ABSTRACT
INTRODUCTION
Bisphosphonates (BF) are antiresorptive drugs (AR) that have been used for many years in the treatment of bone diseases such as osteoporosis, osteopenia, Paget's disease and in the treatment of malignancies such as multiple myeloma, bone metastatic diseases and malignant hypercalcemia ( 1 , 2 ). Although their positive therapeutic use is known for many years, it was only in 2003 that the side effects of their therapy, which is osteonecrosis of the jaw ( 3 ), were first mentioned in the literature. This specific, antiresorptive drugs-related form of osteonecrosis occurs primarily in the jaw bones, probably due to a combination of active remodeling, thin mucosa, susceptibility to infection, and it may affect the fibroblasts of the connective tissue ( 4 ).
In recent years, it has been described that new drugs can also cause MRONJ such as denosumab and romosozumab from the group of AR drugs, and bevacizumab, sunitinib, and sorafenib as part of antiangiogenic drugs ( 5 ). Due to the emergence of new drugs that can cause osteonecrosis, the previous name bisphosphonate osteonecrosis of the jaw (BRONJ) is not appropriate anymore, so the name is changed to medication-related osteonecrosis of the jaw (MRONJ).
The development of MRONJ is attributed to various factors, of which the most important is for those patients undergoing therapy with antiresorptive or antiangiogenic drugs. The type of administration of the drugs is also important. Intravenous administration of high-potency BFs used in malignancies carries a much higher risk of osteonecrosis than oral BFs, which are most commonly used in osteoporosis ( 5 - 9 ). The duration of therapy and higher doses of BF also pose a higher risk of developing osteonecrosis ( 10 , 11 ). Dental procedures also increase the development of osteonecrosis such as tooth extraction, placement of dental implants, periodontal and endodontic surgery ( 5 , 7 , 12 , 13 ), and concomitant bacterial contamination. Additional risks are older age (60 years and older), use of immunosuppressive drugs, anemia, corticosteroid use, renal failure, etc. ( 14 - 16 ).
For differential diagnosis of MRONJ, osteoradionecrosis as a consequence of radiation in the head and neck area, suppurative osteomyelitis following infection, various fibro-osseous lesions, alveolar sinusitis and chronic sclerosing osteitis should also be considered in the differential diagnostics ( 5 ).
The clinical picture of osteonecrosis can vary from small localized lesions involving no exposed necrotic bone tissue to exposed tissue of the entire jaw ( 5 ). A higher occurrence of osteonecrosis is present in the lower jaw (due to its poor blood circulation) and in places covered only with a thin mucosa (lingual side of the lower jaw, exostosis, torus) ( 13 ). Lesions may be present with or without signs of infection, while in the advanced stage they may spread to adjacent structures such as the mandibular canal or maxillary sinus ( 5 ).
MRONJ therapy is complex and unpredictable, and knowledge about this disease is essential for its prevention. Therefore, dentists must be familiar with this topic.
The purpose of this study is to determine how doctors of dental medicine (DDM) are familiar with drugs that can cause MRONJ, with the indications for the use of individual drugs, and in general to collect information about their experience of treating the disease by themselves. To further raise awareness of MRONJ, all participant DDMs received a brochure as part of the national disease prevention program.
MATERIALS AND METHODS
The research was conducted through an anonymous survey questionnaire distributed to DDMs throughout the Republic of Croatia in written and e-form. We followed up with non-responders by sending a reminder email 3-4 weeks after the initial email.
The research was approved by the Ethics Committee of the School of Dental Medicine, University of Zagreb, protocol number 05-PA-15-3 / 2017.
The questionnaire consisted of 21 questions divided into three parts. The first part included general data on respondents such as age, gender, work experience, location of business, counties of business and academic degree (postgraduate studies and area of specialty).
The second section contained information on the knowledge of BF and their risk for osteonecrosis (indications, risks, factors, type of procedure associated with osteonecrosis).
