Is there a professional manner to address the issue of HPV with patients in the dental office?

This question was submitted by a general dentist: Does anyone have a polite and professional way to address the HPV issue with patients in a dental office setting?

Drs. Nita Mazurat, from the University of Manitoba, and Suham Alexander provided a quick initial response. 

The major role of the dentist with respect to HPV is to provide a head and neck examination, to encourage patients to perform regular self-examinations, to encourage adult patients and parents of appropriately aged children to consider having HPV vaccine, and to refer patients with suspicious lesions or persistent symptoms.  The patient’s health history, particularly any verbal or written indication of initially suggestive symptoms, such as persistent sore throat, dysphagia, hoarseness, ear pain, enlarged lymph nodes or weight loss, should be carefully evaluated as part of the full clinical assessment and head and neck examination.^1,2

• Open the conversation with appropriately aged patients by providing information that all men and women are at risk of developing oral cancer even in the absence of other risk factors such as alcohol, smoking, or smokeless tobacco use.

• Explain to the patient that an integral part of the dental examination is the extraoral and intraoral soft tissue examination and that you perform a head & neck examination at your new patient exam and thereafter, at every recare/recall appointment.

• While performing the examination, explain to patients that oral cancer screening includes examining the lymph nodes of the neck and the intraoral mucosal tissues, tongue, base of the tongue, and throat and encourage them to perform a regular self-examination (at least monthly).

• The discussion can then easily and comfortably segue into a discussion about HPV and the relationship between HPV and oral cancers. The dental team should encourage adult patients as individuals and as parents to discuss HPV vaccine as a preventive health measure with their physician.

Oral cancer screening is an integral part of the clinical examination process. Practitioners should keep in mind that oropharyngeal cancers are difficult to detect manually and visually because of their position in the orofacial complex and their symptoms mimic more common benign conditions.²

To help dentists with useful information for patients, the following information about HPV has been reproduced directly from the Canadian Immunization Guide.³

• Human papillomavirus (HPV) infections are the most common sexually transmitted infections. Most HPV infections occur without symptoms and resolve without treatment.
• If not immunized, most sexually active Canadians will have an asymptomatic HPV infection at some time.
• High-risk HPV types 16 and 18 and others can lead to cervical and anogenital cancers as well as certain cancers of the head and neck.
• Low-risk HPV types 6 and 11 can cause genital warts
• HPV2 or HPV4 vaccine is recommended for prevention of cervical cancer in girls and women (9 to 26 years of age, including those who have had previous Papanicolaou [Pap] test abnormalities, cervical cancer or genital warts).
• HPV4 vaccine is recommended for the prevention of vulvar, vaginal, anal cancers and their precursors and anogenital warts in girls and women (9 to 26 years of age).
• HPV2 or HPV4 vaccine may be administered to women 27 years of age and older at ongoing risk of exposure.
• The choice of vaccine for women depends upon the importance of protection against genital warts.
• HPV4 vaccine is recommended for prevention of anogenital cancer and genital warts in boys and men (9 to 26 years of age), including men who have sex with men (MSM) as they are at higher risk of HPV infection and disease.
• HPV4 vaccine may be administered to men 27 years of age and older, at ongoing risk of exposure. HPV2 vaccine is not recommended in boys and men.

In Canada, it is estimated that HPV infection is associated with 90% of anal cancers, 50% of penile cancers, 35% of oropharyngeal cancers and 25% of oral cavity cancers. Among HPV-associated cancers, approximately 92% of anal cancers, 63% of penile cancers and 89% of oral cavity and oropharyngeal cancers are attributable to high-risk HPV types 16 and 18.

Genital warts: Canadian studies have reported incidence rates of genital warts between 131 to 154 per 100,000 in men and 120 to 121 per 100,000 in women. Prevalence was estimated at 146.4 to 148.0 per 100,000. Prevalence and incidence were consistently higher among men compared to women and incidence peaked between 20 and 24 years of age for women and 25 to 29 years of age for men.

HPV is not the same as herpes or HIV (the virus that causes AIDS). These are all viruses that can be passed on during sex, but they cause different symptoms and health problems.⁴

References

1. http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-human-papillomavirus-and-squamous-cel
2. http://c.ymcdn.com/sites/www.osap.org/resource/resmgr/Symposium_2012uploads/Cleveland_JADA_HPV_OPC_8-11.pdf
3. http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-hpv-vph-eng.php
4. http://www.cdc.gov/hpv/whatishpv.html

Additional References

• http://www.cdc.gov/features/HPVvaccine/
• http://www.cdc.gov/std/HPV/STDFact-HPV.htm
• http://www.dentistryiq.com/articles/2013/04/a-necessary-challenge-how-to-talk-to-your-patients-about-the-con.html