Journal of Investigative and Clinical Dentistry (2010), 1, 90–95

ORIGINAL ARTICLE Oral and Maxillofacial Surgery

Survey of Korean dentists on the awareness on bisphosphonate-related osteonecrosis of the jaws Ji-Yeon Yoo1, Yong-Duk Park2, Yong-Dae Kwon1, Deog-Yoon Kim3 & Joo-Young Ohe1 1 Department of Oral and Maxillofacial Surgery, Kyung Hee University School of Dentistry, Seoul, Korea 2 Department of Social and Preventive Dentistry, Kyung Hee University School of Dentistry, Seoul, Korea 3 Department of Nuclear Medicine, Kyung Hee University School of Medicine, Seoul, Korea

Keywords awareness, bisphosphonate, bisphosphonaterelated osteonecrosis of the jaw, osteonecrosis of the jaw, survey. Correspondence Assistant Prof. Yong-Dae Kwon, Department of Oral and Maxillofacial Surgery, Kyung Hee University School of Dentistry, 1 Hoegi-dong, Dongdaemun-ku, Seoul 130-701, Korea. Tel: +82-2-958-9440 Fax: +82-2-966-4572 Email: [email protected] Received 24 November 2009; accepted 31 July 2010. doi: 10.1111/j.2041-1626.2010.00024.x

Abstract Aim: This survey evaluates the awareness of bisphosphonate-related osteonecrosis of the jaws among Korean dentists. Methods: We prepared a questionnaire based on bisphosphonate-related osteonecrosis of the jaw guidelines, suggested by The American Association of Oral Maxillofacial Surgeons. Among 13 405 dentists, we randomly selected 264 (2%) practitioners. Results: A total of 56.5% of respondents had heard of bisphosphonates asmedication related to osteonecrosis, but only 31.4% routinely recorded bisphosphonate medication history. The cross-sectional analysis demonstrated that most dentists were unaware of The American Association of Oral Maxillofacial Surgeons’ guidelines. Dentists with 5 years’ experience. Experience with treating osteonecrosis of the jaw patients and recording medication histories were significantly greater in dental hospitals with >300 beds or university hospitals. Awareness of the severity of bisphosphonate-related osteonecrosis of the jaws was greatest among oral surgeons. Conclusion: Dentists should thoroughly check patients’ medical histories, including bisphosphonate intake. With the exception of oral surgeons, most Korean dentists were not adequately aware of bisphosphonate-related osteonecrosis of the jaws and its seriousness, making it a potential risk in Korean dentistry. Therefore, it is important to educate clinicians regarding the potential risk of bisphosphonate medication in dentistry through education programs.

Introduction Many general dentists occasionally neglect to question patients on systemic diseases and are reluctant to treat patients with systemic diseases. Korean dentists are still somewhat passive in recording medical history before treating patients with systematic diseases. Until recently, there were no means of treating elderly, edentulous patients, with the exception of dentures, but the oral maxillofacial surgery field has expanded the treatment spectrum, and the elderly can now be provided with bone grafts, maxillofacial implant surgeries, and treatment for 90

temporomandibular disorders. Furthermore, the demand for dental implants has greatly increased in Korea. Thus, the interest in bone formation and bone material for dentists has increased as well. An increasingly aging society has become evident in Korea, with people over the age of 65 constituting 7% of the Korean population in 1999, and future projections predict the elderly proportion to be 20% in 2026. The average life span of females is 7 years longer than that of males, creating a female:male ratio of 2:1 among the senior population.1 The fact that female patients are more prone to osteoporosis explains the number of increasing ª 2010 Blackwell Publishing Asia Pty Ltd

J.-Y. Yoo et al.

female senior patients. The incidence of osteoporosis for female patients is five times greater than male patients, and the risk of osteoporotic fractures is three times greater than male patients. Since most female elderly patients experience postmenopausal osteoporosis, many patients take preventive measures for osteoporosis.2 However, some of the medications for osteoporosis have been associated with osteonecrosis of the jaw. Kubo et al.3 reported cases of osteonecrosis of the jaw in female, Japanese patients with malignant breast cancer. The cause was attributed to bisphosphonates (BP), which had been taken to prevent osteoporosis. BP-related osteonecrosis of the jaws (BRONJ) was first reported as an adverse effect by Marx in 2003.4 There were no specific cases connected with the oral preparations, but there were 36 cases related to intravenous BP. Soon afterwards, case reports on BRONJ were reported, and various studies were vigorously carried out, as BRONJ became a new disease entity in the medical field. A retrospective study reported that there was no difference in the success rate of bone grafts and implants for patients with or without BP medication. Nevertheless, Dougall and Fiske5 emphasized the importance of medical history taking in order to minimize complications for medically-compromised patients. They also described the necessity of checking for a history of epilepsy, latex sensitivity, congenital or genetic bleeding disorder, and oral BP medication. The American Association of Oral Maxillofacial Surgeons (AAOMS) had already reported guidelines on BRONJ in 20076 and 2009,7 highlighting the severity of the complications. However, in Korea, the disadvantages of osteoporosis medications are not well known because Korean dentists lack experience in treating patients in cooperation with medical doctors. Thus, professional awareness of BRONJ and studies on the disease entity itself are very scarce.8 Therefore, in the present study, we carried out a survey to determine Korean dentists’ knowledge of the severity of BRONJ and to evaluate their awareness of it. Materials and methods Survey method Currently, the number of Korean dentists is 13 405 (according to the Korean Dental Association, 2008). We randomly selected 264 (2%) practitioners, regardless of their working region, field of specialty, and years of experience, to participate in a mailed survey from May 2008 to October 2008. A total of 256 surveys were collected, and 226 (85.6%) were evaluated (Table 1). The excluded surveys were considered incomplete. All data collected were self-reported. ª 2010 Blackwell Publishing Asia Pty Ltd

