Knowledge, Practices, and Opinions

of Ontario Dentists When Treating

Patients Receiving Bisphosphonates
Ahmed Alhussain, DDS, MSc,* Sean Peel, PhD,y
Laura Dempster, DipDH, BScD(DH), MSc, PhD,z Cameron Clokie, PhD, DDS, DipABOMS,x
and Amir Azarpazhooh, DDS, MSc, PhDk
Purpose: Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is a severe but extremely rare
complication of prolonged treatment with bisphosphonates (BPs). Improper treatment or misdiagnosis
can have serious repercussions. In some cases, the treatment of BRONJ can require jaw resection, pro-
longed use of antibiotics, and long hospitalizations. This study aimed to measure the awareness of dentists
in the Province of Ontario, Canada about BRONJ and to identify any gaps in their knowledge of the con-
dition and its treatment. In particular, the study aimed to answer questions about the dentists’ knowledge
of the current guidelines and their opinions and practices related to performing surgical dental procedures
in patients taking BPs.
Materials and Methods: The study involved sending a Web-based questionnaire to a random sample of
dentists in Ontario, Canada (n = 1,579). Information about their awareness of BPs, their experiences
treating patients presenting with ONJ, their experiences with different surgical procedures in patients
taking intravenous or oral BPs, and their awareness of the BRONJ guidelines suggested by the American
Association of Oral and Maxillofacial Surgeons was collected.
Results: A response rate of 30% was achieved. Sixty percent of responding dentists had a good knowl-
edge of BP and BRONJ; however, only 23% followed the guidelines for surgical treatment of a patient taking
BPs, and 63% would refer patients if they were taking BPs. Approximately 50% of responding Ontario
dentists were not comfortable treating patients with BRONJ at their current knowledge.
Conclusion: The finding shows that although 60% of Ontario general dentists and specialists have a good
knowledge about BRONJ, most are not comfortable performing oral surgery in patients taking BPs. Those
who are comfortable have higher knowledge scores, suggesting greater educational efforts should be made
to promote the knowledge of dentists regarding BP, ONJ, and BRONJ.
Ó 2015 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 73:1095-1105, 2015

Osteoporosis is a skeletal disorder characterized by
decreased bone density, a condition that predisposes in-
dividuals to an increased risk of fracture. This particular
medical condition is most frequent in people older than
45 years, with a probable prevalence ratio of up to 1 in
4 women and 1 in 8 men in North America. There
are more than 5 million prescriptions written for
osteoporosis per year in North America, and the
overwhelming medication of choice for more
than 95% of patients with osteoporosis is a
bisphosphonate (BP).1 BPs also are used in oncologic pa-
tients to decrease bone metastasis, fractures, and pain.

Received from the Faculty of Dentistry, University of Toronto, Address correspondence and reprint requests to Dr Azarpaz-
Toronto, ON, Canada. hooh: Faculty of Dentistry, University of Toronto, Room 515-C,
*Former Resident. 124 Edward Street, Toronto, ON, Canada M5G 1G6; e-mail: amir.
yAssistant Professor. azarpazhooh@dentistry.utoronto.ca
zAssistant Professor. Received September 9 2014
xProfessor. Accepted December 11 2014
kAssistant Professor. Ó 2015 American Association of Oral and Maxillofacial Surgeons

This study was supported in part by the Ronald E. Warren Award 0278-2391/15/00023-3
from the Canadian Association of Oral and Maxillofacial Surgeons. http://dx.doi.org/10.1016/j.joms.2014.12.040

