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Compendium
February 2020
Volume 41, Issue 2

How Can Dental Practitioners Join the Fight Against HPV-Associated Oropharyngeal Cancer?

Jack Dillenberg, DDS, MPH; A. Ross Kerr, DDS, MSD; Alexis Koskan, PhD; Seena Patel, DMD, MPH; Mai-Ly Duong, DMD, MPH, MAEd

Dr. Dillenberg

The entire dental team has the responsibility of impacting the overall health of their patients. This becomes even more relevant with the realization that up to 27 million people each year visit a dentist and not a physician, thus providing a special opportunity for primary care issues to be addressed in the dental setting.

One such opportunity is oropharyngeal cancer (OPC) prevention and control. An estimated 51,540 new cases of oral and pharyngeal cancer occurred in 2019, with a 5-year relative survival rate of 65%.1 Of these, it is estimated that 19,000 are human papilloma virus (HPV)-associated OPC, which is the only cancer that has increased in prevalence in the past 5 years, and that these numbers will continue to rise.1

Whereas the use of alcohol and tobacco were once the leading causes of OPC, the emergence of HPV infection as the main cause of OPC has changed everything. Infection with HPV (particularly HPV type 16) is transmitted primarily through sexual contact and is a vaccine-preventable virus. HPV is the most common sexually transmitted disease and can be spread even when someone infected with this virus has no signs or symptoms. Therefore, the dental team should be aware of this serious emerging cancer, be able to educate patients about risk factors, and engage in preventive activities, such as opportunistic screening and detection, and the promotion of vaccination.

Dr. Kerr

Dental clinicians should be able to recognize the presenting signs and symptoms of HPV-associated OPC (HPV-OPC). The oropharynx encompasses the soft palate, fauces, tonsillar fossae and palatine tonsils, posterior pharyngeal wall, and the base of tongue/lingual tonsils. The most common presenting symptom of a patient who may have a HPV-OPC is a non-painful neck mass.2,3 This occurs in approximately 50% to 70% of patients with OPC, and it corresponds to the spread of the cancer from the primary oropharyngeal site to the regional lymph nodes of the neck. In patients without a neck mass, other symptoms include one or more of the following: sore throat, visible oropharyngeal mass, dysphagia or odynophagia, globus sensation, or otalgia.4

There is insufficient evidence for the US Preventive Services Task Force to recommend specific screening guidelines for the early detection of HPV-OPC. However, standard dental practice dictates that at new patient and recall visits, patients are asked about current symptoms as well as receive a visual and tactile head and neck soft-tissue examination. Palpation with detection of lymphadenopathy that cannot be attributed to a benign cause (such as inflammatory lymph nodes secondary to an odontogenic infection) and/or visualization/palpation of accessible oropharyngeal structures with detection of abnormal lesions or gross asymmetry of tonsillar structures should all raise suspicion for malignancy. Abnormal signs and symptoms should trigger a referral to an expert, ideally an otolaryngologist/head and neck oncologic surgeon.

There is no evidence to support the use of salivary or serum-based screening tests to detect oncogenic HPV genotypes in the general population. Large cohort studies where subjects submit mouthrinse samples demonstrate an approximate prevalence of 1% patients testing positive for HPV 16 infection, the most cancerous of the HPV strains.5 Yet, few of these infections represent persistent infection, and even fewer lead to malignant transformation. Research suggests testing patients who are at higher risk for acquiring persistent HPV 16 infection as a feasible OPC screening strategy in a dental setting.6

Benign HPV-associated lesions (ie, viral papilloma, verruca vulgaris, condyloma acuminatum) involving the oral cavity (and oropharynx) may be detected during examination. Such lesions are typically solitary, exophytic, often pedunculated, pink to white in color, and with a variable surface ranging from papillary (ie, fingerlike projections) to flat. These lesions have no malignant potential, are associated with non-oncogenic HPV genotypes,7 and should be excised.

Dr. Koskan

What is the HPV vaccine? Vaccines that protect against HPV, and therefore HPV-OPC, have been commercially available in the United States since 2006. Currently, healthcare providers administer Gardasil® 9, a vaccine series that protects against nine different HPV genotypes, seven which cause the majority of HPV-related cancers (including OPC) and two that cause genital warts and recurrent respiratory papillomatosis. More specifically, the vaccine protects against HPV type 16, the strain most commonly associated with OPC. Therefore, vaccine uptake and completion is believed to help prevent HPV-OPC.

