Knowledge, Awareness, and Preventive Practices Regarding Medication‐Related Osteonecrosis of the Jaw Among Dental Students: A Cross‐Sectional Study

Knowledge, Awareness, and Preventive Practices Regarding Medication‐Related Osteonecrosis of the Jaw Among Dental Students: A Cross‐Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Knowledge, Awareness, and Preventive Practices Regarding Medication‐Related Osteonecrosis of the Jaw Among Dental Students: A Cross‐Sectional Study Zeynep Allahverdi, Gaye Keser, Filiz Namdar Namdar Pekiner This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9366232/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 16 You are reading this latest preprint version Abstract Background Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication associated with antiresorptive and antiangiogenic medications used in osteoporosis and malignancy-related skeletal conditions. Dental professionals play a critical role in its prevention, early diagnosis, and management. This study aimed to comprehensively evaluate the knowledge, attitudes, and risk awareness of MRONJ among senior dental students using a structured and validated questionnaire, and to compare the findings with existing literature. Methods A cross-sectional survey was conducted among 254 fourth- and fifth-year dental students. The questionnaire assessed familiarity with MRONJ terminology, information sources, awareness of diagnostic criteria according to the American Association of Oral and Maxillofacial Surgeons (AAOMS), knowledge of disease staging, clinical decision-making, recognition of systemic and local risk factors, and identification of associated medications. Data were analyzed using descriptive statistics and inferential tests to evaluate differences by academic year and gender. Results Of the participants, 39.0% (n = 99) were male and 61.0% (n = 155) female; 44.1% (n = 112) were fourth-year and 55.9% (n = 142) fifth-year students. Although 93% had heard of bisphosphonates, only 32% correctly identified the AAOMS definition of MRONJ. Fifth-year students demonstrated significantly higher knowledge scores regarding MRONJ definition and medication identification compared to fourth-year students (p < 0.01). While 97% recognized the importance of assessing bisphosphonate use and performing dental clearance prior to therapy, only 27% correctly identified appropriate management for patients receiving oral bisphosphonates for more than four years. Awareness of risk factors was moderate: 94% associated osteoporosis and 68% bone metastases with bisphosphonate therapy, whereas only 24% recognized chronic corticosteroid use as a risk factor. The main sources of information were lectures (54%) and textbooks (20%). No significant gender differences were observed. Conclusions Despite high awareness of MRONJ terminology, notable deficiencies exist in knowledge of diagnostic criteria, risk factors, and clinical management. These findings align with previous studies indicating insufficient undergraduate education on MRONJ. Incorporating comprehensive, case-based and interdisciplinary training into dental curricula may improve students’ competence in MRONJ prevention and management. Osteonecrosis Biphosphonates Jaw Diseases Students Dental Knowledge Education Dental Figures Figure 1 Introduction Medication-related osteonecrosis of the jaw (MRONJ) represents a serious complication associated with the use of antiresorptive and antiangiogenic medications, most commonly bisphosphonates and denosumab [ 1 – 4 ]. These agents are widely used for the treatment of osteoporosis, metastatic bone disease, multiple myeloma, and other metabolic bone disorders. While they provide significant therapeutic benefits in reducing skeletal-related events, their use may result in adverse effects, including osteonecrosis of the jaw [ 1 , 2 ]. The condition was first reported by Marx in 2003 in patients receiving intravenous bisphosphonates for cancer-related bone disease [ 5 ]. Initially described as bisphosphonate-related osteonecrosis of the jaw (BRONJ), subsequent reports demonstrated that similar lesions could develop in patients receiving other antiresorptive medications such as denosumab or antiangiogenic agents. Consequently, the American Association of Oral and Maxillofacial Surgeons (AAOMS) introduced the broader term medication-related osteonecrosis of the jaw (MRONJ) in order to encompass all medication-associated cases [ 2 , 6 ]. According to AAOMS diagnostic criteria, MRONJ is defined by three major clinical features: (1) current or previous treatment with antiresorptive or antiangiogenic agents; (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula persisting for more than eight weeks; and (3) absence of a history of radiation therapy or metastatic disease affecting the jaws [ 2 , 6 ]. Although MRONJ is relatively uncommon, it is considered clinically significant due to its chronic nature, risk of infection, potential for pathological fractures, and negative impact on quality of life [ 7 – 9 ]. Epidemiological studies indicate that MRONJ occurs rarely in patients receiving antiresorptive therapy for osteoporosis, with reported prevalence ranging between 0.001% and 0.01% [ 10 ]. However, the incidence increases significantly in oncology patients receiving high-dose intravenous therapy, where reported prevalence rates may reach 1–12% [ 7 , 11 ]. A population-based study conducted in Finland reported MRONJ incidence of approximately 0.3% in patients receiving low-dose antiresorptive therapy and approximately 9% among individuals receiving high-dose treatment for malignancies [ 12 ]. Similarly, a Korean multidisciplinary task force estimated the overall incidence of MRONJ between 10 and 45 cases per 100,000 person-years, with substantially higher rates observed in patients receiving intravenous bisphosphonate therapy or denosumab [ 13 ]. The pathophysiology of MRONJ is multifactorial and remains incompletely understood. Proposed mechanisms include suppression of bone remodeling, impaired angiogenesis, local infection, inflammation, and immune dysfunction [ 4 , 14 ]. Systemic risk factors include cumulative drug exposure, intravenous administration, concurrent corticosteroid therapy, chemotherapy, diabetes, and malignancy. Local factors such as invasive dental procedures, periodontal disease, trauma from dentures, and poor oral hygiene also play an important role in MRONJ development [ 8 , 15 ]. Furthermore, the combination of antiresorptive and antiangiogenic medications appears to significantly increase the risk of developing osteonecrosis of the jaw [ 4 ]. Preventive strategies are considered the most effective approach for reducing MRONJ risk. Clinical guidelines recommend that patients undergo comprehensive dental examination prior to initiation of antiresorptive therapy [ 3 , 16 ]. Primary prevention includes elimination of oral infection sources, treatment of periodontal disease, restoration of carious lesions, and extraction of non-restorable teeth before initiating therapy [ 16 ]. Secondary prevention focuses on minimizing invasive dental procedures during therapy, while tertiary prevention involves management of established MRONJ lesions to prevent disease progression [ 8 ]. Dental professionals play a crucial role in identifying patients at risk, implementing preventive measures, and managing complications associated with MRONJ [ 17 ]. Consequently, adequate knowledge and awareness among dentists and dental students are essential. However, numerous studies have demonstrated that MRONJ awareness among healthcare professionals remains inconsistent and often inadequate [ 18 – 21 ].Several international studies have reported substantial knowledge gaps among dental practitioners. Surveys have shown that many dentists are unable to correctly identify MRONJ diagnostic criteria or associated medications [ 18 ]. Similarly, studies involving dental students indicate limited understanding of MRONJ risk factors, pharmacological agents, and preventive strategies [ 19 , 20 ]. As the use of bone-modifying medications continues to increase due to aging populations and advancements in cancer therapy, dentists will increasingly encounter patients at risk of MRONJ [ 7 ]. Adequate training during undergraduate education may therefore play a critical role in improving prevention and patient safety. The present study aimed to evaluate knowledge, awareness, and preventive attitudes regarding MRONJ among fourth- and fifth-year dental students at Marmara University Faculty of Dentistry. Additionally, the study compared responses according to academic year and gender in order to assess whether clinical training influences MRONJ awareness. Material and Methods Ethical Considerations Ethical approval for this study was obtained from the XXXUniversity Non-Drug and Medical Device Research Ethics Committee (Approval No: 09.2025.25–0538, dated 20 June 2025). All procedures were conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Participation in the study was entirely voluntary and anonymous. Prior to completing the questionnaire, participants were informed about the purpose and scope of the research and provided electronic informed consent. Students were free to withdraw from the study at any stage without any academic or personal consequences. No financial or academic incentives were provided for participation, and all collected data were stored securely and analyzed in a de-identified manner to ensure participant confidentiality. Study Design This study employed a descriptive cross‑sectional design to assess knowledge, attitudes and risk awareness regarding MRONJ among senior dental students. The cross‑sectional approach was chosen because it enables collection of data from a cohort at a single point in time and facilitates identification of associations between demographic factors (such as gender and year of study) and knowledge levels. The research was carried out at a tertiary teaching hospital’s faculty of dentistry, which hosts a diverse cohort of students from various regions. All enrolled fourth‑ and fifth‑year dental students during the 2025–2026 academic year were invited to participate. Inclusion criteria were enrolment in the appropriate year and consent to participate. There were no exclusion criteria based on previous MRONJ training or clinical exposure, as the goal was to capture a realistic picture of knowledge levels among impending graduates. Sample Size and Power Analysis Prior to data collection, a power analysis was conducted to determine the minimum sample size required for the study. The calculation was performed using G*Power software (version 3.1; Heinrich Heine University, Düsseldorf, Germany). An independent samples t-test was planned to compare knowledge levels between two groups (fourth-year and fifth-year dental students). The analysis was conducted with a medium effect size (d = 0.50), a significance level (α) of 0.05, and a statistical power of 80% (1 − β = 0.80). Based on these parameters, the minimum required sample size was calculated as 63 participants per group, resulting in a total sample size of 127 participants. Considering the possibility of incomplete responses or non-participation, a larger number of students were invited to participate in the survey to ensure that the minimum required sample size was achieved. Of 270 eligible students, 254 completed the survey, yielding a response rate of 94.1%. Participants provided written informed consent after being briefed on the study objectives and assured of confidentiality and anonymity. Questionnaire Development The survey instrument was developed in accordance with the diagnostic criteria and clinical recommendations outlined in the American Association of Oral and Maxillofacial Surgeons (AAOMS) position papers on MRONJ [ 6 ]. The final questionnaire consisted of structured multiple-choice questions designed to assess students’ familiarity with MRONJ terminology, knowledge of AAOMS diagnostic criteria, awareness of disease staging, attitudes toward patient management, recognition of systemic and local risk factors, and identification of medications associated with MRONJ. To establish face validity, the instrument was pilot tested among 15 volunteer students who were excluded from the main study; feedback led to minor wording adjustments for clarity. Internal consistency reliability was determined using Cronbach’s alpha, yielding a coefficient of 0.82, which indicates good reliability. The questionnaire comprised the following domains: Knowledge of Terminology Students were asked to indicate which terms they recognised from among “BRONJ (bisphosphonate‑related osteonecrosis)”, “MRONJ (medication‑related osteonecrosis)”, and “ONJ (osteonecrosis of the jaw)”. Sources of Information : Respondents identified where they had learned about MRONJ: scientific meetings, literature reviews, the dental school curriculum, continuing education, or none. Multiple selections were permitted. Awareness of AAOMS Diagnostic Criteria : Students selected from four statements those that constitute the diagnostic criteria for MRONJ according to AAOMS: (a) history of anti‑resorptive or anti‑angiogenic therapy; (b) presence of exposed bone or bone that can be probed through a fistula persisting for at least eight weeks; (c) history of radiotherapy or metastatic disease; (d) all of the above. Only the first two constitute diagnostic criteria; the third is an exclusion criterion. Knowledge of MRONJ Staging Participants indicated whether they were familiar with the AAOMS staging system for MRONJ. Those who answered yes were asked to match clinical scenarios to stages 0 through 3. Attitudes Toward Clinical Management The questionnaire assessed the perceived importance of obtaining a bisphosphonate history and referring patients for dental evaluation before initiating anti‑resorptive therapy. Perceptions of Risk Persistence Students indicated whether they believed MRONJ risk persists after cessation of bisphosphonate therapy. Identification of High‑Risk Systemic Conditions The survey listed systemic conditions (breast cancer, prostate cancer, leukemia and multiple myeloma), and students selected which they believed