1095
1096
Despite the many benefits of BPs, in the early 2000s,
several patients presented to dental offices with
exposed necrotic bone in the maxilla or mandible of
then-unknown etiology. Further investigations identi-
fied a common feature in these patients: they were
taking BPs and most of them had recently undergone
a surgical dental procedure.2 In 2003, Marx2 was the
first to describe the relation of treatment with BPs to
the occurrence of osteonecrosis of the jaw (ONJ).
Subsequently, Ruggiero et al3 published a case series
of ONJ related to the use of BPs. This realization led
to numerous studies2,4,5 that examined the relation
between BPs and exposed necrotic bone in the
mouth, a clinical scenario that is now known as
BP-related ONJ (BRONJ).
BRONJ is defined as an area of exposed bone that
persists longer than 8 weeks in a patient taking a
BP.3 It is a severe but extremely rare complication of
prolonged treatment with BPs.3,6 Studies have not yet
conclusively established a mechanism by which BPs
are responsible for causing BRONJ. However, one
hypothesis is that BPs prevent osteoclastic activity by
inhibiting farnesyl pyro-phosphonate synthase, a key
amino acid in the mevalonate pathway.5,7 This action
can lead to a decrease in bone absorption. It also has
been suggested that BPs can prevent normal bone
turnover remodeling. Microfractures of the bone are
no longer repaired and angiogenesis might be
inhibited, which leads to weakening of the bone
structure.5,7 More recently, cases of ONJ have been
reported in patients taking medications other than
BPs, including the antiresorptive drug denosumab and
the antiangiogenic drugs bevacizumab and sunitinib,8
suggesting that the mechanism of action is most likely
related to antiresorptive and antiangiogenic effects
rather than effects on a specific pathway.
The incidence of oral BRONJ has been discussed
in some studies, with important differences being
reported.5,9 The incidence of BRONJ associated
with oral BPs ranges from 0.001 to 0.1%, and that
associated with intravenous (IV) BPs ranges from 1 to
12%. Longer duration of exposure results in increased
risk.10 There has been no report of BRONJ associated
with the less active BPs etidronate and clodronate,
although they are used in oncologic studies.11
The American Association of Oral and Maxillofacial
Surgeons (AAOMS) produced a guideline in 2009 that
categorized patients into at-risk and stage 0, 1, 2, and 3
categories with specific treatment recommendations
for each group.3 Contrary to the established guideline,
there are anecdotal reports of some dentists refusing
to treat patients who previously received or are
currently receiving BPs. Barriers to a dentist’s adher-
ence to practice guidelines include lack of awareness
of the guideline and their attitudes and behaviors.12
This study aimed to evaluate the knowledge, practices,
DENTISTS TREATING PATIENTS ON BISPHOSPHONATES
and opinions of Ontario dentists about BRONJ when
treating patients receiving BPs by measuring their
knowledge of BPs and BRONJ and to identify how
they manage patients on BP therapy.
Materials and Methods
DESIGN
This study is a cross-sectional Web-based survey
that was conducted over a period of 2 months and
was approved by the research ethics board at the
University of Toronto (Toronto, ON, Canada; protocol
27571). A list of the members of the Royal College of
Dental Surgeons of Ontario (RCDSO) was obtained
through the membership directory. Potential partici-
pants were defined as those who might perform
dentoalveolar surgeries based on their professional
RCDSO registration (general dentists, oral and maxillo-
facial surgeons, periodontists, prosthodontists, and
endodontists). They were approached by e-mail and
directed by link to an online interface (SurveyGizmo,
Boulder, CO) displaying the survey instrument.
Follow-up e-mail reminders were sent 4 times during
a period of 2 months. No gift or remuneration was
provided to the participants in the study.
SURVEY INSTRUMENT
The survey tool included questions about partici-
pants’ knowledge of BPs, their experiences treating
patients presenting with ONJ, any treatment modifica-
tion in performing different surgical procedures
(eg, tooth extraction, dental implant placement, peri-
odontal surgery, or endodontic surgery) in patients
taking IV or oral BPs, and their awareness of the BRONJ
guidelines suggested by the AAOMS.3 For validation
and adjustment, the survey instrument was pilot
tested among 15 specialists and dentists at the Faculty
of Dentistry, University of Toronto. Pilot testing aimed
to evaluate the clarity of the survey questions, respon-
dent burden (time needed to respond and level of
understanding), face validity, and feasibility of the
planned data analysis. Further, each respondent was
asked follow-up questions to ensure that all sections
were easy to understand. This field test resulted in
revisions to the original questionnaire, from which a
final questionnaire was drafted based on the following
4 principal domains.
Domain 1—Perception and Current Practice
Included in this domain were questions that mea-
sure participants’ general knowledge about BRONJ.
They were asked 9 key knowledge questions about
BP use, route of administration, incidence, and treat-
ment for a patient with BRONJ based on the AAOMS
2009 position paper.3 They also were asked about
ALHUSSAIN ET AL 1097

the volume of patients they see with BRONJ symp- historically low response rates of dentists, the authors
toms, at which stage of BRONJ they would refer the selected all 6,920 dentists with available e-mail ad-
patient to a specialist, and their treatment. dresses who would have direct surgical interventions
(Fig 1).
Domain 2—Scenario Cases
In this domain, the participants were provided with DATA ANALYSIS
a scenario of a patient who takes BPs and presents for a
Data from the online survey were downloaded from
surgical procedure relevant to the field of specialty of
the SurveyGizmo Web site as an Excel file (Microsoft,
the participant. Six scenarios were presented for
Redmond, WA). After recoding the variables, the data-
simple, complicated, and impacted tooth extraction,
base was imported to SAS 9.2 (SAS Institute, Cary, NC)
placing dental implants, or performing periodontal
for management and analysis. Responses to the ques-
or endodontic surgeries. The scenarios differed based
tions in this survey were summarized using descriptive
on duration (#3 or >3 yr) and route of BPs given (oral
statistics (percentages for categorical data and means
or IV). The participants were asked about their man-
and standard deviations for continuous variables).
agement plan for these different scenarios: whether
Descriptive analyses were conducted for the entire
they would perform the surgical procedure; or would
sample and for subgroups of participants (general den-
discontinue BPs for 3 months and then perform the
tists, periodontists, prosthodontists, oral surgeons,
procedure; or would not perform the procedure; or
and endodontists). Responses were compared among
would refer to a specialist.
these subgroups using the c2 test and the Fisher exact
test for categorical variables and the Student t test for
Domain 3—Demographics
continuous variables. A score of 9 of 9 was given if the
Included in this domain were questions pertaining
participant answered all knowledge questions
to participants’ age, gender, pattern of practice
correctly in the first domain. A series of bivariate and
(currently practicing vs retired or not practicing),
linear regression analyses were conducted to identify
primary professional activity (eg, general dentist,
the characteristics of those with good knowledge of
specialist, military dentist, or academic instructor),
the guideline. Moreover, the results of the 6 scenario
location and years of practice, specialty field, and
questions in domain 2 were divided into right or
population of town or city where they practice.
wrong treatment answers based on the AAOMS guide-
line3 or referral. The percentage of each category was
Domain 4—Knowledge Acquisition
Included in this domain were questions that asked
about the resources participants use to stay current
in their knowledge (educational courses, scientific
meetings, journal articles, or Internet), where they
first learned about BRONJ, whether they feel comfort-
able treating patients with BRONJ, and their preferred
method for continuing education related to BRONJ.

