UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2024.e4125
1
Braz Dent Sci 2024 Jan/Mar; 27 (1): e4125
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Knowledge of Brazilian dentists about bisphosphonate-associated
osteonecrosis of the jaw
Conhecimento de dentistas brasileiros sobre a osteonecrose dos maxilares associada ao uso de bisfosfonatos
Thainara Alexia Marinho de SOUZA1 , Gabriela Ribeiro ZUCCO1 , Janete Dias ALMEIDA1
1 - Universidade Estadual Paulista “Júlio de Mesquita Filho”, Instituto de Ciência e Tecnologia, Departamento de Biociências e Diagnóstico Bucal.
São José dos Campos, SP, Brazil.
How to cite: Souza TAM, Zucco GR, Almeida JD. Knowledge of Brazilian dentists about bisphosphonate-associated osteonecrosis of the jaw.
Braz Dent Sci. 2024; 27(1):e4125. https://doi.org/10.4322/bds.2024.e4125
ABSTRACT
Osteonecrosis of the jaw associated with bisphosphonate use is a matter of utmost importance in clinical practice
for the safe treatment of patients using this medication. Objective: The aim of this study was to evaluate the
level of knowledge of dentists who carry out clinical practice about bisphosphonate-associated jaw osteonecrosis.
Material and Methods: The methodology used in the present research consisted of a non-probability sampling approach
for the selection of participants. To conduct the study, a questionnaire created on the Google Forms platform was sent via
Direct on Instagram to the professionals who agreed to participate. The data were sent for analysis, using the frequency
for each response, and the professionals were divided into subcategories according to their time of professional practice.
Results: Participants were familiar with the purpose of the medication (65%) or had heard of it (34%); regarding
the professionals’ opinion on their knowledge and practice about bisphosphonate-related osteonecrosis a signicant
percentage (93.24%) responded positively regarding the existence of side effects resulting from the therapeutic use of
bisphosphonates and 48.65% self-evaluated their level of knowledge on the subject as insufcient. Conclusion: The
study reveals that almost all participating dentists have good knowledge about the effects caused by bisphosphonates,
but some of them still do not feel specically condent about the management and knowledge of jaw osteonecrosis.
KEYWORDS
Bisphosphonate-Associated Osteonecrosis; Bisphosphonates; Jaw; Knowledge; Osteonecrosis.
RESUMO
A osteonecrose dos maxilares associada ao uso de bisfosfonatos é um assunto de suma importância na prática clínica para
o atendimento seguro dos pacientes que fazem uso terapêutico do medicamento. Objetivo: O objetivo deste trabalho
foi avaliar o nível de conhecimento de cirurgiões dentistas que realizam atendimento clínico acerca da osteonecrose
dos maxilares associada ao uso dos bisfosfonatos. Material e Métodos: A metodologia utilizada na presente pesquisa
consistiu em uma abordagem de amostragem não probabilística para a seleção dos participantes. Para conduzir o
estudo, enviamos um questionário criado na plataforma Google Forms via Direct no Instagram para os prossionais
que concordaram em participar. Os dados foram enviados para análise, usando a frequência para cada resposta, sendo
que os prossionais foram divididos em subcategorias por tempo de formação. Resultados: Os participantes estavam
familiarizados com a nalidade do medicamento (65%) ou já haviam ouvido falar deles (34%); em relação à opinião
dos prossionais sobre seu conhecimento e prática acerca da osteonecrose relacionada aos bisfosfonatos, observou-se
que 48,65% autoavaliaram seu nível de conhecimento sobre o assunto como insuciente e uma parcela expressiva
(93,24%) respondeu positivamente em relação à existência de efeitos colaterais decorrentes ao uso terapêutico dos
bisfosfonatos. Conclusão: O estudo revela que quase todos os dentistas participantes possuem um bom conhecimento
acerca dos efeitos causados pelos bisfosfonatos, mas que parte deles ainda não se sentem seguros especicamente em
relação ao manejo e conhecimento da osteonecrose dos maxilares.
PALAVRAS-CHAVE
Osteonecrose Associada aos Bisfosfonatos; Bisfosfonatos; Maxilares; Conhecimento; Osteonecrose.