The third unit contained information on the treatment of MRONJ (knowledge of the factors that reduce the risk of osteonecrosis and treatment experience).
In the second and third units, multiple-choice answers to the questions are offered. Five questions ( 11 , 13 - 16 ) had more than one correct answer. Questions with multiple correct answers were scored as follows: +1 point for the correct answer, and -1 point for the incorrect answer. Based on the total number of points, the researchers determined two groups according to the point scale for individual questions: "KNOWS" and "DOES NOT KNOW". ( Table 1 .) Each question with more correct answers offered the possibility to complete the answer "I AM NOT SURE" or "I AM NOT FAMILIAR WITH THIS ISSUE", which in that case would be classified as the answer "I DON'T KNOW".
Table 1
Score scale for multiple-choice questions.
| Number of questions | Number of correct answers | KNOWS | DOES NOT KNOW |
| 11 | 4 | 3-4 | 0-2 |
| 13 | 5 | 2-5 | 0-1 |
| 14 | 4 | 2-4 | 0-1 |
| 15 | 2 | 2 | 0-1 |
| 16 | 5 | 3-5 | 0-2 |
RESULTS
The questionnaire was distributed to a total number of 951 participants out of which 504 responded. 46 questionnaires were not usable, so they were discarded. Finally, the study involved 458 (48.2%) DDM from all over the Republic of Croatia, of which 233 (50.9%) were female and 215 (49.1%) were male. The average age of the respondents is 41.33 years with an average work experience of 25.2 years. Respondents were classified according to specialization, academic degree, work experience, and county. Tables 1 and 2 show the results of the respondents from the first group of questions.
Table 2
Presentation of the results of the respondents according to the first group of questions.
| CATEGORY | GROUP | NUMBER OF RESPONDENTS | PERCENTAGE (%) |
| Sex | Female | 243 | 53.06 |
| Male | 215 | 46.94 | |
| Average age | 41.33 years | ||
| Average work experience | 25.2 years | ||
| Specialization | No specialization | 329 | 71.83 |
| Oral surgery | 37 | 8.08 | |
| Prosthodontics | 23 | 5.02 | |
| Pedodontics | 12 | 2.62 | |
| Oral medicine | 5 | 1.09 | |
| Endodontics | 18 | 3.93 | |
| Periodontists | 10 | 2.18 | |
| Orthodontics | 22 | 4.80 | |
| Postgraduate studies | None | 354 | 77.29 |
| Doctorate | 49 | 10.70 | |
| Master's Degree | 47 | 10.26 | |
| In process | 8 | 1.75 | |
| Work | Private practice | 174 | 37.99 |
| Health center | 172 | 37.55 | |
| Polyclinic | 66 | 14.41 | |
| Hospital | 14 | 3.06 | |
| Faculty | 32 | 6.99 |
Table 3 and Figure 1 show DDM’s general knowledge about the main complication (osteonecrosis of the jaw) of BF in the oral cavity by county. The highest number of participants who offered correct answers was in the city of Zagreb, but also the highest number of incorrect answers was in the city of Zagreb as well, which can be explained by the highest number of participants in this region since it is the most populated region in Croatia.
Table 3
DDMs’ knowledge about the main complication of BF in the oral cavity by county.
