- Email: [email protected]
Medical students’ knowledge of medication related osteonecrosis of the jaw
G Model
JORMAS-758; No. of Pages 3 J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original Article
Medical students’ knowledge of medication related osteonecrosis of the jaw S. Franchi, M. Brucoli, P. Boffano *, C. Dosio, A. Benech Division of Maxillofacial Surgery, University of Eastern Piedmont, Novara, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 September 2019 Received in revised form 21 September 2019 Accepted 14 October 2019
Introduction: The objective of this study was to assess medical students’ knowledge of ‘‘medication related osteonecrosis of the jaws’’ (MRONJ). Methods: A questionnaire survey was administered to all the medical students in the last two years of school of medicine at the University of Eastern Piedmont between January 2019 and March 2019. The questionnaire contained a first section regarding demographic and personal data of the student and a second section regarding the knowledge on MRONJ. Results: On the whole, 72 medical students agreed to participate to this study and filled in the questionnaire. As for indications for the use of bisphosphonates 45 students correctly answered ‘‘osteoporosis, osteogenesis imperfecta, multiple myeloma, or metastasis of some malignant tumors’’. Almost all students (71 out of 72) answered that a thorough examination of oral cavity and a dentist screening is needed and fundamental before starting bisphosphonate assumption. As for drugs responsible for MRONJ, only 12 students out of 72 correctly answered ‘‘bisphosphonates, denosumab, and antiangiogenic drugs’’. Discussion: A better level of knowledge and awareness by medical doctors and young physicians may lead, in future, to minimize incidence of MRONJ as well as to a better resolution of ONJ cases. Theoretical and practical initiatives could be promoted to improve and consolidate the knowledge of future physicians about this important issue.
C 2019 Elsevier Masson SAS. All rights reserved.
Keywords: MRONJ Questionnaire Knowledge
1. Introduction Medication related osteonecrosis of the jaw (MRONJ) is a severe complication of treatment with bisphosphonates, antiresorptive or antiangiogenetic drugs. The real mechanism by which several drugs are responsible for causing MRONJ has not been cleared today. Intravenous bisphosphonates are used in the treatment of osteogenesis imperfecta, multiple myeloma, metastasis of some malignant tumors, or hypercalcemia of malignancy. Instead, oral bisphosphonates are used in the management of osteoporosis, osteopenia, osteogenesis imperfecta, and Paget’s disease [1–18]. In 2014, the American Association of Oral and Maxillofacial Surgeons (AAOMS) confirmed that other medications (denosumab, sunitinib, sorafenib, bevacizumab, sirolimus, and others), are also associated with the development of ONJ [1–16]. Treatment of ONJs is an important challenge for clinicians, and there is not a gold standard treatment [1–10]. At present, the best
* Corresponding author. E-mail address: [email protected] (P. Boffano).
measure for the treatment of MRONJ is to prevent it from occurring. The effectiveness of preventive strategies is strictly related to the knowledge of the most important risk factors [1–16]. In the recent literature, several studies about the knowledge of dentists and dental students about MRONJ have been published. However, no study is focusing about the knowledge of medical students about MRONJ. The role of family doctors in the prevention of MRONJ is crucial for an appropriate management of patients that have to take antiresorptive or antiangiogenic drugs. Therefore, the objective of this study was to evaluate the medical students’ knowledge of MRONJ.