SAMPLE SIZE CALCULATION

The study sample (n) was calculated based on the
size of the population (N = 11,151 RCDSO registered
dentists and dental specialists): n = ([N][P][1P])/
([N1][C/Z]2 + [P][1P]), where P is the proportion
of the population expected to choose 1 of 2 responses
(P = .5 to allow for maximum variance), C is the
assumed sampling error (C = 0.05), and Z is the Z-
statistic of the confidence interval (CI; Z = 1.96 for
95% confidence level).13 The sampling frame for the
specialists was changed to their total population,
because the difference between the calculated sample
size using the method described earlier and the total
population for each group of specialists was small. FIGURE 1. Flow diagram of survey response. RCDSO, Royal
The sample size of the general dentists was calculated College of Dental Surgeons of Ontario.
as 419. However, because of an anticipated inability Alhussain et al. Dentists Treating Patients on Bisphosphonates.
to draw a truly random sample and considering the J Oral Maxillofac Surg 2015.
1098 DENTISTS TREATING PATIENTS ON BISPHOSPHONATES

derived for each practitioner. Multivariate regression Table 1. DESCRIPTION OF THE DENTISTS PARTICI-
analyses were applied to analyze the association of PATING IN THE SURVEY
the frequency of scenario responses with the practi-
tioner characteristics. All tests were conducted at a sig- Demographics n (%)
nificance level of .05.
Men 678 (68.0)
Oral surgeons 48 (85.7)
Results Periodontists 30 (73.2)
From a total of 6,920 RCDSO dentists with e-mail ad- Prosthodontists 13 (68.4)
dresses who might perform dentoalveolar surgeries, Endodontists 18 (78.3)
General practitioners 555 (66.5)
the authors achieved a database of 5,255 members
Age (yr)
with valid e-mail addresses. From this pool, a total of
25-34 131 (12.9)
1,579 survey responses were collected, resulting in a 35-44 233 (22.9)
response rate of 30%. The demographic characteristics 45-54 297 (29.2)
of survey participants are listed in Table 1. Most partic- 55-64 271 (26.6)
ipants were men (68%) and general practitioners (GPs; >65 86 (8.4)
86.2%) with more than 20 years of experience as a Dental specialty
general dentist (56.1%) or as a specialist (50%). Almost Oral surgeons 57 (4.9)
half (45.7%) the participants were working in areas Periodontists 42 (3.6)
that have a population of more than 500,000 people. Prosthodontists 20 (1.7)
Endodontists 26 (2.2)
GPs 1,003 (86.2)
KNOWLEDGE QUESTIONS
Other 16 (1.4)
Table 2 presents the results of the knowledge ques- Working years
tions in the survey. Most participants (66.4%) correctly As a GP
identified osteoporosis as the indication for BP use. 1-5 125 (13.5)
Very few participants identified wrong indications for 6-10 89 (9.6)
BP (2.3% for diabetes and 0.5% for hypertension). 11-20 193 (20.8)
More than 80% of participants correctly selected the >20 521 (56.1)
BP route to be oral or IV. Almost one fourth of partici- As a specialist
1-5 24 (20.3)
pants did not know the answer to the question on
6-10 12 (10.2)
the incidence of BRONJ in patients taking oral or IV 11-20 23 (19.5)
BPs. The remaining knowledge questions (questions >20 59 (50.0)
5 to 9) pertained to the assessment of the knowledge Local population
of participants on treatment strategies of BRONJ in <5,000 45 (4.5)
different stages of risk. The least aggressive strategies 5,000-50,000 161 (16.1)
was selected for the lower degrees of risk, that is, pa- 50,000-500,000 338 (33.7)
tient education, treating symptoms, and mouth rinse >500,000 458 (45.7)
were mostly selected for patients at risk, at stage 0,
Abbreviation: GP, general practitioner.
and at stage 1, respectively. Most participants selected
antibiotics and in particular surgical debridement for Alhussain et al. Dentists Treating Patients on Bisphosphonates.
J Oral Maxillofac Surg 2015.
the higher stages of risk, with 70.1% recommending
antibiotics for stage 2 treatment and 68.3% recom-
mending surgical debridement fort stage 3. Conversely, edge score compared with other age groups. Being
for the patient in stage 1, almost 12.3 and 66.4% of par- a specialist and in particular being an oral and maxillo-
ticipants selected the wrong choices of no treatment facial surgeon, being comfortable treating patients
and antibiotics, respectively, as their approach to treat- with BRONJ, having some exposure to BRONJ cases
ment. This pattern of incorrect answers was similar for in a given month, and practicing in large urban centers
the scenario of a patient in stage 2. were associated with higher knowledge scores
Table 3 presents the impact of participants’ charac- (P < .05). All these significant variables were analyzed
teristics on their knowledge score. Overall, the mean in a linear regression model (Table 3). Only 2 factors
( standard deviation) knowledge score for all partic- remained important. 1) A pattern of a better knowl-
ipants was 5.6  1.9. No statistical difference was edge score was found in those 25 to 34 years old
found between participants’ knowledge score and compared with other groups. In particular, those 45
their gender or years in practice. However, there was to 54 years old had a statistically lower knowledge
a statistical difference in knowledge score with age, score compared with younger practitioners 25 to
in which those 45 to 54 years old had a lower knowl- 34 years old (b = 0.73; 95% CI, 1.07 to 0.30). 2)
ALHUSSAIN ET AL 1099