| COUNTIES | No DDM | No ( Figure 1 ) | KNOW | DOES NOT KNOW | ||
| No | PRENCENTAGE (%) | No | PERCENTAGE (%) | |||
| City of Zagreb | 148 | 1 | 125 | 84.46 | 23 | 15.54 |
| Međimurje | 30 | 2 | 18 | 60 | 12 | 40 |
| Osijek-Baranja | 29 | 3 | 16 | 55.17 | 13 | 44.83 |
| Brod-Posavina | 25 | 4 | 16 | 64 | 9 | 36 |
| Primorje-Gorski Kotar | 24 | 5 | 19 | 79.17 | 5 | 20.83 |
| Split-Dalmatia | 20 | 6 | 11 | 55 | 9 | 45 |
| Šibenik-Knin | 19 | 7 | 8 | 42.11 | 11 | 57.89 |
| Zadar | 18 | 8 | 11 | 61.11 | 7 | 38.88 |
| Bjelovar-Bilogora | 17 | 9 | 9 | 52.94 | 8 | 47.06 |
| Krapina-Zagorje | 16 | 10 | 5 | 31.25 | 11 | 68.75 |
| Zagreb county | 15 | 11 | 8 | 53.33 | 7 | 46.67 |
| Sisak-Moslavina | 15 | 12 | 7 | 46.67 | 8 | 53.33 |
| Lika-Senj | 14 | 13 | 4 | 28.57 | 10 | 71.43 |
| Požega-Slavonija | 13 | 14 | 4 | 30.77 | 9 | 69.23 |
| Istra | 13 | 15 | 10 | 76.92 | 3 | 23.08 |
| Koprivnica-Križevci | 10 | 16 | 1 | 10 | 9 | 90 |
| Karlovac | 9 | 17 | 4 | 44.44 | 5 | 55.56 |
| Virovitica-Podravina | 9 | 18 | 4 | 44.44 | 5 | 55.56 |
| Vukovar-Srijem | 7 | 19 | 6 | 85.71 | 1 | 14.29 |
| Varaždin | 4 | 20 | 4 | 100 | 0 | 0 |
| Dubrovnik-Neretva | 3 | 21 | 1 | 33.33 | 2 | 66.67 |
Table 4 shows DDM’s knowledge of the main complication of bisphosphonate therapy, MRONJ. The table also categorizes DDMs by specialization, level of academic education, place of employment, and work experience.
Table 4
Does the DDM know which the main complication of the application of BF in the oral cavity is - analysis according to the years of graduation, areas of specialization, postgraduate studies and working area.
| KNOWS | DOES NOT KNOW | |||
| Number | Percentage (%) | Number | Percentage (%) | |
| All (458) | 290 | 63.32 | 168 | 36.68 |
| Specialization | ||||
| No specialization | 195 | 59.27 | 134 | 40.73 |
| Oral surgery | 33 | 89.19 | 4 | 10.81 |
| Prosthodontics | 17 | 73.91 | 6 | 26.09 |
| Pedodontics | 8 | 66.66 | 4 | 33.33 |
| Oral medicine | 3 | 60.00 | 2 | 40.00 |
| Endodontics | 13 | 72.22 | 5 | 27.78 |
| Periodontics | 5 | 50.00 | 5 | 50.00 |
| Orthodontics | 17 | 77.27 | 5 | 22.73 |
| Postgraduate studies | ||||
| None | 207 | 58.47 | 146 | 41.53 |
| Master's Degree | 33 | 70.21 | 14 | 29.79 |
| Doctorate | 43 | 87.6 | 6 | 12.24 |
| In process | 7 | 87.50 | 1 | 12.50 |
| Workplace | ||||
| Private practice | 97 | 56.07 | 76 | 43.93 |
| Health center | 90 | 52.33 | 82 | 47.67 |
| Polyclinic | 60 | 90.91 | 6 | 9.09 |
| Hospital | 13 | 92.86 | 1 | 7.14 |
| Faculty | 30 | 93.75 | 2 | 6.25 |
| Work experience | ||||
| Up to 5 years | 103 | 86.55 | 16 | 13.45 |
| 6-10 years | 68 | 72.34 | 26 | 27.66 |
| 11-15 years | 46 | 68.66 | 21 | 31.34 |
| 16-20 years | 35 | 56.45 | 27 | 43.55 |
| 21 and more years | 38 | 33.33 | 76 | 66.67 |
The results show that 36.68% of all subjects do not know that MRONJ is a main complication of BF therapy.
Tables 5 and 6 show the knowledge of all respondents and respondents of oral surgery specialists about the knowledge of complications of BF therapy, risks, factors, and types of dental procedures that lead to an increased risk for the development of osteonecrosis of the jaw.
