Oral cancer awareness among dental students in a private university setting.

INTRODUCTION: There is a great deal of research on the awareness of students and professionals regarding oral cancer. The aim of this study was to find out students' opinions in their final years of dental school training who have clinic time about the importance of correct mucosal examination of the oral cavity. MATERIALS AND METHODS: A cross-sectional study was carried out and a questionnaire was designed and distributed to fourth- and fifth-year dental students. The questionnaire included demographic aspects of the participants and five closed questions related to the importance given to the exploration of the soft tissues during patient visits, the importance of the university training received, their interest in continuing education on this subject, their role as dentists in early diagnosis and whether they consider themselves prepared to diagnose oral cancer. RESULTS: A total of 214 undergraduate dental students participated in the study, 24.3% fourth year and 75.7% fifth year. Moreover, 97.7% of the students considered soft tissue examination to be important or very important, 90.2% of the students surveyed considered the university training received to be important or very important and 66.4% of the students considered that the most qualified professional to diagnose an oral lesion is the dentist. CONCLUSION: In this study, most of the students felt that graduate training in oral cancer is important, as well as soft tissue examination. In addition, the majority considered that the professional most indicated to diagnose oral lesions is the dentist. However, a very small percentage felt prepared to diagnose oral cancer themselves.

Evaluation of the diagnostic ability of oral lesions on clinical images among undergraduate dental students.

INTRODUCTION: The dentist should be able to carry out systematic oral examinations of the mucosa of patients in order to diagnose any alterations at an early stage. MATERIALS AND METHODS: An observational, analytical, prospective, and longitudinal study was carried out. 161 students were evaluated at the beginning of their clinical practice in their 4th year of dental school (September 2019), at the beginning and at the end of their 5th year of dental school (June 2021). Thirty oral lesions were projected, and the students were asked to provide an answer; if the lesions were benign, malignant, or potentially malignant, whether they should be biopsied and/or treated and a presumptive diagnosis. RESULTS: Significant improvement (p < .001) was obtained between the 2019 and 2021 results, in relation to the classification, need for biopsy and treatment of lesions. For differential diagnosis, no significant difference (p = .985) was obtained between the 2019 and 2021 responses. Malignant lesions and PMD obtained mixed results, with the best results corresponding to OSCC. DISCUSSION: In this study, a correct lesion classification by the students was over 50%. As for the OSCC, the results were superior to the rest of the images, reaching more than 95% correct. CONCLUSION: Theoretical-practical training from universities and continuing education for graduates in relation to oral mucosal pathologies should be further promoted.

Can Music Decrease Anxiety and Pain During Dental Implant Surgery? A Randomized Clinical Trial.

PURPOSE: Music has proven to be an effective tool in the management of anxiety during some surgical procedures. The aim of this study was to test the effect of baroque (BM) and classical era music (CM) as a nonpharmacological therapy on the control of anxiety and pain levels among patients undergoing dental implant placement surgery. METHODS: A randomized controlled clinical trial of patients attending a dental clinic was conducted. Patients with psychiatric disorders were excluded. Twenty six patients of Spanish nationality requiring single-tooth dental implant were included. Each patient was assigned to 1 of the 3 experimental groups, which acted as an independent variable: Group I (n = 8) listened to BM; Group II (n = 10) listened to CM; and Group III (n = 8) did not listen to music and was the control group (C). The dependent variables were divided into physiological variables and psychological variables. The physiological dependent variables analysed were systolic and diastolic blood pressure, heart rate, and oxygen saturation, recorded at 4 different times during surgery. The Kruskal-Wallis test compared each of these variables between the 3 experimental groups. The psychological dependent variable analyzed was the degree of anxiety, measured by the self-completed Modified Dental Anxiety Scale and Visual Analog Scale (measured before and after surgery). The Wilcoxon statistical test compared degree of anxiety before and after surgery. In all cases, the level of statistical significance was set at P < .05. RESULTS: The mean age of the sample was 46.5 ± 10.6 (range, 24-69 years), 50% male and 50% female. Statistically significant differences in degree of anxiety before and after surgery were found in the BM (P = .027, confidence interval [CI] = 0.146-6.104; BM before = 4.25 ± 3.91 and BM after = 1.13 ± 1.45) and CM groups (P = .044, CI = 0.161-3.039; CM before = 3.10 ± 2.88 and CM after = 1.50 ± 1.43) and were not found in group C (P = .180, CI = 1.104-3.604; C before = 2.63 ± 3.62 and C after = 1.38 ± 1.99). When comparing the perceived pain after the intervention among the 3 groups (C, BM, and CM), no significant differences were observed between them (P = .319; CI = -0.58-1.96; C = 0.75 ± 1.75, BM = 1.25 ± 1.75, and CM = 1.70 ± 1.70). CONCLUSION: Listening to BM and CM reduces anxiety in patients undergoing dental implant placement surgery. Musical flow should be applied in this practice.

