## 4 Discussion
\begin{table}
\begin{tabular}{c c c c c} \hline \hline
**Recommendation for** & & & & \\
**Discontinuation of BMA** & **Bisphosphonates** & **Denosumab** & **Teriparatide** & **Tyrosine Kinase Inhibitors** \\
**before Dental Treatment** & & & & \\ \hline Specialy & & & & \\ Endocrinology & 10 (40\%) & 6 (24\%) & 2 (8\%) & 1 (4\%) \\ General practitioner & 9 (82\%) & 7 (64\%) & 6 (55\%) & 7 (64\%) \\ Oncology & 7 (78\%) & 5 (56\%) & 3 (33\%) & 6 (67\%) \\ Rheumatology & 4 (40\%) & 3 (30\%) & 3 (30\%) & 3 (30\%) \\ Overall & 30 (55\%) & 26 (47\%) & 14 (25\%) & 17 (31\%) \\ \(p\)-value for comparisons & 0.041 \({}^{\star}\) & 0.086 & 0.025 \({}^{\star}\) & \textless{}0.001 \({}^{\star}\) \\ \hline \hline \end{tabular}
\end{table} 
Table 6: Recommendations for discontinuation of BMAs before dental treatment and comparisons between specialties. Significant differences are marked with \({}^{\star}\). Unfortunately, only 17% of prescribers were familiar with the definition of MRONJ, and the BRONJ term is still preferred. Continuing medical education should increase knowledge about BMA therapy and the risk of developing MRONJ, not only after bisphosphonate use, because new treatments involving the antiangiogenic activity of the targeted agents can inhibit bone remodeling and delay the healing of tissues and thus enhance the development of ONJ [4]. Risk factors for the development of MRONJ are dental surgery, trauma, and poor oral hygiene with periodontal disease. Therefore, a dental check-up before initializing BMA treatment should be mandatory, good oral health should be ensured, and invasive treatments should be performed before any BMA initiation. Local development is primarily influenced by the drug administered, the pathology for which bisphosphonates are administered, the intravenous or oral route of administration, the dose administered, and the duration of treatment. A higher incidence is seen in patients with bone metastases receiving high doses of intravenous bisphosphonates over long periods [6]. Once initiated, treatment of MRONJ becomes a challenge. The decrease in quality of life for these patients is important, with eating and speaking disorders and toothbrushing difficulties being very common because of local pain. Non-surgical treatment of ONJ aims, firstly, to improve quality of life by improving symptoms and, secondly, to stop the progression of the disease. The treatment is influenced by the stage of the disease and can vary from simple conservative measures, such as clinical and radiological follow-up, oral hygiene with antiseptic solutions, local and general antibiotic treatment, symptomatic treatment, including pain control, or, in advanced stages, minimally invasive surgery [7] to remove sharp bone edges, or, in some cases, major surgery with partial maxillectomy or mandibular resection [8]. In addition, treatment is influenced by the type of BMA, as evidenced by the review conducted by [PERSON] [7] which differentiates ONJ caused by oral bisphosphonates, where conservative treatment, clinical and radiological follow-up, minimally invasive surgical treatment, and adjuvant therapies are recommended, and i.v. bisphosphonates, where local conservative treatment, clinical and radiological follow-up, minimally invasive surgical treatment, but no adjuvant therapies are the most favorable approach [7]. Patient dental follow-up should also include an imaging screening by X-ray, where osteolysis, bone sclerosis, bone cortical erosion, bone sequestration, and the persistence of post-extraction unhaled alveoli with no bone formation may be observed, making imaging examinations essential in the early diagnosis of osteeecrosis. In advanced stages, pathological fractures and osteolysis can extend to the inferior border of the mandible or sinus floor; also, for the identification of early stages, measuring bone density can be recommended.