confer high MRONJ risk. An “all” option allowed recognition of multiple high‑risk conditions. Identification of Local Risk Factors Respondents indicated local factors that increase MRONJ risk from a list including periodontal disease, tooth extraction, denture trauma, infection and “all”. Recognition of Implicated Medications : Students selected medications associated with MRONJ: bisphosphonates, denosumab, corticosteroids, anti‑angiogenic agents, or “all”. Demographic Information Gender and year of study were collected. Data Collection Procedure Data collection was coordinated with course schedules to maximize participation. The principal investigator introduced the study to the students, explained its objectives, emphasized the voluntary nature of participation and confidentiality, and obtained informed consent prior to participation. The questionnaire was administered electronically using Google Forms, and students completed the survey during a scheduled class session. Researchers were present to clarify any questions related to the wording of the survey items but did not influence the participants’ responses. After completion, responses were automatically recorded through the online platform. The collected data were exported for analysis, and data verification was performed independently by two researchers to minimize potential entry or processing errors, with any discrepancies resolved through consensus. Statistical Analysis Data were analysed using IBM SPSS Statistics version 31. Descriptive statistics (frequencies, percentages) summarised responses. Comparisons by sex and year were conducted using Pearson’s Chi‑square test or Fisher’s exact test when expected counts were small. For questions with more than two response options, the Fisher–Freeman–Halton test was applied. Significance was set at p < 0.05. Missing data were excluded from the analysis of individual questions. Results Overview of Participant Characteristics A total of 254 students completed the questionnaire. The demographic distribution reflected a female predominance: 155 respondents (61.0%) were female and 99 (39.0%) were male. The majority of respondents were fifth‑year students (55.9%, n = 142), with the remainder in the fourth year (44.1%, n = 112). The mean age was 23.4 ± 1.1 years, with a range from 22 to 26 years. Participants demonstrated high familiarity with MRONJ-related terminology. Overall, 91.7% were familiar with the term MRONJ, 89.8% with BRONJ, and 79.5% with ONJ. The primary source of knowledge was dental school education (92.9%). Regarding diagnostic criteria defined by the American Association of Oral and Maxillofacial Surgeons (AAOMS), the most frequently selected criterion was a history of antiresorptive or antiangiogenic therapy (52.4%).Approximately 49.2% of students reported knowing the main stages of MRONJ, whereas 50.8% indicated that they did not know them. Most participants ( 91.3% ) considered questioning bisphosphonate use during medical history taking to be important, and 98.0% emphasized the importance of dental evaluation prior to initiating therapy. Regarding systemic risk factors, 63.0% correctly identified all listed systemic diseases as potential contributors to MRONJ. Similarly, 72.8% identified all listed local risk factors (periodontal disease, tooth extraction, prosthetic trauma, and infection). Among medications associated with MRONJ, bisphosphonates were the most recognized (66.5%), followed by denosumab (49.6%) (Table 1 ). Table 1 Knowledge and Awareness of Medication-Related Osteonecrosis of the Jaw Among Participants Variable Response n % Known terminology BRONJ 228 89.8 MRONJ 233 91.7 ONJ 202 79.5 Source of knowledge Scientific meetings 16 6.3 Review articles 26 10.2 Dental school 236 92.9 Frequent training 11 4.3 No knowledge 1 0.4 AAOMS diagnostic criteria awareness History of antiresorptive or antiangiogenic therapy 133 52.4 Exposed bone or lesion without another cause 56 22.0 History of radiotherapy or metastasis 31 12.2 All criteria 91 35.8 Knowledge of MRONJ stages Yes 125 49.2 No 129 50.8 Importance of questioning bisphosphonate use in medical history Important 232 91.3 Not important 1 0.4 Do not know 21 8.3 Importance of dental examination before therapy Important 249 98.0 Not important 2 0.8 Do not know 3 1.2 Risk in patients who previously used BP MRONJ risk exists 234 92.1 No risk 15 5.9 Treatment type not important 8 3.1 Systemic diseases associated with risk Breast cancer 23 9.1 Prostate cancer 17 6.7 Leukemia 51 20.1 Multiple myeloma 66 26.0 All 160 63.0 Local risk factors Periodontal disease 39 15.4 Tooth extraction 57 22.4 Denture trauma 19 7.5 Infection 47 18.5 All 185 72.8 Drugs associated with MRONJ Bisphosphonates 169 66.5 Denosumab 126 49.6 Corticosteroids 24 9.4 Antiangiogenic drugs 59 23.2 All 81 31.9 The AAOMS defines MRONJ using three criteria: current or previous treatment with anti‑resorptive or anti‑angiogenic agents, exposed bone or bone that can be probed through an intra‑oral or extra‑oral fistula persisting for at least eight weeks, and no history of radiation therapy or metastatic disease to the jaws[ 15 ]. Respondents were asked to select which statements constituted diagnostic requirements. The most frequently selected statement was “history of completed or ongoing anti‑resorptive or anti‑angiogenic therapy,” chosen by 52.4% (n = 133). Only 41.7% (n = 106) selected “persistent exposed bone or bone that can be probed through a fistula for eight weeks,” and 36.2% (n = 92) incorrectly selected “history of radiotherapy or metastasis” (which is an exclusion criterion). Only 25.6% (n = 65) selected both correct diagnostic criteria without selecting the exclusion criterion. Fourth‑year students were more likely than fifth‑year students to choose “history of radiotherapy or metastasis” (42.9% vs. 31.0%, p = 0.040) (Table 1 ). Male participants demonstrated significantly higher familiarity with the general term osteonecrosis of the jaw (ONJ ) compared with female participants (85.9% vs. 75.5%, p = 0.046). However, female students were significantly more likely to emphasize the importance of questioning bisphosphonate use in the patient’s medical history (95.5% vs. 84.8%, p = 0.007).Similarly, female participants more frequently indicated that MRONJ risk persists even after completion of bisphosphonate therapy (94.8% vs. 87.9%, p = 0.045). Regarding local risk factors, male students more frequently identified tooth extraction as a risk factor for MRONJ compared with female students (29.3% vs. 18.1%, p = 0.036). In contrast, female participants were significantly more likely to select all listed local risk factors (78.1% vs. 64.6%, p = 0.019. In terms of medications associated with osteonecrosis of the jaws, male participants were significantly more likely to identify corticosteroids as a potential causative agent (15.2% vs. 5.8%, p = 0.013). No statistically significant gender differences were observed for other medications, including bisphosphonates, denosumab, or antiangiogenic drugs ( p > 0.05) (Table 2 ). Table 2 Evaluation of Knowledge Levels Regarding MRONJ According to Gender Variable Category Male n (%) Female n (%) p value Known terminology BRONJ (Bisphosphonate-related osteonecrosis of the jaw) 89 (89.9) 139 (89.7) 0.995ᵃ MRONJ (Medication-related osteonecrosis of the jaw) 90 (90.9) 143 (92.3) 0.703ᵃ ONJ (Osteonecrosis of the jaw) 85 (85.9) 117 (75.5) 0.046ᵃ* Source of terminology knowledge Scientific meetings 6 (6.1) 10 (6.5) 0.900ᵃ Review articles 11 (11.1) 15 (9.7) 0.713ᵃ Dental school education 92 (92.9) 144 (92.9) 0.994ᵃ Frequent training programs 5 (5.1) 6 (3.9) 0.755ᵇ No knowledge 0 (0.0) 1 (0.6) 1.000ᵇ AAOMS diagnostic criteria for MRONJ History of antiresorptive or antiangiogenic therapy 47 (47.5) 86 (55.5) 0.213ᵃ Exposed bone or lesion in the jaw without another cause 22 (22.2) 34 (21.9) 0.957ᵃ History of radiotherapy or metastasis 12 (12.1) 19 (12.3) 0.974ᵃ All criteria 35 (35.4) 56 (36.1) 0.900ᵃ Knowledge of MRONJ stages Yes 45 (45.5) 80 (51.6) 0.338ᵃ No 54 (54.5) 75 (48.4) Importance of questioning BP use in patient history Important 84 (84.8) 148 (95.5) 0.007ᶜ** Not important 1 (1.0) 0 (0.0) Do not know 14 (14.1) 7 (4.5) Dental examination before initiating therapy Important 96 (97.0) 153 (98.7) 0.198ᶜ Not important 2 (2.0) 0 (0.0) Do not know 1 (1.0) 2 (1.3) Correct statement for patients who completed BP therapy MRONJ risk exists 87 (87.9) 147 (94.8) 0.045ᵃ* No MRONJ risk 8 (8.1) 7 (4.5) 0.240ᵃ Medical specialty not important 6 (6.1) 2 (1.3) 0.059ᵇ Systemic diseases associated with MRONJ risk Breast cancer 10 (10.1) 13 (8.4) 0.642ᵃ Prostate cancer 6 (6.1) 11 (7.1) 0.747ᵃ Leukemia 23 (23.2) 28 (18.1) 0.316ᵃ Multiple myeloma 30 (30.3) 36 (23.2) 0.210ᵃ All 59 (59.6) 101 (65.2) 0.370ᵃ Local risk factors for MRONJ Periodontal disease 20 (20.2) 19 (12.3) 0.087ᵃ Tooth extraction 29 (29.3) 28 (18.1) 0.036ᵃ* Denture trauma 8 (8.1) 11 (7.1) 0.771ᵃ Infection 22 (22.2) 25 (16.1) 0.223ᵃ All 64 (64.6) 121 (78.1) 0.019ᵃ* Medications causing osteonecrosis of the jaws Bisphosphonates (Fosamax) 68 (68.7) 101 (65.2) 0.561ᵃ Denosumab (Prolia) 46 (46.5) 80 (51.6) 0.424ᵃ Corticosteroids 15 (15.2) 9 (5.8) 0.013ᵃ* Antiangiogenic drugs 20 (20.2) 39 (25.2) 0.361ᵃ All 29 (29.3) 52 (33.5) 0.478ᵃ ᵃPearson Chi-square test ᵇFisher’s Exact test ᶜFisher-Freeman-Halton test *p < 0.05 ** p < 0.01 Multiple responses were allowed. When MRONJ-related knowledge levels were compared according to academic year, several statistically significant differences were identified. Fifth-year students demonstrated significantly higher familiarity with the term BRONJ (bisphosphonate-related osteonecrosis of the jaw) compared with fourth-year students (96.5% vs. 81.3%, p = 0.001). In addition, fifth-year students more frequently reported scientific meetings as a source of knowledge regarding MRONJ (9.9% vs. 1.8%, p = 0.009). Conversely, fourth-year students selected “history of radiotherapy or metastasis ” as a diagnostic criterion for MRONJ significantly more often than fifth-year students (17.0% vs. 8.5%, p = 0.040). However, knowledge of the main stages of MRONJ was significantly higher among fifth-year students compared with fourth-year students (57.0% vs. 39.3%, p = 0.005). Regarding medications associated with osteonecrosis of the jaws, fifth-year students were significantly more likely to identify antiangiogenic drugs as potential causative agents compared with fourth-year students (28.2% vs. 17.0%, p = 0.036) (Fig. 1 ). No statistically significant differences were observed between the two academic years with respect to other variables, including awareness of MRONJ terminology (except BRONJ), knowledge of systemic risk conditions, recognition of local risk factors, or attitudes toward questioning bisphosphonate use and recommending dental examination prior to initiating antiresorptive therapy ( p > 0.05). Overall, these findings suggest that while senior dental students generally demonstrate a high level of awareness regarding MRONJ, certain aspects of disease definition, staging, and medication-related risk recognition improve with increasing clinical training (Table 3 ). Table 3 Evaluation of Knowledge Levels Regarding MRONJ According to Academic Year Variable Category 4th Year n (%) 5th Year n (%) p value Known terminology BRONJ (Bisphosphonate-related osteonecrosis of the jaw) 91 (81.3) 137 (96.5) 0.001ᵃ** MRONJ (Medication-related osteonecrosis of the jaw) 99 (88.4) 134 (94.4) 0.086ᵃ ONJ (Osteonecrosis of the jaw) 84 (75.0) 118 (83.1) 0.112ᵃ Source of terminology knowledge Scientific meetings 2 (1.8) 14 (9.9) 0.009ᵃ** Review articles 7 (6.3) 19 (13.4) 0.063ᵃ Dental school education 107 (95.5) 129 (90.8) 0.148ᵃ Frequent training programs 3 (2.7) 8 (5.6) 0.356ᵇ No knowledge 0 (0.0) 1 (0.7) 1.000ᵇ AAOMS diagnostic criteria for MRONJ History of antiresorptive or antiangiogenic therapy 59 (52.7) 74 (52.1) 0.929ᵃ Exposed bone or lesion without another cause 25 (22.3) 31 (21.8) 0.925ᵃ History of radiotherapy or metastasis 19 (17.0) 12 (8.5) 0.040ᵃ* All criteria 34 (30.4) 57 (40.1) 0.106ᵃ Knowledge of MRONJ stages Yes 44 (39.3) 81 (57.0) 0.005ᵃ** No 68 (60.7) 61 (43.0) Importance of questioning BP use in patient history Important 100 (89.3) 132 (93.0) 0.262ᶜ Not important 0 (0.0) 1 (0.7) Do not know 12 (10.7) 9 (6.3) Dental examination before initiating therapy Important 109 (97.3) 140 (98.6) 0.792ᶜ Not important 1 (0.9) 1 (0.7) Do not know 2 (1.8) 1 (0.7) Correct statement for patients who completed BP therapy MRONJ risk exists 100 (89.3) 134 (94.4) 0.136ᵃ No MRONJ risk 7 (6.3) 8 (5.6) 0.836ᵃ Medical specialty not important 5 (4.5) 3 (2.1) 0.307ᵇ Systemic diseases associated with MRONJ risk Breast cancer 8 (7.1) 15 (10.6) 0.346ᵃ Prostate cancer 10 (8.9) 7 (4.9) 0.205ᵃ Leukemia 23 (20.5) 28 (19.7) 0.872ᵃ Multiple myeloma 27 (24.1) 39 (27.5) 0.545ᵃ All 66 (58.9) 94 (66.2) 0.234ᵃ Local risk factors for MRONJ Periodontal disease 20 (17.9) 19 (13.4) 0.326ᵃ Tooth extraction 25 (22.3) 32 (22.5) 0.968ᵃ Denture trauma 5 (4.5) 14 (9.9) 0.105ᵃ Infection 20 (17.9) 27 (19.0) 0.814ᵃ All 81 (72.3) 104 (73.2) 0.870ᵃ Medications associated with osteonecrosis of the jaws Bisphosphonates (Fosamax) 77 (68.8) 92 (64.8) 0.507ᵃ Denosumab (Prolia) 58 (51.8) 68 (47.9) 0.537ᵃ Corticosteroids 15 (13.4) 9 (6.3) 0.056ᵃ Antiangiogenic drugs 19 (17.0) 40 (28.2) 0.036ᵃ* All 31 (27.7) 50 (35.2) 0.201ᵃ ᵃPearson Chi-square test ᵇFisher’s Exact test ᶜFisher-Freeman-Halton test *p < 0.05 ** p < 0.01 Multiple responses were allowed. Discussion This comprehensive cross‑sectional study evaluated the knowledge, attitudes and risk awareness regarding medication‑related osteonecrosis of the jaw among fourth‑ and fifth‑year dental students. Overall, participants demonstrated high recognition of MRONJ and BRONJ terminology, indicating that these concepts have permeated the dental curriculum. However, a closer examination revealed substantive knowledge gaps, particularly in understanding diagnostic criteria, staging systems, and non‑bisphosphonate medications. Differences in responses by gender and academic year further illuminate specific areas requiring educational emphasis. The findings of the present study are broadly consistent with previous