-39 | 17 | 33.3 |
| 20-29 | 17 | 33.3 |
| Unanswered | 4 | 7.8 |
| Years of experience as a pharmacist | ||
| ≥20 | 6 | 11.8 |
| 15-19 | 7 | 13.7 |
| 10-14 | 2 | 3.9 |
| 5-9 | 16 | 31.4 |
| ≤4 | 16 | 31.4 |
| Unanswered | 4 | 7.8 |
About 52.9% were male participants, whereas 47.1% were female participants. The most common age groups were 20s and 30s, each representing 33.3% of the cohort. Regarding experience, 31.4% of the pharmacists had less than or equal to four years of experience, and 31.4% had five to 10 years of experience.
Table 2 shows the frequency and circumstances of oral cavity checks conducted by pharmacists during medication counseling.
Table 2
Items in the questionnaire related to checking the oral cavity
| Second section | n | % |
| Q. 1 Oral cavity checks during medication instruction | ||
| Always | 0 | 0 |
| Sometimes | 11 | 21.6 |
| Almost never | 21 | 41.2 |
| Never | 19 | 37.3 |
| Q. 1-1 Related question: When would you check? (multiple choice) | ||
| When there are oral mucosal disorders | 22 | 78.6 |
| When using medicines affecting the oral cavity | 20 | 71.4 |
| When oral mucosal disorders are anticipated | 15 | 53.6 |
| When there is oral dryness | 5 | 17.9 |
| When undergoing radiotherapy | 4 | 14.3 |
| When there is time to spare | 4 | 14.3 |
| When dentures or orthodontics are used | 2 | 7.1 |
| When intervening with terminally-ill patients | 2 | 7.1 |
| During team care rounds | 1 | 3.6 |
| When there is a complaint of any oral symptoms | 1 | 3.6 |
| When there are subjective symptoms | 1 | 3.6 |
| When intervening in elderly patients (over 65 years) | 0 | 0 |
| Q. 2 Have you ever provided medication counseling to cancer patients or their families? | ||
| Yes | 46 | 90.2 |
| No | 5 | 9.8 |
| Q. 3 Have you ever suggested oral care to the patient's physician or dentist before or after surgery or the start of anti-cancer drug treatment? | ||
| Yes | 15 | 29.4 |
| No | 36 | 70.6 |
Although no pharmacists reported always checking the oral cavity, 21.6% sometimes checked, 41.2% rarely checked, and 37.3% never checked it. The most common reasons for conducting oral checks included the presence of oral mucosal damage, medication use affecting the oral cavity, and anticipation of oral mucosal damage.
Table 3 shows the pharmacists' experience with dispensing bisphosphonates and denosumab, providing medication counseling, and their knowledge of associated adverse events.
Table 3
Items in the questionnaire related to experience in dispensing bisphosphonates and denosumab, providing medication guidance, and knowledge of adverse events MRONJ, medication-related osteonecrosis of the jaw; ZOA, zoledronic acid.
