I’ve spent decades teaching my dental colleagues to perform traditional head and neck cancer screenings and to use fluorescence devices to enhance their visual screenings. My passion for the early detection of oral cancers began early in my career as a dental hygienist. We were all taught to perform oral cancer screenings in dental school and dental hygiene school; however, once in practice in “the real world,” I observed that the vast majority of dental professionals did not do these screenings.
When I questioned my peers about not screening for cancer, the unanimous answer was that there simply isn’t enough time during a regular dental hygiene appointment. When I began coaching dental teams, I heard that the dentists and dental hygienists didn’t really know what to look for or how to determine if they were seeing normal variances in oral tissues or pathology.
It became my mission to teach dental professionals that it only takes three minutes to perform a thorough head and neck cancer screening. I always include visuals to show what structures are “normal” and which abnormalities need further evaluation to determine if they are potential pathologies. I also teach how to care for patients undergoing treatment for head and neck cancers because I learned that this is an area for which many dental professionals also feel unprepared.
Having been a head and neck cancer crusader for nearly thirty years, my cancer screening protocols are well established. When detecting cancers caused by the use of tobacco and alcohol, where lesions are typically found on the lateral borders of the tongue and in the floor of the mouth, these protocols are very effective. However, we now know that the majority of head and neck cancers are no longer caused by the use of alcohol and tobacco. Now the main culprit is the Human Papilloma Virus (HPV), where lesions are typically found in the most posterior regions of the mouth and throat (oropharyngeal cancer), and this makes an enormous difference in the way we screen for and detect this disease. Our traditional screening examination cannot reliably detect HPV-related cancers simply because we don’t have access to the areas most often affected.
This does not mean that we no longer perform the traditional head and neck cancer-screening exam. We absolutely do, and while we’re performing the exam is the perfect time to discuss HPV-related head and neck cancers and how patients can best protect themselves.
HPV Infection and Head and Neck Cancer
HPV is now the most common sexually transmitted disease in the United States according to the Centers for Disease Control and Prevention (CDC). Usually, when HPV is contracted there are no symptoms and the immune system clears the infection without the person ever knowing they had the disease. Most people are infected with HPV more than once in their lifetimes. When there is a “glitch in the system” for some reason, the immune system is unable to clear the infection and cancer (cervical, vulvar, vaginal, penile, anal and oropharyngeal) can be the result. Rates of HPV-related oral and oropharyngeal cancers now exceed rates of cervical cancer. The CDC reports that oral cancer is increasing annually at a rate of approximately 30%. White males are affected 3.5 times more than white females.
Because traditional head and neck cancer screening can miss HPV-related head and neck cancers, it’s more important than ever to educate patients about the symptoms, which include a feeling of a lump in the throat, difficulty swallowing, swelling in the neck, loss of appetite, rapid weight loss, hoarseness, speech difficulties, weakness and excessive fatigue.
If any of the above symptoms are present, a referral to an ear, nose and throat (ENT) specialist is in order. ENT specialists have the equipment and expertise to examine the oropharynx as well as diagnose and treat oropharyngeal cancers.
It is possible to diagnose HPV in the dental office with a simple swish and spit test, which detects some of the most common oral cancer causing strains of HPV. It’s important to make it clear to the patient that this is not a cancer detection test and that a positive result for HPV infection is not a cancer diagnosis. It does mean the patient who tests positive must be vigilant about possible early signs of disease.
There are more than 100 strains of HPV. The HPV vaccine has been shown to be more than 95% effective for prevention of HPV vaccine-type infections (HPV strains 6, 11, 16, 18, 31, 33, 45, 52 and 58) and disease among people without prior infection, according to the CDC. Originally, when the first vaccine, Gardasil, was introduced in 2006, it was only approved for use in girls. Then, in 2010, it became approved for use in boys as well.
The current vaccine, Gardasil 9, which protects against the nine strains that cause head and neck cancer, is available to prevent HPV infection. The vaccines bivalent Cervarix (only approved for use in girls) and quadrivalent Gardasil are no longer distributed in the U.S.