research conducted among dental students in Türkiye. In a recent study evaluating the knowledge level of Turkish dental students regarding MRONJ, Şahin et al. reported that although most students considered questioning medications associated with osteonecrosis during patient history taking to be important, substantial deficiencies remained in knowledge of diagnostic criteria, risk factors, and associated medications. Notably, only about one fifth of students were able to correctly identify the three main diagnostic criteria required for MRONJ diagnosis, while a considerable proportion failed to identify any of the criteria correctly [ 22 ]. Similarly, Erdil et al. conducted a multicenter study among senior dental students in Türkiye and reported that although awareness of MRONJ terminology was relatively high, students demonstrated insufficient knowledge regarding disease staging, preventive strategies, and medication-related risk factors [ 23 ]. In line with these findings, the present study also demonstrated high awareness of MRONJ terminology among senior dental students, yet important gaps were observed in knowledge related to diagnostic criteria, staging, and medications associated with MRONJ. These similarities suggest that although theoretical awareness may be relatively widespread among Turkish dental students, more comprehensive and clinically oriented education may be required to improve understanding of MRONJ prevention and management. Comparable trends have also been reported in international studies evaluating MRONJ awareness among dental students. Rosella et al. found that although Italian dental students were familiar with the general concept of MRONJ, their ability to identify risk factors and appropriate management strategies remained limited [ 14 ]. Similarly, Teślak et al. reported that while Polish dental students demonstrated relatively high awareness of bisphosphonates, knowledge regarding other medications associated with MRONJ, particularly denosumab, was insufficient [ 24 ]. These findings are consistent with the results of the present study and suggest that knowledge gaps related to MRONJ are not limited to a specific country but represent a broader educational challenge in dental training programs worldwide. Collectively, the available evidence highlights the need for improved curricular integration of MRONJ-related topics, particularly focusing on clinical risk assessment, medication awareness, and interdisciplinary management. Our results show that 91.7% of students recognised the term MRONJ and 89.8% recognised BRONJ, while 79.5% recognised the broader term ONJ. This level of awareness exceeds that reported in some prior studies[ 14 ], suggesting effective integration of MRONJ terminology into the curriculum. Nevertheless, recognition of a term does not equate to mastery. Only 25.6% accurately identified both diagnostic criteria specified by the AAOMS (history of anti‑resorptive/anti‑angiogenic therapy and persistent exposed bone for eight weeks) and avoided selecting the exclusion criterion (radiotherapy or metastasis). Furthermore, only 49.2% claimed familiarity with the staging system, and of these, a minority could correctly match clinical scenarios to stages. These findings align with earlier research indicating that even when clinicians know of MRONJ, they may not understand its diagnostic nuances[ 13 ]. A striking finding is the high value students placed on preventive practices: over 91% considered it important to enquire about bisphosphonate use, and 98% recognised the need for dental evaluation before therapy initiation. These rates are higher than those reported for general dental practitioners in some countries[ 16 ], reflecting perhaps the emphasis placed on prevention in academic settings. Encouragingly, 92.1% understood that MRONJ risk persists after therapy cessation, consistent with evidence that bisphosphonate accumulation in bone can prolong risk [ 8 ]. Yet male students were less inclined to emphasise medication history and risk persistence, implying potential differences in perception or retention of pharmacologic information. The observed gender differences merit further exploration. Female students were more likely to appreciate the importance of taking a bisphosphonate history and to recognise that MRONJ risk persists after therapy. They also more frequently selected “all” when identifying local risk factors, indicating a more comprehensive view. These patterns may reflect greater attentiveness to detail or risk aversion among female students, consistent with studies suggesting that women in healthcare professions may prioritise patient safety[ 18 ]. Conversely, male students’ higher recognition of corticosteroids and the generic term ONJ could reflect differential interest or prior exposure to pharmacology. Educational interventions should be inclusive of varying learning styles and address areas where either sex demonstrates deficits. Another notable finding was the limited recognition of medications beyond bisphosphonates. Only about half of students identified denosumab, and fewer recognised anti‑angiogenic agents or corticosteroids. This gap is consistent with prior surveys [ 14 , 24 ] and highlights the need to update curricula as new therapies emerge. The misattribution of unrelated medications in free text responses underscores confusion and emphasises the necessity for clear, repeated instruction. Progression through the curriculum was associated with improved knowledge of BRONJ, MRONJ staging and recognition of anti‑angiogenic agents. Fifth‑year students’ greater participation in scientific meetings and exposure to clinical rotations likely contributed to these gains. Nonetheless, the persistence of misconceptions among final‑year students, such as misclassifying radiotherapy or metastasis as diagnostic criteria, indicates that certain topics require repeated emphasis and possibly alternative teaching methods, such as case‑based learning or simulation. The results of this study have significant implications for dental education. First, curricula should include comprehensive coverage of MRONJ, including pathophysiology, risk factors, diagnostic criteria, staging, management strategies and interprofessional collaboration [ 25 ]. Given the evolving nature of MRONJ and the introduction of new medications, curriculum content should be regularly updated. Second, teaching methods should extend beyond didactic lectures to incorporate interactive and experiential learning. Case‑based discussions, problem‑based learning scenarios, simulation of patient interactions and clinical rotations in oral and maxillofacial surgery can enhance understanding and retention [ 25 – 27 ]. Third, an emphasis on interprofessional education is warranted. Collaboration between dental and medical students in learning activities could foster a holistic understanding of MRONJ and other conditions requiring cross‑disciplinary management. Joint seminars with oncologists, endocrinologists and oral surgeons could expose dental students to the complexity of medical decision‑making around anti‑resorptive therapy and emphasise the importance of communication across specialties [ 25 , 27 ]. Fourth, faculty development programmes should ensure that educators are well versed in the latest MRONJ guidelines and literature. Faculty may need support to integrate new evidence into teaching materials. Access to continuing education and consensus documents, such as the AAOMS position papers [ 15 ] and MASCC/ISOO/ASCO guidelines[ 19 ], should be facilitated. Beyond the educational context, this study holds implications for clinical practice. Graduating dentists must be able to identify patients at risk of MRONJ, counsel them appropriately, and coordinate with physicians to modify therapy when necessary. In clinical settings, obtaining thorough medical histories, including drug names, dosages and duration, should be standard practice. Dental practitioners should maintain a high index of suspicion for MRONJ in patients presenting with unexplained oral pain, swelling, or non‑healing extraction sockets, particularly if they have a history of anti‑resorptive or anti‑angiogenic therapy. When invasive procedures are planned for at‑risk patients, dentists should liaise with prescribers to consider drug holidays where evidence supports their efficacy [ 5 ]. However, because the benefits of drug holidays remain uncertain, particularly for agents with long half‑lives, decisions must be individualised and based on current guidelines and patient risk factors[ 12 ]. In all cases, optimisation of oral hygiene and treatment of existing infections or periodontal disease before initiating therapy are essential preventive strategies. Like any cross‑sectional survey, our study has inherent limitations. The findings reflect the knowledge and attitudes of students at a single institution; they may not be generalisable to students in other geographical regions or educational systems. Additionally, self‑reported familiarity may not translate into practical competence; observational studies assessing clinical performance would complement these findings. Social desirability bias could lead participants to overstate their knowledge or positive attitudes, though anonymity was emphasised to mitigate this. Further research is needed to evaluate the effectiveness of targeted educational interventions in improving MRONJ knowledge and clinical competence. Randomised controlled trials could compare traditional didactic teaching with case‑based or simulation‑based curricula. Longitudinal studies following students into practice could assess knowledge retention and translate learning into clinical decision‑making. Qualitative research involving focus groups could explore students’ perceptions of MRONJ teaching and identify barriers to understanding complex pharmacological interactions. Additionally, research across multiple institutions and countries would provide a broader picture of MRONJ awareness and allow for cross‑cultural comparisons.Beyond education, basic science research continues to be crucial for elucidating the pathophysiology of MRONJ. Studies investigating genetic predisposition, molecular pathways involved in bone remodeling and vascularisation, and the role of microbiota could lead to improved preventive and therapeutic strategies[ 29 ][30]. Clinical trials assessing novel management approaches, including regenerative therapies, could expand treatment options for established MRONJ. Conclusion Medication‑related osteonecrosis of the jaw represents a significant iatrogenic condition with complex pathophysiology and serious implications for patients’ quality of life. The present study investigated knowledge, attitudes and risk awareness among fourth‑ and fifth‑year dental students, revealing high recognition of MRONJ terms but significant gaps in understanding diagnostic criteria, staging, systemic and local risk factors, and the spectrum of implicated medications. Differences by sex and academic year suggest that learning styles and educational exposure influence knowledge, underscoring the need for tailored interventions. These findings emphasise the importance of comprehensive MRONJ education within dental curricula. Core components should include the biology of bone turnover and how anti‑resorptive and anti‑angiogenic drugs disrupt this balance; clear differentiation between MRONJ, BRONJ, osteoradionecrosis and other jaw pathologies; instruction on current diagnostic criteria and staging systems; and practical guidance on preventive strategies, patient counselling and interprofessional collaboration. Interactive teaching methods, such as case‑based learning and simulations, may enhance understanding and retention. Continuing education for practising dentists is also essential to update knowledge as new therapies emerge and guidelines evolve. Future studies should evaluate the effectiveness of specific educational interventions, explore factors influencing learning disparities, and investigate the impact of interprofessional education on collaborative practice. Abbreviations MRONJ Medication-related osteonecrosis of the jaw BRONJ Bisphosphonate-related osteonecrosis of the jaw ONJ Osteonecrosis of the jaw AAOMS American Association of Oral and Maxillofacial Surgeons Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Marmara University Non-Drug and Medical Device Research Ethics Committee (Approval No: 09.2025.25–0538, dated 20 June 2025). All procedures were conducted in accordance with the Declaration of Helsinki. Participation was voluntary, and informed consent was obtained from all participants prior to data collection. Consent for publication Not applicable. Competing Interests The authors declare that they have no competing interests. Clinical trial number Not applicable. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution Z.A. and G.K. wrote the main manuscript text and designed the study.Z.A. performed data collection and questionnaire implementation.G.K. supervised the study and contributed to data interpretation.F.N.P. critically revised the manuscript and provided scientific supervision. Acknowledgements This study was conducted as part of the undergraduate thesis of Zeynep Allahverdi at Marmara University Faculty of Dentistry under the supervision of Assoc. Prof. Gaye Keser. Availability of data and materials The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. References Hadaya S, Goman D, Massie AM, Moubayed MJ, Rahal SP. Medication-related osteonecrosis of the jaw: knowledge and perceptions of medical professionals on the usage of bone modifying agents and dental referrals. J Med Life. 2022;PMID:35449990. 10.25122/jml-2021-0085 . AlRowis R, Alhadlaq A, Alkhodair R. Medication-Related Osteonecrosis of the Jaw (MRONJ): A Review of Pathophysiology, Risk Factors, Preventive Measures and Treatment Strategies. Saudi Dent J. 2022;34(3):202–10. 10.1016/j.sdentj.2022.01.003 . PMID: 35935720. Demir A, Pekiner FN. Radiographic findings of bisphosphonate-related osteonecrosis of the jaws: Comparison with cone-beam computed tomography and panoramic radiography. Niger J Clin Pract. 2017;20(3):346–54. 