2
Braz Dent Sci 2024 Jan/Mar; 27 (1): e4125
Souza TAM et al.
Knowledge of Brazilian dentists about bisphosphonate-associated osteonecr osis of the jaw
Souza TAM et al.
Knowledge of Brazilian dentists about bisphosphonate-associated
osteonecrosis of the jaw
INTRODUCTION
Bisphosphonates are antiresorptive drugs
that are part of a class of drugs that have high
afnity for bone tissue and bind to hydroxyapatite
crystals. The medication has a short half-life in
plasma, however, it can remain for up to 10
years inside the tissue, preventing the action of
osteoclasts and, consequently, inhibiting bone
remodeling [1-4]. This type of medication is
often used in the treatment of diseases such as
osteoporosis, multiple myeloma, bone metastasis,
Paget’s disease, heterotopic ossification,
brous dysplasia, osteogenesis imperfecta and
hypercalcemia [1,5]. Depending on the duration
of the treatment, route of administration and
dosage, they can cause some side effects, such
as jaw osteonecrosis [6].
Bisphosphonate-associated jaw osteonecrosis
is characterized by exposed bone for more
than eight weeks in individuals treated with
bisphosphonates and with no history of
radiotherapy, in addition, it is considered a
complex and multifactorial process because it
presents some risk factors that contribute to
its development, such as the administration of
intravenous bisphosphonates, tooth extraction,
jaw injuries and poorly positioned partial
dentures [1,7]. In addition to bisphosphonates,
alendronate, zoledronate, and other drugs such
as denosumab and antiangiogenics are related
to osteonecrosis of the jaw [8]. For preventing,
diagnosing, and treating this disease in the most
appropriate manner, it is essential that dentists
possess knowledge about this pathology [9].
The maxillary bones are affected due to their
location, intimate contact with the oral cavity
and their corresponding microbiota [7,10]. This
condition can be categorized into four stages: (0)
no evidence of necrotic bone, but with the presence
of undened symptoms; (1) bone stripping with
no signs of infection; (2) pain and swelling,
suggesting bacterial infection; (3) infection beyond
the alveolar level; (4) bone exposure with the
addition of other symptoms [7,11].
In dentistry, preventive measures are
recommended before, after and during initiation
of bisphosphonate therapy. Thus, the professional
must carry out a complete and careful anamnesis,
leading the appointment based on the medical
history and use of pharmacological medication of
each patient and paying attention to the groups of
risk for the development of osteonecrosis [12-14].
Bearing in mind the factors that lead to the
unfolding of jaw osteonecrosis, it is understood
that this is a topic that should have the attention
of dentists, therefore it is necessary to know what
is the level of knowledge of professionals around
the subject. This research aimed to evaluate
the level of knowledge of dentists with clinical
practice on the theme bisphosphonate-associated
osteonecrosis of the jaw.
MATERIALS & METHODS
This is a descriptive observational study
of a qualitative nature, with data collection
through questionnaires applied to volunteers.
The methodology used in the present research
consisted of a non-probability sampling approach
to select the participants. The questionnaire was
carried out with general dentists and specialist,
and distributed through the Instagram social
network during the COVID-19 pandemic due to
the impossibility of face-to-face interviews.
After receiving approval with protocol number
5.006.594 from the Human Research Ethics
Committee (CAAE 48569821.0.0000.0077), the
questionnaire, previously prepared and adapted from
Hristamyan-Cilev et al. [1] and Masson et al. [15],
on knowledge about osteonecrosis induced by
bisphosphonates, was sent to dentists via Direct on
Instagram. All participants that agreed to answer the
questionnaire, rst signed the Consent Form. This
form outlined the research objective, the benets
of professional participation, and assured the
condentiality and secrecy of responses. Participants
completed the questionnaire using the digital
platform “Google Forms” which was individually
dispatched through Direct on Instagram.
It is crucial to emphasize that the research
was conducted during the COVID-19 pandemic, a
challenging period to secure the participation of
a signicant number of individuals. The adopted
strategy aimed to encompass maximum diversity
within the target population, taking into account
the availability and willingness to respond to the
questionnaire. Therefore, participant selection
was conducted for convenience, based on the
analysis of the bio/prole of professionals in the
eld of Dentistry.