Table 2. FREQUENCY OF RESPONSES TO THE QUESTIONS MEASURING PARTICIPANTS’ GENERAL KNOWLEDGE

ABOUT BRONJ

Knowledge Q1: osteoporosis, diabetes, osteitis bone multiple hypertension,

indication 66.4%* 2.3% deformans, metastases, myeloma, 0.5%
for BP use 26.7%* 34.2%* 30.3%*
Knowledge Q2: Oral, 64.6%* IV, 61.9%* IM, 5.8% not sure, 10.6%
BP route of
administration
Knowledge Q3, 4: >11% <11% don’t know
incidence
of BRONJ
Oral 3.6% 72.2%* 24.2%
IV 21.2% 51.2%* 27.6%
Knowledge Q5-9: no treatment patient treat mouth antibiotics surgical
selected education symptoms rinse debridement
treatment for
BRONJ stages
At risk 46.1%* 80.2%* 9.2% 9.7% 5.9% 0.8%
Stage 0 20.6% 78.1%* 56.0%* 22.3% 15.5% 1.3%
Stage 1 12.3% 66.4%* 51.1%* 61.8%* 39.8% 21.1%
Stage 2 12.8% 63.2%* 54.6%* 58.3%* 70.1%* 46.4%
Stage 3 12.7% 62.2%* 52.4%* 55.3%* 68.2%* 68.3%*

Note: Table presents the percentages of participants’ answers for each knowledge question. Percentages might not add up to
100% because the participants could choose all options that were applicable.
Abbreviations: BP, bisphosphonate; BRONJ, bisphosphonate-related osteonecrosis of the jaw; IM, intramuscular; IV, intrave-
nous; Q, question.
* Correct answers.
Alhussain et al. Dentists Treating Patients on Bisphosphonates. J Oral Maxillofac Surg 2015.

Those who described themselves as being comfortable
with their current level of knowledge treating patients
with BRONJ had a statistically higher knowledge score
compared with those who were not comfortable treat-
ing such patients (b = 0.34; 95% CI, 0.06-0.62).
SCENARIO QUESTIONS
Table 4 presents the frequency distribution for
responses of the 6 scenario questions. In general, no
matter the surgical intervention, participants tended
to select referral if the patient had been taking oral
BPs for more than 3 years or if they have been taking
IV BPs regardless of duration. Among the 3 scenarios
of tooth extraction (simple, complex, and impacted),
participants tended not to extract and refer as the
complexity of extraction increased.
Table 5 presents the aggregated responses, catego-
rized as the percentages of right answer, wrong
answer, and referral answer. Participants more
frequently chose the correct management for patients
receiving oral BP for less than 3 years; in contrast, in
scenarios in which patients were given oral BP for
more than 3 years, they more frequently chose the
wrong management. When patients in these scenarios
were given IV BP, participants were frequently more
likely to refer the patient. In an aggregate of all sce-
narios combined together, 23.8% of participants
answered correctly to all 6 scenarios, 15.9% answered
wrong, and 60.3% referred.
To understand the impact of practitioners’ charac-
teristics, 2 regression models were constructed. The
first model identified the characteristics of those
who referred versus those who selected the right treat-
ment strategy (Table 6) and showed that women, GPs,
those working in urban locations with a population of
50,000 to 500,000, and those who are not comfortable
with their current knowledge were more likely to
refer. The second model aimed to identify the charac-
teristics of those who selected the wrong treatment
strategy versus those who selected the right treatment
strategy or who would refer the patient and showed
no statistical differences between participants who
gave wrong answers and those who gave correct an-
swers or referred the patient (data not shown).
Knowledge score also predicts when practitioners
would refer their patients. As presented in Table 7,
those with a lower knowledge score would refer pa-
tients from a lower risk category compared with those
with a higher knowledge score who would tend to
refer later. For example, those with 1 unit more knowl-
edge score would be 1.42 times (95% CI, 1.23-1.64)
1100 DENTISTS TREATING PATIENTS ON BISPHOSPHONATES