10.4103/1119-3077.183241 . PMID: 28256491. Dodson TB. The Frequency of Medication-related Osteonecrosis of the Jaw and its Associated Risk Factors. Oral Maxillofac Surg Clin North Am. 2015;27(4):509–16. 10.1016/j.coms.2015.06.003 . PMID: 26362367. Hasegawa T, Kawakita A, Ueda N, Japanese Study Group of Cooperative Dentistry with Medicine (JCDM), et al. A multicenter retrospective study of the risk factors associated with medication-related osteonecrosis of the jaw after tooth extraction in patients receiving oral bisphosphonate therapy: can primary wound closure and a drug holiday really prevent MRONJ? Osteoporos Int. 2017;28(8):2465–73. 10.1007/s00198-023-06745-3 . Ruggiero SL, Dodson TB, Aghaloo T, Carlson ER, Ward BB, Kademani D. AAOMS’ Position Paper on MRONJ—2022 Update. J Oral Maxillofac Surg. 2022;80(5):920–43. 10.1016/j.joms.2022.02.008 . PMID: 35300956. Khan AA, Morrison A, Kendler DL, et al. Osteonecrosis of the jaw (ONJ): diagnosis and management—an update. Osteoporos Int. 2016;27(3):853–8. Khosla S, Burr D, Cauley J, et al. Bisphosphonate-associated osteonecrosis of the jaw: Report of a task force of the American Society for Bone and Mineral Research. J Bone Min Res. 2007;22(10):1479–91. 10.1359/jbmr.0707onj . PMID: 17663640. Lo JC, O’Ryan FS, Gordon NP, et al. Prevalence of osteonecrosis of the jaw in patients with oral bisphosphonate exposure. J Oral Maxillofac Surg. 2010;68(2):243–53. 10.1016/j.joms.2009.03.050 . PMID: 19772941. 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. 10.1016/S0278-2391(03)00720-1 . PMID: 12966493. Nicolatou-Galitis O, Schiødt M, Amaral Mendes R, et al. Medication-related osteonecrosis of the jaw: definition and best practice for prevention, diagnosis and treatment. Oral Surg Oral Med Oral Pathol Oral Radiol. 2019;127(2):117–35. 10.1016/j.oooo.2018.09.008 . Otto S, Pautke C, Opelz C, et al. Medication-related osteonecrosis of the jaw: Prevention, diagnosis and management in patients with cancer and bone metastases. Cancer Treat Rev. 2018;69:177–87. 10.1016/j.ctrv.2018.06.007 . PMID: 30055439. Patil V, Acharya S, Vineetha R, Nikhil K. Awareness About Medication-Related Osteonecrosis of the Jaw Among Dental Professionals: A Multicentre Study. Oral Health Prev Dent. 2020;18(3):505–509. 10.3290/j.ohpd.a43361 . PMID: 32016175. Rosella D, Papi P, Giardino R, Cicalini E, Piccoli L, Di Carlo S. Dental students’ knowledge of medication-related osteonecrosis of the jaw. Eur J Dent. 2017;11:461–8. 10.4103/ejd.ejd_27_17 . Ruggiero SL, Dodson TB, Fantasia J, et al. 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. 10.1016/j.joms.2014.04.031 . PMID: 25234529. 16.Sturrock A, Preshaw PM, Hayes C, Wilkes S, Laws R. General dental practitioners’ perceptions of, and attitudes towards, MRONJ. BMJ Open. 2019;9(6):e029951. 10.1136/bmjopen-2019-029951 . PMID: 31213454. 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):121–125. 10.1038/sj.bdj.2017.79 . PMID:28126996. Thomas JG, Bui P. Medication-related osteonecrosis of the jaw: A narrative review. Front Oral Maxillofac Med. 2023;5:31. 10.21037/fomm-21-106 . PMID: (yok / PubMed’de indeksli değil). Yarom N, Shapiro CL, Peterson DE, et al. MRONJ: MASCC/ISOO/ASCO clinical practice guideline. J Clin Oncol. 2019;37(25):2270–90. 10.1200/JCO.19.01186 . PMID: 31329513. Soutome S, Hayashida S, Funahara M, et al. Factors affecting MRONJ development in cancer patients on high-dose bisphosphonate/denosumab: Is tooth extraction a risk factor? PLoS ONE. 2018;13(8):e0201343. 10.1371/journal.pone.0201343 . PMID: 30071018. Lai T, Wang T, Liu C, et al. Risk factors for osteonecrosis of the jaw in oral cancer patients… potential role of chemotherapy. Radiother Oncol. 2017;123(3):406–411. PMID:28457700. DOI: 10.1016/j.radonc.2017.04.022. Şahin M, Doğan FB, Demir A. Evaluation of dental students’ knowledge levels regarding medication-related osteonecrosis of the jaw (MRONJ). Selcuk Dent J. 2024;11(2):132–6. 10.15311/selcukdentj.1334465 . Erdil A, Sami Demirsoy M, Çolak S, İğneci M, Başal A. Awareness of medication-related osteonecrosis of the jaw among dentistry students: a multicenter survey study. Essent Dent. 2025;4:0003. 10.5152/EssentDent.2025.25003 . Teślak M, Chmielewska-Władyka M, Kiełtyka-Konieczny K, Grzech-Leśniak K. Awareness of MRONJ among Polish dentists and dental students. Appl Sci. 2021;11(11):4821. Reeves S, Fletcher S, Barr H, Birch I, Boet S, Davies N, et al. A BEME systematic review of the effects of interprofessional education. Med Teach. 2016;38(7):656–68. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923–58. Nicolatou-Galitis O, Schiødt M, Mendes RA, Ripamonti C, Hope S, Drudge-Coates L, et al. Medication-related osteonecrosis of the jaw: definition and best practice for prevention, diagnosis and treatment. Oral Surg Oral Med Oral Pathol Oral Radiol. 2019;127(2):117–35. Allen MR, Burr DB. The pathogenesis of bisphosphonate-related osteonecrosis of the jaw: so many hypotheses, so few data. J Oral Maxillofac Surg. 2009;67(5 Suppl):61–70. 10.1016/j.joms.2009.01.007 . PMID: 19371816. Reid IR, Cornish J. Epidemiology and pathogenesis of osteonecrosis of the jaw. Nat Rev Rheumatol. 2012;8(2):90–96 (online 2011). PMID: 22124271. 10.1038/nrrheum.2011.181 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9366232","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":628420777,"identity":"064d3607-9ffa-46af-979b-a1193660e2a4","order_by":0,"name":"Zeynep Allahverdi","email":"","orcid":"","institution":"Marmara University","correspondingAuthor":false,"prefix":"","firstName":"Zeynep","middleName":"","lastName":"Allahverdi","suffix":""},{"id":628420778,"identity":"676a0764-83cf-4bac-ae2f-e3975ccd92de","order_by":1,"name":"Gaye Keser","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYJACxgYQyd4D5vDwEa+F5wwDwwEgxUa8FokcsBYGglrk3c8YPpxRUSdnPvPtwccfc+xk2BiYHz66gUeL4ZkcY8MNZw4by9zOSzY4uC0Z6DA2Y+McfFoacswkH7YdSJwhnWMmcXAbM1ALD5s0Xi39b8x/PvxXVz9D8gxISz1hLfISOWaMGxuYEyQkeEBaDhPWYiDxrFhyxrHDhjN4cowNzm47zsPGTMAv8v3JGz/21NTJS7CfMXxQua3anp+9+eFjvLYc4DBAE2LGoxxsSwP7AwJKRsEoGAWjYMQDADmVR8AWILzaAAAAAElFTkSuQmCC","orcid":"","institution":"Marmara University","correspondingAuthor":true,"prefix":"","firstName":"Gaye","middleName":"","lastName":"Keser","suffix":""},{"id":628420779,"identity":"518c73f4-a707-4c92-80d9-40888c201b53","order_by":2,"name":"Filiz Namdar Namdar Pekiner","email":"","orcid":"","institution":"Marmara University","correspondingAuthor":false,"prefix":"","firstName":"Filiz","middleName":"Namdar Namdar","lastName":"Pekiner","suffix":""}],"badges":[],"createdAt":"2026-04-09 09:24:59","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9366232/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9366232/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107834121,"identity":"dbd4cb88-a7bb-4ec2-a311-fb8a048031c1","added_by":"auto","created_at":"2026-04-26 15:43:14","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":210681,"visible":true,"origin":"","legend":"\u003cp\u003eRecognition of medications associated with medication-related osteonecrosis of the jaw (MRONJ) according to academic year\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9366232/v1/3032250a4be63d5b35e16a75.jpeg"},{"id":107870560,"identity":"52143413-1a27-49e4-8df8-7e2d361d1a11","added_by":"auto","created_at":"2026-04-27 07:39:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":767008,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9366232/v1/8e82323b-c78b-4c7e-b368-b10d3bcafd53.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Knowledge, Awareness, and Preventive Practices Regarding Medication‐Related Osteonecrosis of the Jaw Among Dental Students: A Cross‐Sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedication-related osteonecrosis of the jaw (MRONJ) represents a serious complication associated with the use of antiresorptive and antiangiogenic medications, most commonly bisphosphonates and denosumab [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These agents are widely used for the treatment of osteoporosis, metastatic bone disease, multiple myeloma, and other metabolic bone disorders. While they provide significant therapeutic benefits in reducing skeletal-related events, their use may result in adverse effects, including osteonecrosis of the jaw [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The condition was first reported by Marx in 2003 in patients receiving intravenous bisphosphonates for cancer-related bone disease [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Initially described as bisphosphonate-related osteonecrosis of the jaw (BRONJ), subsequent reports demonstrated that similar lesions could develop in patients receiving other antiresorptive medications such as denosumab or antiangiogenic agents. Consequently, the American Association of Oral and Maxillofacial Surgeons (AAOMS) introduced the broader term medication-related osteonecrosis of the jaw (MRONJ) in order to encompass all medication-associated cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to AAOMS diagnostic criteria, MRONJ is defined by three major clinical features: (1) current or previous treatment with antiresorptive or antiangiogenic agents; (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula persisting for more than eight weeks; and (3) absence of a history of radiation therapy or metastatic disease affecting the jaws [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Although MRONJ is relatively uncommon, it is considered clinically significant due to its chronic nature, risk of infection, potential for pathological fractures, and negative impact on quality of life [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEpidemiological studies indicate that MRONJ occurs rarely in patients receiving antiresorptive therapy for osteoporosis, with reported prevalence ranging between 0.001% and 0.01% [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, the incidence increases significantly in oncology patients receiving high-dose intravenous therapy, where reported prevalence rates may reach 1\u0026ndash;12% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A population-based study conducted in Finland reported MRONJ incidence of approximately 0.3% in patients receiving low-dose antiresorptive therapy and approximately 9% among individuals receiving high-dose treatment for malignancies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Similarly, a Korean multidisciplinary task force estimated the overall incidence of MRONJ between 10 and 45 cases per 100,000 person-years, with substantially higher rates observed in patients receiving intravenous bisphosphonate therapy or denosumab [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe pathophysiology of MRONJ is multifactorial and remains incompletely understood. Proposed mechanisms include suppression of bone remodeling, impaired angiogenesis, local infection, inflammation, and immune dysfunction [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Systemic risk factors include cumulative drug exposure, intravenous administration, concurrent corticosteroid therapy, chemotherapy, diabetes, and malignancy. Local factors such as invasive dental procedures, periodontal disease, trauma from dentures, and poor oral hygiene also play an important role in MRONJ development [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Furthermore, the combination of antiresorptive and antiangiogenic medications appears to significantly increase the risk of developing osteonecrosis of the jaw [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePreventive strategies are considered the most effective approach for reducing MRONJ risk. Clinical guidelines recommend that patients undergo comprehensive dental examination prior to initiation of antiresorptive therapy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Primary prevention includes elimination of oral infection sources, treatment of periodontal disease, restoration of carious lesions, and extraction of non-restorable teeth before initiating therapy [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Secondary prevention focuses on minimizing invasive dental procedures during therapy, while tertiary prevention involves management of established MRONJ lesions to prevent disease progression [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDental professionals play a crucial role in identifying patients at risk, implementing preventive measures, and managing complications associated with MRONJ [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Consequently, adequate knowledge and awareness among dentists and dental students are essential. However, numerous studies have demonstrated that MRONJ awareness among healthcare professionals remains inconsistent and often inadequate [\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].Several international studies have reported substantial knowledge gaps among dental practitioners. Surveys have shown that many dentists are unable to correctly identify MRONJ diagnostic criteria or associated medications [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, studies involving dental students indicate limited understanding of MRONJ risk factors, pharmacological agents, and preventive strategies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs the use of bone-modifying medications continues to increase due to aging populations and advancements in cancer therapy, dentists will increasingly encounter patients at risk of MRONJ [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Adequate training during undergraduate education may therefore play a critical role in improving prevention and patient safety. The present study aimed to evaluate knowledge, awareness, and preventive attitudes regarding MRONJ among fourth- and fifth-year dental students at Marmara University Faculty of Dentistry. Additionally, the study compared responses according to academic year and gender in order to assess whether clinical training influences MRONJ awareness.