2. Materials and methods A questionnaire survey was administered to all the medical students in the last two years of school of medicine at the University of Eastern Piedmont between January 2019 and March 2019. The questionnaire contained a first section regarding demographic and personal data of the student (age, gender, year of medical school, preferred post degree course) and a second
https://doi.org/10.1016/j.jormas.2019.10.005 C 2019 Elsevier Masson SAS. All rights reserved. 2468-7855/
Please cite this article in press as: Franchi S, et al. Medical students’ knowledge of medication related osteonecrosis of the jaw. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.10.005
G Model
JORMAS-758; No. of Pages 3 S. Franchi et al. / J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
2
section regarding the knowledge on MRONJ (containing questions concerned the current knowledge of MRONJ and clinical guidelines for its treatment). The questions regarding MRONJ measured the future physicians’ cognition about the clinical presentation, predisposing risk factors, diagnosis and prevention procedures, and management of this condition. The surveys were anonymously distributed to all medical students in the last two years of school of medicine to be filled in. The total time taken to answer was approximately 15 minutes. Descriptive analyses were conducted for the entire sample and for subgroups of participants. Fisher exact tests and Chi2 tests were used to compare qualitative variables between groups. 3. Results On the whole, 72 medical students (31 males, 41 females) in the last two years of medical school (40 five-year students and 32 sixyear students) agreed to participate to this study and filled in the questionnaire (Table 1), out of the 120 students attending the two final years (60 five-year students, 60 six-year students). Therefore, the percentage of answer was 60%. Mean age was 24 years with a slight difference between six-year students (24,3 years; standard deviation 0,65; range 23–26) and five-year students (23,8 years; standard deviation 1,84; range 23–32). Most desired post medical degree courses were family medicine (10 students), followed by general medicine, anesthesiology, and cardiology (all with for 7 students each). As for indications for the use of bisphosphonates, out of 72 students, 45 correctly answered ‘‘osteoporosis, osteogenesis imperfecta, multiple myeloma, or metastasis of some malignant tumors’’, whereas 25 students answered ‘‘osteoporosis’’ and 2 students answered ‘‘metastasis of some malignant tumors’’. A statistically significant association was found between five-year students and the answer ‘‘osteoporosis’’ and between six-year
students and the correct answer (P < 0.05; Confidence Interval 1.57–12.53). As for administration routes of bisphosphonates, 56 students correctly answered ‘‘both intravenous and oral route’’, whereas 14 students answered ‘‘oral route only’’, and 2 students answered ‘‘intravenous route only’’. No statistically significant association was found. Almost all students (71 out of 72) answered that a thorough examination of oral cavity and a dentist screening is needed and fundamental before starting bisphosphonate assumption. As for drugs responsible for MRONJ, only 12 students out of 72 correctly answered ‘‘bisphosphonates, denosumab, and antiangiogenic drugs’’. Furthermore, a statistically significant association was found between five-year students and the answer ‘‘only bisphosphonates’’ and between six-year students and the correct answer (P < 0.05). A statistically significant association was also found between five-year students and the answer ‘‘only with necrotic bone exposition’’ and between six-year students and the correct answer (‘‘with and/or without necrotic bone exposition’’) (P < 0.05). Finally, statistically significant associations were found between six-year students and the correct answers to the questions regarding administration route and the permanence of bisphosphonates in the body for years (P < 0.05). 4. Discussion This cross-sectional study was designed to investigate the knowledge of medical students regarding bisphosphonates and MRONJ. The interest was in whether students’ knowledge of MRONJ was consistent with the established guidelines [1–16]. This present study found that despite the existence of guidelines, medical students might have an incomplete understanding of MRONJ. Five-year and six-year students of medical school should be aware of this important condition. Students of medical school
Table 1 Questionnaire items and answers. Question
Answers
Five-year students
Six-year students
Total
What are the pathologies target of a Bisphosphonate therapy?
Osteoporosis Osteoporosis, osteogenesis imperfecta, multiple myeloma, or metastasis of some malignant tumors Metastasis of some malignant tumors both intravenous and oral route Oral route only Intravenous route only Yes
18 14
7 31
25 45
0 24 7 1 31
2 32 7 1 40
2 56 14 2 71
No Only bisphosphonates Bisphosphonates and antiangiogenic drugs Bisphosphonates and denosumab Bisphosphonates, denosumab, and antiangiogenic drugs Other drugs Only with necrotic bone exposition Without necrotic bone exposition With and/or without necrotic bone exposition Yes
1 20 3 7 1
0 15 8 6 11
1 35 10 13 12
2 22 3 7 5
0 16 4 20 18
2 38 7 27 23
No I do not know Yes
18 9 30
10 12 31
28 21 61
No I do not know Yes
0 2 12
6 3 34
6 5 46
No I do not know
7 13
4 2
11 15
What are the administration routes for bisphosphonate therapy?
