Knowledge, Attitude, and Management of General Dentist toward Medication-related Osteonecrosis of the Jaws

ABSTRACT

Background:

Medication-related osteonecrosis of the jaw (MRONJ) is an intense negative drug response causing increasing bone destruction in the maxillofacial area of patients.

Aims and Objectives:

To evaluate the knowledge and attitude of dental practitioner regarding risk factors of MRONJ in Saudi Arabia.

Materials and Methods:

A cross-sectional, questionnaire survey was carried out in King Khalid Hospital, Al-Kharj among dental practioners.

Results:

Approximately 60% of the practioners had a poor knowledge and there was a weak positive correlation with work experience.

Conclusion:

Poor knowledge regarding the MRONJ invites a continuing dental education specially to focus on general practioners.

INTRODUCTION

Osteonecrosis of the jaw (ONJ) is due to lack of blood supply, which eventually makes exposed bone nonvital. ONJ may either result from radiation therapy to the jaw termed as osteoradionecrosis (ORN) or adverse reaction to certain drugs such as bisphosphonate (BP), sunitinb, and denosumab.

A necrosis condition found in patients with intravenous or oral forms of BP therapy for various bone-related conditions is known as bisphosphonate-related osteonecrosis of the jaw (BRONJ). This manifests in maxillofacial structures as exposed and nonvital bone.[1]

The American Association of Oral and Maxillofacial Surgeon (AAOMS) changed the term of BRONJ to MRONJ in 2014 to accommodate the increasing number of the drugs causing osteonecrosis of jaw including denosumab, bevacizumab, and sunitinb.[2]

Bisphosphonate (BP), an antiresorptive drug, acts as osteoclast function inhibitor which is led to decrease bone remodeling.[3] BP is effective against several conditions such as hypercalcemia of malignancy, multiple myeloma, and osteoporosis[4,5] in addition to skeletal-related events associated with metastatic bone disease along with solid tumors such as prostate, breast, lung cancers, and renal cell carcinoma.[6] The oral form of BP is used to treat osteoporosis, osteogenesis imperfecta, osteopenia in addition to Paget’s disease.[7,8,9,10]

Another antiresorptive has been found known as RANK ligand inhibitor (denosumab) as class of monoclonal antibody which function to inhibit osteoclast[2] in turn reducing the resorption and improve the bone mass.

Antiangiogenic medication comes in two classes: the first is monoclonal antibodies (bevacizumab), which acts by binding to the vascular endothelial growth factor (VEGF) to prevent formation of new blood vessels and subsequently prevents its association with endothelial receptors. The second is tyrosine kinase inhibitor (e.g., sunitinib), which inhibits the tyrosine kinase receptor; both medication is antiangiogenic that has been believed to facilitate the antineoplastic agents delivery.

Assessment of the risks for the patients using antiresorptive drug or antiangiogenic drug depends on type and duration of treatment and underlying medical condition. The severity of MRONJ patients was classified according to the history, types of drug duration, and any adjunctive drugs.

However, the definitive treatment of MRONJ has not yet been fully discovered. So in this condition, the prevention is highly recommended and essential to avoid further complication of MRONJ. As there is no study found to evaluate the knowledge attitude and management about MRONJ toward general dental practitioner (GDP) and interns in Saudi Arabia, the aim of the study was to assess the knowledge and attitude of dental practitioners of Saudi Arabia toward MRONJ.

MATERIALS AND METHODS

After obtaining permission from King Khalid Hospital, Al-Kharj, a questionnaire survey was conducted by interview and web-based to a random sample of dentist in Saudi Arabia, which includes information about MRONJ, opinions, and how to treat patient presenting with MRONJ. The study is designed to evaluate the knowledge, practice, and management by general dentist toward MRONJ patients. The inclusion criteria of the study were general dentists and the exclusion criteria of the study were dental specialist, students, and interns.

Informed consent was taken from each subject during answering the questionnaire. People denying giving consent were excluded. This study was a cross-sectional study. It was conducted among 20–50 years old people. A close-ended questionnaire was designed with 15 questions. Questions were explained whenever necessary and the participants were given assurance regarding the confidentiality of their responses and were requested to mark their answers and complete it individually.

