Having a difficult HPV conversation with dental patients

Due to the nature of HPV transmission and our evolving knowledge on how different areas of the body are impacted, some medical and dental providers have admitted the lack of a clear protocol for patient dialogue and screening. Because HPV and oral cancer numbers increase each year, it’s our duty to patients to have these critical conversations. Interestingly, , “More than 70% (of adults of all age groups) did not know about the link between HPV and penile, anal, and oral cancers.”² With more than half of the people who pass through our operatory not understanding that oropharyngeal cancers are caused by HPV, we have an opportunity to inform them.

According to the Centers for Disease Control and Prevention (CDC), “85% of people will get an HPV infection in their lifetime. About 13 million Americans, including teens, become infected with HPV each year.”³ HPV is thought to cause 70% of oropharyngeal cancers in the United States.⁴ The American Cancer Society states, “HPV type 16 (HPV16) is the type most often linked to cancer of the oropharynx, especially those in the tonsil and base of the tongue. HPV DNA (a sign of HPV infection) is found in about two out of three oropharyngeal cancers and in a much smaller portion of oral cavity cancers.”⁵ HPV is extremely prevalent and early detection is key to detection and long-term oropharyngeal cancer prognosis.

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What can oral health-care professionals do?

How can dental providers aid in the detection and diagnosis or oropharyngeal cancers? Traditional oral cancer screenings have been a part of our dental hygiene appointments for years. However, we must ask, do we complete these exams with intention and schedule enough time for these assessments?

Oral/oropharyngeal conversations begin during our medical and dental history interviews. During this time, we determine patient risk factors and discuss any concerns. Our traditional head and neck screening should be completed. In addition, it is recommended we provide a referral for follow up for any unexplained ulcerations or lesions in the oral cavity that last more than three weeks and for a persistent and unexplained lump in the neck. Both follow-ups should be considered a referral for suspected cancer and the patient should be scheduled with a medical provider within two weeks.⁶

Are we asking the right questions to determine the need for referral and follow-up with our patients? During these assessments, dental care providers may use oral cancer screening dye or an oral cancer screening light to determine a need for further biopsy or a referral.⁷ Oral cancer and oral cancer-related lesions may be detected radiographically as radiolucent lesions in the presence of bone destruction and radiopaque in the instance of tumor development.⁸ Any suspicious findings should be referred to the patient’s medical provider for a possible chest x-ray, CT or CAT scan, MRI, PET, bone scan, barium swallow, or ultrasound.⁹

Though oral sex and HPV may not be a typical topics of conversation with dental patients, HPV and oropharyngeal cancers are impacting them. We ask other medical/dental history questions that may indicate oral cancer risks, and we perform head and neck screenings to assess clinical findings, but are we educating our patients on why we do this? By taking our assessment and patient education a step further, we set patients up to ask questions of their medical and dental providers.

How to get started

How can we start this conversation? In dental, we are continually exposed to the cause-and-effect relationship of patient habits and decay, patient habits and periodontal disease, and we can provide education to help them alter their habits to prevent progression of disease. The same applies to our knowledge of HPV. We know that it is primarily transmitted via oral sex, and that many partners can lead to an increase in someone contracting HPV.¹⁰

We know that patients with HPV that does not clear on its own can lead to cancer.² Similar to the fact that not all patients will eliminate sugar or snacking from their diet, we know most patients will not eliminate or alter their sexual habits due to a conversation. However, we should set our patients up with knowledge to help them make choices for themselves. For example, as it relates to the HPV vaccine, “Almost every unvaccinated person who is sexually active will get HPV at some time in their life.”³ Patients should be aware that, “HPV vaccination can prevent over 90% of cancers caused by HPV, as well as anal, vaginal, cervical, and vulvar precancers (abnormal cells that can lead to cancer).”¹

The dental community has many professionals ready to educate and empower their peers and provide tools to better serve our patients. One great resource is dental hygienist Susan Cotten, owner of Oral Cancer Consulting. She has developed the Cotten Method to help dental practitioners complete an improved in-office screening method. One of her course descriptions states, “Consequences of an incomplete oral and oropharyngeal cancer evaluation, inadequate documentation, and delayed referrals can result in increased liability, delayed diagnosis, and lives lost.”¹¹

By providing an opportunity for in-office conversations related to safe oral sex practices, offering salivary diagnostic and biopsy services,⁹ oral cancer screenings, and information related to HPV vaccinations, we allow patients access to the tools and knowledge to make informed decisions about their cancer prevention.

 References

1. Cancers Caused by HPV. Centers for Disease Control and Prevention. February 28. 2022. https://www.cdc.gov/hpv/parents/cancer.html
2. Shmerling RH. HPV and cancer: The underappreciated connection. Harvard Health. November 25, 2019. https://www.health.harvard.edu/blog/hpv-and-cancer-the-underappreciated-connection-2019110818285
3. Reasons to get HPV vaccine. Centers for Disease Control and Prevention. November 10, 2021. https://www.cdc.gov/hpv/parents/vaccine/six-reasons.html
4. HPV and oropharyngeal cancer. Centers for Disease Control and Prevention. December 13, 2021. https://www.cdc.gov/cancer/hpv/basic_info/hpv_oropharyngeal.htm
5. Risk factors for oral cavity and oropharyngeal cancers. American Cancer Society. https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/causes-risks-prevention/risk-factors.html#references
6. Grafton-Clarke C, Chen KW, Wilcock J. Diagnosis and referral delays in primary care for oral squamous cell cancer: a systematic review. Brit J Gen Prac. 2019;(69):e112-e126. doi:10.3399/bjgp18X700205
7. Tests and procedures. Mayo Clinic. https://www.mayoclinic.org/tests-procedures
8. Iannucci JM., Howerton LJ. Dental Radiography: Principles and Techniques. Elsevier/Saunders, 2017.
9. Tests for oral cavity (mouth) and oropharyngeal (throat) cancers. American Cancer Society. https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/detection-diagnosis-staging/how-diagnosed.html
10. Dunleavy BP. Oral sex rrequency, number of partners linked to HPV-related cancer risk in study.” UPI. January 11, 2021 https://www.upi.com/Health_News/2021/01/11/Oral-sex-frequency-number-of-partners-linked-to-HPV-related-cancer-risk-in-study/7871610373829/
11. Cotten S. Oral cancer screening. Oral Cancer Consulting. https://oralcancerconsulting.com/