Assessment of Clinical Parameters of Dental Anxiety during Noninvasive Treatments in Dentistry.

Dental anxiety is a matter of interest for the dentist since an anxious patient is a potential source of complications in the dental office. The main objectives of this study are to describe the correlation between dental anxiety levels and the values of physiological parameters related to dental anxiety and to study the evolution of blood pressure and heart rate over time during noninvasive dental treatments, i.e., not requiring local anesthesia. A descriptive, longitudinal, and prospective observational study was designed. The study population consisted of 200 patients who attended a university clinic for dental treatment without local anesthesia. The patients were asked to complete the Corah Dental Anxiety Scale. Afterward, blood pressure and heart rate were measured by means of a digital sphygmomanometer. Blood pressure and heart rate were taken throughout the procedure on four occasions. Most of the patients showed mild dental anxiety (5 [IQR: 3] points on Corah Dental Anxiety Scale). Significant but weak correlations were found between the level of dental anxiety and heart rate (Spearman rho: 0.166 and 0.176; p = 0.019 and 0.013; 3 min before and after treatment, respectively), as well as between the level of dental anxiety and the duration of treatment (Spearman rho: 0.191 3 min; p = 0.007). As for the evolution of physiological parameters, all patients showed a progressive decrease in values at different time points during treatment. When the types of treatment were evaluated separately, it was observed that there were statistically significant differences between them with respect to the level of dental anxiety (p = 0.006).

Salivary LDH in oral cancer and potentially malignant disorders: A systematic review and meta-analysis.

OBJECTIVES: To evaluate whether salivary lactate dehydrogenase (LDH) levels are increased in patients with oral cancer (OC) or oral potentially malignant disorders (OPMD) when compared to a healthy control group (CG). MATERIAL AND METHODS: We conducted a comprehensive search of specialized databases (PubMed/MEDLINE, The Cochrane Library, Web of Science, Scopus, and OpenGrey), including observational analytical studies evaluating the salivary LDH levels (in UI/L or µ/L) in OC or OPMD patients and compared them with a CG. RESULTS: Thirteen case-control studies were included. A total of 755 patients were evaluated, including 303 OC cases, 149 OPMD cases, and 303 controls. The meta-analysis showed that LDH levels were higher within the OC group than the CG (SMD 9.49; 95% CI 6.97-12; p = .00001). Patients with oral leucoplakia (SMD 11.67; 95% CI 1.01-22.33; p = .03) and oral submucous fibrosis (SMD 25.83; 95% CI -1.74-53.40; p = .07) also presented higher levels than the CG. In addition, OC patients had higher salivary LDH levels than oral leucoplakia patients (SMD 5.62; 95% CI 2.14-9.11; p = .002). Heterogeneity was high across all the evaluated studies. CONCLUSIONS: The determination of salivary LDH may be a useful method for screening and tracking OC and OPMD, but new protocolized studies are required to establish precise cutoff values.

Effects of photobiomodulation with low-level laser therapy in burning mouth syndrome: A randomized clinical trial.

BACKGROUND: Photobiomodulation (PBM) has proven to be effective in different painful conditions. OBJECTIVES: To assess the effect of photobiomodulation for pain management in burning mouth syndrome (BMS) patients, besides analysing the impact on different aspects of quality of life. METHODS: A randomized, single-blind, clinical trial was performed among 20 patients with BMS. Photobiomodulation was applied in the study group (n = 10) with a dose of 12 J/cm2 during 10 sessions, comparing with a placebo group (n = 10) with the laser turned off. Pain was assessed using the visual analogue scale (VAS) before starting each treatment session, and at the 1-month and 4-month follow-up appointments. Some validated questionnaires for general health were also complete: SF-36, OHIP-14, Epworth, SCL 90-R and McGill. RESULTS: All patients (n = 10) in the study group improved their pain ending treatment and remaining among 90% (n = 9) in the 4-month follow-up. Significant improvement was found in the study group in some sections of McGill questionnaire, Epworth scale, and SCL 90-R at the end of the treatment and in the 1-month and 4-month follow-ups. CONCLUSIONS: Photobiomodulation seems to be effective in reducing pain in patients with BMS, as well as, having a positive impact on the psychological state of these patients.