| Third section | n | % |
| Q. 4 Have you ever dispensed bisphosphonates? | ||
| Yes | 50 | 98.0 |
| No | 1 | 2.0 |
| Q. 5 Have you ever dispensed denosumab? | ||
| Yes | 48 | 94.1 |
| No | 3 | 5.9 |
| Q. 6 Have you ever given medication counseling for bisphosphonates (oral medicines)? | ||
| Yes | 45 | 88.2 |
| No | 6 | 11.8 |
| Q. 7 Have you ever given medication counseling for bisphosphonates (injectable medicines)? | ||
| Yes | 18 | 35.3 |
| No | 33 | 64.7 |
| Q. 8 Have you ever given denosumab medication counseling? | ||
| Yes | 18 | 35.3 |
| No | 33 | 64.7 |
| Q. 9 Indicate known bisphosphonates and denosumab adverse events (multiple choice) | ||
| Jawbone disorders (osteonecrosis of the jaw, jaw osteomyelitis) | 50 | 98.0 |
| Hypocalcemia | 46 | 90.2 |
| Gastrointestinal symptoms (stomatitis, oral herpes, upper abdominal pain, etc.) | 27 | 52.9 |
| Skin symptoms (eczema, cellulitis, etc.) | 12 | 23.5 |
| Back pain | 9 | 17.6 |
| Fatigue | 8 | 15.7 |
| Constipation | 8 | 15.7 |
| Anemia | 6 | 11.8 |
| Dyspnea | 2 | 3.9 |
| I have never heard of any of these | 0 | 0.0 |
| Q. 10 Have you heard that ZOA can cause MRONJ of the jaw? | ||
| Yes | 49 | 96.1 |
| No | 2 | 3.9 |
| Q. 11 Have you heard that denosumab can cause MRONJ? | ||
| Yes | 45 | 88.2 |
| No | 6 | 11.8 |
| Q. 12 Do you think there is a difference in the incidences of MRONJ between ZOA and denosumab? | ||
| ZOA < denosumab | 5 | 9.8 |
| ZOA > denosumab | 8 | 15.7 |
| Similar level | 9 | 17.6 |
| I am not sure | 29 | 56.9 |
Nearly all pharmacists had dispensed bisphosphonates (98.0%) and denosumab (94.1%). MRONJ was the most widely recognized adverse event, followed by hypocalcemia and gastrointestinal symptoms.
Table 4 shows a summary of the pharmacists' knowledge about MRONJ.
Table 4
Items in the questionnaire related to MRONJ knowledge and consultation experience MRONJ, medication-related osteonecrosis of the jaw.
| Fourth section | n | % |
| Q. 13 Selected conditions diagnosed as MRONJ (multiple choice) | ||
| Prior treatment with bisphosphonates or denosumab | 31 | 60.8 |
| Bone exposure in the oral, maxillofacial, or mandibular region persisting for >8 weeks | 20 | 39.2 |
| Prior combination of bisphosphonates or denosumab with angiogenesis inhibitors or immunomodulators | 19 | 37.3 |
| Not primary cancer or cancer metastasis to the jawbone | 16 | 31.4 |
| Exposed bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region that has persisted for >8 weeks | 12 | 23.5 |
| In principle, no history of radiation therapy to the jawbone | 12 | 23.5 |
| I am not sure | 18 | 35.3 |
| Q. 14 Select all risk factors for developing MRONJ (multiple choice) | ||
| Medication | 45 | 88.2 |
| Periodontal disease | 44 | 86.3 |
| Tooth extraction | 39 | 76.5 |
| Dental caries | 37 | 72.5 |
| Poor oral hygiene | 36 | 70.6 |
| Dental implant | 32 | 62.7 |
| Radiation | 31 | 60.8 |
| Diabetes | 30 | 58.8 |
| Smoking | 29 | 56.9 |
| Rheumatoid arthritis | 24 | 47.1 |
| Obesity | 18 | 35.3 |
| Dialysis | 18 | 35.3 |
| Alcohol consumption | 16 | 31.4 |
| I am not sure | 3 | 5.9 |
| Q. 15 Have you seen intraoral photographs of MRONJ? | ||
| Yes | 30 | 58.8 |
| No | 21 | 41.2 |
| Q. 16 Have you seen actual intraoral views of MRONJ? | ||
| Yes | 2 | 3.9 |
| No | 49 | 96.1 |
| Q. 17 Have you ever discussed a patient with suspected MRONJ with their physician or dentist? | ||
| Yes | 7 | 13.7 |
| No | 44 | 86.3 |
| Q. 18 Selected as the highest priority treatment for MRONJ | ||
| Surgical removal of sequestrum | 24 | 47.1 |
| Oral rinses | 18 | 35.3 |
| Antibiotics | 1 | 2.0 |
| Analgesics | 1 | 2.0 |
| I am not sure | 7 | 13.7 |
| Q. 19 Do you think MRONJ is a disease that can be treated and cured? | ||
| Curable | 30 | 58.8 |
| Not curable | 21 | 41.2 |