The questionnaire consisted of 30 questions
(27 objective questions and 3 discursive questions)
divided into three blocks. The rst block addressed
topics of a personal and professional nature
3
Braz Dent Sci 2024 Jan/Mar; 27 (1): e4125
Souza TAM et al.
Knowledge of Brazilian dentists about bisphosphonate-associated osteonecr osis of the jaw
Souza TAM et al.
Knowledge of Brazilian dentists about bisphosphonate-associated
osteonecrosis of the jaw
(gender, age, length of experience, area of
specialization, main place of work). The second
block consisted of questions related to clinical
practice and knowledge about bisphosphonates;
the third block formed by the 3 discursive questions
addressed the self-assessment of dentists about
their own knowledge and professional colleagues
knowledge.
A pre-test with 10 questions was used before
sending the 30-question questionnaire to the
professionals to ensure cohesion and compliance
to validate the answers. The pre-test used was
reviewed by a Linguistics Professsor from the
Federal University of Rio Grande do Sul (UFRGS),
Brazil, Maria José Bocorny Finatto.
The data obtained from the objective questions
were analyzed in SPSS® (version 20), MiniTab®
(version 16) and Microsoft Excel 2010, and a
quantitative exploratory study was carried out.
For the discursive questions, discourse analysis
was carried out.
To characterize the distribution of the relative
frequency (percentages) of each of the questions,
the Equality of Two Proportions test was used to
compare the percentages (indices) between them
and we emphasize that the indices were always
calculated for a total of 74 respondents. The level
of signicance was of 0.05 (5%).
RESULTS
Seventy-four professionals answered the
questionnaire. Considering the profile of the
professionals, it was found that most of the
participants were women (81.08%) and mean
age was 31.6 ± 1.9 years. The majority (55.41%)
have up to 5 years of graduation and professional
experience, and only 26% of them said they had
encountered patients who had complications due
to the use of bisphosphonates.
Regarding knowledge about the indication
of bisphosphonates, the participants were familiar
with the purpose of the medication (65%) or
had already heard about it (34%); correctly
identied the indication for osteoporosis (93%),
bone metastasis (49%) and Paget’s disease (15%)
(Table I).
In Table II, it is possible to verify that most
professionals (95%) identied the dental implant
surgery as one of the risk procedures for jaw
osteonecrosis in patients who use bisphosphonates.
As for the route of administration, 31% answered
that the intravenous administration had the
highest risk for jaw osteonecrosis.
Table III reports the clinical conduct of
professionals in cases of osteonecrosis, where
the majority of participants (93.24%) believe
it is necessary to perform a dental examination
before starting treatment with bisphosphonates.
In case of doubt, whether or not the patient has
complications due to the medication, 74.32%
would refer the case to the general surgeon or
oral and maxillofacial dentist.
About the opinion of professionals on their
knowledge and practice regarding osteonecrosis
related to bisphosphonates, it was observed that
48.65% self-assessed their level of knowledge
on the subject as insufcient, however, 48.65%
claimed to have acquired knowledge about
the complications during graduation from
dental school (Graph 1), and also, a signicant
percentage, 93.24% responded positively in
relation to the existence of side effects resulting
from the therapeutic use of bisphosphonates.
Table I - Dentists knowledge about the indication of bisphosphonates
Bisphosphonates Indications Total n (%) P-value
Osteoporosis 69 (93.2) Ref.
Bone Metastasis 36 (48.6) <0.001
Rheumatoid Arthritis 7 (9.5) <0.001
Diabetes - -
Paget’s Disease 11 (14.9) <0.001
Hypertension - -
The total value of responses to items exceeds the number of
respondents. as the question allowed more than one answer.
Ref. (reference): most prevalent answers.
Table II - Dentists knowledge about risk factors for jaw osteonecrosis
Risk factors for jaw osteonecrosis Total n (%) P-value
Dental implant surgery 70 (94.6) Ref.