Table 3. SUMMARY OF MULTIVARIATE ANALYSES FOR PREDICTORS OF GENERAL KNOWLEDGE SCORE ABOUT BRONJ

Bivariate Analysis Linear Regression Analysis

Factors (n) Mean  SD P Value Coefficient Estimate 95% CI P Value

Total practitioners (825) 5.6  1.9

Age <.01 age
25-34 (108) 5.9  1.8 reference
35-44 (195) 5.5  1.8 0.42 0.87 to 0.03 .07
45-54 (240) 5.2  1.9 0.73 1.07 to 0.30 <.01
55-64 (193) 5.8  1.9 0.35 0.81 to 0.11 .14
>65 (58) 5.7  2.2 0.34 1.00 to 0.31 .31
Gender .61 variable not included in regression model
Men (536) 5.6  1.9
Women (252) 5.5  1.8
Practitioner type <.01 variable found not significant
Specialists (127) 6.3  2.1
GPs (660) 5.4  1.8
Specialists .04 variable found not significant
Oral surgeons (54) 6.8  1.6
Periodontists (37) 5.7  2.0
Prosthodontists (18) 6.7  2.2
Endodontists (18) 5.7  2.9
Working years .46 variable not included in regression model
1-5 (95) 5.5  1.8
6-10 (73) 5.2  1.6
11-20 (144) 5.5  1.7
>20 (321) 5.3  1.9
Patients per month <.01 variable found not significant
0 (563) 5.4  1.8
$1 (209) 6.0  2.1
Population .05 variable found not significant
<50,000 (15) 5.1  2.9
50,000-500,000 (49) 6.5  1.9
>500,000 (80) 6.4  1.9
Comfortable treating .01 comfortable treating patients with BRONJ with current
patients with BRONJ knowledge
with current knowledge
No or/unsure (442) 5.4  2.0 reference
Yes with minor 5.8  1.8 0.34 0.06, 0.62 0.02
supplementation (357)

Abbreviations: BRONJ, bisphosphonate-related osteonecrosis of the jaw; CI, confidence interval; GP, general practitioner;
SD, standard deviation.
Alhussain et al. Dentists Treating Patients on Bisphosphonates. J Oral Maxillofac Surg 2015.

more likely to treat patients who are at risk and only
refer a patient when they are showing some early signs
of BRONJ (stage 0).
KNOWLEDGE ACQUISITION
The last part of the survey asked participants how
they obtained their knowledge related to BRONJ
(Table 8). Most participants (87%) identified continuing
education courses as the leading resource to stay cur-
rent in dentistry. Other primary resources included
journal articles (86%), scientific meetings (72%), and
Internet browsing (63%). Most participants (56%)
learned about BRONJ through journal articles. Almost
half (49%) reported that they are not comfortable treat-
ing patients with BRONJ with their current knowledge.
Further inquiry identified participants as preferring
journal articles (55%) or full- or half-day courses (51%)
as their source of information about BPs and BRONJ.
Discussion
This cross-sectional study was designed to investi-
gate the knowledge, practices, and opinions of
ALHUSSAIN ET AL 1101

Table 4. FREQUENCY OF MANAGEMENT PLANS FOR THE 6 SCENARIO PROCEDURES DIFFERING BY ROUTE AND
DURATION OF BP ADMINISTRATION

Perform Discontinue BP for 3 mo, Do Not Perform

Scenario Then Perform Scenario Scenario Refer,
Procedure, % Procedure, % Procedure, % %

Scenario 1: simple tooth extraction

Oral BP #3 yr 73.4* 6.5 0.4 19.7
Oral BP >3 yr 46.3 18.1* 1.0 34.6
IV BP #3 yr 13.7* 5.8 2.9 77.6
IV BP >3 yr 10.0* 5.2 4.7 80.1
Scenario 2: complicated tooth extraction
Oral BP #3 yr 52.7* 7.2 0.6 39.5
Oral BP >3 yr 29.3 16.7* 0.6 53.4
IV BP #3 yr 9.1* 3.6 2.7 84.6
IV BP >3 yr 5.9* 4.7 3.6 85.7
Scenario 3: impacted tooth extraction
Oral BP #3 yr 26.5* 4.7 1.6 67.3
Oral BP >3 yr 13.0 10.1* 2.2 74.7
IV BP #3 yr 5.6* 2.3 4.4 87.8
IV BP >3 yr 3.8* 3.5 5.1 87.6
Scenario 4: implant placement
Oral BP #3 yr 60.3* 8.4 4.1 27.2
Oral BP >3 yr 29.3 26.9* 6.3 37.5
IV BP #3 yr 14.7 6.2 22.6* 56.5
IV BP >3 yr 8.2 7.6 28.5* 55.7
Scenario 5: periodontal surgery
Oral BP #3 yr 81.0* 8.2 2.0 8.8
Oral BP >3 yr 59.6 16.8* 2.1 21.6
IV BP #3 yr 27.0* 8.9 8.9 55.3
IV BP >3 yr 23.1* 5.8 10.9 60.2
Scenario 6: endodontic surgery
Oral BP #3 yr 61.9* 6.5 1.9 29.8
Oral BP >3 yr 34.6 18.7* 3.7 43.0
IV BP #3 yr 10.2* 7.0 8.8 74.0
IV BP >3 yr 6.1* 8.5 10.8 74.6
Abbreviations: BP, bisphosphonate; IV, intravenous.
* Correct answer to scenario question.
Alhussain et al. Dentists Treating Patients on Bisphosphonates. J Oral Maxillofac Surg 2015.