Whereas the HPV vaccine was once marketed for women, all individuals aged 9 to 26 years should receive the vaccine. Individuals aged 9 to 14 years with healthy immune systems need two doses to complete the series, and persons over age 15 and/or who are immunosuppressed should receive three doses.8 The vaccine is most effective prior to sexual debut. However, even among those previously exposed to HPV strains, the vaccine can protect from future infection from strains in which the individual has not been exposed and from future re-infection from previously exposed HPV strains, thus reducing cancer risk.9

Insurance provides coverage for this otherwise prohibitively expensive vaccine (roughly $230 per dose) series. Some plans provide coverage for adults up to age 45. For this reason, the Centers for Disease Control and Prevention (CDC) recommends shared decision-making with a primary care provider to discuss the vaccine benefits.

The HPV vaccine is safe and effective.10 The most common side effects include mild pain, redness, and, less common, slight swelling at the site of vaccine injection.11 The vaccine is effective in preventing genital warts and infection with the most common cancerous HPV strains.

Drs. Patel and Duong

Oral healthcare providers should be proactive in educating their patients in HPV-OPC prevention, promoting the HPV vaccine, and learning more to reduce the disease's incidence, as provider recommendation is a vital predictor of HPV vaccine uptake and completion.

First, improving HPV-related health literacy is necessary among dental providers.12-17 Specifically, dental providers having a sound understanding of HPV, its pathophysiology, and its cancer-causing potential is key to educating patients and parents. Second, dental providers need to be well-versed in HPV-associated OPC preventive methods, specifically the HPV vaccine. Most oral health providers still do not know enough about the vaccine, and hence, do not feel comfortable recommending it.18

When discussing the HPV vaccine, it is important to promote it as a cancer prevention tool. It can be likened to other vaccines that have a similar purpose, such as the hepatitis B vaccine, which prevents viral hepatitis and hepatocellular carcinoma. The provider should give a strong recommendation for the vaccine and emphasize that HPV-OPC is a public health epidemic. Communicating the rise in incidence of this disease and the fact that it is caused by a very common infection may help parents understand how critical HPV vaccination is. Alleviating concerns about common myths is also important, such as the vaccine is not only for girls, it does not encourage early sexual debut, and it is not associated with any serious health risks or mortality.

Most practitioners do not feel confident answering patients' questions about HPV vaccination.19 However, if a trustworthy standard set of talking points were made available, providers are willing to educate their patients about the importance of HPV vaccination and refer patients to medical providers to receive the vaccine.18,19 Further, providers were willing to participate in training programs to promote and administer the HPV vaccine.

Tools are available to improve communication practices about HPV in the dental setting, such as the #HowIRecommend videos posted on the CDC website (cdc.gov). Keeping brochures and educational videos about HPV, HPV-OPC, and the HPV vaccine in the office lobby and patient rooms can help increase knowledge and awareness. Additionally, adding a question on patient intake forms about whether the patient has received HPV vaccine doses allows the provider to more easily start this conversation. Another prime time to recommend this cancer prevention vaccine is during an oral cancer screening.

Conclusion

Dental providers have the unique opportunity to help reduce the incidence of oropharyngeal cancer. Two critical steps can be taken. First, they can work with state and local dental associations to pass regulatory legislation that would allow dentists to administer the HPV vaccine to their patients, as needed. Second, they can educate their patients and patients' parents that the HPV vaccine is a cancer prevention resource. Enacting these steps may lead to increased HPV vaccine uptake and, in turn, reduced cases of HPV-related oropharyngeal cancer.

About the Authors

Jack Dillenberg, DDS, MPH
Dean Emeritus, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona; The ATSU Center for the Future of the Health Professions

A. Ross Kerr, DDS, MSD
Clinical Professor, Oral and Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry, New York, New York

Alexis Koskan, PhD
Assistant Professor, College of Health Solutions, Arizona State University, Phoenix, Arizona

Seena Patel, DMD, MPH
Associate Professor and Associate Director of Oral Medicine, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona; Private Practice, Phoenix, Arizona

Mai-Ly Duong, DMD, MPH, MAEd
Associate Professor and Associate Director of Special Care Dentistry, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona; Private Practice, Phoenix, Arizona

Resources to help educate providers about HPV, HPV-OPC, and the HPV vaccination:

CDC: https://www.cdc.gov/hpv/index.html
CDC #HowIRecommend: https://www.cdc.gov/vaccines/howirecommend/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhpv%2Fhcp%2Fhow-I-recommend.html
American Cancer Society: https://www.cancer.org/cancer/cancer-causes/infectious-agents/hpv.html
National AHEC Organization, HPV Project: https://www.nationalahec.org/index.php/what-we-do/national-training-center/hpv-project
Immunize Nevada: https://immunizenevada.org/hpvfreenv
Public Health Foundation: http://www.phf.org/events/Pages/Perspectives_on_Oropharyngeal_Cancer.aspx
American Dental Association: https://ebusiness.ada.org/education/viewcourse.aspx?id=58

References

1. Howlader N, Noone AM, Krapcho M, et al, eds. SEER Cancer Statistics Review, 1975-2016, National Cancer Institute. Bethesda, MD. https://seer.cancer.gov/csr/1975_2016/, based on November 2018 SEER data submission, posted to SEER website, April 2019.

2. Khalid MB, Ting P, Pai A, et al. Initial presentation of human papillomavirus-related head and neck cancer: a retrospective review. Laryngoscope. 2019;129(4):877-882.

3. Carpen T, Sjoblom A, Lundberg M, et al. Presenting symptoms and clinical findings in HPV-positive and HPV-negative oropharyngeal cancer patients. Acta Otolaryngol. 2018;138(5):513-518.

4. McIlwain WR, Sood AJ, Nguyen SA, Day TA. Initial symptoms in patients with HPV-positive and HPV-negative oropharyngeal cancer. JAMA Otolaryngol Head Neck Surg. 2014;140(5):441-447.

5. Gillison ML, Broutian T, Pickard RK, et al. Prevalence of oral HPV infection in the United States, 2009-2010. JAMA. 2012;307(7):693-703.

6. Rindal DB, Gilbert GH, Carcelen C, et al. Feasibility and acceptance of oral human papillomavirus detection in the dental office: results from The National Dental Practice-Based Research Network. J Am Dent Assoc. 2019;150(2):130-139.e4.

7. Castro TP, Bussoloti Filho I. Prevalence of human papillomavirus (HPV) in oral cavity and oropharynx. Braz J Otorhinolaryngol. 2006;72(2):272-282.

8. Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination-updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405-1408.

9. Castellsagué X, Schneider A, Kaufmann AM, Bosch FX. HPV vaccination against cervical cancer in women above 25 years of age: key considerations and current perspectives. Gynecol Oncol. 2009;115(3 suppl):S15-S23.

10. Shimabukuro TT, Su JR, Marquez PL, et al. Safety of the 9-valent human papillomavirus vaccine. Pediatrics. 2019;144(6). doi: 10.1542/peds.2019-1791.

11. Moreira E, Giuliano A, de Hoon J, et al. Safety profile of the 9-valent human papillomavirus vaccine: assessment in prior quadrivalent HPV vaccine recipients and in men 16 to 26 years of age. Hum Vaccin Immunother.2018;14(2):396-403.

12. Van Dyne EA, Henley SJ, Saraiya M, et al. Trends in human papillomavirus-associated cancers: United States, 1999-2015. MMWR Morb Mortal Wkly Rep. 2018;67(33):918-924.

13. Kline N, Vamos C, Thompson E, et al. Are dental providers the next line of HPV-related prevention? Providers' perceived role and needs. Papillomavirus Res. 2018;5:104-108.

14. Dodd RH, Forster AS, Waller J, Marlow LA. Discussing HPV with oropharyngeal cancer patients: a cross-sectional survey of attitudes in health professionals. Oral Oncol. 2017;68:67-73.

15. Rowan SD, Hu SL, Brotzman JS, et al. Knowledge assessment of the dental community in Texas on the role of human papilloma virus in oropharyngeal cancer. Tex Dent J. 2015;132(8):528-536.

16. Daley EM, Thompson EL, Vamos CA, et al. HPV-related knowledge among dentists and dental hygienists. J Cancer Educ. 2018;33(4):901-906.

17. Arora S, Ramachandra SS, Squier C. Knowledge about human papillomavirus (HPV) related oral cancers among oral health professionals in university setting: a cross sectional study. J Oral Biol Craniofac Res. 2018;8(1):35-39.

18. Walker KK, Jackson RD, Sommariva S, et al. USA dental health providers' role in HPV vaccine communication and HPV-OPC protection: a systematic review. Hum Vaccin Immunother. 2019;15(7-8):1863-1869.

19. Patel S, Koskan A, Spolarich A, et al. Dental professionals' knowledge, attitude, practice behaviors related to human papillomavirus vaccination. J Public Health Dent. 2019. doi: 10.1111/jphd.12350. [Epub ahead of print]

 

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