Table 5
Analysis of questions from the DDM knowledge questionnaire - knowledge of the complications of BF therapy, risks, factors, and types of dental procedures - included all respondents.
| Number of questions and keywords from the question | Answers to the questions in percentages and the number of DDMs who have chosen the listed answer | |||
| 11. Indications for the use of BF | KNOWS | DOES NOT KNOW | ||
| 182 39.74% | 276 60.26% | |||
| Diseases for which BF is applied | Osteoporosis | Multiple myeloma | Bone metastases | |
| 286 62.45% | 109 23.80% | 192 41.92% | ||
| 12. Method of BF administration and risk of osteonecrosis | po. | iv. | EQUALLY | DOES NOT KNOW |
| 23 5.02% | 174 37.99% | 30 6.55% | 225 49.13% | |
| 13. Factors influencing the occurrence of osteonecrosis | KNOWS | DOES NOT KNOW | ||
| 214 46.72% | 244 53.26% | |||
| 14. Association of dental procedures with the risk of osteonecrosis | KNOWS | DOES NOT KNOW | ||
| 263 57.42% | 195 42.58% | |||
| Type of dental procedure | Extraction | Implant placement | ||
| 220 48.03% | 217 47.38% | |||
| 15. The need to discontinue BF th. Before an invasive procedure | KNOWS | DOES NOT KNOW | ||
| 155 33.84% | 303 66.16% | |||
| 16. Procedures to reduce the risk of complications | KNOWS | DOES NOT KNOW | ||
| 140 30.57% | 318 69.43% |
Table 6
Analysis of questions from the DDM knowledge questionnaire - knowledge of complications of BF therapy, risks, factors, and types of dental procedures - only specialists in oral surgery are included.
| Number of questions and keywords from the question | Answers to the questions in percentages and the number of DDMs who have chosen the listed answer | |||
| 11. Indications for the use of BF | KNOWS | DOES NOT KNOW | ||
| 27 72.97% | 10 27.03% | |||
| Diseases for which BF is applied | Osteoporosis | Multiple myeloma | Bone metastases | |
| 25 67.57% | 21 56.76% | 27 72.97% | ||
| 12. Method of BF administration and risk of osteonecrosis | po. | iv. | EQUALLY | DOES NOT KNOW |
| 0 0% | 30 81.08% | 2 5.41% | 5 13.51% | |
| 13. Factors influencing the occurrence of osteonecrosis | KNOWS | DOES NOT KNOW | ||
| 28 75.68% | 9 24.32% | |||
| 14. Relationship between dental procedure and risk for the development of osteonecrosis | KNOWS | DOES NOT KNOW | ||
| 31 83.78% | 6 16.22% | |||
| Type of dental procedure | Extraction | Implant placement | Subgingival scaling | |
| 29 78.38% | 29 78.38% | 7 18.92% | ||
| 15. The need to discontinue BF th. Before an invasive procedure | KNOWS | DOES NOT KNOW | ||
| 28 7568% | 9 24.32% | |||
| 16. Procedures to reduce the risk of complications | KNOWS | DOES NOT KNOW | ||
| 26 70.27% | 11 29.73% |
The study found that: 39.74% of DDMs know the indications for the use of AR/BF. 67.57% of DDMs know that the main indication for the use of AR/BF therapy is osteoporosis, 41.92% know that AR is also indicated in bone metastases, while only 23.80% of DDMs managed to mention multiple myeloma as an indication; oral surgeons, as physicians who primarily treat patients with osteonecrosis, have shown better knowledge. 72.97% of oral surgeons know the indications for the use of AR/BF therapy. 72.97% point out that the BF/AR therapy is indicated for bone metastases, 67.57% for osteoporosis, and 56.76% state multiple myeloma as an indication for this therapy; 49.13% of DDMs do not know which way to administer AR/BF therapy or that it carries a higher risk of developing osteonecrosis. Only 13.51% of oral surgery specialists do not know the same data; 66.16% of respondents do not know whether bisphosphonate therapy should be discontinued before invasive dental surgery, while 75.68% of oral surgery specialists are aware of this issue. Complication reduction factors were accurately indicated by 30.57% DDM`s. Greater knowledge was shown by oral surgeons. The main complication of AR/BF therapy is precisely determined by 63.32% DDMs, equal representation of responses in physicians with and without specialization: 59.27% without specialization, 89.19% oral surgery specialists, 73.91% prosthodontics specialists, 50.00% periodontology specialists. The degree of academic education also correlates with the number of correct answers. Doctors with a Ph.D. (87.76%), a Master's Degree (70.21%), and doctors who are currently in postgraduate studies (87.50%) show better knowledge than doctors who have not done postgraduate studies (58.47%). Considering the working place, DDMs employed in a polyclinic, hospital, or School of Dental Medicine answered the question about the main complication of AR/BF therapy more accurately. More than 90% answered correctly; DDM`s knowledge of AR/BF is inversely proportional to work experience. 