When asked about diagnostic conditions, the most commonly recognized criterion was prior treatment with bisphosphonates or denosumab (60.8%), followed by the presence of exposed bone in the maxillofacial region persisting for more than eight weeks (39.2%), and prior combination therapy with bisphosphonates or denosumab and angiogenesis inhibitors or immunomodulators (37.3%). Regarding the risk factors for MRONJ, medication use was most frequently identified (88.2%), whereas dental-related factors, including periodontal disease (86.3%), tooth extraction (76.5%), and dental caries (72.5%), were also highly recognized. Poor oral hygiene was cited by 70.6% of the respondents. Regarding clinical experience, 58.8% of the pharmacists had observed intraoral photographs of patients with MRONJ; however, only 3.9% had directly observed MRONJ lesions in the oral cavity. Furthermore, 86.3% had no experience of consulting a physician or dentist regarding a suspected case of MRONJ. Concerning treatment modalities, surgical removal of sequestrum was the most frequently selected approach (47.1%), followed by oral rinses (35.3%) and antibiotics (2.0%). Regarding the curability of MRONJ, 58.8% of the pharmacists believed that it could be cured, whereas 41.2% believed that it could not.
Table 5 shows the pharmacists' experiences concerning collaboration with other healthcare professions.
Table 5
Items in the questionnaire regarding collaboration with other professions and the medical community
| Fifth section | n | % | ||
| Q. 20 Have you ever provided information about bisphosphonates and denosumab to external medical institutions using a medication handbook or other means? | ||||
| Yes | 12 | 23.5 | ||
| No | 39 | 76.5 | ||
| Q. 21 Have you ever shared information about dental and oral health issues with dental clinics outside the hospital? | ||||
| Yes | 0 | 0 | ||
| No | 51 | 100 | ||
| Q. 22 Do you think it is necessary to cooperate with dentists? | ||||
| Yes | 50 | 98.0 | ||
| No | 1 | 2.0 | ||
| Q. 23 In which areas do you think collaboration between pharmacy and dentistry should be promoted? (multiple choice) | ||||
| Perioperative oral management | 42 | 82.4 | ||
| Oral function management | 32 | 62.7 | ||
| Feeding and swallowing management | 30 | 58.8 | ||
| Prevention of aspiration pneumonia | 26 | 51.0 | ||
| Home healthcare | 21 | 41.2 | ||
| Nursing care insurance | 9 | 17.6 | ||
| Healthcare for people with disabilities | 9 | 17.6 | ||
| Q. 24 As a pharmacist, please select the healthcare professions with which you find it easy or difficult to collaborate. (multiple choice) | Easy | Difficult | ||
| ｎ | ％ | ｎ | ％ | |
| Dentist | 10 | 19.6 | 23 | 45.1 |
| Dental hygienist | 8 | 15.7 | 31 | 60.8 |
| Physician / Doctor | 43 | 84.3 | 4 | 7.8 |
| Pharmacist | 45 | 88.2 | 2 | 3.9 |
| Nurse | 45 | 88.2 | 1 | 2 |
| Registered dietitian / Dietitian | 17 | 33.3 | 11 | 21.6 |
| Physical therapist | 5 | 9.8 | 28 | 54.9 |
| Medical social worker | 3 | 5.9 | 33 | 64.7 |
Overall, 23.5% of the pharmacists reported having provided information about bisphosphonates and denosumab to medical institutions outside their hospital using a medication handbook or similar means. Importantly, none of the pharmacists had provided dental or oral health information to dental clinics outside the hospital. Regarding collaboration with other healthcare professionals, pharmacists indicated that they found it easier to collaborate with nurses (88.2%), fellow pharmacists (88.2%), and physicians (84.3%) than they did with dentists (45.1%) and dental hygienists (60.8%). However, 98.0% of the pharmacists agreed on the necessity of collaborating with dentists. Regarding areas where drug-dental cooperation should be promoted, perioperative oral management was most frequently selected (82.4%), followed by oral function management (62.7%), feeding and swallowing management (58.8%), prevention of aspiration pneumonia (51.0%), home healthcare (41.2%), and nursing insurance and healthcare for individuals with disability (17.6% for both).