Ontario dentists when treating patients receiving
BPs. The interest was in whether participants’ knowl-
edge and approach to care of BRONJ was consistent
with the established guidelines. The AAOMS 2009
guidelines were used to develop the knowledge and
scenario questions and score the answers given by
the participants.3 This position paper was prepared
by clinicians based in multicenter hospitals and was
approved by the AAOMS Board of Trustees in January
2009. The intent of the guidelines was to provide
perspective on the risk of developing BRONJ and the
risks and benefits of BPs to facilitate evidence-based
decision making by the treating clinicians and the
patient and provide guidelines for treating BRONJ.3
The recommendations of this multidisciplinary task
force representing oral and maxillofacial surgery, oral
medicine, endocrinology, and medical oncology in
the AAOMS 2009 position paper provide detailed guid-
ance regarding the use of dental devices and selection
of appropriate antibiotic therapy.3,13
This present study found that despite the existence
of guidelines, Ontario dentists had a poor understand-
ing of how or even whether to carry out surgical dental
treatment in patients taking BPs. In total, only 23.8% of
1,579 responding dentists followed the AAOMS guide-
line, and 49.7% were not comfortable treating patients
with BRONJ. The results show that in some scenarios
almost 50% of participants, if they did not refer, would
select the wrong treatment strategy. This approach
can exacerbate or fail to resolve the main dental condi-
tion, can lead to serious complications for the patient,
or might lead them to develop BRONJ. In particular, it
has been shown that most patients taking BPs might
be unfamiliar with the drug and its possible adverse
1102 DENTISTS TREATING PATIENTS ON BISPHOSPHONATES

Table 5. FREQUENCY OF AGGREGATED RESPONSES TO SCENARIO QUESTIONS

Route and Duration of

Scenario BP Administration Right Answer, % Wrong Answer, % Referral, % Total, n

Extraction
Simple oral <3 yr 73.4 6.8 19.8 836
oral >3 yr 18.1 47.2 34.7 834
IV <3 yr 13.7 8.75 77.6 840
IV >3 yr 10 9.9 80.1 809
Complicated oral <3 yr 52 7.8 39.5 833
oral >3 yr 16.7 30 53.4 828
IV <3 yr 9.1 6.3 84.6 824
IV >3 yr 5.9 8.4 85 826
Impacted oral <3 yr 26.5 6.3 67.3 831
oral >3 yr 10.1 15.2 74.7 829
IV <3 yr 5.6 6.7 87.8 826
IV >3 yr 3.8 8.7 87.5 819
Implant oral <3 yr 60.3 12.5 27.2 368
oral >3 yr 26.8 35.6 37.5 365
IV <3 yr 22.6 20.9 56.5 368
IV >3 yr 28.5 15.8 55.7 368
Periodontal oral <3 yr 81 10.2 8.8 294
oral >3 yr 16.8 61.6 21.6 292
IV <3 yr 27 17.7 55.3 293
IV >3 yr 23.1 16.7 60.2 294
Endodontic oral <3 yr 61.9 8.4 29.8 215
oral >3 yr 18.7 38.3 43 214
IV <3 yr 10.2 15.8 74 215
IV >3 yr 6.1 19.2 74.6 213

Abbreviations: BP, bisphosphonate; IV, intravenous.

Alhussain et al. Dentists Treating Patients on Bisphosphonates. J Oral Maxillofac Surg 2015.

oral side effects. This would further highlight the re-
sponsibility of the treating dentists to be prepared to
educate patients about the oral complications result-
ing from BP use and the need for appropriate
dental care.14
Participants more frequently gave correct answers
for the scenarios of patients on oral BP for less than
3 years, but more frequently gave wrong answers for
the scenarios of patients on oral BP for more than
3 years or IV BP regardless of duration. This could be
related to the participants not knowing the differences
between oral and IV BPs, or the effect of extended
duration of use, or the benefits and disadvantages of
continuing or discontinuing BPs.
When scenario patients were given IV BPs, partici-
pants were more likely to refer the patient. The
authors also noted a decreased comfort level and
increased referral when the complexity of the

Table 6. SUMMARY OF FINAL REGRESSION MODEL PRESENTING THE IMPACT OF SIGNIFICANT PRACTITIONERS’
CHARACTERISTICS ON DECISION MAKING OF REFERRAL VERSUS SELECTING A CORRECT TREATMENT STRATEGY

Parameter Estimate (95% CI) P Value

Gender (reference, women) men 3.53 (6.49 to 0.56) .02

Specialist (reference, GP) specialist 17.17 (22.68 to 11.67) <.001
Population (reference, <50,000) 50,000-500,000 4.54 (0.77 to 8.32) .02
>5,000,000 1.29 (2.29 to 4.88) .48
Comfortable treating patients with BRONJ yes 8.36 (11.11 to 5.63) <.001
with current knowledge (reference, no)