86.55% of DDMs with less than five years of work experience correctly answered the question about the main complication of AR/BF therapy, while only 33.33% of DDMs with more than 21 years of work experience answered the same question correctly; 57.42% of DDM`s do not know which procedures should not be performed on patients under AR/BF therapy, and only 20.97% of DDMs would refer such patients to a specialist; 10.81% of oral surgeons successfully treat complications, and 40.54% of oral surgeons partially successfully treat complications. It was recorded that 291 patients with osteonecrosis were treated, averaging 0.64 per physician. Of these, 144 were treated by oral surgery specialists, 3.89 per oral surgeon; 69.43% of DDMs claim that in the last 5 years, they have not taken any course on this issue because it was not organized. 6.77% of DDMs are not interested in this topic. 93.89% of respondents would like to know more.
DISCUSSION
The incidence of MRONJ in recent years has increased significantly ( 9 , 17 - 25 ). Constant education of both patients and therapists is necessary with an accent on prevention and early detection of complications caused by these drugs.
In 2015, a pilot study was conducted on the knowledge of DDMs on the side effects of BF therapy in the Republic of Croatia ( 26 ). The results ( 26 ) showed that 44.1% of the DDMs did not know that osteonecrosis was the main complication of BF therapy. For these reasons, a study collected information on knowledge of DDMs about AR/BF drugs and side effects of the therapy from the entire territory of the Republic of Croatia to obtain representative data on this topic, which was achieved given the response percentage of the questionnaire.
The study showed that 36.68% of DDMs did not know that osteonecrosis was a major complication of BF therapy. Results vary significantly by academic degree, specialization, place of work, county, and work experience. These results are consistent with the results of many publications ranging from 16.67% - 59.5% ( 22 - 24 , 27 - 33 ). Various publications exclude oral surgeons from research because it is assumed that they deviate from the average with their knowledge ( 26 ). The study compared knowledge about BF, osteonecrosis, and disease treatment between oral surgeons and other DDMs and showed that the results differed significantly, which is consistent with many publications ( 24 , 27 ). If specialists from various branches of dental medicine are excluded from the research, 40.73% of the DDMs do not know that osteonecrosis is the main complication of BF therapy.
In the study, subjects encountered 291 osteonecroses, averaging 0.64 per physician. It is a worrying fact that 60.26% of respondents do not know the main indications for the use of BF, 53.26% do not know the factors that influence the onset of the disease and 42.58% do not know which procedures are not recommended for patients on BF therapy. Dentoalveolar surgery is a major risk factor for the development of MRONJ. This data states that DDM education on detailed anamnesis, BF recognition, risk assessment of the disease and the recognition of the disease itself is extremely important.
The length of work experience was shown to be a major factor in recognizing and being informed about the disease. The most correct answers were given by DDMs with less than 5 years of work experience due to the fact that they have been increasingly informed about this topic during their studies in recent years, while the least correct answers were given by DDMs with more than 20 years of work experience, which is consistent with many publications ( 24 - 27 , 29 ).
