Today, in a time where 75% of our illnesses are preventable, and where prevention takes a backseat to sickness (including vaccinations for communicable illnesses), we as dental professionals can make a difference. In the future, there may come a time when dental offices will be part of the point-of-care vaccination campaign for a deadly disease run rampant: oral pharyngeal cancer (OPC) from the human papillomavirus (HPV). HPV is the single most prevalent sexually transmitted infection in the United States,1 and, because of that, HPV-OPC is now considered an epidemic, causing 70% of all oral cancers.
Traditionally, dental patients believed that coming to our offices was all about the health of their teeth and gums. Now they are growing accustomed to the idea that dentists and hygienists are also talking about systemic health. As a dental professional, you are likely familiar with a few (among the oodles) of connections between oral and systemic health, and hopefully you are already passing some important information along to your patients. Unfortunately, our profession has been slow to change, so the majority of our patients have been better informed about oral-systemic links by the news, magazines, and social media than by their own dental offices.
Take HPV-OPC for example. Most of the public awareness about HPV has come from Gardasil (Merck) vaccine advertisements. Unfortunately, the Food and Drug Administration has delayed the vaccine’s assignment for prevention of OPC. So the ad campaign primarily targeted females for cervical cancer, and, to a much lesser extent, males because of HPV-related anal and penile cancers. HPV was first identified as a cause of cervical cancer in women, although now, according to the Centers for Disease Control, it causes one-third more cases of oropharynx cancer than cervical cancer.2 Shockingly, 82% of HPV-OPC occurs in men, compared to 18% in women.
HPV is a topic of conversation all dental professionals should be initiating with every teen/adult patient since HPV infection is avoidable, preventable, identifyable, and somewhat treatable. Because oral HPV is transmitted primarily through oral sex, this can be an awkward topic to bring up. The purpose of this article is to help you get past this uneasiness. It’s time to lift the science off the page and into the hearts and minds of our patients!
My dental team wanted to make a difference. So, in a full-on effort to improve our communication, we committed to a yearlong HPV awareness campaign. We aimed to inform 100% of our adult patients, with hopes they would pass on the message to their children and extended family members as well. The refined outcomes of our campaign are summarized in the following 7 tips to help you overcome your initial awkwardness, discuss early HPV detection, and promote HPV prevention and vaccination among your patients.
1. Start the conversation during your routine oral cancer screening. Be honest. During your routine oral cancer screening, inform your patient that this traditional oral cancer screening will not find 70% of the oral cancers existing today because most are out of your visual field. Say something like:
“I’m conducting a routine oral cancer screening by looking all around your mouth for early signs of cancer. Unfortunately, oral cancer is a growing epidemic because of a group of viruses called HPV, and most of it is hiding in the back of the mouth, behind the tonsils, in the back of the throat, or on the base of the tongue where neither you nor I can see it. That makes screening for oral cancer very difficult these days, and watching this epidemic grow among our population is frustrating.”
2. State the cause with confidence. Lead by example on sensitive health topics with your patients. If you act strange, they will feel strange. Use a professional and matter-of-fact tone. Remember, you are talking to adult patients, and you are their health professional. This may be the first time they hear about this condition, and your foundational information will form their basic understanding. Try continuing your explanation with these words: “HPV is transmitted primarily through oral sex, and until we get most of our adolescent and adult populations vaccinated, this upsurge will persist.”
If you have already established a professional and trusting relationship, your patient may ask more questions about HPV-OPC and its risk factors. If there are questions you can’t answer, let them know you will find out and get back to them.
3. Always rely on evidence-based information. With the amount of inaccurate news shared on the internet and by word of mouth, your patients can’t really be sure of the validity of the information they hear these days. Stick with published facts from current articles in well-respected journals. State concise, well-documented facts, and don’t be afraid to utilize a printed pamphlet or leaflet to further illustrate your factual points.
4. Recruit your patients to help you spread the word. Encourage your patients to discuss this growing epidemic with their friends and families since you will not be having this conversation directly with your pediatric patients. One-third of teenagers in the United States aged 15 to 17 reported having oral sex.3 In our culture, many teens and young adults consider oral sex to be casual sex. Meanwhile, 50% of all new HPV infections occur between 15 and 24 years old. The clear message for adults (and their children) should be “Oral sex is not safe sex!”