Xerostomia and Aalivary Flow in Patients Taking Antihypertensive Drugs.

The aims of this systematic review are (1) to compare the prevalence of xerostomia and hyposalivation between patients taking antihypertensive drugs with a control group (CG), (2) to compare salivary flow rate between patients treated with a CG, and (3) to identify which antihypertensives produce xerostomia. This systematic review was carried out according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. To evaluate methodological quality of the eligible studies Cochrane Collaboration tool for assessing the risk of bias for clinical trials and the modified Newcastle-Ottawa scale case-control studies were used. The databases were searched for studies up to November 19th 2019. The search strategy yielded 6201 results and 13 publications were finally included (five clinical trials and eight case-control studies). The results of the included studies did not provide evidence to state that patients taking antihypertensives suffer more xerostomia or hyposalivation than patients not taking them. With regard to salivary flow, only two clinical studies showed a significant decrease in salivary flow and even one showed a significant increase after treatment. The case-control studies showed great variability in salivary flow, but in this case most studies showed how salivary flow is lower in patients medicated with antihypertensive drugs. The great variability of antihypertensive drugs included, the types of studies and the outcomes collected made it impossible to study which antihypertensive drug produces more salivary alterations. The quality assessment showed how each of the studies was of low methodological quality. Therefore, future studies about this topic are necessary to confirm whether antihypertensive drugs produce salivary alterations.

General health status of a sample of patients with burning mouth syndrome: A case-control study.

BACKGROUND: The relationship of burning mouth syndrome (BMS) with possible alterations in patients' general health has been subject of study and controversy during the last years. OBJECTIVE: To analyse the general health status of patients with BMS, comparing it with a control group. METHODS: A case-control study was conducted to compare the diseases, medications, blood test alterations, disturbances in general health, oral quality of life, xerostomia, sleep quality and psychological status between a group of 20 patients with BMS and a group of 40 patients who did not suffer from this disease. RESULTS: BMS patients suffered more comorbidities and consumed more medications than controls. More mental, behavioural or neurodevelopmental disorders in BMS patients were found, consuming more drugs for nervous and cardiovascular systems, and alimentary tract and metabolism. Lower levels of iron and higher levels of folic acid were found in BMS patients compared to controls. General health status, oral health impact, sleepiness, psychological status and xerostomia levels were also significantly worsened in BMS patients than in controls. CONCLUSIONS: BMS patients presented a worsened health status over controls suffering more comorbidities, consuming more medications and showing adverse results in all the health variables analysed in this study.

Oral lesions in patients with primary Sjögren's syndrome. A case-control cross-sectional study

BACKGROUND: To evaluate the presence of oral lesions in a group of patients with primary Sjögren's syndrome (pSS) and compare these results with a matched control group (CG). MATERIAL AND METHODS: An observational cross-sectional study was conducted. 61 pSS patients (60 women, 1 man, mean age 57.64 ± 13.52) diagnosed according to the American European Criteria (2002), and 122 matched control patients (120 women, 2 men, mean age 60.02 ± 13.13) were included. Demographic and medical data, oral lesions and salivary flow rate were collected. RESULTS: Compared with the controls, pSS patients were 3.95 more likely to have oral lesions (OR 3.95; 95% CI 2.06-7.58; p = 0.0001). 57.4% pSS patients presented oral lesions compared to 25.4% in CG. The most common were candidiasis (13.1% vs 2.5%), traumatic lesions (13.1% vs 4.1%), apthae (8.2% vs 0), and fissuration of the tongue (8.2% vs 0.8%). pSS patients with oral lesions had lower salivary flow levels (stimulated and unstimulated), although these differences were not significant. Significant associations were found between the presence of oral lesions and systemic manifestations and history of parotid gland enlargement in pSS patients. CONCLUSION: pSS patients suffer more oral lesions than general population and these lesions may aggravate the pSS disease

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Efficacy of Low-Level Laser Therapy for the Therapeutic Management of Neuropathic Orofacial Pain: A Systematic Review.

