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Short Commentary: HPV and Oral Cancer - Implications for the Dental Hygienist

HPV and Oral Cancer: Implications for the Dental Hygienist

A hygienist using the VELscope
Oral Cancer Screening System
from LED Dental.		 by Carinne L. Hawley, RDH, MPH

We were all trained in dental hygiene school to perform oral cancer screenings on all our patients, regardless of risk. As you know, not all patients entering the dental office receive an oral cancer screening; that is unless they have come to see you. The focus of this article is to reinforce the importance of a routine oral cancer screening and highlight the increased risk for oral lesions among patients who engage in oral sex.

From the Hygienetown message boards to Oprah, there has been a lot of media attention focused on the rising number of individuals engaging in oral sex. In addition, the public has become increasingly aware of the link between the human papillomavirus (HPV) and cervical cancer and the benefits associated with the HPV vaccine. Not only is HPV the most common sexually transmitted disease (STD) in the United States but it is also implicated as the cause in most cases of cervical cancer.

What does this have to do with dental hygiene, you ask? Newer evidence has demonstrated a link between HPV and oral cancer. More specifically, the HPV-16 and HPV-18 strains that are common in oral squamous cell carcinomas (OSCC). Transmission of the virus can be achieved through oral sex, a practice common among homosexual men, and increasingly common among teenagers. By sharing this information I don't mean to suggest we question our patients regarding their sexual practices, but rather use it as impetus to be more diligent with our screenings.

The Role of HPV in Oral Cancer
There are both low-risk and high-risk types of HPV. Low-risk HPVs are commonly known as genital warts, though they often concurrently appear with oral lesions of a benign nature. These types of lesions (HPV-6 and HPV-11) can be readily acquired through sexual transmission and often resolve on their own. High-risk HPVs (HPV-16 and HPV-18) have a strong affinity for squamous epithelial tissue, as do the low-risk, but are known for their presence in oropharyngeal cancers.i A recent study focused specifically on Mexicans found that 42 percent of oral cancers in this population contained the HPV genome.ii

Interestingly, patients who present with oropharyngeal tumors with the HPV genome are of younger age when compared to those with similar tumors without the HPV genome. Studies indicate an increased prevalence in men over women for these HPV specific tumors.iii

As HPV infection is mainly transmitted sexually, there are certain behaviors that put a person at increased risk for oral infection. Such risk factors for men and women include: high number of sexual partners; HIV infection; young age at first intercourse; history of performing oral sex; oral-anal contact; and history of genital warts.iv Infection with HPV precedes the development of OSCC of the head and neck thus infection with HPV increases the risk for developing OSCC. Oral squamous cell carcinomas are the eighth most common cancer among men.v

D. Gypsyamber, et. al., found that men and women who had six or more oral sex partners had a nine-fold increased risk of developing cancer of the tonsils or at the base of the tongue.vi In addition, a chronic bacterial infection such as periodontitis might serve an important role in the pathogenesis of cancer as poor oral hygiene has been associated with an increased risk of OSCC.vii

Lack of Awareness Leads to Increased Transmission
Despite the high prevalence of HPV infection among both men and women it is disconcerting to find that both sexes have a low level of understanding of the disease. For instance, most homosexual men know that condoms can prevent transmission of HIV/AIDS but are uncertain of their ability to protect against other STDs.viii Research shows that condom use can lessen the probability that HPV will be transmitted between heterosexual partners by up to 70 percent.ix In the homosexual community transmission has shown to be halted by an equal percentage with condom use.x

Conclusion
In review, the extent of infection with HPV and the concomitant risk of oral cancer when oral sex is practiced fuel the need to educate our patients. Tact and discretion are critical with this topic, so if appropriate dispel the notion that oral sex is synonymous with safe sex, and encourage patients who engage in oral sex with multiple partners to use condoms. Along with the routine performance of oral cancer screenings on all of our patients, this additional information may save lives. Future trends include potential use of the HPV vaccine in men.
Carinne Hawley has been practicing clinical dental hygiene since 2002 after graduating from Oxnard College. She went on to complete her BSDH through the degree completion program at Northern Arizona University and continued her education further by completing an MPH degree at UCLA in 2008. She also works part-time as an instructor at
Oxnard College.
Bibliography
  1. Fakhry C, and Gillison M. (2006). Clinical Implications of Human Papillomavirus in Head and Neck Cancers. Journal of Clinical Oncology, 24(17): 2606-2611.
  2. Anaya-Saaverdra G., Ramirez-Amador V., Irigoyen-Camacho E., Garcia-Cuellar C., Guido-Jimenez M., Mendez-Martinez R., and Garcia-Carranca A. (2008). High Association of Human Papillomavirus Infection with Oral Cancer: A case-control study. Archives of Medical Research, 39:189-197.
  3. Chaturvedi A., Engels E., Anderson W., and Gillison M. (2008). Incidence trends for Human Papillomavirus- Related and Unrelated Oral Squamous Cell Carcinomas in the United States. Journal of Clinical Oncology, 26(4): 612-619.
  4. Fakhry C, and Gillison M. (2006). Clinical Implications of Human Papillomavirus in Head and Neck Cancers. Journal of Clinical Oncology, 24(17): 2606-2611.
  5. Chaturvedi A., Engels E., Anderson W., and Gillison M. (2008). Incidence trends for Human Papillomavirus- Related and Unrelated Oral Squamous Cell Carcinomas in the United States. Journal of Clinical Oncology, 26(4): 612-619.
  6. Gypsyamber D., Kreimer A., Viscidi R., Pawlitia M., Fakhry C., Kock, W., Westra W., and Gillison M. (2007). Case-Control Study of Human Papillomavirus and Oropharyngeal Cancer. New England Journal of Medicine 356:1944-1956.
  7. Gypsyamber D., Kreimer A., Viscidi R., Pawlitia M., Fakhry C., Kock, W., Westra W., and Gillison M. (2007). Case-Control Study of Human Papillomavirus and Oropharyngeal Cancer. New England Journal of Medicine 356:1944-1956.
  8. Pitts M., Fox C., Willis J., and Anderson J. (2007). What do Gay Men Know about Human Papillomavirus? Australian Gay Men’s Knowledge and Experience of Anal Cancer Screening and Human Papillomavirus. Sexually Transmitted Diseases, 34(3): 170-173.
  9. Winer R., Hughes J., Feng Q., O’Reilly S., Kiviat N., Holmes K., and Koutsky L. (2006). Condom Use and the Risk of Genital Human Papillomavirus Infection in Young Women. New England Journal of Medicine, 354(25): 2645-2654.
  10. Wen L., Estcourt C., Simpson J., and Mindel A. (1999) Risk Factors for the Acquisition of Genital Warts: Are Condoms Protective? Sexually Transmitted Infection, 75: 312-316.
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