The prevention and treatment of MRONJ require the cooperation of physicians and DDMs ( 34 - 36 ). The worrying results from this study demonstrate that additional education is needed for all physicians considering the prevention and early detection of this disease. It is a promising fact that during the survey 93.89% of respondents expressed a desire to be educated about the issue. All participant DDMs received a brochure as part of the national disease prevention program, so we expect better results and understanding on this topic in the future.
CONCLUSION
Osteonecrosis reduces the quality of life and requires long-term and complex treatment. Due to the increased incidence of osteonecrosis over the past few years, it is important to establish DDM`s knowledge on the same issue. Prevention and early diagnosis are most important in reducing its incidence. This is evidenced by the national program of Information and prevention of side effects of antiresorptive therapy, which was also the impetus for this study. It is recommended that lifelong learning about this issue preferably with multidisciplinary collaboration is necessary to prevent and treat this disease.
Anonymous questionnaire on the side effects of BF/AR therapy in the oral cavity
BIPHOSPHONATE (ANTIRESORPTIVE) THERAPY IN DENTAL MEDICINE
Q1 SEX M F
Q2 YEAR OF BIRTH:
Q3 YEAR OF GRADUATION:
Q4 HAVE YOU SPECIALIZED IN SOMETHING?
A) NO
B) YES (NAME OF SPECIALIZATION))
Q5 HAVE YOU COMPLETED POSTGRADUATE STUDIES?
A) I HAVEN’T
B) SPECIALIST POSTGRADUATE STUDY (MASTER'S DEGREE)
C) DOCTORAL POSTGRADUATE STUDIES
Q6 WHICH COUNTY DO YOU WORK IN AS A DOCTOR OF DENTAL MEDICINE?
Q7 IN WHICH INSTITUTION DO YOU PERFORM THE JOB OF DENTAL MEDICINE DOCTOR?
A) OWN PRACTICE
B) HEALTH CENTER
C) POLYCLINIC
D) HOSPITAL
E) FACULTY
Q8 DID YOU GAIN KNOWLEDGE ABOUT THE APPLICATION OF BIPHOSPHONATE (ANTIRESOPTIVE) THERAPY DURING YOUR EDUCATION?
A) YES
B) NO
Q9 DO YOU KNOW THE MAIN COMPLICATIONS OF BIPHOSPHONATE (ANTIRESOPTIVE) APPLICATION IN THE ORAL CAVITY?
A) SUBPERIOSTEAL AND CENTRAL OSTEOMA OF THE JAW
B) GENERALIZED PERIODONTITIS AND GINGIVITIS
C) OSTEONECROSIS OF THE JAW
D) DRY OR BURNING MOUTH SYNDROME
E) I DON'T KNOW
Q 10 HAVE YOU ENCOUNTERED COMPLICATIONS OF BIPHOSPHONATE THERAPY DURING YOUR WORK?