AIMS: To evaluate the efficacy of low-level laser therapy (LLLT) for the therapeutic management of neuropathic orofacial pain. METHODS: This systematic review was conducted according to PRISMA guidelines. A comprehensive search of the literature was conducted in the PubMed/MEDLINE, Scopus, and Cochrane Library databases up to March 8, 2018, using terms such as low-level laser therapy, neuropathic pain, orofacial pain, neuralgia, neuropathy, and all the entities described in section 13 of the International Classification of Headache Disorders, third edition. The primary outcome was measurement of pain intensity. RESULTS: A total of 997 studies were obtained with the initial search; 13 (8 randomized controlled trials, 2 prospective studies, and 3 case series) met the inclusion criteria and were analyzed for data extraction. Three provided data for the treatment of trigeminal neuralgia, 1 for occipital neuralgia, and 10 for burning mouth syndrome. All studies showed a reduction in pain intensity (most of them significant). The different studies analyzed LLLT alone and compared to placebo, to another treatment, or to different LLLT application protocols. CONCLUSION: LLLT seems to be effective as a treatment option for different neuropathic orofacial pain entities such as trigeminal neuralgia, occipital neuralgia, and burning mouth syndrome as a single or combined treatment. However, more quality studies assessing all outcome measures of chronic pain are needed in the medium and long terms. Furthermore, due to the lack of standardization of the application technique, more well-designed studies are required to confirm the results of this systematic review.

Impact and Efficacy of Topical Dry Mouth Products in Haemodialysis Patients with Xerostomia: A Pilot Study.

Purpose: Previous studies have shown that haemodialysis (HD) patients frequently suffer from xerostomia. This problem is associated with difficulties in oral functions, increased risk of oral diseases and interdialytic weight gain (IDWG). The aims of this preliminary study are to evaluate the efficacy and safety of topical dry mouth products in treating xerostomia in HD patients and their impact in reducing IDWG. Materials and Methods: We included 25 HD patients that suffered from xerostomia and complied with inclusion criteria. Subjects received toothpaste, mouthwash and mouth gel for dry mouth. The duration of treatment was 4 weeks. Patients filled out a visual analogue scale (VAS) for xerostomia and Oral Heath Impact Profile (OHIP)-14 questionnaires. Clinical data and IDWG were collected of the medical history of HD patients. Questionnaires and IDWG were collected at baseline, 2 and 4 weeks post-treatment. Results: Twenty-five patients completed the study (56% male and 44% female). The mean age was 63.52 ± 12.50 years. The topical treatment statistically significantly (p = 0.0001) alleviated the symptoms of xerostomia and improved their quality of life (OHIP-14 scores) (p = 0.0001). We observed a statistically significantly IDWG (kg) and IDWG% reduction (p = 0.03) after the use of topical treatment for xerostomia. None of the patients reported side effects. Conclusions: Xerostomia might affect the quality of life and increase the IDWG of these patients. The daily use of topical treatment for xerostomia could decrease thirst and IDWG, improving the quality of life of HD patients. Future randomised studies are needed to confirm these results.

Osteonecrosis of the jaws produced by sunitinib: a systematic review

Background: Tyrosine kinase receptor family is involved in tumor growth, pathological angiogenesis and the progression (metastasis) of cancer. Sunitinib (Sutent(R)) inhibits members of the tyrosine kinase receptor family affecting the induction of angiogenesis and tumor progression. It is not clear if sunitinib increases the risk of osteonecrosis of the jaws (ONJ). The aim of this study was to carry out a systematic review about ONJ related to sunitinib, describing existing cases and possible associated risk factors. Material and Methods: The PubMed/MEDLINE and Cochrane Library databases were searched without date restriction up to September 2018. We included prospective and retrospective observational studies, cross-sectional studies, clinical cases and series of cases, involving only human subjects. The methodological quality of the studies was assessed using The Joanna Briggs Institute (JBI) and Newcastle-Ottawa tools. Results: A total of 13 studies fulfilled our inclusion criteria of which 7 were clinical cases, 5 case series and a retrospective study. All the articles were published between 2009 and 2018. Of the 102 patients treated with sunitinib analyzed in this study, 58 developed ONJ, being or having been treated with sunitinib and bisphosphonates or exclusively with sunitinib. Conclusions: In this systematic review, we found an increase of ONJ in patients who are medicated with other drugs different than bisphosphonates and denosumab. It is necessary that dentists, oral and maxillofacial surgeons as well as oncologists know the risk of ONJ that these antiresorptive drugs could have. There is a need to continue researching in this field with the aim of an increasing knowledge in this area and creating an adequate protocol of action for this population

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Effects of Xerostom® products on xerostomia in primary Sjögren's syndrome: A randomized clinical trial.