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003efor this study was obtained from the XXXUniversity Non-Drug and Medical Device Research Ethics Committee (Approval No: 09.2025.25\u0026ndash;0538, dated 20 June 2025). All procedures were conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Participation in the study was entirely voluntary and anonymous. Prior to completing the questionnaire, participants were informed about the purpose and scope of the research and provided electronic informed consent. Students were free to withdraw from the study at any stage without any academic or personal consequences. No financial or academic incentives were provided for participation, and all collected data were stored securely and analyzed in a de-identified manner to ensure participant confidentiality.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Design\u003c/h3\u003e\n\u003cp\u003eThis study employed a descriptive cross‑sectional design to assess knowledge, attitudes and risk awareness regarding MRONJ among senior dental students. The cross‑sectional approach was chosen because it enables collection of data from a cohort at a single point in time and facilitates identification of associations between demographic factors (such as gender and year of study) and knowledge levels.\u003c/p\u003e \u003cp\u003eThe research was carried out at a tertiary teaching hospital\u0026rsquo;s faculty of dentistry, which hosts a diverse cohort of students from various regions. All enrolled fourth‑ and fifth‑year dental students during the 2025\u0026ndash;2026 academic year were invited to participate. Inclusion criteria were enrolment in the appropriate year and consent to participate. There were no exclusion criteria based on previous MRONJ training or clinical exposure, as the goal was to capture a realistic picture of knowledge levels among impending graduates.\u003c/p\u003e\n\u003ch3\u003eSample Size and Power Analysis\u003c/h3\u003e\n\u003cp\u003ePrior to data collection, a power analysis was conducted to determine the minimum sample size required for the study. The calculation was performed using G*Power software (version 3.1; Heinrich Heine University, D\u0026uuml;sseldorf, Germany). An independent samples t-test was planned to compare knowledge levels between two groups (fourth-year and fifth-year dental students). The analysis was conducted with a medium effect size (d\u0026thinsp;=\u0026thinsp;0.50), a significance level (α) of 0.05, and a statistical power of 80% (1\u0026thinsp;\u0026minus;\u0026thinsp;β\u0026thinsp;=\u0026thinsp;0.80). Based on these parameters, the minimum required sample size was calculated as 63 participants per group, resulting in a total sample size of 127 participants. Considering the possibility of incomplete responses or non-participation, a larger number of students were invited to participate in the survey to ensure that the minimum required sample size was achieved. Of 270 eligible students, 254 completed the survey, yielding a response rate of 94.1%. Participants provided written informed consent after being briefed on the study objectives and assured of confidentiality and anonymity.\u003c/p\u003e\n\u003ch3\u003eQuestionnaire Development\u003c/h3\u003e\n\u003cp\u003eThe survey instrument was developed in accordance with the diagnostic criteria and clinical recommendations outlined in the American Association of Oral and Maxillofacial Surgeons (AAOMS) position papers on MRONJ [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The final questionnaire consisted of structured multiple-choice questions designed to assess students\u0026rsquo; familiarity with MRONJ terminology, knowledge of AAOMS diagnostic criteria, awareness of disease staging, attitudes toward patient management, recognition of systemic and local risk factors, and identification of medications associated with MRONJ. To establish face validity, the instrument was pilot tested among 15 volunteer students who were excluded from the main study; feedback led to minor wording adjustments for clarity. Internal consistency reliability was determined using Cronbach\u0026rsquo;s alpha, yielding a coefficient of 0.82, which indicates good reliability.\u003c/p\u003e \u003cp\u003eThe questionnaire comprised the following domains:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eKnowledge of Terminology\u003c/strong\u003e \u003cp\u003eStudents were asked to indicate which terms they recognised from among \u0026ldquo;BRONJ (bisphosphonate‑related osteonecrosis)\u0026rdquo;, \u0026ldquo;MRONJ (medication‑related osteonecrosis)\u0026rdquo;, and \u0026ldquo;ONJ (osteonecrosis of the jaw)\u0026rdquo;.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSources of Information\u003c/b\u003e: Respondents identified where they had learned about MRONJ: scientific meetings, literature reviews, the dental school curriculum, continuing education, or none. Multiple selections were permitted.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAwareness of AAOMS Diagnostic Criteria\u003c/b\u003e: Students selected from four statements those that constitute the diagnostic criteria for MRONJ according to AAOMS: (a) history of anti‑resorptive or anti‑angiogenic therapy; (b) presence of exposed bone or bone that can be probed through a fistula persisting for at least eight weeks; (c) history of radiotherapy or metastatic disease; (d) all of the above. Only the first two constitute diagnostic criteria; the third is an exclusion criterion.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eKnowledge of MRONJ Staging\u003c/strong\u003e \u003cp\u003eParticipants indicated whether they were familiar with the AAOMS staging system for MRONJ. Those who answered yes were asked to match clinical scenarios to stages 0 through 3.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAttitudes Toward Clinical Management\u003c/strong\u003e \u003cp\u003eThe questionnaire assessed the perceived importance of obtaining a bisphosphonate history and referring patients for dental evaluation before initiating anti‑resorptive therapy.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePerceptions of Risk Persistence\u003c/strong\u003e \u003cp\u003eStudents indicated whether they believed MRONJ risk persists after cessation of bisphosphonate therapy.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIdentification of High‑Risk Systemic Conditions\u003c/strong\u003e \u003cp\u003eThe survey listed systemic conditions (breast cancer, prostate cancer, leukemia and multiple myeloma), and students selected which they believed confer high MRONJ risk. An \u0026ldquo;all\u0026rdquo; option allowed recognition of multiple high‑risk conditions.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIdentification of Local Risk Factors\u003c/strong\u003e \u003cp\u003eRespondents indicated local factors that increase MRONJ risk from a list including periodontal disease, tooth extraction, denture trauma, infection and \u0026ldquo;all\u0026rdquo;.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eRecognition of Implicated Medications\u003c/b\u003e: Students selected medications associated with MRONJ: bisphosphonates, denosumab, corticosteroids, anti‑angiogenic agents, or \u0026ldquo;all\u0026rdquo;.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDemographic Information\u003c/strong\u003e \u003cp\u003eGender and year of study were collected.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eData Collection Procedure\u003c/h3\u003e\n\u003cp\u003eData collection was coordinated with course schedules to maximize participation. The principal investigator introduced the study to the students, explained its objectives, emphasized the voluntary nature of participation and confidentiality, and obtained informed consent prior to participation. The questionnaire was administered electronically using Google Forms, and students completed the survey during a scheduled class session. Researchers were present to clarify any questions related to the wording of the survey items but did not influence the participants\u0026rsquo; responses. After completion, responses were automatically recorded through the online platform. The collected data were exported for analysis, and data verification was performed independently by two researchers to minimize potential entry or processing errors, with any discrepancies resolved through consensus.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData were analysed using IBM SPSS Statistics version 31. Descriptive statistics (frequencies, percentages) summarised responses. Comparisons by sex and year were conducted using Pearson\u0026rsquo;s Chi‑square test or Fisher\u0026rsquo;s exact test when expected counts were small. For questions with more than two response options, the Fisher\u0026ndash;Freeman\u0026ndash;Halton test was applied. Significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Missing data were excluded from the analysis of individual questions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eOverview of Participant Characteristics\u003c/h2\u003e \u003cp\u003eA total of 254 students completed the questionnaire. The demographic distribution reflected a female predominance: 155 respondents (61.0%) were female and 99 (39.0%) were male. The majority of respondents were fifth‑year students (55.9%, n\u0026thinsp;=\u0026thinsp;142), with the remainder in the fourth year (44.1%, n\u0026thinsp;=\u0026thinsp;112). The mean age was 23.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 years, with a range from 22 to 26 years.\u003c/p\u003e \u003cp\u003e Participants demonstrated high familiarity with MRONJ-related terminology. Overall, 91.7% were familiar with the term MRONJ, 89.8% with BRONJ, and 79.5% with ONJ. The primary source of knowledge was dental school education (92.9%). Regarding diagnostic criteria defined by the American Association of Oral and Maxillofacial Surgeons (AAOMS), the most frequently selected criterion was a history of antiresorptive or antiangiogenic therapy (52.4%).Approximately 49.2% of students reported knowing the main stages of MRONJ, whereas 50.8% indicated that they did not know them. Most participants \u003cb\u003e(\u003c/b\u003e91.3%\u003cb\u003e)\u003c/b\u003e considered questioning bisphosphonate use during medical history taking to be important, and 98.0% emphasized the importance of dental evaluation prior to initiating therapy. Regarding systemic risk factors, 63.0% correctly identified all listed systemic diseases as potential contributors to MRONJ. Similarly, 72.8% identified all listed local risk factors (periodontal disease, tooth extraction, prosthetic trauma, and infection). Among medications associated with MRONJ, bisphosphonates were the most recognized (66.5%), followed by denosumab (49.6%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKnowledge and Awareness of Medication-Related Osteonecrosis of the Jaw Among Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eKnown terminology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBRONJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e89.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRONJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eONJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e79.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eSource of knowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScientific meetings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview articles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDental school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e92.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequent training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eAAOMS diagnostic criteria awareness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHistory of antiresorptive or antiangiogenic therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExposed bone or lesion without another cause\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHistory of radiotherapy or metastasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eKnowledge of MRONJ stages\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eImportance of questioning bisphosphonate use in medical history\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImportant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eImportance of dental examination before therapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImportant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e249\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e98.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eRisk in patients who previously used BP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRONJ risk exists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e92.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTreatment type not important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eSystemic diseases associated with risk\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProstate cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeukemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple myeloma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e63.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eLocal risk factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeriodontal disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDenture trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e72.