HPV vaccines were initially given in three doses. Now the Advisory Committee on Immunization Practices (ACIP) recommends a two-dose vaccine schedule for those who start the series before their 15th birthday. The two doses should be separated by six to 12 months. A three-dose schedule is recommended for those who start the series on or after their 15th birthday and for people with compromised immune systems due to conditions such as cancer or HIV infection or who are taking immunosuppressive drugs. The second dose should be taken one to two months following the first dose, and the third dose should be given six months after the first dose.
It is now recommended to vaccinate girls between the ages of 9 and 26 years and boys between the ages of 9 and 21 years. Vaccination is also recommended for males age 22 to 26 who have sexual contact with males or are Immunocompromised as a result of infection (including HIV), disease or medication. It is also recommended that transgender people up to age 26 receive the HPV vaccine. Although health insurance covers the vaccine only up to the age of 26, it is possible to get the vaccine until age 45 at the patient’s expense.
The CDC estimates that 50% of all new HPV infections occur in young adults between the ages of 15 and 24. It is estimated that only 44% of boys and 53% of girls have been fully vaccinated against HPV. Many children start the series and don’t complete it, according to the CDC’s 2017 National Immunization SurveyTeen (NIS-Teen).
The HPV vaccine can and should be given to people who are already sexually active, according to the Advisory Committee on Immunization Practices (ACIP). Ideally, people should be vaccinated before the onset of sexual activity; however, people who have already been infected with one or more HPV types will still be protected in the vaccine from the other HPV types that have not been acquired.
As it becomes more common to vaccinate children against HPV, it will become more common for middle-aged men and women, who have not had the advantage of vaccination, to develop HPV-related cancers. For this reason, people over the age of 26 are advised to receive the vaccine at their own expense up until they reach the age of 45. The cost is approximately $1,000 for the entire three-dose series.
What Can a Dental Professional Do?
When I was in dental hygiene school, I learned that the number one priority for dental professionals is prevention and the number two priority is early detection of disease. Therefore, it seems prudent to educate our patients regarding the risks of HPV so they can prevent infection.
Sexual contact, including oral sex, which is often considered “safe sex” in our culture, is the greatest risk for HPV infection. Avoidance of unprotected sex, including oral sex, is the best way to prevent HPV infection. Safe sex, meaning the use of condoms (and dental dams for oral sex), should also be discussed with dental patients. In the case of minors, it’s prudent to discuss the issue with the parents initially and get permission to inform their child about the risks of HPV infection and how to prevent infection. Additionally, it can be beneficial to ask the parent if they would be present in the treatment room while you educate the child. This could be a great opportunity to facilitate a frank conversation between the parent and child once they return home.
I have had very positive responses from the vast majority of parents I have talked to about discussing health risks such as HPV with their children. When I coach my client teams about discussing potentially delicate topics such as this with their patients, many are very hesitant to do so. I remind them, and all of my peers, that we are health care providers first and foremost. We must leave any judgment or personal embarrassment behind and focus on the prevention of a deadly infection. We owe it to our patients to fully inform them of the risks of HPV and head and neck cancer. That’s worth a few moments of awkwardness or discomfort. Additionally, as dental professionals, we are within our scope of practice to advise our patients to take better overall care of themselves, including optimal nutrition, exercise and sleep. A healthy immune system is the best way to fight infections of any kind.
I challenge and encourage all of my colleagues to educate patients about the deadly risks of HPV-related head and neck cancer. Use this opportunity to grow beyond the traditional role of dental professional and step into a new role as health care professional to save lives in the dental office.
1. Centers for Disease Control and Prevention – https://www.cdc.gov/cancer/hpv/basic_info/hpv_oropharyngeal.htm
2. Human Papillomavirus (HPV) ACIP Vaccine Recommendations – http://www.immunize.org/askexperts/experts_hpv.asp