HPV Vaccine: What is the Role of the Dental Office in Protecting Your Patients from Cervical Cancer?
One in four teen girls are infected with the sexually transmitted infection, human papillomavirus (HPV), according to major press reports which appeared a few weeks ago. What this has to do with dental office is our discussion on 360 this week. Should the dental office do anything to prevent HPV infection by recommending HPV? What do you think?
Read about each of these virtual voices.
Dentist, Dental Researcher
Protecting Your Patients
Margaret Scarlett, DDS
Those news reports were based on results of an analysis from Dr. Sara Forhan and colleagues at the Centers for Disease Control and Prevention (CDC), who estimated one in four teen girls had high risk types of HPV. The estimated prevalence was based on a national evaluation of data from the National Health and Nutrition Survey 2003-2004 for teens aged 14 to 19. Results were obtained from samples of 2,026 self-collected vaginal swabs from women 14 to 19 who reported any prior sexual activity. This includes oral, vaginal or anal sex (1).
HPV is the most common sexually transmitted disease. Studies have shown that high risk types of HPV are highly associated with development of cervical cancer. CDC has recommended Gardisil, a quadrivalent human papillomavirus (HPV) vaccine approved by the Food and Drug Administration for young women beginning at age 11 or 12 up to ages 26. Gardisil is nearly 100 percent effective in preventing four types of HPV infection, HPV 6, 11, 16, and 18. While the HPV vaccine is recommended as a three-dose vaccine, it is not intended to preclude the use of the Pap Test.
As we probably know from our own preventive health regime, Pap Tests for cervical cancer has been recommended yearly for women for a number of years. While the vaccine is not recommended for pregnant women, it is most effective when given to young women prior to their first sexual contact. Since other data suggest that the median age for first sex is 16.9 years old, recommending vaccination of girls beginning at age 11 or 12 made sense to health policy makers when they recommended the vaccine in 2006.
So what does this have to do with the dental office? Shouldn’t the physician take care of recommending this to their teenage female patients? What does this mean for your practice? Does this vaccine have any impact on preventing oral cancer? Why haven’t we made much progress in mortality rates for oral cancers, like other cancers, like breast and cervical?
First, it means that you may wish to ask your patients whether or not they have received the vaccine in your medical history form. Why? Because many adolescents don’t see their physicians very often, because teens are mostly healthy and may see their dentist more often than their physician. Second, consider whether or not you want to add questions about this to your medical history form, along with information about other vaccines. Some states require that adolescent girls receive the vaccine. Check whether your state is one of these.
While we don’t know if the HPV vaccine will prevent oral cancers, we do know that HPV is associated with certain types of oral cancers. In 2007, the New England Journal of Medicine, reported that men and women having six or more oral-sex partners during their lifetime were nine times more likely to develop oral cancer than those who did not have oral sex. In a separate case control study of 300 people, people infected with HPV were 32 times more likely to develop tongue and tonsil cancer than those who did not have the virus. Though additional data is needed, this suggests that HPV could be associated with oral cancers of the throat and tongue. (2,3)
Since the oral mucosa in the oral cavity are similar to mucosa lining the reproductive track, there is much conjecture in the scientific community that the HPV vaccine could prevent development of certain types of oral cancers. This is what they call “proof of concept” in scientific jargon. Proof of concept for the HPV vaccine working against oral cancer would need to be proven, mostly in animal models first. Then, an expensive and long term efficacy trial would have to be undertaken to assess whether the vaccine might prevent oral cancers. This would take years, probably ten years or more to determine.
What we do know is that oral cancer mortality and five year survival rates are relatively high and unchanged compared to other types of cancers. There are about 15, 000 new cases of oral cancer each year, and about 3000 a year die from oral cancer. This is why oral cancer screening and early detection are very important. Right now, evaluating the vaccine for prevention of oral cancers for “proof of concept”is happening at leading research organizations, such as Forsyth Dental.
Since discussing oral sex risks with patients is not part of dental education, most dental offices don’t want to talk about sensitive topics with their patients. However, it does make sense to recommend the HPV vaccine to prevent the leading cause of cervical cancer from the dental team. And just maybe, the HPV vaccine might prevent oral cancer, if an expensive study could be done to prove that HPV vaccine work against some types of oral cancers. Do you think the dental office should recommend the HPV vaccine, as part of the team of health providers who care for teenage girls? What do you think?
1. Forhan et al. Prevalence of Sexually Transmitted Infections and Bacterial Vaginosis among Female Adolescents in the United States: Data from the National Health and Nutrition Examination Survey 2003-2004. EIS conference, Atlanta, April 2008. 2. Garland SM et al. Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases. N Engl J Med 2007 May 10; 356:1928-43. 3. D’Souza, et al. Case Control Study of Human Papillomvirus and Oropharyngeal Cancer. N Engl J Med 2007 May 10:356:1944-1956.