Abbreviations: BRONJ, bisphosphonate-related osteonecrosis of the jaw; CI, confidence interval; GP, general practitioner.
Alhussain et al. Dentists Treating Patients on Bisphosphonates. J Oral Maxillofac Surg 2015.
ALHUSSAIN ET AL 1103

Table 7. SUMMARY OF FINAL REGRESSION MODEL

achieved higher knowledge scores compared with
PRESENTING THE ASSOCIATION BETWEEN REFERRING general dentists, with oral surgeons having higher
TO A SPECIALIST AND KNOWLEDGE SCORE knowledge scores than other dental specialists. This
increased knowledge among surgeons could be
When to Refer Knowledge Score, Odds Ratio
related to their increased exposure to patients with
to a Specialist Mean  SD (95% CI)*
BRONJ. Recent graduates showed more BRONJ
At risk 4.3  2.2 reference
knowledge than older dentists, which can be attrib-
Stage 0 5.5  1.8 1.42 (1.23-1.64) uted to the up-to-date education acquired through
Stage 1 5.9  1.8 1.53 (1.33-1.77) their training in dental schools, especially since BRONJ
Stage $2 5.9  1.5 1.58 (1.28-1.95) was first reported in 2003.
With an increase in knowledge about BRONJ, den-
Note: Table presents the main stage when a dentist will refer
tists tended to be more comfortable when treating
a patient with bisphosphonate-related osteonecrosis of the
jaw. these patients than referring them out. This suggests
Abbreviations: CI, confidence interval; SD, standard devia- that increasing or refreshing the level of BRONJ knowl-
tion. edge can make them considerably more comfortable
* Adjusted for practitioner type and being comfortable in treating these patients and their condition appropri-
treating patients with bisphosphonate-related osteonecrosis
ately. Therefore, continuing education courses, scien-
of the jaw with the current knowledge.
tific meetings, or journal articles directed to the
Alhussain et al. Dentists Treating Patients on Bisphosphonates.
J Oral Maxillofac Surg 2015. clinical aspect of treating patients at risk of BRONJ
should be designed.
One limitation of this study was that the authors
procedure increased in the scenarios given in the failed to determine whether the respondents were
survey. Although they did not ask specifically about specifically aware of the AAOMS guidelines related to
the reasons for referral in their survey, the authors BRONJ.3 The quality of guidelines is limited to the
hypothesize that although dentists might be comfort- current stage of knowledge. Although the AAOMS posi-
able performing these procedures in patients in gen- tion paper in some instances represents expert opinion
eral, more complex dental care might make them with debatable guidance (eg, whether a drug holiday
unwilling to accept the responsibility of treating pa- will decrease the risk of BRONJ with dentoalveolar sur-
tients taking BPs, possibly as a result of assuming an gery), it is still the best currently available guideline.3 It
increased risk of complications. is likely that many participants were not aware of the
As noted earlier, women, GPs, those working in a existence of this guideline, which was published only
city with a population of 50,000 to 500,000, and those in the Journal of Oral Maxillofacial Surgery.3 Howev-
who are not comfortable with their current knowl- er, guidelines are not the only source of treatment plan-
edge were more likely to refer the patient. Specialists ning that dentists use. Other sources can include
were less likely to refer patients with BRONJ, perhaps clinical reports in journals, continuing education
because of their additional training. They also courses, and their experience.