Tooth extraction 63 (85.61) 0.057
Orthodontic treatment 24 (32.4) <0.001
Partial dentures 10 (13.5) <0.001
Endodontic treatment 10 (13.5) <0.001
Tartar removal 6 (8.1) <0.001
Other surgical manipulations 54 (73) <0.001
Intravenous administration 23 (31.1) 0.387
Oral administration 5 (6.8) <0.001
All forms of administration present
the same risk 18 (24.3) 0.076
Ref. (reference): most prevalent answers.
4
Braz Dent Sci 2024 Jan/Mar; 27 (1): e4125
Souza TAM et al.
Knowledge of Brazilian dentists about bisphosphonate-associated osteonecr osis of the jaw
Souza TAM et al.
Knowledge of Brazilian dentists about bisphosphonate-associated
osteonecrosis of the jaw
DISCUSSION
The aim of this study was to assess dentists’
knowledge concerning bisphosphonate-associated
jaw osteonecrosis, a condition reported by Marx [16]
and Migliorati [17]. Intravenous bisphosphonates,
as highlighted by Ruggiero et al. [11], are
antiresorptive drugs prescribed for cancer-related
conditions such as malignant hypercalcemia, bone
metastasis in solid tumors (e.g., breast, prostate,
lung cancer), and for the management of lytic
lesions such as multiple myeloma. Orally ingested
bisphosphonates are indicated for osteopenia and
osteoporosis [11,16-18].
In our study, a signicant majority of dentists
(93.24%) demonstrated awareness of side effects
resulting from bisphosphonate use. However,
when asked to self-evaluate their knowledge
and management of jaw osteonecrosis, 48.65%
felt they lacked sufcient expertise. This echoes
ndings from studies by Hristamyan-Cilev et al. [1],
Alhussain et al. [19], El Osta et al. [20], and others,
emphasizing a need for targeted education [21,22].
A survey carried out by Hristamyan-
Cilev et al. [1] with 323 dentists in Plovdiv,
Bulgaria, showed that approximately 70% of the
participants knew for which uses bisphosphonates
Table III - Conduct of professionals facing osteonecrosis of the jaws
Clinical Conduct Total n (%) P-value
Is a dental examination necessary before starting
treatment with bisphosphonates?
Yes 69 (93.2) Ref.
No 1 (1.4) <0.001
I’m not sure 4 (5.4) <0.001
Routine exams
Clinical examination 4 (5.4) <0.001
Clinical examination + imaging exams
+ biopsy 19 (25.7) <0.001
Clinical examination and biopsy 1 (1.4) <0.001
Clinical examination and imaging exams 50 (67.6) Ref.
Would you do the mentioned exams?
Yes 56 (75.7) Ref.
No 5 (6.8) <0.001
I’m not sure 13 (17.6) <0.001
Would refer the case to which professional?
General surgeon or oral and maxillofacial
dentist.
55 (74.3) Ref.
Oncologist 5 (6.8) <0.001
Orthopedist 3 (4.1) <0.001
Periodontist 4 (5.4) <0.001
Ref. (reference): most prevalent answers.
Graph 1 - How/where did you learn about the possible complications of treatment with bisphosphonates?
5
Braz Dent Sci 2024 Jan/Mar; 27 (1): e4125
Souza TAM et al.
Knowledge of Brazilian dentists about bisphosphonate-associated osteonecr osis of the jaw
Souza TAM et al.
Knowledge of Brazilian dentists about bisphosphonate-associated
osteonecrosis of the jaw
are directed, however only 14.86% were aware
that partial dentures are one of the risk factors
for the occurrence of jaw osteonecrosis in patients
who make use of the drug [1]. A research by
Al-Eid et al. [21] in Saudi Arabia, pointed out that
60.8% of the interviewed dentists were aware of
bisphosphonate-associated jaw osteonecrosis, and
39.2% said they did not know what this condition
was. Another study conducted with a sample of
100 dentistry students from private institutions
in the state of São Paulo, Brazil, showed that
their knowledge about bisphosphonates and
bisphosphonate-related osteonecrosis of the
jaw were variable, where 60% of the students
recognized osteonecrosis of the jaws as a side
effect of bisphosphonates and 56% identied at
least one risk factor associated with the drug, but
on the other hand, 66% of the students did not
recognize any bisphosphonate and 79% did not
recognize their trademark names [22].