In the free-text responses, pharmacists emphasized the importance of sharing detailed patient information with dentists to ensure appropriate dental care, particularly in patients at risk for MRONJ. The essential information included basic medical information, current medication use (especially bisphosphonates and denosumab), medication history, and history of adverse drug reactions. Additionally, pharmacists highlighted the need for sharing the history of chemotherapy (including the types of drugs used, treatment duration, and adverse events), bisphosphonate use (particularly injectable forms), and radiotherapy, which are key determinants in evaluating the risk of jawbone necrosis. Information on the use of antiplatelet or anticoagulant agents, which may increase the risk of bleeding, was also considered necessary to be communicated to dental professionals.
Discussion
In this study, we assessed the awareness and knowledge regarding MRONJ among pharmacists working at a designated community cancer care hospital, as well as their involvement in dental care and potential strategies to strengthen their role in preventing MRONJ. Our findings revealed a substantial gap between their theoretical understanding of MRONJ and their practical engagement in its prevention and management. Despite limited clinical engagement, most pharmacists recognized the importance of collaborating with dental professionals, indicating a generally positive attitude toward interprofessional cooperation.
A high proportion of pharmacists demonstrated awareness of MRONJ and its associated risk factors, consistent with the findings of previous studies among medical and dental professionals [ 4 , 5 ]. Nevertheless, only 3.9% had encountered an MRONJ case in the clinic. Moreover, the limited frequency of oral cavity assessments during medication counseling highlights the disconnection between theoretical knowledge and proactive preventive practices. The need for early identification of oral risk factors, such as mucosal disorders and periodontal disease, has been emphasized as an essential factor in preventing MRONJ [ 12 , 13 ]; however, our findings indicate that such preventive strategies have yet to be fully integrated into routine pharmacy practice, even in oncology-focused settings where BMAs are commonly used. Notably, 98% of the pharmacists acknowledged the importance of interprofessional collaboration with dental professionals, indicating a strong prospect for future engagement. However, despite this high level of acceptance, the actions of the pharmacists did not align with their stated attitudes because none of the respondents had ever provided oral health-related information to external dental clinics. This discrepancy between awareness and practice shows that pharmacists may face practical difficulties in translating their intentions into clinical actions. This may be attributable to factors such as uncertainty about which information should be shared, lack of institutional protocols for interprofessional communication, and insufficient confidence in discussing oral health with dental professionals. These challenges highlight the presence of systemic barriers, similar to those reported in previous interdisciplinary studies [ 14 ]. These structural challenges may include the absence of formal referral pathways, lack of reimbursement incentives for pharmacist-dentist communication, and insufficient interprofessional training opportunities. Similar structural challenges have also been previously reported among dental hygienists working in private dental clinics in Japan, suggesting the need for comprehensive and system-wide efforts to reinforce interprofessional collaboration across medical and dental care settings [ 8 ].
Given these findings, three measures are recommended to bridge the gap between the theoretical knowledge of pharmacists and their limited clinical engagement in MRONJ prevention. First, structured educational interventions should be implemented to strengthen the clinical competencies of pharmacists. Structural interventions should include training in recognizing early oral signs and symptoms of MRONJ, oral examination techniques, and effective communication strategies for risk explanation to patients and dental professionals. Previous studies have shown that such targeted training can significantly enhance the preparedness of healthcare providers in preventing MRONJ [ 9 , 10 ], suggesting that similar programs tailored for pharmacists could be highly beneficial.
