## 4 Discussion  
The study sought to draw attention to the side effects of BMA treatment in the oro-maxillofacial region. Unfortunately, in addition to the positive effects of BMA therapy used in the treatment of osteoporosis or bone metastases, the side effects remain a topic worthy of consideration. Osteonecrosis of the jaw (ONJ) is a process of bone degradation that occurs through the action of several internal and external factors on bone tissue. During the last two decades, a strong correlation between BMA and ONJ has been reported. The correlation between dosing and the pathophysiological mechanisms of osteonecrosis due to BMA has not yet been established. One theory is related to the effect of BMA in inhibiting osteoclast differentiation and increasing apoptosis, due to the fact that the differentiation of osteoclasts has an important role in bone healing and remodeling. Another theory is related to local bacterial inflammation and infection, because periapical or periodontal pathology usually presents at the time of extraction alongside evidence of bacteriological factors, especially from the Actinomyces group, at the necrotic zone of the jawbone. [6] Medications such as bisphosphonates [1], denosumab [2; 3], and sunitinib [4; 5] have been implicated in the occurrence of MRONJ. This shows that different classes of drugs can cause MRONJ and that other agents from the same drug class should also be investigated in more controlled prospective studies aimed at assessing the risk of ONJ associated with these agents. Among these, the bisphosphonates are most frequently involved in a condition also known as BRONJ, due to their use as a gold-standard therapy for osteoporosis, where they increase bone mineral density and decrease the risk of spine and hip fracture, and for preventing the skeletal manifestation of bone metastases. Currently, they are used both in oral and i.v. forms, and in our study more than 96% of our prescribers were still using these agents. Bisphosphonates have been shown to be beneficial in suppressing bone remodeling that helps slow bone loss in patients with osteoporosis. However, the danger posed by osteonecrosis has caused researchers to lose some of their enthusiasm for this class of drugs, and new treatment options have yet to be developed. Special attention should be paid to denosumab, which has been gaining more widespread use lately. In our study, almost 30% of prescribers, especially endocrinologists, were prescribing denosumab for osteoporosis with good results in patients with renal dysfunction. Compliance with this treatment has increased because of the biannual administration of denosumab, although more frequent administration, including monthly administration, can be used, which increases the risk of MRONJ. Prescribers should always advise patients to inform their dentist if they are using bisphosphonates or other BMAs before any dental treatment is performed. In our study, there was a significant negative correlation between the use of tyrosine kinase inhibitors and teriparatide and the recommendation of a prior dental status check. In a systematic review of ONJ associated with sunitinib published by [PERSON] et al., 91% of patients received sunitinib at a dose of 50 mg/day for 1 to 36 months before the occurrence of ONJ. Due to this fact, attention should be given to those cases in which bisphosphonates and sunitinib are combined [4].