Table 8. FREQUENCY OF RESPONSES TO QUESTIONS ON KNOWLEDGE ACQUISITION

What resources do you use (or would you use) to staycurrent in dentistry?
Browsing Internet, scientific meetings, 72.2% journal articles, 86.4% continuing education
63.6% courses, 87.6%
Where did you first learn about BRONJ?
Graduate residency, no knowledge, Internet, dental scientific continuing journal
program, 5.8% 13.8% 14.6% school, meetings, education articles,
3.3% 20.0% 34.6% courses, 43.0% 56.7%
Do you feel comfortable treating patients with BRONJ with your current knowledge?
Unsure, 12.2% yes, could use minor supplementation, 22.7% no, 49.7%
15.4%
Which would be your preference for continuing education related to BRONJ?
DVD or videos, 28.3% annual Internet-based courses, 36.4% Full- or half-day courses, 51.2% journal
meetings, article,
33.9% 55.3%
Abbreviation: BRONJ, bisphosphonate-related osteonecrosis of the jaw.
Alhussain et al. Dentists Treating Patients on Bisphosphonates. J Oral Maxillofac Surg 2015.
1104
Table 9. COMPARISON OF DEMOGRAPHICS OF
STUDY PARTICIPANTS AND CENSUS DATA OF
DENTISTS IN ONTARIO, CANADA
Present Survey Ontario Data
(n = 1,579) (n = 7,053)*y
Men, n (%) 678 (68.0) 5,149 (73.0)y
Working years, n (%)
0-10 214 (23.1) 1,072 (15.2)y
11-20 193 (20.8) 1,841 (26.1)y
$21 521 (56.1) 4,140 (58.7)y
Age (yr), %
25-34 30.10 30.60*
35-44
45-54 31.60 30.70*
55-64
$65 5.70 6.10
* From the 2008 registry list of the Royal College of Dental
Surgeons of Ontario.18
y From the Canadian Institute for Health Information.19
Alhussain et al. Dentists Treating Patients on Bisphosphonates.
J Oral Maxillofac Surg 2015.
The respondents did indicate that they became
aware of BRONJ predominantly from journal articles
(56%), continuing education courses (43%), scientific
meetings (34%), or dental school (20%). Therefore, it
would be expected that they should be aware of the
appropriate treatment strategies, even if they were un-
aware of the guidelines.
This study was limited to Ontario dentists and special-
ists. The response rate of 30% was well within the range
of 17 to 44% reported in recent mail-out surveys of den-
tists in Ontario addressing different topics and much
higher than the achieved response rate of 15% using
Web-based surveys of this population.15,16 Asch et al17
performed a comprehensive review of surveys pub-
lished in medical journals and suggested that a survey’s
response rate is at best an indirect indication of the
extent of nonrespondent bias and that attention should
be devoted to assessments of bias rather than to specific
response rate thresholds. In this regard, the participants’
demographics were compared with the available data
from the RCDSO registry (Table 9).18,19 The results
showed that for those demographics that could be
compared, differences between the participants and
their Ontario counterparts were small, suggesting a
minimal response bias and a sample that can be
considered representative of practicing dentists in
Ontario. However, conclusions drawn from this study
might not necessarily be extrapolated beyond this
survey population and might not be generalizable to
dentists in the rest of Canada or elsewhere.
An inherent limitation to the Web-based survey
methodology is a possible sampling bias because
Web users might be demographically different from
DENTISTS TREATING PATIENTS ON BISPHOSPHONATES
other users. In recent years, investigators have relied
increasingly on Internet-based surveys to collect data
from various populations owing to the benefits of
Internet-based over mail-based surveys. It has been
shown that Internet-based surveys can decrease
turnaround time and cost considerably compared
with mail surveys, and thus they might increase survey
completion rates.20 Internet-based surveys also are
considered valid alternatives to traditional telephone-
based surveys.21 Various challenges, technical and
logistical, have been raised in the past with Internet-
based surveys, such as incompatibility with target
computers, computer literacy of the target population,
and program deficiencies. However, with recent
advancements in Internet-related software, most of
these problems have been rectified.20 Nonetheless,
the single most important issue with Internet-based
surveys remains the accessibility of the target popula-
tion to the Internet.21 However, as found in a 2006
study, Canadian dentists’ Internet usage was greater
than the North American general public and even
greater than their American counterparts.22 There-
fore, as far as the present study is concerned, accessi-
bility to the Internet was considered a minimal issue.
That said, although the survey was validated by dental
faculty, any Web-based survey study must recognize
that there is an inherent bias toward capturing only
those dentists who are interested or have experience
in treating BRONJ. Therefore, the results of this study
are likely an overestimate of the level of knowledge
and experience within this dental community.
Because the findings of this suggest only a moderate
level of knowledge regarding this topic, the real level
of understanding could be much lower.
Having noted these possible limitations, to the best of
the authors’ knowledge, this is the first study to mea-
sure dentists’ knowledge about BRONJ and their related
treatment strategies. The information gathered from
this study can assist in understanding how dentists
might treat patients with BRONJ and avenues for further
education or guidelines to assist in ensuring that pa-
tients receive the most appropriate and evidence-
based treatment. Moreover, it should be noted that
there is currently no such guideline in the general
dentistry forum readership. It is likely that Ontario den-
tists are not aware of such a specialized guideline;
hence, this study suggests having guidelines developed
by the Canadian or American Dental Association or
regulatory bodies such as the RCDSO so that such
important guidelines could be widely circulated to prac-
ticing dentists. Such targeted guidelines and more
hands-on experience might improve the knowledge
and approach to care when treating patients on BPs.
The authors note that there are more cases of ONJ asso-
ciated with other antiresorptive (denosumab) and anti-
angiogenic therapies. In consequence, the most current
ALHUSSAIN ET AL
position statement of the AAOMS (published after this
study was concluded) recommends changing the
nomenclature of BRONJ and favors the term medica-
tion-related osteonecrosis of the jaw (MRONJ).23
This survey suggested that although almost half the
responding Ontario dentists had moderate knowledge
of BRONJ, only approximately one fourth followed
the AAOMS guideline when surgical treatment was
indicated for a patient taking BPs and 63% would refer
patients on BP for surgical procedures that they other-
wise would be comfortable managing. There also was
an increased trend of referring patients with BRONJ
as the complexity of the surgical procedure increased.
Recent graduates have more knowledge about BRONJ,
as do dental specialists compared with general dentists,
with oral and maxillofacial surgeons having more
knowledge about BRONJ compared with other dental
specialists.
Increased awareness among dentists as to the
importance of following established guidelines is rec-
ommended. Well-planned implementation strategies
should be conducted involving existing continuing
dental education activities, such as day courses and
national meetings. Therefore, future research should
focus on methods to successfully implement guide-
lines. The study recommends that national dental
associations should implement strategies to educate
dentists about BRONJ treatment and prevention. The
authors recommend that regulatory and licensure
organizations have a mandatory continuing education
course to educate dentists on how to treat and prevent
BRONJ when treating patients taking BPs and other
drugs associated with ONJ.
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