The descriptive statistics were analyzed and all responses were expressed in form of frequencies and percentages. Comparisons were done by using chi-square test and Pearson correlation test using Statistical Package for the Social Sciences (SPSS, IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, N.Y., USA)) for Windows.

RESULTS

Table 1 shows knowledge score of participants. On the basis of knowledge scores, participants were categorized into poor (<50% of score), fair (50%–75%), and good (>75%). Majority of practitioners (60%) were found to have poor knowledge levels regarding MORNJ. Mean knowledge was found to be 6.09 ± 2.1.

Table 1.

Knowledge score of patients

Knowledge level	Frequency	Percent
Poor	124	59.9
Fair	78	37.7
Good	5	2.4
Total	207	100.0

Table 2 shows association between gender and knowledge level, which was statistically significant (Χ, df = 8.9,2; P = 0.012). Men had much poor knowledge than women.

Table 2.

Comparison of knowledge with gender

Gender	Knowledge level			Total	χ2,df	P Value
	Poor	Fair	Good
Male	79	33	3	115	8.923,2	0.012
Female	45	45	2	92
Total	124	78	5	207

Χ = chi-square test statistic, df = degree of freedom, P value = probability value

Table 3 shows that there was not any statistically significant association between age groups and knowledge level (Χ, df = 12.482,6; P = 0.052).

Table 3.

Comparison of knowledge and age

Age	Knowledge level			Total	χ2,df	P Value
	Poor	Fair	Good
25–30	103	66	3	172	12.482,6	0.052
30–35	15	6	2	23
35–40	4	0	0	4
over 40	2	6	0	8
Total	124	78	5	207

Χ = chi-square test statistic, df = degree of freedom, P value = probability value

Table 4 shows statistically significant association between workplace and knowledge level (Χ, df = 15.682,6; P = 0.0001). Government workplace participants had higher knowledge levels than private.

Table 4.

Comparison of knowledge and workplace

Work	Knowledge level			Total	χ2, df	P Value
	Poor	Fair	Good
Private	61	19	0	80	15.682,2	0.0001
Government	63	59	5	127
Total	124	78	5	207

Χ = chi-square test statistic, df = degree of freedom, P value = probability value

Table 5 shows a two-tailed Pearson correlation test, which revealed that there is very weak positive relation between knowledge scores and experience in years which was found to be statistically nonsignificant (r = 0.074, P = 0.293).

Table 5.

Comparison of knowledge with experience in years

		Knowledge score	Experience years
Knowledge score	Pearson correlation	1	0.074
	P Value		0.293 (NS)
	N	207	207

DISCUSSION

In Jana Mexican study, 99.7% of dentists and specialists showed lack of sufficient knowledge to diagnose and manage BRONJ.[11] This was much higher compared to this study.

A study conducted in Ontario showed that 60% of participants have good knowledge toward BRONJ. Although 50% of the participant was not comfortable to treat patient taking BP, 63% would refer the any patient taking BP.[12] This was similar to this study. A study conducted on students in Italy showed 99% of participants declared to know BPs and sixth-term students had better knowledge compared to fourth-term students.[13] On the contrary, in this study, there is a weak correlation between knowledge and number of years of experience. A study conducted in Spain showed that knowledge of side effects of antiresorptive drugs decreases with increasing years of professional practice.[14] Other study showed that oral maxillofacial surgeons have more knowledge compared to general dentists.[15]

All these differences may be due to variation in the way of teaching and the level of knowledge obtained in different countries. Some studies have also insisted on effective professional patient education and prevention of developing MRONJ.[16]

We would like to acknowledge Hend Ali Alghamdi, Dental Intern, College of Dentistry, Princess Nourah Bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia.

CONCLUSION

A better knowledge in future may lead to minimize incidence of MRONJ, as well as a better clinical and legal solution for ONJ cases. Properly trained dental professionals reduce the possibility of legal cost and damages. As it also affects quality of life, appropriate preventative education is required and a periodic reinforcement of the same is necessary to enhance the clinical and competency education of the individual.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.