Is a thorough examination of oral cavity and a dental examination needed before a bisphosphonate therapy? what drugs are responsible for MRONJ?
How can the initial clinical presentation of MRONJ be observed?
Has the oral administration route of bisphosphonates a higher risk for MRONJ in comparison of intravenous route?
Do bisphosphonates decrease the function of osteoclasts and the bone remodeling?
May the presence of bisphosphonates last for years in the body of patients following their assumption?
Please cite this article in press as: Franchi S, et al. Medical students’ knowledge of medication related osteonecrosis of the jaw. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.10.005
G Model
JORMAS-758; No. of Pages 3 S. Franchi et al. / J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
attend lessons regarding MRONJ during two courses: dentistry and maxillofacial surgery, and oncology. Such courses are typically kept during fifth and sixth year of medical school. In the literature, several studies regarding the knowledge of MRONJ by dentists and students of dental schools can be found. Nevertheless, the knowledge of osteonecrosis by medical students that are going to become doctors is crucial: in fact, family doctors are often responsible for the prescription of bisphosphonates for osteoporosis and they usually perform a follow up of general conditions in patients affected by tumors. In our study population, we observed a statistically significant improvement in the knowledge of MRONJ by students when they were at the final (sixth) year of school of medicine. This result may be attributed to the wider practical experience with patients that is typically performed by students in Italian medical school during the final year: the clinical approach with patients might determine an increase of awareness in multidisciplinary conditions such as MRONJ, whose learning may reveal to be fragmented during the different courses of medical school. The use of bisphosphonates was not clear for several (27 out of 72) students: such students reported that bisphosphonates are useful for osteoporosis only. This lack of knowledge may be less severe if we consider that oncological patients strictly follow hospital clinical pathways that include dental and/or maxillofacial consultation before the first assumption of antiresorptive or antiangiogenic drugs. Instead, almost all students correctly answered that a thorough examination of oral cavity and a dental screening is needed and fundamental before starting bisphosphonate assumption. A lack of knowledge was encountered about the drugs responsible for MRONJ: only 12 students out of 72 correctly answered ‘‘bisphosphonates, denosumab, and antiangiogenic drugs’’. This information is crucial for an appropriate screening and follow up of patients. It was predictable to observe that quite few students were aware of the new classifications of MRONJ with the inclusion of osteonecrosis without necrotic bone exposition as a characteristic of initial stages of osteonecrosis. The answers to the three questions regarding the risk for MRONJ according to administration route, the action of bisphosphonates to osteoclasts, and the permanence of bisphosphonates in the body for years confirmed the improved and acceptable knowledge of these issues in final year students. Increasing the level of MRONJ knowledge in medical students can make them considerably more comfortable in managing these patients and their condition appropriately [1–16]. In conclusion, a better level of knowledge and awareness by medical doctors and young physicians may lead, in future, to minimize incidence of MRONJ as well as to a better resolution of ONJ cases. Theoretical and practical initiatives could be promoted to improve and consolidate the knowledge of future physicians about this important issue; however, further studies with a comparison between 2 or more medical schools with different teaching strategies could be interesting.
Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki
3
declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study. Funding No funding received. Disclosure of interest The authors declare that they have no competing interest.
