In decades past, cancers of the oropharynx were primarily caused by tobacco and alcohol use. But now, an estimated 70% of oropharyngeal cancers are caused by human papillomavirus (HPV) infection, according to the Centers for Disease Control and Prevention (CDC). Oral cancers caused by HPV infection include cancer in the back of the throat and at the base of the tongue and tonsils.1
The results of a recent study suggest that young adult patients may be uncomfortable discussing HPV-related issues with their oral healthcare providers, but that this is a necessary group to target to prevent oropharyngeal cancer.2
“HPV is the most prevalent infectious disease — more so than gonorrhea and chlamydia,” says Laura K. Merrell, PhD, CPH, lead study author and an associate professor in the department of health sciences at James Madison University in Harrisonburg, VA. “Anyone who is sexually active will [likely] have an HPV infection in their lifetime. Something like 87% of people who even have one lifetime sexual partner will have an HPV infection.”
HPV causes nearly all cervical cancers as well as vaginal cancer, anal cancer, and penile cancer. Oropharyngeal cancer can result from HPV infection through common oral sexual activity. “It’s super common. We have this great invention of a vaccine, which can be what we call primary prevention,” Merrell says. “It can stop a health issue before it develops, stop you from ever getting HPV.” Reproductive health providers should ask every patient of reproductive age if they have taken the HPV vaccine, she suggests.
Currently, the HPV vaccine is available in two or three shots for anyone who is younger than age 26 years, but the CDC specifically recommends it for children at ages 11 and 12 years, with two doses before age 15 years. For teens and adults who receive the vaccine at age 15 years or older, three doses are needed. It is recommended for all genders. People who are younger than age 45 years also could receive the vaccine if their physician recommends it.3
The three HPV vaccines are the 9-valent HPV vaccine, quadrivalent HPV vaccine, and bivalent HPV vaccine. All three protect against the HPV types that cause most related cancers and can potentially prevent 90% of HPV-attributable cancers, according to the CDC.3
Dental professionals should be among the healthcare providers who recommend HPV vaccination.1 “The vaccine we currently have protects against nine strains,” Merrell says. “It protects against the most harmful strains that cause cancer and the strain that causes genital warts.”
Despite the ubiquitous nature of HPV infection — and the fact that it leads to tens of thousands of cancer cases each year — too few young people have received the HPV vaccine. The National Institutes of Health reports that in 2020, about 55% of adolescents ages 13 to 15 years received two or three doses of the HPV vaccine. The Healthy People 2030 target set a goal of increasing HPV vaccination to 80% of adolescents.4
Sexual politics involving adolescents have been one of the barriers to a higher vaccination rate, Merrell notes. “There have been, historically, a lot of discussions about the HPV vaccine since it came out,” she explains. “A political discussion point: ‘We shouldn’t vaccine our kids and cause them to be sexually promiscuous’ — all these ridiculous claims.” There also is the anti-vaccination movement, which grew during the COVID-19 pandemic.
The technology exists to save people from cancer and to save lives. Providers should do more to promote vaccination among the young adults who missed out on the HPV vaccine when they were adolescents. “The No. 1 predictor of whether or not someone will get the HPV vaccine is provider recommendation,” Merrell says. “Because it can prevent oral cancer, we saw that we needed oral health providers to be included in this discussion to be another voice to recommend the vaccine.”
Female children are more likely to have received the HPV vaccine, but there is good health information about why it is important for all children to be vaccinated. “They initially studied the HPV vaccine in female adolescents, and initially it was only available to young girls between the ages of 9 and 17,” Merrell explains.
As research began to include adolescent males and older age groups, national recommendations expanded access to the HPV vaccine. “Recommendations have to be led by the science, and if it is not studied in certain populations, it will not be recommended,” Merrell says. “Not a lot of physicians are willing to do an off-label use of the vaccine because they could be liable in some ways.”
Also, when the HPV vaccine is given to adolescents, it works well and maintains efficacy even when they are older. “I think it is a question of priorities: Who is it most important to give this vaccine [to]? The first off is adolescents, and then you move from there,” Merrell says.
Family planning leadership and physicians can help educate community dentists about HPV or partner with them at reproductive health fairs and events. They also could provide dentists with information about HPV and related oral cancers, and how to broach the subject with their young adult patients or with parents of adolescents.
“It doesn’t have to be a discussion about sex,” Merrell says. “It can be about preventing cancer and asking, ‘Have you had the HPV vaccine? Did you know it could prevent oral cancer?’” If their patients have any additional questions, dentists could refer them to their primary care provider or to a local family planning clinic.
When researchers asked college students how they felt about discussing HPV and the vaccine with their oral healthcare provider, their responses were mixed.2
“Some said, ‘That’s fine,’ and others said, ‘Why would I ever do this?’” Merrell explains. “We’re talking about HPV. It’s conflated with sex, and this doesn’t have to be a sex discussion; it could be a cancer prevention discussion.”
Most people do not understand the oral-systemic connection and how a person’s oral health affects every other part of their body. “Young people are a prime, catch-up population as they start adult life and are making medical decisions for themselves,” Merrell says. “What do we need to know about what they know? How can we educate them on how important this vaccine is?”
Providers can talk about HPV and the oral cancer connection by discussing oral systemic health and how HPV is the No. 1 cause of oral cancers.
“HPV has overtaken tobacco use,” Merrell adds. “We need to educate our patients about this relationship, and one way is to get oral healthcare providers comfortable with having this discussion.”
If they wanted, dentists could provide the HPV vaccine in their offices. But they also could refer patients to other providers for the vaccine.
“They could provide patient education materials that people could take home and read,” Merrell says. “Especially for parents of adolescents, if they’re hearing from their pediatrician and from their dentist that this is important, then maybe they’d give more thought to the HPV vaccine than they previously would have.”
Providers should ask anyone of reproductive age if they have taken the HPV vaccine. “I’m a reproductive health specialist,” Merrell says. “If you’ve had young people coming in who are not vaccinated, ask them to talk to their primary care providers.”
REFERENCES
- Centers for Disease Control and Prevention. HPV and oral cancer. Page last reviewed Feb. 24, 2022.
- Merrell LK, Bishop JM, Henry DS, et al. Exploring young adult comfort with oral health care providers’ discussions related to HPV: A mixed methods study. J Dent Hyg 2022;96:23-36.
- Centers for Disease Control and Prevention. Human papillomavirus (HPV) vaccination: What everyone should know. Page last reviewed Nov. 16, 2021.
- National Cancer Institute. HPV vaccination. April 2022.
In decades past, cancers of the oropharynx were primarily caused by tobacco and alcohol use. But now, an estimated 70% of oropharyngeal cancers are caused by HPV infection, according to the CDC.
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