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eDrugs associated with MRONJ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBisphosphonates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDenosumab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorticosteroids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAntiangiogenic drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe AAOMS defines MRONJ using three criteria: current or previous treatment with anti‑resorptive or anti‑angiogenic agents, exposed bone or bone that can be probed through an intra‑oral or extra‑oral fistula persisting for at least eight weeks, and no history of radiation therapy or metastatic disease to the jaws[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Respondents were asked to select which statements constituted diagnostic requirements. The most frequently selected statement was \u0026ldquo;history of completed or ongoing anti‑resorptive or anti‑angiogenic therapy,\u0026rdquo; chosen by 52.4% (n\u0026thinsp;=\u0026thinsp;133). Only 41.7% (n\u0026thinsp;=\u0026thinsp;106) selected \u0026ldquo;persistent exposed bone or bone that can be probed through a fistula for eight weeks,\u0026rdquo; and 36.2% (n\u0026thinsp;=\u0026thinsp;92) incorrectly selected \u0026ldquo;history of radiotherapy or metastasis\u0026rdquo; (which is an exclusion criterion). Only 25.6% (n\u0026thinsp;=\u0026thinsp;65) selected both correct diagnostic criteria without selecting the exclusion criterion. Fourth‑year students were more likely than fifth‑year students to choose \u0026ldquo;history of radiotherapy or metastasis\u0026rdquo; (42.9% vs. 31.0%, p\u0026thinsp;=\u0026thinsp;0.040) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMale participants demonstrated significantly higher familiarity with the general term osteonecrosis of the jaw (ONJ\u003cb\u003e)\u003c/b\u003e compared with female participants (85.9% vs. 75.5%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.046). However, female students were significantly more likely to emphasize the importance of questioning bisphosphonate use in the patient\u0026rsquo;s medical history (95.5% vs. 84.8%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007).Similarly, female participants more frequently indicated that MRONJ risk persists even after completion of bisphosphonate therapy (94.8% vs. 87.9%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045). Regarding local risk factors, male students more frequently identified tooth extraction as a risk factor for MRONJ compared with female students (29.3% vs. 18.1%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036). In contrast, female participants were significantly more likely to select all listed local risk factors (78.1% vs. 64.6%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019. In terms of medications associated with osteonecrosis of the jaws, male participants were significantly more likely to identify corticosteroids as a potential causative agent (15.2% vs. 5.8%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013). No statistically significant gender differences were observed for other medications, including bisphosphonates, denosumab, or antiangiogenic drugs (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEvaluation of Knowledge Levels Regarding MRONJ According to Gender\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eKnown terminology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBRONJ (Bisphosphonate-related osteonecrosis of the jaw)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89 (89.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e139 (89.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.995ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRONJ (Medication-related osteonecrosis of the jaw)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90 (90.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e143 (92.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.703ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eONJ (Osteonecrosis of the jaw)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85 (85.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e117 (75.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.046ᵃ*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eSource of terminology knowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScientific meetings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.900ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview articles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.713ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDental school education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e92 (92.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e144 (92.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.994ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequent training programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.755ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eAAOMS diagnostic criteria for MRONJ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHistory of antiresorptive or antiangiogenic therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (47.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e86 (55.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.213ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExposed bone or lesion in the jaw without another cause\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34 (21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.957ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHistory of radiotherapy or metastasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19 (12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.974ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (35.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56 (36.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.900ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eKnowledge of MRONJ stages\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80 (51.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.338ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54 (54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75 (48.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eImportance of questioning BP use in patient history\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImportant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84 (84.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e148 (95.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.007ᶜ**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (14.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eDental examination before initiating therapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImportant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96 (97.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e153 (98.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.198ᶜ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eCorrect statement for patients who completed BP therapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRONJ risk exists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87 (87.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e147 (94.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.045ᵃ*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo MRONJ risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.240ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical specialty not important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.059ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eSystemic diseases associated with MRONJ risk\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13 (8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.642ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProstate cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.747ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeukemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.316ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple myeloma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (30.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.210ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59 (59.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e101 (65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.370ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eLocal risk factors for MRONJ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeriodontal disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (20.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19 (12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.087ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.036ᵃ*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDenture trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.771ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.223ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64 (64.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e121 (78.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.019ᵃ*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eMedications causing osteonecrosis of the jaws\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBisphosphonates (Fosamax)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68 (68.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e101 (65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.561ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDenosumab (Prolia)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46 (46.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80 (51.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.424ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorticosteroids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.013ᵃ*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAntiangiogenic drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (20.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.361ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52 (33.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.478ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eᵃPearson Chi-square test\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eᵇFisher\u0026rsquo;s Exact test\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eᶜFisher-Freeman-Halton test\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003e** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eMultiple responses were allowed.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen MRONJ-related knowledge levels were compared according to academic year, several statistically significant differences were identified. Fifth-year students demonstrated significantly higher familiarity with the term BRONJ (bisphosphonate-related osteonecrosis of the jaw) compared with fourth-year students (96.5% vs. 81.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). In addition, fifth-year students more frequently reported scientific meetings as a source of knowledge regarding MRONJ (9.9% vs. 1.8%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009). Conversely, fourth-year students selected \u0026ldquo;history of radiotherapy or metastasis\u003cb\u003e\u0026rdquo;\u003c/b\u003e as a diagnostic criterion for MRONJ significantly more often than fifth-year students (17.0% vs. 8.5%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.040). However, knowledge of the main stages of MRONJ was significantly higher among fifth-year students compared with fourth-year students (57.0% vs. 39.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e \u003cp\u003eRegarding medications associated with osteonecrosis of the jaws, fifth-year students were significantly more likely to identify antiangiogenic drugs as potential causative agents compared with fourth-year students (28.2% vs. 17.0%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No statistically significant differences were observed between the two academic years with respect to other variables, including awareness of MRONJ terminology (except BRONJ), knowledge of systemic risk conditions, recognition of local risk factors, or attitudes toward questioning bisphosphonate use and recommending dental examination prior to initiating antiresorptive therapy (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Overall, these findings suggest that while senior dental students generally demonstrate a high level of awareness regarding MRONJ, certain aspects of disease definition, staging, and medication-related risk recognition improve with increasing clinical training (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEvaluation of Knowledge Levels Regarding MRONJ According to Academic Year\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4th Year n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5th Year n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eKnown terminology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBRONJ (Bisphosphonate-related osteonecrosis of the jaw)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e91 (81.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e137 (96.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001ᵃ**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRONJ (Medication-related osteonecrosis of the jaw)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e99 (88.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e134 (94.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.086ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eONJ (Osteonecrosis of the jaw)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e118 (83.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.112ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eSource of terminology knowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScientific meetings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.009ᵃ**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview articles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19 (13.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.063ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDental school education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e107 (95.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e129 (90.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.148ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequent training programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.356ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eAAOMS diagnostic criteria for MRONJ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHistory of antiresorptive or antiangiogenic therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59 (52.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e74 (52.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.929ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExposed bone or lesion without another cause\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (22.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31 (21.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.925ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHistory of radiotherapy or metastasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (17.