References [1] Rosella D, Papi P, Pompa G, Capogreco M, De Angelis F, Di Carlo S. Dental students’ knowledge of medication-related osteonecrosis of the jaw. Eur J Dent 2017;11(4):461–8. [2] Escobedo MF, Cobo JL, Junquera S, Milla J, Olay S, Junquera LM. Medicationrelated osteonecrosis of the jaw. Implant presence-triggered osteonecrosis: case series and literature review. J Stomatol Oral Maxillofac Surg 2019. http:// dx.doi.org/10.1016/j.jormas.2019.04.012 [Article in press. Epub ahead of print. Pii: S2468-7855(19)30123-5]. [3] 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. [4] Sturrock A, Preshaw PM, Hayes C, Wilkes S. General dental practitioners’ perceptions of, and attitudes towards, improving patient safety through a multidisciplinary approach to the prevention of medication-related osteonecrosis of the jaw (MRONJ): a qualitative study in the North East of England. BMJ Open 2019;9(6):e029951. [5] Al-Samman AA, Al-Ani RS. Across-sectional survey on medication-related osteonecrosis of the jaws’ knowledge and awareness in a sample of dental society. J Craniomaxillofac Surg 2019;47(6):926–31. [6] Brucoli M, Boccafoschi F, Boffano P, Broccardo E, Benech A. The anatomage table and the placement of titanium mesh for the management of orbital floor fractures. Oral Surg Oral Med Oral Pathol Oral Radiol 2018;126(4):317–21. [7] Brucoli M, Boffano P, Magnano M, Mistretta R, Benech R, Benech A. The management of a high-risk patient with edentulous mandibular fractures. Otorinolaringol 2019;69:42–4. [8] Brucoli M, Boffano P, Bonaso M, Benech A. The management of a Y-shaped fracture of the mandibular ramus. Otorinolaringol 2019;69(3):192–5. [9] Brucoli M, Nestola DF, Baragiotta N, Boffano P, Benech A. Maxillofacial fractures: epidemiological analysis of a single-center experience. Otorinolaringol 2018;68(4):132–7. [10] Brucoli M, Boffano P, Franchi S, Pezzana A, Baragiotta N, Benech A. The use of teleradiology for triaging of maxillofacial trauma. J Craniomaxillofac Surg 2019;47(10):1535–41. http://dx.doi.org/10.1016/j.jcms.2019.07.007 [Article in press. Pii: S1010-5182(19)30081-2]. [11] Boffano P, Benech R, Gallesio C, Arcuri F, Benech A. Current opinions on surgical treatment of fractures of the condylar head. Craniomaxillofac Trauma Reconstr 2014;7(2):92–100. [12] Arcuri F, Brucoli M, Grivetto F, Benech A. Mandibular symphyseal fracture simulated by a foreign body in the chin. J Craniofac Surg 2012;23(2):e91–3. [13] Arcuri F, Brucoli M, Benech A. Analysis of the retroauricular transmeatal approach: a novel transfacial access to the mandibularskeleton. Br J Oral Maxillofac Surg 2012;50(2):e22–6. [14] Saponaro A, Stecco A, Brucoli M, Armienti F, Stellin L, Favano F, et al. Magnetic resonance imaging in the postsurgical evaluation of patients with mandibular condyle fractures treated using the transparotid approach: our experience. J Oral Maxillofac Surg 2009;67(9):1815–20. [15] Brucoli M, Sonzini R, Bosetti M, Boffano P, Benech A. Plasma rich in growth factors (PRGF) for the promotion of bone cell proliferation and tissue regeneration. Oral Maxillofac Surg 2018;22(3):309–13. [16] Brucoli M, Baena RR, Corio C, Boffano P, Benech R, Benech A. ‘‘Curette technique’’ and FiSH analysis for the assessment of oral field cancerization. Otorinolaringol 2018;68(4):119–23. [17] Escobedo M, Garcı´a-Consuegra L, Junquera S, Olay S, Ascani G, Junquera L. Medication-related osteonecrosis of the jaw: a survey of knowledge, attitudes, and practices among dentists in the principality of Asturias (Spain). J Stomatol Oral Maxillofac Surg 2018;119(5):395–400. [18] Tanna N, Steel C, Stagnell S, Bailey E. Awareness of medication related osteonecrosis of the jaws (MRONJ) amongst general dental practitioners. Br Dent J 2017;222(2):121–5.