A survey on the awareness of BRONJ

Table 1. Data of the survey respondents (including non-respondents) Categories Years’ clinical experience Under 3 years Under 5 years 6–10 years >11 years Total Type (scale) of hospital  Local private dental clinic Dental hospital (under 300 beds) Medical school affiliated dental hospital Dental school-affiliated dental hospital OMS in general hospital (over 300 beds) Total

%

73 55 45 53 226

(32.3) (24.3) (19.9) (23.5) (100)

93 22 34 41 18 224

(41.5) (9.8) (15.2) (18.3) (8.0) (100)

OMS, oral maxillofacial surgery.  Based on the classification by the Koran National Health Insurance Corporation of dental clinics and hospitals.

Survey content The number of years’ clinical experience, type of hospital, and field of specialty were recorded as background information. Information on awareness of BP, habits on taking a medication history before an invasive dental procedure, experience treating patients presenting with osteonecrosis, and awareness of the BRONJ guidelines suggested by the AAOMS were also collected. Survey analysis To fully reflect the survey data, 18 surveys with partial responses were included in the analysis when the responses were considered significant. A frequency analysis was conducted for the general questionnaires, and the response concerning BP was analyzed by v2-test to evaluate the significance for years’ clinical experience and field of specialty. Results Descriptive statistics In total, 25.3% respondents reported having experience in treating patients presenting with osteonecrosis. Poor healing and persistent bone exposure after extraction had reportedly been observed by 45.1% of the respondents, but only 33.3% had taken a medication history. The main treatment methods were curettage of the inflammation area (58.3%) and dressing with antibiotic therapy (54.2%). Only 31.4% of the respondents took a BP medication history before invasive dental procedures, but 56.5% of the respondents had basic awareness of BP-related 91

A survey on the awareness of BRONJ

J.-Y. Yoo et al.

Table 2. Awareness of the severity of BRONJ and the BRONJ guidelines suggested by the AAOMS

Table 3. Correlation with years’ clinical experience (n [%])

Question

Response

%

Category

Awareness of BRONJ guidelines suggested by the AAOMS Awareness of the severity of BRONJ

Yes No Total

43 (19.3) 180 (80.7) 223 (100)

Not at all serious Not alarming Average Severe Very severe Total

2 26 66 94 32 220

Experience treating patients with ONJ symptoms Yes 21 (28.8) 17 (30.9) 10 (22.2) 9 (17.3) No 52 (71.2) 38 (69.1) 35 (77.8) 43 (82.7) Total 73 (100) 55 (100) 45 (100) 52 (100) History taking on bisphosphonates or other medication Yes 13 (50.0) 10 (50.0) 6 (25.0) 5 (15.6) No 13 (50.0) 10 (50.0) 18 (75.0) 27 (84.4) Total 26 (100) 20 (100) 24 (100) 32 (100) Awareness of BRONJ guidelines suggested by the AAOMS Yes 12 (16.4) 19 (35.2) 8 (17.8) 4 (7.8) No 61 (83.6) 35 (64.8) 37 (82.2) 47 (92.2) Total 73 (100) 54 (100) 45 (100) 51 (100) Awareness of the severity of BRONJ Not at all 0 (0.0) 1 (1.9) 0 (0) 1 (2.0) serious Not alarming 11 (15.1) 7 (13.0) 4 (9.1) 4 (8.2) Average 31 (42.5) 11 (20.4) 16 (36.4) 8 (16.3) Severe 23 (31.5) 29 (53.7) 18 (40.9) 24 (49.0) Very severe 8 (11.0) 6 (11.1) 6 (13.6) 12 (24.5) Total 73 (100) 54 (100) 44 (100) 49 (100)

(0.9) (11.8) (30.0) (42.7) (14.5) (100)

AAOMS, American Association of Oral Maxillofacial Surgeons; BRONJ, bisphosphonate-related osteonecrosis of the jaws.

osteonecrosis and prescribed BP for osteoporosis. This simple knowledge had been obtained mainly through textbooks or specialized journals (41.4%) and continuing education programs or conferences (41.4%). Only 30.2% of the dentists were fully aware of BP as a medication for osteoporosis and their relation to osteonecrosis; 28.9% reported that they had warned patients of BRONJ before invasive dental procedures and had carried out prudent treatment; 19.3% were aware of BRONJ and the AAOMS guidelines of BRONJ, which suggest detailed history taking and caution before invasive dental treatment; and 57.2% of the respondents were previously unaware of the severity of BP before the study survey (Table 2). Cross-sectional analysis of respondent clinical experience, type of hospital, and field of specialty When the respondents’ years’ clinical experience were studied, dentists with >5 years’ experience reported more experience treating patients with osteonecrosis of the jaws (ONJ), while dentists with

Survey of Korean dentists on the awareness on bisphosphonate-related osteonecrosis of the jaws.

This survey evaluates the awareness of bisphosphonate-related osteonecrosis of the jaws among Korean dentists...
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