Hygienist & Mother
Dental hygiene isn't just cleaning teeth anymore…
Jodie Probst, RDH and mother of three daughters
In this age of periodontal related heart disease, diabetes, and low birth weight babies, we now have proof that the mouth is truly the gateway to the entire body. As dental hygienists, we always preach home care, proper diet and exercise for all of our patients, and especially those that are medically compromised. We also stress they see their medical doctor regularly and check their blood. So, making that complete connection of dental-medical wellness in addition to being the patient’s cheerleader and sometimes front line of notification has become all important.
So what about HPV? Whose responsibility is it to talk to parents regarding their young daughters? Mine! Most patients come to the dentist two times a year. This is a prime opportunity to discuss the HPV vaccine with the patient's parents. Do your patients know what HPV is?
As a mother of three daughters, I was personally very interested in learning more about the HPV vaccine. A simple vaccine can prevent a certain type of cervical cancer. After my own research and many discussions with countless healthcare professionals, we decided this was a good choice for our daughters. The HPV vaccine is a series of three shots over a six month period of time.
Ironically, I was working the day of my girls’ last shot series. I was telling my patient that after work - all three of my daughters would be getting their third and final HPV immunization. I inquired if she thought about the vaccine for her teenage daughter. She informed me her daughter was NOT sexually active and there was no need to get it done. Of course, I told her given that my twin daughters’ were 10 and my older daughter, 11 years old; they were not sexually active either. After seeing her face, I dropped the subject knowing I was going no where.
Obviously, this subject was something the patient did not want to hear. Maybe she took my care suggestion in the wrong way and raced to judgment. Perhaps, she was just having a bad day and wanted to get her “cleaning” done! But, in my mind, the information that I shared with her in a non-threatening way is important and timely.
For my daughters, the HPV isn't the here and now it is the future...their future. If I can help prevent my daughters and other daughters from getting one type of cancer, I will take one for the team and continue to ask my mothers of teenage daughters if they know about the HPV vaccine!
Dentist
Speed Bumps Along this "New" Journey
Lori Trost, DMD
Founder of PinkTooth.net
As more medical and dental connections are made, these links make for some very timely topics, awareness, and education that we, as dental professionals – whether you are the dentist, hygienist, assistant, or business team member have the ability and opportunity to share with our patients. So the questions become, what do we discuss within this realm, what is appropriate, and what should be pertinent for each particular patient?
In general, have you or your team members ever sat down and discussed what is relevant for patient discussion? What discussion emphasis does your practice focus on? What current information and education should you “push” out through your practice? How far does the envelope extend beyond dental awareness? Do you currently crossover into any medical connections for your patients.
You and your team members may want to take the topic of HPV, Human papillomavirus and pay very close attention as to how, what, when, and why you may or may not choose to discuss this with your patients. Let’s take a look at what we know.
HPV is the most common sexually transmitted infection (STI) with approximately 20 million Americans already infected and another 6.2 million people becoming newly infected each year. The virus infects the skin and mucous membranes and there are more than 40 HPV types. Most people who become infected with HPV do not even know they have it. At least 50% of sexually active men and women acquire genital HPV infection at some point in their lives.
There are other forms of HPV which are sexually transmitted, and are a serious problem. The most common of these are; HPV-16, HPV-18, HPV-31, and HPV-45. These cancer-associated types of HPV's cause growths that usually appear flat and are nearly invisible, as compared with the warts caused by HPV-6 and HPV-11. In the broadest terms they can be differentiated into these areas; HPV related appear to occur on the tonsillar area, the base of the tongue and the oropharynx, and non-HPV positive tumors tend to involve the anterior tongue, floor of the mouth, the mucosa that covers the inside of the cheeks and alveolar ridges (the ridge area in which the teeth reside). Two types of genital tract HPV in particular, HPV 16 and HPV 18, are known to cause the vast majority of cervical cancers, and new studies show that they also linked to oral cancer as well. In the oral environment these manifest themselves primarily in the back (posterior) regions such as the base of the tongue, the oropharynx (the back of the throat in the mouth), the tonsils and the tonsillar pillars.
Enter cervical cancer… The American Cancer Society estimates that in 2008, 11,070 women will be diagnosed with cervical cancer in the U.S. There is now a vaccine available that can protect females from the four types of HPV that cause most cervical cancers and genital warts. The vaccine is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 who have not yet been vaccinated or completed the vaccine series.
So it is now clear that the path that brings people to oral cancer is made up of two distinct etiologies - one through tobacco and alcohol and the other via the HPV virus ( particularly version 16, though other versions of the virus might be implicated as the research unravels). In general it appears that HPV positive tumors occur most frequently in a younger group of individuals than tobacco related malignancies. They also occur more in white males and in non- smokers. The HPV group is the fastest growing segment of the oral cancer population.
Where do we begin? Or do we, as dental professionals? Is our connection, treatment, and well-being underscored, taken for granted, or are we even trusted to be a source for information and education such as this?
My challenge to each of our readers is to discover their practice comfort zone of education and information exchange with their patients. Think about the lives you intersect. Whether you discuss or perhaps not bring “up” this HPV topic is your choice. I suggest that each team member educate and inform themselves. Role play possible patient interaction, acceptance, and potential inferences that may occur. Then begin a frank and open discussion about the direction you and your practice want to move, well-knowing there will be speed bumps ahead.
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