Understanding the frequency of patients
using bisphosphonates (35.14% of participants
annually), we underscore the importance of
all dentists being aware of the drug’s effects,
as patients are often unfamiliar with their
medications [23]. Risk factors highlighted by
the American Association of Oral Maxillofacial
Surgeon, including dentoalveolar surgeries
(extractions, implants, periodontal procedures)
and anatomical factors (more common in the
mandible than in the maxilla, due to greater
bone mineral density), further emphasize the
need for a thorough anamnesis and proactive
measures before initiating bisphosphonate
therapy [5,6,15,24,25].
The diagnosis of bisphosphonate-associated
jaw osteonecrosis is reliant on a comprehensive
clinical history, complemented by imaging exams
like CT scans and MRIs [21]. Our study revealed
a positive inclination among participants toward
routine exams and clinical dental examinations
for patients on or starting bisphosphonate
treatment.
Recognizing the imperative to disseminate
our ndings, especially among dentists and health
professionals nationwide, we draw attention to a
signicant gap in dental education, as highlighted
by Maeda et al. [22]. Urging investment in
continuous education, we propose integrating
bisphosphonate-focused classes into academic
curricula to better prepare future professionals
from the outset.
Our findings underscore the need for a
strategic enhancement of educational curricula
within institutions to ensure a more comprehensive
understanding among dentists. By incorporating
topics pertinent to our study, we aim not only to
bolster dentists’ knowledge but also to enhance
safety protocols associated with procedures related
to bisphosphonates. This focused educational
approach will empower dental professionals
to navigate challenges condently, ultimately
contributing to the overall improvement of
patient care in the evolving landscape of oral
healthcare.
Continuous education is paramount in
cultivating a dental community that is well-
informed about bisphosphonate-associated
conditions and equipped with the condence to
manage such cases effectively. These ongoing
efforts will bridge existing knowledge gaps, leading
to a safer and more procient dental practice. This,
in turn, will benet both practitioners and patients
alike, ensuring a higher standard of care within
the dental community.
CONCLUSION
In conclusion, our study highlights
a commendable level of awareness among
participating dentists regarding the effects of
bisphosphonates. However, a notable percentage
expresses reservations about their condence in
managing and understanding jaw osteonecrosis.
This underscores the importance of addressing
specific aspects of bisphosphonate-associated
conditions in dental education.
Acknowledgements
Prof. Dr. Maria José Bocorny Finatto (Federal
University of Rio Grande do Sul, UFRGS) for
reviewing the pre-test.
Author’s Contributions
TAMS: Formal Analysis, Investigation,
Resources, Data Curation, Writing – Review &
Editing, Visualization. GRZ: Formal Analysis,
Investigation, Resources, Data Curation,
Writing – Review & Editing, Visualization. JDA:
Conceptualization, Methodology, Formal Analysis,
Writing – Original Draft Preparation, Writing –
Review & Editing, Visualization, Supervision.
6
Braz Dent Sci 2024 Jan/Mar; 27 (1): e4125
Souza TAM et al.
Knowledge of Brazilian dentists about bisphosphonate-associated osteonecr osis of the jaw
Souza TAM et al.
Knowledge of Brazilian dentists about bisphosphonate-associated
osteonecrosis of the jaw
Conict of Interest
The authors have no proprietary, nancial,
or other personal interest of any nature or kind
in any product, service, and/or company that is
presented in this article.
Funding
PIBIC Unesp for the scientific initiation
scholarship (process 4004 - Notice 4/2022)
and São Paulo Research Foundation (FAPESP)
grants #2020/10362-0 (Almeida JD) and
#2021/06500-1 (Zucco GR).
Regulatory Statement
This study was conducted in accordance
with all the provisions of the local human
subjects oversight committee guidelines and
policies of: Human Research Ethics Committee.
The approval code for this study is: (CAAE
48569821.0.0000.0077).
REFERENCES
1. Hristamyan-Cilev MA, Pechalova PP, Raycheva RD, Hristamyan
VP, Kevorkyan AK, Stoilova YD. Bisphosphonate-associated
osteonecrosis of the jaws: a survey of the level of knowledge
of dentists about the risks of bisphosphonate therapy.
Folia Med. 2019;61(2):303-11. http://dx.doi.org/10.2478/
folmed-2018-0075. PMid:31301653.
