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What Is HPV?
HPV is a ubiquitous virus with over 120 strains. HPV 16 and 18 are considered the most virulent strains and are responsible for almost all cervical cancers. HPV 16 is found in 50% to 65% of all OPCs1,2 and in 85% to 95% of all HPV-positive head-and-neck squamous cell carcinomas.3-5 HPV is considered a sexually transmitted disease that affects multiple systems of the body. It can be categorized as an oral–systemic condition. HPV infection is transmitted primarily through sexual behaviors. It is hypothesized that a genital HPV infection precedes an oral infection. Oral HPV is believed to be acquired through high-risk sexual behaviors such as the performance of oral sex.6,7
Why the Concern?
HPV infection is the most common sexually transmitted disease. In the United States, 20 million individuals currently are infected and 6.2 million new genital infections are reported annually.7 Fifty percent of sexually active males and females contract an HPV infection sometime during their lives. It is important to note, however, that over 90% of sexually active adults have antibodies to the L1 protein, the serological marker for HPV. More than 70% of new HPV infections clear within 1 year; up to 91% clear within 2 years. Thus, only a small percentage of individuals are at risk for or contract an oral HPV infection.8
Over the past 3 decades, while tobacco use and oral cavity cancers associated with tobacco use have declined, the occurrence of HPV-associated oropharyngeal cancers has escalated.4 Many consider changes in sexual mores to be the driving force for the escalation of HPV incidence and the populations most at risk. In a 2011 CDC survey on the prevalence of performing oral sex, 90% of adults, 27% of 15-year-old boys and 23% of 15-year-old girls reported engaging in this behavior.8
HPV-Associated Head-and-Neck Cancers Described
HPV-associated head-and-neck cancers typically are found in the oropharyngeal region; ie, the soft palate, tonsils, uvula, and the base of the tongue, rather than in the oral cavity. The profile of patients who most commonly contract HPV-positive cancers are adult white males, typically between the ages of 40 and 54, who use tobacco and/or alcohol in moderation. Oral cancers associated with tobacco and alcohol use typically occur in an older population dominated by African-American males. The incidence rates for HPV-positive OPCs also are rising for white women.4 The patient at risk for HPV-positive OPC has a different profile from the “traditional” oral cavity cancer patient.
The Dental Hygienist’s Responsibilities
When considering HPV and OPCs, the most important role the dental hygienist can assume is in the arena of prevention. During the assessment phase of care, the health history interview may uncover information that suggests a patient at risk; patients’ reports of symptoms including headaches, difficulty swallowing, or a sore throat could be leading information; an intraoral examination may reveal a suspicious lesion. Thorough extraoral examinations could potentially reveal pre/post auricular and/or other lymph node involvement, clinical signs of head-and-neck cancers. During an intraoral exam, dental hygienists should ensure that patients are supine so that visual access to oropharyngeal areas is enhanced. A thorough examination of the pharyngeal area including the tonsils, the uvula, and the pharyngeal walls is necessary. Patients must open wide and say “ah” while a tongue blade or mirror retracts the tongue. Any relevant findings need to be conveyed to appropriate team members, documented, and monitored. Referrals for further diagnosis or biopsy may be warranted. Recent literature suggests that vaccinations to prevent the occurrence of genital HPV may be promising in preventing oral infection.9 It behooves all dental hygienists to advise parents of young children, adolescents, and young adult patients to get the vaccination. Typically recommended ages for vaccine administration are 9 to 26 years, for both males and females. Because prevention of oral disease is the basis of dental hygiene practice, recommending the vaccination in the context of OPC prevention is appropriate, seamless, and mandatory. Advice about sexual behaviors may be uncomfortable, so discretion when broaching this subject is necessary and will depend upon the established relationship with the patient. In general, high numbers of sexual partners, engaging in oral sex, sexual orientation, young age at first sexual encounter, and the performance of high-risk sexual acts increase an individual’s risk for contracting the virus.6,7
Another emerging body of research suggests that there may be relationships between oral hygiene, periodontal disease, and the risk for HPV-positive OPC.10,11 At present, reported associations are weak and further research is required. Because chronic periodontal infection could facilitate viral invasion, dental hygienists must assist their patients in adopting health behaviors that can decrease the oral bacterial load. Reducing infection in the oral cavity can play a role in enhancing systemic wellness and may minimize the risk for developing HPV-associated head-and-neck cancers. The threat of HPV-associated head-and-neck cancers makes dental hygiene advocacy, service delivery, and health promotion messages all the more critical.
1. Oral Cancer Foundation. www.oralcancerfoundation.org. Accessed August 28, 2013.
2. U.S. Centers for Disease Control and Prevention. www.cdc.gov. Accessed August 28, 2013.
3. Chaturvedi AK, Engels EA, Anderson WF, Gillison ML. Incidence trends for human papillomavirus-related and -unrelated oral squamous cell carcinomas in the United States. J Clin Oncol. 2008;26(4):612-619. doi: 10.1200/JCO.2007.14.1713.
4. Chaturvedi AK, Engles EA, Pfeiffer RM, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011;29(32):4294-4301. Epub 2011 Oct 3. doi:10.1200/JCO.2011.36.4596.
5. Kreimer AR, Clifford GM, Boyle P, Franceschi S. Human papillomavirus types in head and neck squamous cell carcinomas worldwide: a systematic review. Cancer Epidemiol Biomarkers Prev. 2005;14(2):467-475.
6. Gillison ML, Broutian T, Pickard RKL, et al. Prevalence of oral HPV infection in the United States, 2009-2010. JAMA. 2012;307(7):693-703. doi:10.1001/jama.2012.101.
7. D’Souza G, Kreimer AR, Viscidi R, et al. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007;356(10):1944-1956. Available at: www.nejm.org/doi/pdf/10.1056/NEJMoa065497.
8. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Surveillance. Atlanta; 2010. Updated 2011 Nov 17. Available at: http://www.cdc.gov/std/stats10/trends.htm. Accessed Mar. 5, 2011.
9. Chandra A, Mosher WD, Copen C, Sionean C. Sexual behavior, sexual attraction, and sexual identity in the United States: Data from the 2006-2008 National Survey of Family Growth. National Health Statistics Reports. 2011;3(36):1-36.
10. Gillison ML, Chaturvedi AK, Lowy DR. HPV prophylactic vaccines and the potential prevention of noncervical cancers in both men and women. Cancer. 2008;113(10 Suppl):3036-3046. doi: 10.1002/cncr.23764.
11. Tezal M. Interaction between chronic inflammation and oral HPV infection in the etiology of head and neck cancers. Int J Otolaryngology. 2012. doi 10.1155/2012/575242.
12. Bui TC, Markham CM, Ross MW, Mullen PD. Examining the association between oral health and oral HPV infection. Cancer Prev Res. 2013;6(9):1-8. doi: 10.1158/1940-6207.CAPR-13-0081.
About the Author
Jacquelyn L. Fried, RDH, MS, is an associate professor and the director of Interprofessional Initiatives at the University of Maryland School of Dentistry. She has been in dental hygiene education for over 35 years. Her interest areas, research, and public speaking focus on HPV-associated head-and-neck cancers, tobacco issues, interprofessional education, and scientific writing. An active member of the American Dental Hygienists’ Association, Fried is widely published and has authored numerous manuscripts. She teaches both didactically and clinically and has received student awards for her teaching abilities.