Second, it is essential to establish institutional systems that enable pharmacists to apply this knowledge practically. Developing standardized tools, such as medication handbooks with dental risk indicators, referral forms for dental evaluation, and checklists for oral risk assessment, could facilitate interprofessional communication. Additionally, creating formalized referral pathways and regular multidisciplinary meetings involving pharmacists and dental professionals would provide critical platforms for collaboration. Integrated care models used in other fields, such as osteoporosis management, may offer useful frameworks for designing these systems [ 15 , 16 ]. Notably, free-text responses in our study underscored the need for clear information-sharing protocols between pharmacists and dental providers, including patient histories of medication use (especially bisphosphonates and denosumab), chemotherapy, radiotherapy, and bleeding risks.
Third, broader multi-institutional research is warranted to validate these findings across diverse clinical settings and to guide the development of national or international strategies in preventing MRONJ. This study was limited to a single community cancer care hospital; nonetheless, it is among the first to empirically examine the awareness, knowledge, and interprofessional practices of pharmacists concerning MRONJ in Japan. The results provide data that can inform future policy development, educational frameworks, and collaborative models in oncology pharmacy practice.
This study has several strengths, including addressing an underexplored area by evaluating the knowledge, attitudes, and collaboration of pharmacists regarding MRONJ, and highlighting the importance of interprofessional approaches. However, several limitations should be acknowledged. First, the single-institution design may limit the generalizability of the findings to other settings or countries. Second, the reliance on self-reported data introduces the potential for reporting bias, including social desirability bias. Third, while awareness and attitudes were assessed, actual clinical skills and engagement in MRONJ-related care were not evaluated. Fourth, as this study was conducted in a single institution with a relatively small sample of 51 pharmacists, the ability to perform more detailed subgroup analyses was restricted. Despite these limitations, it provides valuable insights and offers a foundation for future multi-institutional research and educational initiatives.
Conclusions
This exploratory study suggests that pharmacists in a designated community cancer care hospital possess substantial theoretical knowledge of MRONJ and generally hold a positive attitude toward interprofessional collaboration with dental professionals. However, their actual clinical engagement appeared limited, indicating a potential disconnection between knowledge and practice. These findings highlight the possible value of structured educational interventions and institutional support systems to help address this gap. In addition, further multi-institutional research will be important to confirm these observations and to guide the development of standardized frameworks that enhance the role of pharmacists in preventing MRONJ.
We would like to thank the pharmacists of the Department of Pharmacy and all staff members involved in the survey at Saitama Medical Center, Saitama Medical University, for their valuable support and cooperation in this research.
Disclosures
Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. The Ethics Committee of the Center for Medical Science of Saitama University issued approval 2023-032.
Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
Author Contributions
Concept and design: Motohiko Sano, Yosuke Iijima, Saya Watanabe, Atsunobu Sagara, Kenta Ushikubo, Miki Yamada, Hiroyuki Ohya, Mashu Morimoto, Norio Horie, Takahiro Kaneko
Acquisition, analysis, or interpretation of data: Motohiko Sano, Yosuke Iijima, Saya Watanabe, Atsunobu Sagara, Kenta Ushikubo, Miki Yamada, Hiroyuki Ohya, Mashu Morimoto, Norio Horie, Takahiro Kaneko
Drafting of the manuscript: Motohiko Sano, Yosuke Iijima, Saya Watanabe, Atsunobu Sagara, Kenta Ushikubo, Miki Yamada, Hiroyuki Ohya, Mashu Morimoto, Norio Horie, Takahiro Kaneko