Please cite this article in press as: Franchi S, et al. Medical students’ knowledge of medication related osteonecrosis of the jaw. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.10.005
JORMAS-758; No. of Pages 3 J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original Article
Medical students’ knowledge of medication related osteonecrosis of the jaw S. Franchi, M. Brucoli, P. Boffano *, C. Dosio, A. Benech Division of Maxillofacial Surgery, University of Eastern Piedmont, Novara, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 September 2019 Received in revised form 21 September 2019 Accepted 14 October 2019
Introduction: The objective of this study was to assess medical students’ knowledge of ‘‘medication related osteonecrosis of the jaws’’ (MRONJ). Methods: A questionnaire survey was administered to all the medical students in the last two years of school of medicine at the University of Eastern Piedmont between January 2019 and March 2019. The questionnaire contained a first section regarding demographic and personal data of the student and a second section regarding the knowledge on MRONJ. Results: On the whole, 72 medical students agreed to participate to this study and filled in the questionnaire. As for indications for the use of bisphosphonates 45 students correctly answered ‘‘osteoporosis, osteogenesis imperfecta, multiple myeloma, or metastasis of some malignant tumors’’. Almost all students (71 out of 72) answered that a thorough examination of oral cavity and a dentist screening is needed and fundamental before starting bisphosphonate assumption. As for drugs responsible for MRONJ, only 12 students out of 72 correctly answered ‘‘bisphosphonates, denosumab, and antiangiogenic drugs’’. Discussion: A better level of knowledge and awareness by medical doctors and young physicians may lead, in future, to minimize incidence of MRONJ as well as to a better resolution of ONJ cases. Theoretical and practical initiatives could be promoted to improve and consolidate the knowledge of future physicians about this important issue.
C 2019 Elsevier Masson SAS. All rights reserved.
Keywords: MRONJ Questionnaire Knowledge
1. Introduction Medication related osteonecrosis of the jaw (MRONJ) is a severe complication of treatment with bisphosphonates, antiresorptive or antiangiogenetic drugs. The real mechanism by which several drugs are responsible for causing MRONJ has not been cleared today. Intravenous bisphosphonates are used in the treatment of osteogenesis imperfecta, multiple myeloma, metastasis of some malignant tumors, or hypercalcemia of malignancy. Instead, oral bisphosphonates are used in the management of osteoporosis, osteopenia, osteogenesis imperfecta, and Paget’s disease [1–18]. In 2014, the American Association of Oral and Maxillofacial Surgeons (AAOMS) confirmed that other medications (denosumab, sunitinib, sorafenib, bevacizumab, sirolimus, and others), are also associated with the development of ONJ [1–16]. Treatment of ONJs is an important challenge for clinicians, and there is not a gold standard treatment [1–10]. At present, the best
* Corresponding author. E-mail address: [email protected] (P. Boffano).
measure for the treatment of MRONJ is to prevent it from occurring. The effectiveness of preventive strategies is strictly related to the knowledge of the most important risk factors [1–16]. In the recent literature, several studies about the knowledge of dentists and dental students about MRONJ have been published. However, no study is focusing about the knowledge of medical students about MRONJ. The role of family doctors in the prevention of MRONJ is crucial for an appropriate management of patients that have to take antiresorptive or antiangiogenic drugs. Therefore, the objective of this study was to evaluate the medical students’ knowledge of MRONJ.