A) YES
B) NO
C) I'M NOT SURE
Q11 CIRCULATE THE INDICATIONS OF BIPHOSPHONATE (ANTIRESORPTIVE) USE KNOWN TO YOU (MULTIPLE ANSWERS):
A) OSTEOARTHRITIS
B) OSTEOPOROSIS
C) METASTATIC PROSTATE CANCER
D) SYSTEMIC ERYTHEMATIC LUPUS
E) MULTIPLE MYELOMA
F) DIABETES MELLITUS
D) ANEMIA
H) METASTATIC BREAST CANCER
I) MULTIPLE SCLEROSIS
J) ADDISON'S DISEASE
K) I AM NOT AWARE OF THIS ISSUE
Q12 HIGHER RISK FOR COMPLICATIONS IN THE ORAL CAVITY CAUSES:
A) ORAL ADMINISTRATION OF BISPHOSPHONATES
B) INTRAVENOUS APPLICATION OF BIPHOSPHONATE
C) EQUALLY (Irrespective of the METHOD OF APPLICATION)
D) I'M NOT SURE
Q13 WHICH FACTORS AFFECT THE COMPLICATION OF COMPLICATIONS CAUSED BY BIPHOSPHONTIC DRUGS? (MORE ANSWERS)
A) AGE OF 60 AND OVER
B) ARTIFICIAL HEART VALVES
C) CORTICOSTEROID THERAPY
D) SMOKING
E) KIDNEY INSUFFICIENCY
F) LONG-TERM BISPHOSPHONATE THERAPY
D) I'M NOT SURE
Q14 WHICH DENTAL PROCEDURES WOULD YOU POSTPONE ON PATIENTS WHO HAVE RECEIVED OR ARE CURRENTLY ON BIPHOSPHONATE THERAPY WITHOUT PRIOR CONSULTATION WITH SPECIALISTS? (MORE ANSWERS)
A) ENDODONTIC TREATMENT
B) TEETH EXTRACTION
C) ENDODONTIC SURGERY (APICOECTOMY)
D) PRODUCTION OF PROSTHETIC SUBSTITUTE
E) INSTALLATION OF DENTAL IMPLANT
F) SUPRAGINGIVAL REMOVAL OF HARD DENTAL DEPOSITS
G) SUBGINGIVAL REMOVAL OF HARD DENTAL DEPOSITS
H) I'M NOT SURE
Q15 IS THERE A NEED TO STOP BIPHOSPHONATE THERAPY BEFORE AN INVASIVE DENTAL PROCEDURE? (MORE ANSWERS)
A) NO NEED
B) YES, IT DEPENDS ON THE DURATION OF THE SAME THERAPY
C) YES, IT DEPENDS ON THE METHOD OF APPLICATION OF BIPHOSPHONATE
D) I'M NOT SURE
Q 16 DO YOU KNOW WHICH FACTORS AFFECT COMPLICATION REDUCTION IN PATIENTS ON BISPHOSPHONATE THERAPY? (MORE CORRECT ANSWERS)
A) USE OF ANTIBIOTICS
B) TOPICAL RINSING WITH ANTISEPTIC LIQUIDS
C) ENHANCED ORAL HYGIENE
D) ADDITIONAL USE OF VITAMIN
E) TYPE OF DENTAL PROCEDURE
F) I'M NOT SURE
Q 17 DO YOU THINK YOU CAN EVALUATE WHEN TO PERFORM A PROCEDURE ON A PATIENT AND WHEN TO CONTACT A SPECIALIST?
A) YES
B) NO
Q18 HOW MANY COMPLICATIONS HAVE YOU ENCOUNTERED RELATED TO BISPHOSPHONATE THERAPY, WHAT ARE YOUR EXPERIENCES?
A) I COMPLY WITH COMPLICATIONS TO A SPECIALIST
B) I SUCCESSFULLY TREAT COMPLICATIONS
C) I PARTIALLY SUCCESSFULLY TREAT COMPLICATIONS
D) I AM SUCCESSFULLY TREATING COMPLICATIONS
Q19 HOW MANY COMPLICATIONS HAVE YOU ENCOUNTERED SINCE (NUMBER OF PATIENTS)? ________
Q 20 HAVE YOU PARTICIPATED IN A COURSE 5 YEARS AGO IN WHICH THE TOPIC WAS THE SIDE EFFECTS OF BIPHOSPHONATE (ANTIRESOPTIVE) THERAPY?
A) YES
B) NO, SUCH A COURSE WAS NOT ORGANIZED
C) NO, I THINK I KNOW ENOUGH ABOUT THIS TOPIC
D) NO, I AM NOT INTERESTED IN THIS TOPIC
Q21 WOULD YOU LIKE TO KNOW MORE ABOUT THE THERAPY AND SIDE EFFECTS OF BIPHOSPHONATE (ANTIRESOPTIVE) THERAPY?
A) YES
B) NO
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