Critical review of the manuscript for important intellectual content: Motohiko Sano, Yosuke Iijima, Saya Watanabe, Atsunobu Sagara, Kenta Ushikubo, Miki Yamada, Hiroyuki Ohya, Mashu Morimoto, Norio Horie, Takahiro Kaneko
Supervision: Motohiko Sano, Yosuke Iijima, Norio Horie
References
1 Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic J Oral Maxillofac Surg Marx RE 1115 1117 61 2003 https://www.joms.org/article/S0278-2391(03)00720-1/pdf 12966493 10.1016/s0278-2391(03)00720-1
2 Medication-related osteonecrosis of the jaw in patients with cancer using zoledronic acid and denosumab: single-center retrospective study J Oncol Pharm Pract Sano M Amano M Yamada M 10781552251316440 2025 39871778 10.1177/10781552251316440
3 Prevalence of bisphosphonate and denosumab use in elderly care facilities: implications for the management of medication-related osteonecrosis of the jaw Cureus Sano M Iijima Y Yamada M 0 17 2025 10.7759/cureus.83490 PMC12051078 40329970
4 Across-sectional survey on medication-related osteonecrosis of the jaws' knowledge and awareness in a sample of dental society J Craniomaxillofac Surg Al-Samman AA Al-Ani RS 926 931 47 2019 30952475 10.1016/j.jcms.2019.02.006
5 Knowledge and awareness of medication-related osteonecrosis of the jaw among dental practitioners in Mumbai: a questionnaire-based survey Cureus Shapurwala MA Kharkar V More S Kalsi H Sachdev SS 0 16 2024 10.7759/cureus.76448 PMC11769707 39867037
6 Medication-related osteonecrosis of the jaw: a survey of knowledge, practices and opinions of dentists Ann Med Res Sahin O 2421 2427 27 2020
7 Medical students' knowledge of medication related osteonecrosis of the jaw J Stomatol Oral Maxillofac Surg Franchi S Brucoli M Boffano P Dosio C Benech A 344 346 121 2020 31672685 10.1016/j.jormas.2019.10.005
8 Dental hygienists' awareness of medication-related osteonecrosis of the jaw in private dental clinics in Japan Gerontol Geriatr Med Iijima Y Yamada M Amano M 23337214241292794 10 2024 39494315 10.1177/23337214241292794 PMC11528679
9 The awareness and practice of dentists regarding medication-related osteonecrosis of the jaw and its prevention: a cross-sectional survey BMC Oral Health Han AL 155 21 2021 33761923 10.1186/s12903-021-01475-6 PMC7992948
10 Choosing the right partner for medication related osteonecrosis of the jaw: what central European dentists know Int J Environ Res Public Health Bruckmoser E Palaoro M Latzko L Schnabl D Neururer SB Laimer J 4466 18 2021 33922326 10.3390/ijerph18094466 PMC8122803
11 Development and evaluation of the clinimetric properties of the medication-related osteonecrosis of the jaw quality of life questionnaire (MRONJ-QoL) Int J Oral Maxillofac Surg El-Rabbany M Blanas N Sutherland S Shah PS Lam DK Azarpazhooh A 768 775 51 2022 34924268 10.1016/j.ijom.2021.11.007
12 Impact of dental care in the prevention of bisphosphonate-associated osteonecrosis of the jaw: a single-center clinical experience Ann Oncol Vandone AM Donadio M Mozzati M 193 200 23 2012 21427065 10.1093/annonc/mdr039
13 Prevention of bisphosphonate-related osteonecrosis of the jaws in patients with prostate cancer treated with zoledronic acid - a prospective study over 6 years J Craniomaxillofac Surg Mücke T Deppe H Hein J 1689 1693 44 2016 27555374 10.1016/j.jcms.2016.07.026
14 General dental practitioners' perceptions of, and attitudes towards, improving patient safety through a multidisciplinary approach to the prevention of medication-related osteonecrosis of the jaw (MRONJ): a qualitative study in the North East of England BMJ Open Sturrock A Preshaw PM Hayes C Wilkes S 0 9 2019 10.1136/bmjopen-2019-029951 PMC6597093 31213454
15 Supporting patients to get the best from their osteoporosis treatment: a rapid realist review of what works, for whom, and in what circumstance Osteoporos Int Paskins Z Babatunde O Sturrock A Toh LS Horne R Maidment I 2245 2257 33 2022 35688897 10.1007/s00198-022-06453-4 PMC9568441
16 Models of care for osteoporosis: a systematic scoping review of efficacy and implementation characteristics EClinicalMedicine Jones AR Herath M Ebeling PR Teede H Vincent AJ 101022 38 2021 34345811 10.1016/j.eclinm.2021.101022 PMC8319463