2. Materials and methods A questionnaire survey was administered to all the medical students in the last two years of school of medicine at the University of Eastern Piedmont between January 2019 and March 2019. The questionnaire contained a first section regarding demographic and personal data of the student (age, gender, year of medical school, preferred post degree course) and a second
https://doi.org/10.1016/j.jormas.2019.10.005 C 2019 Elsevier Masson SAS. All rights reserved. 2468-7855/
Please cite this article in press as: Franchi S, et al. Medical students’ knowledge of medication related osteonecrosis of the jaw. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.10.005
G Model
JORMAS-758; No. of Pages 3 S. Franchi et al. / J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
2
section regarding the knowledge on MRONJ (containing questions concerned the current knowledge of MRONJ and clinical guidelines for its treatment). The questions regarding MRONJ measured the future physicians’ cognition about the clinical presentation, predisposing risk factors, diagnosis and prevention procedures, and management of this condition. The surveys were anonymously distributed to all medical students in the last two years of school of medicine to be filled in. The total time taken to answer was approximately 15 minutes. Descriptive analyses were conducted for the entire sample and for subgroups of participants. Fisher exact tests and Chi2 tests were used to compare qualitative variables between groups. 3. Results On the whole, 72 medical students (31 males, 41 females) in the last two years of medical school (40 five-year students and 32 sixyear students) agreed to participate to this study and filled in the questionnaire (Table 1), out of the 120 students attending the two final years (60 five-year students, 60 six-year students). Therefore, the percentage of answer was 60%. Mean age was 24 years with a slight difference between six-year students (24,3 years; standard deviation 0,65; range 23–26) and five-year students (23,8 years; standard deviation 1,84; range 23–32). Most desired post medical degree courses were family medicine (10 students), followed by general medicine, anesthesiology, and cardiology (all with for 7 students each). As for indications for the use of bisphosphonates, out of 72 students, 45 correctly answered ‘‘osteoporosis, osteogenesis imperfecta, multiple myeloma, or metastasis of some malignant tumors’’, whereas 25 students answered ‘‘osteoporosis’’ and 2 students answered ‘‘metastasis of some malignant tumors’’. A statistically significant association was found between five-year students and the answer ‘‘osteoporosis’’ and between six-year
students and the correct answer (P < 0.05; Confidence Interval 1.57–12.53). As for administration routes of bisphosphonates, 56 students correctly answered ‘‘both intravenous and oral route’’, whereas 14 students answered ‘‘oral route only’’, and 2 students answered ‘‘intravenous route only’’. No statistically significant association was found. Almost all students (71 out of 72) answered that a thorough examination of oral cavity and a dentist screening is needed and fundamental before starting bisphosphonate assumption. As for drugs responsible for MRONJ, only 12 students out of 72 correctly answered ‘‘bisphosphonates, denosumab, and antiangiogenic drugs’’. Furthermore, a statistically significant association was found between five-year students and the answer ‘‘only bisphosphonates’’ and between six-year students and the correct answer (P < 0.05). A statistically significant association was also found between five-year students and the answer ‘‘only with necrotic bone exposition’’ and between six-year students and the correct answer (‘‘with and/or without necrotic bone exposition’’) (P < 0.05). Finally, statistically significant associations were found between six-year students and the correct answers to the questions regarding administration route and the permanence of bisphosphonates in the body for years (P < 0.05). 4. Discussion This cross-sectional study was designed to investigate the knowledge of medical students regarding bisphosphonates and MRONJ. The interest was in whether students’ knowledge of MRONJ was consistent with the established guidelines [1–16]. This present study found that despite the existence of guidelines, medical students might have an incomplete understanding of MRONJ. Five-year and six-year students of medical school should be aware of this important condition. Students of medical school
Table 1 Questionnaire items and answers. Question
Answers
Five-year students
Six-year students
Total
What are the pathologies target of a Bisphosphonate therapy?