2. Moraes SLC, Afonso AMP, Santos RG, Mattos RP, Oliveira MTF,
Zanetta-Barbosa D,etal. Riscos e complicações para os ossos
da face decorrentes do uso de bisfosfonatos. Rev Bras Odontol.
2013;70(2):114-9.
3. Walter C, Grötz KA, Kunkel M, Al-Nawas B. Prevalence
of bisphosphonate associated osteonecrosis of the jaw
within the field of osteonecrosis. Support Care Cancer.
2007;15(2):197-202. http://dx.doi.org/10.1007/s00520-006-
0120-z. PMid:16941133.
4. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis
of the jaws associated with the use of bisphosphonates: a
review of 63 cases. J Oral Maxillofac Surg. 2004;62(5):527-34.
http://dx.doi.org/10.1016/j.joms.2004.02.004. PMid:15122554.
5. Watts NB. Long-term risks of bisphosphonate therapy. Arq
Bras Endocrinol Metabol. 2014;58(5):523-9. http://dx.doi.
org/10.1590/0004-2730000003308. PMid:25166043.
6. Saldanha S, Shenoy VK, Eachampati P, Uppal N. Dental
implications of bisphophonate-related osteonecrosis.
Gerodontology. 2012;29(3):177-87. http://dx.doi.org/10.1111/
j.1741-2358.2012.00622.x. PMid:22486711.
7. Kim J, Lee DH, Dziak R, Ciancio S. Bisphosphonate-related
osteonecrosis of the jaw: current clinical significance and
treatment strategy review. Am J Dent. 2020;33(3):115-28.
PMid:32470236.
8. Eguia A, Bagán-Debón L, Cardona F. Review and update on
drugs related to the development of osteonecrosis of the jaw.
Med Oral Patol Oral Cir Bucal. 2020;25(1):e71-83. http://dx.doi.
org/10.4317/medoral.23191. PMid:31880288.
9. Barin LM, Pillusky FM, Barcelos RCS, Escobar CAB, Danesi
CC. Surgical treatment of osteonecrosis associated with
bisphosphonates: a case report. Braz Dent Sci. 2017;20(3):132-41.
http://dx.doi.org/10.14295/bds.2017.v20i3.1362.
10. Dotto ML, Dotto AC. Osteonecrose dos maxilares induzida por
bisfosfonatos - revisão de literatura e relato de caso. Rev Fac
Odontol. 2011;16(2):229-33.
11. Ruggiero SL, Dodson TB, Fantasia J, Goodday R, Aghaloo
T, Mehrotra B,etal. American Association of Oral and
Maxillofacial Surgeons position paper on medication-related
osteonecrosis of the jaw--2014 update. J Oral Maxillofac
Surg. 2014;72(10):1938-56. http://dx.doi.org/10.1016/j.
joms.2014.04.031. PMid:25234529.
12. Ribeiro BALM, Oliveira DB, Silva MG, Saraiva WF, Rabelo PMS
Jr R, Casanovas RC. Antirreabsortivos ósseos em pacientes
odontológicos: noções de conduta para o cirurgião-dentista:
uma revisão integrativa. Braz J Health Rev. 2021;4(2):8744-62.
http://dx.doi.org/10.34119/bjhrv4n2-387.
13. Marx RE, Sawatari Y, Fortin M, Broumand V. Bisphosphonate-
induced exposed bone (osteonecrosis/osteopetrosis) of the
jaws: risk factors, recognition, prevention, and treatment.
J Oral Maxillofac Surg. 2005;63(11):1567-75. http://dx.doi.
org/10.1016/j.joms.2005.07.010. PMid:16243172.
14. Vassiliou V, Tselis N, Kardamakis D. Osteonecrosis of the jaws:
clinicopathologic and radiologic characteristics, preventive and
therapeutic strategies. Strahlenther Onkol. 2010;186(7):367-73.
http://dx.doi.org/10.1007/s00066-010-2066-9. PMid:20437019.
15. Masson DR, O’Callaghan E, Seager M. The knowledge
and attitudes of North Wales healthcare professionals to
bisphosphonate associated osteochemonecrosis of the jaws.