5. Encourage HPV testing. Because 51 HPV strains have been identified in the mouth, and 25 of those have been linked to OPC, if you want to offer a saliva test to help your patients better assess their current cancer risk levels, it’s easy. OralDNA Labs offers an affordable saliva test that identifies all 51 types, and if your patient tests positive for a specific strain, it informs them as to the associated risk for OPC. Remember that a positive HPV test does not indicate the presence of cancer. In fact, it’s persistent HPV infection that poses the real risk; fortunately, most humans can “clear” HPV over time. That’s why HPV-positive patients will want to repeat the test in 12 to 18 months. It gives them adequate time to hopefully clear their infections by focusing on improving their overall health, which will boost their host immune responses. Regardless of the test outcome, testing is a great opportunity for you to encourage healthy lifestyle changes, such as clean eating, improving sleep quality/quantity, quitting smoking, reducing drug/alcohol consumption, and/or refraining from unprotected sex.
6. Help de-escalate this epidemic by overtly recommending vaccination. The medical community has fallen short on pushing the Gardasil vaccine. As in recent years,4 in 2019, we will likely vaccinate just more than half of all teenagers, leaving thousands more exposed to the virus. The first vaccine is recommended at ages 11 to 12 years old; however, it’s not yet a requirement (to attend public school), so many practitioners let children slip through the cracks. Dental professionals can help. Whether your patient is infected with an HPV strain or not, it is a good idea to recommend the vaccine. Why?
The current vaccine, Gardasil 9, protects both men and women from 9 strains of HPV infection. Out of more than 200 identified strains of HPV (including the bothersome, but not dangerous ones that cause warts on your fingers and feet), the ones shielded by the vaccine are considered the 9 most carcinogenic. The 9-valent inoculations are not a slam dunk since 51 strains have been identified in the mouth, and 25 of those have been linked to OPC.
Until October 2018, many medical insurances covered young adults through the ages of 21 for males and 26 for females, even though Gardasil was indicated by Merck for persons under the age of 45. In fact, there was nothing prohibiting adults over 45 from receiving the series—except the high cost.
Recognizing this growing cancer epidemic, the new 2018 guidelines extended vaccination recommendation for ages 27 to 45. Hopefully, this will spur most insurance carriers to cover the vaccination for that age group as well. Spread that good news, with hopes that we catch up on the huge population of young people who missed the vaccine series altogether.
7. Take your time. While these conversations may be sensitive, they get easier with experience. Like all health advocacy dialogues, your patients will see how much you care about them and their well-being. There remains a mountain of evidence that patients’ treatment choices and outcomes are greatly improved as a result of our face-to-face, heartfelt relationships with them. So, don’t quickly fly through a discussion about HPV-OPC. Each individual is ultimately responsible for his or her own behavior, but we can help them understand the evidence and make good personal choices. Your genuine approach as a knowledgeable and caring dental professional truly makes a difference!
References
- Centers for Disease Control and Prevention (CDC). HPV and oropharyngeal cancer. https://www.cdc.gov/cancer/hpv/basic_info/hpv_oropharyngeal.htm. Accessed February 4, 2019.
- CDC. How many cancers are linked with HPV each year? https://www.cdc.gov/cancer/hpv/statistics/cases.htm. Accessed February 4, 2019.
- CDC. STD Risk and Oral Sex – Fact Sheet. https://www.cdc.gov/std/healthcomm/stdfact-stdriskandoralsex.htm. Accessed March 15, 2019.
- Walker TY, Elam-Evans LD, Singleton JA, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2016. MMWR Morb Mortal Wkly Rep. 2017;66:874-882. https://www.cdc.gov/mmwr/volumes/66/wr/mm6633a2.htm?s_cid=mm6633a2_w. Accessed February 4, 2019.
Dr. Maples is a practicing general dentist, author, and health educator. She is the creator of Total Health Academy, a complete online learning curriculum for creating a total health dental practice of your own, and author of Blabber Mouth! 77 Secrets Only Your Mouth Can Tell You to Live a Healthier, Happier, Sexier Life. She is an executive board member of the American Academy for Oral and Systemic Health and an expert on the many connections between the mouth and the body. She can be reached at the websites drsusanmaplesspeaker.com, mytotalhealthpractice.com, and drsusanmaples.com.
Disclosure: Dr. Maples reports no disclosures.
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