Osteoporosis Osteoporosis, osteogenesis imperfecta, multiple myeloma, or metastasis of some malignant tumors Metastasis of some malignant tumors both intravenous and oral route Oral route only Intravenous route only Yes
18 14
7 31
25 45
0 24 7 1 31
2 32 7 1 40
2 56 14 2 71
No Only bisphosphonates Bisphosphonates and antiangiogenic drugs Bisphosphonates and denosumab Bisphosphonates, denosumab, and antiangiogenic drugs Other drugs Only with necrotic bone exposition Without necrotic bone exposition With and/or without necrotic bone exposition Yes
1 20 3 7 1
0 15 8 6 11
1 35 10 13 12
2 22 3 7 5
0 16 4 20 18
2 38 7 27 23
No I do not know Yes
18 9 30
10 12 31
28 21 61
No I do not know Yes
0 2 12
6 3 34
6 5 46
No I do not know
7 13
4 2
11 15
What are the administration routes for bisphosphonate therapy?
Is a thorough examination of oral cavity and a dental examination needed before a bisphosphonate therapy? what drugs are responsible for MRONJ?
How can the initial clinical presentation of MRONJ be observed?
Has the oral administration route of bisphosphonates a higher risk for MRONJ in comparison of intravenous route?
Do bisphosphonates decrease the function of osteoclasts and the bone remodeling?
May the presence of bisphosphonates last for years in the body of patients following their assumption?
Please cite this article in press as: Franchi S, et al. Medical students’ knowledge of medication related osteonecrosis of the jaw. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.10.005
G Model
JORMAS-758; No. of Pages 3 S. Franchi et al. / J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
attend lessons regarding MRONJ during two courses: dentistry and maxillofacial surgery, and oncology. Such courses are typically kept during fifth and sixth year of medical school. In the literature, several studies regarding the knowledge of MRONJ by dentists and students of dental schools can be found. Nevertheless, the knowledge of osteonecrosis by medical students that are going to become doctors is crucial: in fact, family doctors are often responsible for the prescription of bisphosphonates for osteoporosis and they usually perform a follow up of general conditions in patients affected by tumors. In our study population, we observed a statistically significant improvement in the knowledge of MRONJ by students when they were at the final (sixth) year of school of medicine. This result may be attributed to the wider practical experience with patients that is typically performed by students in Italian medical school during the final year: the clinical approach with patients might determine an increase of awareness in multidisciplinary conditions such as MRONJ, whose learning may reveal to be fragmented during the different courses of medical school. The use of bisphosphonates was not clear for several (27 out of 72) students: such students reported that bisphosphonates are useful for osteoporosis only. This lack of knowledge may be less severe if we consider that oncological patients strictly follow hospital clinical pathways that include dental and/or maxillofacial consultation before the first assumption of antiresorptive or antiangiogenic drugs. Instead, almost all students correctly answered that a thorough examination of oral cavity and a dental screening is needed and fundamental before starting bisphosphonate assumption. A lack of knowledge was encountered about the drugs responsible for MRONJ: only 12 students out of 72 correctly answered ‘‘bisphosphonates, denosumab, and antiangiogenic drugs’’. This information is crucial for an appropriate screening and follow up of patients. It was predictable to observe that quite few students were aware of the new classifications of MRONJ with the inclusion of osteonecrosis without necrotic bone exposition as a characteristic of initial stages of osteonecrosis. The answers to the three questions regarding the risk for MRONJ according to administration route, the action of bisphosphonates to osteoclasts, and the permanence of bisphosphonates in the body for years confirmed the improved and acceptable knowledge of these issues in final year students. Increasing the level of MRONJ knowledge in medical students can make them considerably more comfortable in managing these patients and their condition appropriately [1–16]. In conclusion, a better level of knowledge and awareness by medical doctors and young physicians may lead, in future, to minimize incidence of MRONJ as well as to a better resolution of ONJ cases. Theoretical and practical initiatives could be promoted to improve and consolidate the knowledge of future physicians about this important issue; however, further studies with a comparison between 2 or more medical schools with different teaching strategies could be interesting.
Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki
3
declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study. Funding No funding received. Disclosure of interest The authors declare that they have no competing interest.
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Please cite this article in press as: Franchi S, et al. Medical students’ knowledge of medication related osteonecrosis of the jaw. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.10.005