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.040ᵃ*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34 (30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57 (40.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.106ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eKnowledge of MRONJ stages\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44 (39.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e81 (57.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.005ᵃ**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68 (60.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61 (43.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eImportance of questioning BP use in patient history\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImportant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100 (89.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e132 (93.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.262ᶜ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eDental examination before initiating therapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImportant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e109 (97.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e140 (98.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.792ᶜ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eCorrect statement for patients who completed BP therapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRONJ risk exists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100 (89.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e134 (94.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.136ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo MRONJ risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.836ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical specialty not important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.307ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eSystemic diseases associated with MRONJ risk\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.346ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProstate cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.205ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeukemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28 (19.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.872ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple myeloma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39 (27.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.545ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66 (58.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e94 (66.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.234ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eLocal risk factors for MRONJ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeriodontal disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19 (13.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.326ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (22.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32 (22.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.968ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDenture trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.105ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.814ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81 (72.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e104 (73.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.870ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eMedications associated with osteonecrosis of the jaws\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBisphosphonates (Fosamax)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77 (68.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e92 (64.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.507ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDenosumab (Prolia)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58 (51.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68 (47.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.537ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorticosteroids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (13.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.056ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAntiangiogenic drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (17.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40 (28.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.036ᵃ*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (27.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50 (35.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.201ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eᵃPearson Chi-square test\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eᵇFisher\u0026rsquo;s Exact test\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eᶜFisher-Freeman-Halton test\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003e** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eMultiple responses were allowed.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis comprehensive cross‑sectional study evaluated the knowledge, attitudes and risk awareness regarding medication‑related osteonecrosis of the jaw among fourth‑ and fifth‑year dental students. Overall, participants demonstrated high recognition of MRONJ and BRONJ terminology, indicating that these concepts have permeated the dental curriculum. However, a closer examination revealed substantive knowledge gaps, particularly in understanding diagnostic criteria, staging systems, and non‑bisphosphonate medications. Differences in responses by gender and academic year further illuminate specific areas requiring educational emphasis.\u003c/p\u003e \u003cp\u003eThe findings of the present study are broadly consistent with previous research conducted among dental students in T\u0026uuml;rkiye. In a recent study evaluating the knowledge level of Turkish dental students regarding MRONJ, Şahin et al. reported that although most students considered questioning medications associated with osteonecrosis during patient history taking to be important, substantial deficiencies remained in knowledge of diagnostic criteria, risk factors, and associated medications. Notably, only about one fifth of students were able to correctly identify the three main diagnostic criteria required for MRONJ diagnosis, while a considerable proportion failed to identify any of the criteria correctly [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Similarly, Erdil et al. conducted a multicenter study among senior dental students in T\u0026uuml;rkiye and reported that although awareness of MRONJ terminology was relatively high, students demonstrated insufficient knowledge regarding disease staging, preventive strategies, and medication-related risk factors [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In line with these findings, the present study also demonstrated high awareness of MRONJ terminology among senior dental students, yet important gaps were observed in knowledge related to diagnostic criteria, staging, and medications associated with MRONJ. These similarities suggest that although theoretical awareness may be relatively widespread among Turkish dental students, more comprehensive and clinically oriented education may be required to improve understanding of MRONJ prevention and management.\u003c/p\u003e \u003cp\u003eComparable trends have also been reported in international studies evaluating MRONJ awareness among dental students. Rosella et al. found that although Italian dental students were familiar with the general concept of MRONJ, their ability to identify risk factors and appropriate management strategies remained limited [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Similarly, Teślak et al. reported that while Polish dental students demonstrated relatively high awareness of bisphosphonates, knowledge regarding other medications associated with MRONJ, particularly denosumab, was insufficient [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These findings are consistent with the results of the present study and suggest that knowledge gaps related to MRONJ are not limited to a specific country but represent a broader educational challenge in dental training programs worldwide. Collectively, the available evidence highlights the need for improved curricular integration of MRONJ-related topics, particularly focusing on clinical risk assessment, medication awareness, and interdisciplinary management.\u003c/p\u003e \u003cp\u003eOur results show that 91.7% of students recognised the term MRONJ and 89.8% recognised BRONJ, while 79.5% recognised the broader term ONJ. This level of awareness exceeds that reported in some prior studies[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], suggesting effective integration of MRONJ terminology into the curriculum. Nevertheless, recognition of a term does not equate to mastery. Only 25.6% accurately identified both diagnostic criteria specified by the AAOMS (history of anti‑resorptive/anti‑angiogenic therapy and persistent exposed bone for eight weeks) and avoided selecting the exclusion criterion (radiotherapy or metastasis). Furthermore, only 49.2% claimed familiarity with the staging system, and of these, a minority could correctly match clinical scenarios to stages. These findings align with earlier research indicating that even when clinicians know of MRONJ, they may not understand its diagnostic nuances[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA striking finding is the high value students placed on preventive practices: over 91% considered it important to enquire about bisphosphonate use, and 98% recognised the need for dental evaluation before therapy initiation. These rates are higher than those reported for general dental practitioners in some countries[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], reflecting perhaps the emphasis placed on prevention in academic settings. Encouragingly, 92.1% understood that MRONJ risk persists after therapy cessation, consistent with evidence that bisphosphonate accumulation in bone can prolong risk [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Yet male students were less inclined to emphasise medication history and risk persistence, implying potential differences in perception or retention of pharmacologic information.\u003c/p\u003e \u003cp\u003eThe observed gender differences merit further exploration. Female students were more likely to appreciate the importance of taking a bisphosphonate history and to recognise that MRONJ risk persists after therapy. They also more frequently selected \u0026ldquo;all\u0026rdquo; when identifying local risk factors, indicating a more comprehensive view. These patterns may reflect greater attentiveness to detail or risk aversion among female students, consistent with studies suggesting that women in healthcare professions may prioritise patient safety[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Conversely, male students\u0026rsquo; higher recognition of corticosteroids and the generic term ONJ could reflect differential interest or prior exposure to pharmacology. Educational interventions should be inclusive of varying learning styles and address areas where either sex demonstrates deficits.\u003c/p\u003e \u003cp\u003eAnother notable finding was the limited recognition of medications beyond bisphosphonates. Only about half of students identified denosumab, and fewer recognised anti‑angiogenic agents or corticosteroids. This gap is consistent with prior surveys [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and highlights the need to update curricula as new therapies emerge. The misattribution of unrelated medications in free text responses underscores confusion and emphasises the necessity for clear, repeated instruction.\u003c/p\u003e \u003cp\u003eProgression through the curriculum was associated with improved knowledge of BRONJ, MRONJ staging and recognition of anti‑angiogenic agents. Fifth‑year students\u0026rsquo; greater participation in scientific meetings and exposure to clinical rotations likely contributed to these gains. Nonetheless, the persistence of misconceptions among final‑year students, such as misclassifying radiotherapy or metastasis as diagnostic criteria, indicates that certain topics require repeated emphasis and possibly alternative teaching methods, such as case‑based learning or simulation.\u003c/p\u003e \u003cp\u003eThe results of this study have significant implications for dental education. First, curricula should include comprehensive coverage of MRONJ, including pathophysiology, risk factors, diagnostic criteria, staging, management strategies and interprofessional collaboration [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Given the evolving nature of MRONJ and the introduction of new medications, curriculum content should be regularly updated. Second, teaching methods should extend beyond didactic lectures to incorporate interactive and experiential learning. Case‑based discussions, problem‑based learning scenarios, simulation of patient interactions and clinical rotations in oral and maxillofacial surgery can enhance understanding and retention [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Third, an emphasis on interprofessional education is warranted. Collaboration between dental and medical students in learning activities could foster a holistic understanding of MRONJ and other conditions requiring cross‑disciplinary management. Joint seminars with oncologists, endocrinologists and oral surgeons could expose dental students to the complexity of medical decision‑making around anti‑resorptive therapy and emphasise the importance of communication across specialties [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Fourth, faculty development programmes should ensure that educators are well versed in the latest MRONJ guidelines and literature. Faculty may need support to integrate new evidence into teaching materials. Access to continuing education and consensus documents, such as the AAOMS position papers [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and MASCC/ISOO/ASCO guidelines[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], should be facilitated.