OBJECTIVES: To assess the effects of Xerostom® toothpaste and mouthwash in primary Sjögren's syndrome (pSS) patients with xerostomia. SUBJECTS AND METHODS: A double-blinded, randomized study where patients were assigned at baseline test or control products. Patients used the products 3 times/day/28 days. We used a visual analogue scale (VAS) for xerostomia and an Oral Health Impact Profile-14 (OHIP-14), baseline and after treatment, to assess possible improvement. RESULTS: A total of 28 patients with pSS were included in this study, but only 24 finished it (all women, mean age 55.21 ± 11.87), and 13 patients received the test and 11 the control. VAS and OHIP-14 scores decreased in both groups after treatment but significant differences between groups were not found. We do not detect VAS intragroup significant differences before and after treatment in test and control groups. A significant improvement in OHIP-14 was identified in the treatment group, while no significant differences were observed in the control group. No adverse effects were present. CONCLUSIONS: Xerostom® toothpaste and mouthrinse may alleviate and improve quality of life without associated side effects, but further research with a larger number of participants and follow-up are necessary to establish the positive efficacy of these topical products in pSS patients.

Oral lesions in Sjögren's syndrome: A systematic review

BACKGROUND: Sjögren's syndrome (SS) is an autoimmune disease related to two common symptoms: dry mouth and eyes. Although, xerostomia and hyposialia have been frequently reported in these patients, not many studies have evaluated other oral manifestations. The aim of this systematic review was to investigate prevalence rates of oral lesions (OL) in SS patients and to compare it to a control group (CG), when available. MATERIAL AND METHODS: An exhaustive search of the published literature of the Pubmed, Scopus, Web of Science and the Cochrane Library databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) for relevant studies that met our eligibility criteria (up to September 1st 2017). RESULTS: Seventeen cross-sectional studies and one cohort study were finally included. The results showed that SS patients presented more OL compared to non-SS patients. The most frequent types of OL registered in primary and secondary SS were angular cheilitis, atrophic glossitis, recurrent oral ulcerations and grooves or fissurations of the tongue, also when compared to a CG. CONCLUSIONS: OL are common and more frequent in SS patients when compared to a CG. This may be a consequence of low levels of saliva. More studies where these OL and all the possible cofounding factors are taken into account are needed

Surgical Treatment of a Peripheral Ossifying Fibroma and Reconstruction with a Porcine Collagen Matrix: A Case Report.

A 35-year-old woman was referred to the Department of Oral Medicine and Orofacial Surgery after several recurrences of an ossifying fibroma (OF) that affected the free and attached gingiva of the maxillary right central incisor. Surgery was performed with a complete excision of the lesion together with the surrounding healthy tissue up to the bone. To guide the healing of the anterior esthetic framework and the excised tissues, a porcine collagen matrix as an alternative to connective tissue graft was used. After an 18-month follow-up, the lesion had not recurred and keratinized gingiva had formed around the area.

Risk factors associated with xerostomia in haemodialysis patients

BACKGROUND: To determine the prevalence of xerostomia and hyposalivation in Haemodialysis (HD) patients, to clarify risk factors, assess patient's quality of life, and to establish a possible correlation among interdialytic weight gain (IDWG) and xerostomia. MATERIAL AND METHODS: This study was performed on a group of 50 HD patients. Data were collected using a questionnaire containing demographic and clinical variables, a visual analogue scale (VAS) for xerostomia, IDWG, and an oral health impact profile questionnaire (OHIP-14). Unstimulated whole saliva (UWS) and stimulated whole saliva (SWS) were collected. RESULTS: A total of 28 HD patients (56%) suffered xerostomia. Dry mouth was associated with hypertension (OR, 5.24; 95% CI, 1.11-24.89) and benzodiazepine consumption (OR, 5.96; 95% CI, 1.05-33.99). The mean xerostomia VAS and OHIP-14 scores were 31.74±14.88 and 24.38±11.98, respectively. No significant correlation was observed between IDWG% and VAS and OHIP total score. Nonetheless, a positive correlation between VAS level of thirst and IDWG% was found (r=0.48 p = 0.0001). UWS and SWS means (determined in 30 patients) were 0.16±0.17 and 1.12±0.64, respectively. Decreased values of UWS and SWS were reported in 53.33% and 36.66% of HD patients. CONCLUSIONS: Xerostomia in HD has a multifactorial aetiology due to accumulative risks as advanced age, systemic disorders, drugs, fluid intake restriction, and salivary parenchymal fibrosis and atrophy. Therefore, it is important to detect possible xerostomia risk factors to treat correctly dry mouth in HD patients and avoid systemic complications