Journal of Disability and Oral Health. 2009;10(4):175-83.
16. Marx RE. Pamidronate (Aredia) and zoledronate (Zometa)
induced avascular necrosis of the jaws: a growing epidemic.
J Oral Maxillofac Surg. 2003;61(9):1115-7. http://dx.doi.
org/10.1016/S0278-2391(03)00720-1. PMid:12966493.
17. Migliorati CA. Bisphosphanates and oral cavity avascular bone
necrosis. J Clin Oncol. 2003;21(22):4253-4. http://dx.doi.
org/10.1200/JCO.2003.99.132. PMid:14615459.
18. López-Jornet P, Camacho-Alonso F, Molina-Miñano F, Gomez-
Garcia F. Bisphosphonate-associated osteonecrosis of the jaw.
Knowledge and attitudes of dentists and dental students: a
preliminary study. J Eval Clin Pract. 2010;16(5):878-82. http://
dx.doi.org/10.1111/j.1365-2753.2009.01203.x. PMid:20663005.
19. Alhussain A, Peel S, Dempster L, Clokie C, Azarpazhooh A.
Knowledge, practices, and opinions of ontario dentists when
treating patients receiving bisphosphonates. J Oral Maxillofac
Surg. 2015;73(6):1095-105. http://dx.doi.org/10.1016/j.
joms.2014.12.040. PMid:25843818.
20. El Osta L, El Osta B, Lakiss S, Hennequin M, El Osta N.
Bisphosphonate-related osteonecrosis of the jaw: awareness
and level of knowledge of Lebanese physicians. Support Care
Cancer. 2015;23(9):2825-31. http://dx.doi.org/10.1007/s00520-
015-2649-1. PMid:25672288.
21. Al-Eid R, Alduwayan T, Bin Khuthaylah M, Al Shemali M. Dentists’
knowledge about medication-related osteonecrosis of the jaw
and its management. Heliyon. 2020;6(7):e04321. http://dx.doi.
org/10.1016/j.heliyon.2020.e04321. PMid:32760820.
22. Maeda CY, Mata PS, Rodrigues SCM, Marcucci M. Knowledge
of dentistry students on bisphosphonate-related osteonecrosis
of the jaw. Braz Dent Sci. 2022;25(2):e2932. http://dx.doi.
org/10.4322/bds.2022.e2932.
23. Bauer JS, Beck N, Kiefer J, Stockmann P, Wichmann M,
Eitner S. Awareness and education of patients receiving
bisphosphonates. J Craniomaxillofac Surg. 2012;40(3):277-82.
http://dx.doi.org/10.1016/j.jcms.2011.04.011. PMid:21612939.
7
Braz Dent Sci 2024 Jan/Mar; 27 (1): e4125
Souza TAM et al.
Knowledge of Brazilian dentists about bisphosphonate-associated osteonecr osis of the jaw
Souza TAM et al.
Knowledge of Brazilian dentists about bisphosphonate-associated
osteonecrosis of the jaw
24. Amazonas EL, Sacht DS, Alves RS, Caires NCM. Atendimento
odontológico a paciente em uso de bifosfonatos: relato de caso.
Research. Soc Dev. 2021;10(9):e22810918103. http://dx.doi.
org/10.33448/rsd-v10i9.18103.
25. Madeira M, Rocha AC, Moreira CA, Aguiar ÁMM, Maeda SS,
Cardoso AS, etal. Prevention and treatment of oral adverse
effects of antiresorptive medications for osteoporosis:
a position paper of the Brazilian Society of Endocrinology and
Metabolism (SBEM), Brazilian Society of Stomatology and Oral
Pathology (Sobep), and Brazilian Association for Bone Evaluation
and Osteometabolism (Abrasso). Arch Endocrinol Metab.
2021;64(6):664-72. PMid:34033275.
Janete Dias Almeida
(Corresponding address)
Universidade Estadual Paulista “Júlio de Mesquita Filho”, Instituto de Ciência e
Tecnologia, Departamento de Biociências e Diagnóstico Bucal, São José dos Campos,
SP, Brazil.
Email: janete.almeida@unesp.br Date submitted: 2023 Nov 01
Accept submission: 2024 Mar 13