\u003c/p\u003e \u003cp\u003eBeyond the educational context, this study holds implications for clinical practice. Graduating dentists must be able to identify patients at risk of MRONJ, counsel them appropriately, and coordinate with physicians to modify therapy when necessary. In clinical settings, obtaining thorough medical histories, including drug names, dosages and duration, should be standard practice. Dental practitioners should maintain a high index of suspicion for MRONJ in patients presenting with unexplained oral pain, swelling, or non‑healing extraction sockets, particularly if they have a history of anti‑resorptive or anti‑angiogenic therapy.\u003c/p\u003e \u003cp\u003eWhen invasive procedures are planned for at‑risk patients, dentists should liaise with prescribers to consider drug holidays where evidence supports their efficacy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, because the benefits of drug holidays remain uncertain, particularly for agents with long half‑lives, decisions must be individualised and based on current guidelines and patient risk factors[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In all cases, optimisation of oral hygiene and treatment of existing infections or periodontal disease before initiating therapy are essential preventive strategies.\u003c/p\u003e \u003cp\u003eLike any cross‑sectional survey, our study has inherent limitations. The findings reflect the knowledge and attitudes of students at a single institution; they may not be generalisable to students in other geographical regions or educational systems. Additionally, self‑reported familiarity may not translate into practical competence; observational studies assessing clinical performance would complement these findings. Social desirability bias could lead participants to overstate their knowledge or positive attitudes, though anonymity was emphasised to mitigate this.\u003c/p\u003e \u003cp\u003eFurther research is needed to evaluate the effectiveness of targeted educational interventions in improving MRONJ knowledge and clinical competence. Randomised controlled trials could compare traditional didactic teaching with case‑based or simulation‑based curricula. Longitudinal studies following students into practice could assess knowledge retention and translate learning into clinical decision‑making. Qualitative research involving focus groups could explore students\u0026rsquo; perceptions of MRONJ teaching and identify barriers to understanding complex pharmacological interactions. Additionally, research across multiple institutions and countries would provide a broader picture of MRONJ awareness and allow for cross‑cultural comparisons.Beyond education, basic science research continues to be crucial for elucidating the pathophysiology of MRONJ. Studies investigating genetic predisposition, molecular pathways involved in bone remodeling and vascularisation, and the role of microbiota could lead to improved preventive and therapeutic strategies[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e][30]. Clinical trials assessing novel management approaches, including regenerative therapies, could expand treatment options for established MRONJ.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMedication‑related osteonecrosis of the jaw represents a significant iatrogenic condition with complex pathophysiology and serious implications for patients\u0026rsquo; quality of life. The present study investigated knowledge, attitudes and risk awareness among fourth‑ and fifth‑year dental students, revealing high recognition of MRONJ terms but significant gaps in understanding diagnostic criteria, staging, systemic and local risk factors, and the spectrum of implicated medications. Differences by sex and academic year suggest that learning styles and educational exposure influence knowledge, underscoring the need for tailored interventions. These findings emphasise the importance of comprehensive MRONJ education within dental curricula. Core components should include the biology of bone turnover and how anti‑resorptive and anti‑angiogenic drugs disrupt this balance; clear differentiation between MRONJ, BRONJ, osteoradionecrosis and other jaw pathologies; instruction on current diagnostic criteria and staging systems; and practical guidance on preventive strategies, patient counselling and interprofessional collaboration. Interactive teaching methods, such as case‑based learning and simulations, may enhance understanding and retention. Continuing education for practising dentists is also essential to update knowledge as new therapies emerge and guidelines evolve. Future studies should evaluate the effectiveness of specific educational interventions, explore factors influencing learning disparities, and investigate the impact of interprofessional education on collaborative practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRONJ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedication-related osteonecrosis of the jaw\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBRONJ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBisphosphonate-related osteonecrosis of the jaw\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eONJ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOsteonecrosis of the jaw\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAAOMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Association of Oral and Maxillofacial Surgeons\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e Ethical approval for this study was obtained from the Marmara University Non-Drug and Medical Device Research Ethics Committee (Approval No: 09.2025.25\u0026ndash;0538, dated 20 June 2025). All procedures were conducted in accordance with the Declaration of Helsinki. Participation was voluntary, and informed consent was obtained from all participants prior to data collection.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eClinical trial number\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZ.A. and G.K. wrote the main manuscript text and designed the study.Z.A. performed data collection and questionnaire implementation.G.K. supervised the study and contributed to data interpretation.F.N.P. critically revised the manuscript and provided scientific supervision.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThis study was conducted as part of the undergraduate thesis of Zeynep Allahverdi at Marmara University Faculty of Dentistry under the supervision of Assoc. Prof. Gaye Keser.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHadaya S, Goman D, Massie AM, Moubayed MJ, Rahal SP. Medication-related osteonecrosis of the jaw: knowledge and perceptions of medical professionals on the usage of bone modifying agents and dental referrals. J Med Life. 2022;PMID:35449990. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.25122/jml-2021-0085\u003c/span\u003e\u003cspan address=\"10.25122/jml-2021-0085\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlRowis R, Alhadlaq A, Alkhodair R. 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Awareness of MRONJ among Polish dentists and dental students. Appl Sci. 2021;11(11):4821.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReeves S, Fletcher S, Barr H, Birch I, Boet S, Davies N, et al. A BEME systematic review of the effects of interprofessional education. Med Teach. 2016;38(7):656\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNicolatou-Galitis O, Schi\u0026oslash;dt M, Mendes RA, Ripamonti C, Hope S, Drudge-Coates L, et al. Medication-related osteonecrosis of the jaw: definition and best practice for prevention, diagnosis and treatment. Oral Surg Oral Med Oral Pathol Oral Radiol. 2019;127(2):117\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllen MR, Burr DB. The pathogenesis of bisphosphonate-related osteonecrosis of the jaw: so many hypotheses, so few data. J Oral Maxillofac Surg. 2009;67(5 Suppl):61\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.joms.2009.01.007\u003c/span\u003e\u003cspan address=\"10.1016/j.joms.2009.01.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 19371816.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReid IR, Cornish J. Epidemiology and pathogenesis of osteonecrosis of the jaw. Nat Rev Rheumatol. 2012;8(2):90\u0026ndash;96 (online 2011). PMID: 22124271. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/nrrheum.2011.181\u003c/span\u003e\u003cspan address=\"10.1038/nrrheum.2011.181\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Osteonecrosis, Biphosphonates, Jaw Diseases, Students, Dental, Knowledge, Education, Dental","lastPublishedDoi":"10.21203/rs.3.rs-9366232/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9366232/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMedication-related osteonecrosis of the jaw (MRONJ) is a serious complication associated with antiresorptive and antiangiogenic medications used in osteoporosis and malignancy-related skeletal conditions. Dental professionals play a critical role in its prevention, early diagnosis, and management. This study aimed to comprehensively evaluate the knowledge, attitudes, and risk awareness of MRONJ among senior dental students using a structured and validated questionnaire, and to compare the findings with existing literature.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA cross-sectional survey was conducted among 254 fourth- and fifth-year dental students. The questionnaire assessed familiarity with MRONJ terminology, information sources, awareness of diagnostic criteria according to the American Association of Oral and Maxillofacial Surgeons (AAOMS), knowledge of disease staging, clinical decision-making, recognition of systemic and local risk factors, and identification of associated medications. Data were analyzed using descriptive statistics and inferential tests to evaluate differences by academic year and gender.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOf the participants, 39.0% (n\u0026thinsp;=\u0026thinsp;99) were male and 61.0% (n\u0026thinsp;=\u0026thinsp;155) female; 44.1% (n\u0026thinsp;=\u0026thinsp;112) were fourth-year and 55.9% (n\u0026thinsp;=\u0026thinsp;142) fifth-year students. Although 93% had heard of bisphosphonates, only 32% correctly identified the AAOMS definition of MRONJ. Fifth-year students demonstrated significantly higher knowledge scores regarding MRONJ definition and medication identification compared to fourth-year students (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). While 97% recognized the importance of assessing bisphosphonate use and performing dental clearance prior to therapy, only 27% correctly identified appropriate management for patients receiving oral bisphosphonates for more than four years. Awareness of risk factors was moderate: 94% associated osteoporosis and 68% bone metastases with bisphosphonate therapy, whereas only 24% recognized chronic corticosteroid use as a risk factor. The main sources of information were lectures (54%) and textbooks (20%). No significant gender differences were observed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDespite high awareness of MRONJ terminology, notable deficiencies exist in knowledge of diagnostic criteria, risk factors, and clinical management. These findings align with previous studies indicating insufficient undergraduate education on MRONJ. Incorporating comprehensive, case-based and interdisciplinary training into dental curricula may improve students\u0026rsquo; competence in MRONJ prevention and management.\u003c/p\u003e","manuscriptTitle":"Knowledge, Awareness, and Preventive Practices Regarding Medication‐Related Osteonecrosis of the Jaw Among Dental Students: A Cross‐Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-26 15:43:10","doi":"10.21203/rs.3.rs-9366232/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-11T09:10:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T12:46:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113221811808726938532512860828313210815","date":"2026-05-01T03:49:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T07:28:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180693432479667480273893406525949713078","date":"2026-04-29T10:51:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"321803586385456631456229575387760436828","date":"2026-04-25T13:58:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-23T11:28:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-21T08:55:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254378738876856453605390287067298409366","date":"2026-04-16T18:28:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205765951517702858514850822448008133626","date":"2026-04-16T17:52:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69359539227064153520202578859205644724","date":"2026-04-16T17:41:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-16T17:39:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-14T17:08:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T03:41:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-13T03:41:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-04-09T09:15:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"efc337e9-ac33-4bd6-89b6-dc3872f9ba51","owner":[],"postedDate":"April 26th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-11T09:10:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T12:46:45+00:00","index":104,"fulltext":""},{"type":"reviewerAgreed","content":"113221811808726938532512860828313210815","date":"2026-05-01T03:49:13+00:00","index":98,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T07:28:56+00:00","index":97,"fulltext":""},{"type":"reviewerAgreed","content":"180693432479667480273893406525949713078","date":"2026-04-29T10:51:36+00:00","index":96,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T09:28:47+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-26 15:43:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9366232","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9366232","identity":"rs-9366232","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}