Prevalence of Oral Mucosal Disorders in Diabetes Mellitus Patients Compared with a Control Group.

Chronic hyperglycemia is associated with impaired wound healing and higher susceptibility to infections. It is unclear whether patients with diabetes mellitus (DM) present more oral mucosal disorders compared to control groups. The objectives were to compare (a) the prevalence rates of oral mucosal disorders in the DM and non-DM population and (b) the prevalence rates of specific disorders in the DM and non-DM population. Full-text articles were included if they met the following inclusion criteria: (a) they must be original articles from scientific journals, (b) they must be only cross-sectional studies in English, (c) the prevalence of oral mucosal disorders in DM patients must be evaluated, (d) results must be compared with a healthy control group, and (e) oral mucosal disorders must be specified in DM and non-DM group. All studies showed higher prevalence of oral mucosal disorders in DM patients in relation to non-DM population: 45-88% in type 2 DM patients compared to 38.3-45% in non-DM groups and 44.7% in type 1 DM patients compared to 25% in non-DM population. Tongue alterations and denture stomatitis were the most frequent significant disorders observed. The quality assessment following the Joanna Briggs Institute (JBI) Prevalence Critical Appraisal Tool showed the low quality of the existing studies.

Xerostomia, Hyposalivation, and Salivary Flow in Diabetes Patients.

The presence of xerostomia and hyposalivation is frequent among diabetes mellitus (DM) patients. It is not clear if the presence of xerostomia and hyposalivation is greater in DM than non-DM patients. The aims of this systematic review are (1) to compare the prevalence rates of xerostomia, (2) to evaluate the salivary flow rate, and (3) to compare the prevalence rates of hyposalivation in DM versus non-DM population. This systematic review was conducted according to the PRISMA group guidelines by performing systematic literature searches in biomedical databases from 1970 until January 18th, 2016. All studies showed higher prevalence of xerostomia in DM patients in relation to non-DM population, 12.5%-53.5% versus 0-30%. Studies that analyzed the quantity of saliva in DM population in relation to non-DM patients reported higher flow rates in non-DM than in DM patients. The variation flow rate among different studies in each group (DM/CG) is very large. Only one existing study showed higher hyposalivation prevalence in DM than non-DM patients (45% versus 2.5%). In addition, quality assessment showed the low quality of the existing studies. We recommend new studies that use more precise and current definitions concerning the determination and diagnosis of DM patients and salivary flow collection.

New Non-Bisphosphonate Drugs that Produce Osteonecrosis of the Jaws.

PURPOSE: The aim of this paper was to review the current literature associating the non-bisphosphonate cancer-treatment drugs Denosumab, Bevacizumab and Sunitinib (used with or without bisphosphonate [BP]) with the presence of osteonecrosis of the jaws (ONJ) in patients. MATERIALS AND METHODS: A literature review was conducted using the keywords osteonecrosis of the jaws, oral biphosphosnates, Denosumab, Bevacizumab and Sunitinib. Articles were obtained that reported cases of ONJ associated with the use of Denosumab, Bevacizumab and Sunitinib. RESULTS: The literature shows that Denosumab can cause ONJ associated with triggers such as microtraumas or dental extractions. The combination of the drug along with zoledronic acid may have a synergistic effect. Bevacizumab may cause ONJ; however, there is much controversy regarding its synergistic action when used with BP. Sunitinib causes ONJ, and together with BP could increase the risk of developing lesions. CONCLUSION: Denosumab, Sunitinib or Bevacizumab are causal agents in the development of ONJ. The combination of any of these along with BPs could increase the risk of developing ONJ over that posed by BP treatment alone.