Are sexual relations closely intertwined with oral health? It would appear so with the connection between the human papillomavirus (HPV) and oral cancer emerging as a global pandemic. Here are the latest and startling statistics that have emerged:• Currently HPV is the fastest growing sexually transmitted infection• At least 50% of sexually active men and women will acquire a genital human papillomavirus (HPV) infection at some point in their lives (1) • Most people who become infected with HPV do not even know they have it (1) • HPV DNA has been detected in 25% of head and neck squamous cell carcinomas overall, but especially in oral squamous cell carcinomas, for which 45-100% of cases were HPV positive (2,3,4)• The human papillomavirus has accounted for a 225% increase in oropharyngeal cancers from 1988-2004 (5)The same viral strain, HPV-16 that is responsible for 70-80% of all cervical cancers, is solely responsible for 85-95% of all HPV related oropharyngeal cancers.(6) If recent incidence trends continue, the annual number of oropharyngeal cancers related to HPV-positive oropharyngeal cancers will surpass annual number of cervical cancers by the year 2020.(7) Among the sites of HPV-associated cancers, the oropharynx is the second most common after the cervix at present.Oral Sex, Safer Sex?
Why the alarming increase? The conjecture is that this sharp increase is the "legacy" of the sexual revolution. HPV is passed on through genital contact during vaginal and anal sex. HPV may also be passed on during oral sex and genital-to-genital contact. HPV can be passed on between straight and same-sex partners—even when the infected partner has no signs or symptoms. It has also been reported that HPV may be passed on through open-mouthed kissing if the virus is active. A study which appeared in the New England Journal of Medicine shows that men and women who reported having six or more oral-sex partners during their lifetime had a nearly nine-fold increased risk of developing cancer of the tonsils or at the base of the tongue. Those with 1-5 oral sex partners are 2x more likely to contract HPV than those who have never had oral sex.(8) This is once again a testimony to the fact that oral sex is not safer sex. What can we do as Oral Health Professionals?
With HPV-positive oropharyngeal cancer often occurring in areas where visual acuity is somewhat restricted, it is imperative to inspect the posterior areas of the mouth to the best of our abilities. HPV-positive oropharyngeal cancer has expressed an affinity for posterior regions of the oral cavity including the base of the tongue, the oropharynx, tonsils and the tonsillar pillars. Full protrusion of the tongue is critical in order to examine the posterior lateral borders and the dorsum. Both visual and tactile examination need to be performed in order to discover the earliest presence of an abnormal lesion. (Refer to Figures 1 and 2).
Figure 2 provided with permission granted from the Canadian Dental Hygienists Association. The images originally appeared in the online course, “4 Life Saving Minutes: The Extraoral and Intraoral Examination”www.cdha.ca/oralcancerThere are also some subtle warning signs that accompany this virally and sexually transmitted oral cancer. Identifying some of the more subtle symptoms may allow our professional to identify posterior oropharyngeal abnormalities at a much earlier stage. The following are signs and symptoms to be aware of in the assessment of the dental patient:• Hoarseness• Continuous sore throat or a throat infection not responding to antibiotics• Pain when swallowing or difficulty swallowing• Pain when chewing• Continual lymphadenopathy• Non-healing oral lesions • Bleeding in the mouth or throat• Ear pain• A lump in the throat or the feeling that something is stuck in the throat Our profession of dental hygiene is strategically positioned to play an integral role in earlier discovery of an abnormal lesion thus contributing strongly to better treatment outcomes, improved survival rates and enhanced quality of life for our dental hygiene clients. No one said it better than John F. Kennedy, “There are costs and risks to a program of action, but they are far less than the long-range risks and costs of comfortable inaction.” We truly can make a difference. Acknowledgements
Figure 1: HPV induced papillary lesion on left lateral border of tongue (image courtesy of Dr. Samson Ng, LED Dental)Figure 2 provided with permission granted from the Canadian Dental Hygienists Association. The images originally appeared in the online course, “4 Life Saving Minutes: The Extraoral and Intraoral Examination” www.cdha.ca/oralcancerReferences
1. Centres for Disease Control and Prevention: Genital HPV Infection – Fact Sheet. www.cdc.gov/std/HPV/STDFact-HPV.htm (Accessed Feb 2012).2. Gillison ML, Koch WM, Capone RB et al. Evidence for a causal association between human papillomavirus and a subset of head and Neck cancers. J Natl Cancer Inst. 2000;92:709-20.3. Ang KK, Harris J, Wheeler R, et al. Human papillomavirus and survival of patients with oropharyngeal cancer. N Eng J Med. 2010;363:24-35.4. Marur S, D’Souza G, Westra WH, et al. HPV-associated head and neck cancer: a virus-related cancer epidemic. Lancet Oncol. 2010;11:781-9.5. Chaturvedi A, Engels A, Pfeiffer RM et al. Human Papillomavirus and Rising Oropharyngeal Cancer Incidence in the United States. Jour of Clin Oncol published on October 3, 2011.6. Dayyani F, Etzel CJ, Liu M et al. Meta analysis of the impact of human papillomavirus(HPV) on cancer risk and overall survival in head and neck squamous cell carcinomas (HNSCC). Head Neck Oncol 2010; 2:15.7. Cleveland JL, Junger ML, Saraiya M et al. The connection between human papillomavirus and oropharyngeal squamous cell carcinomas in the United States. Implications for Dentistry. JADA 142(8):2011;915-9248. D’Souza G, Kreimer AR, Viscidi R, et al. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med 2007 May 10:356(19):1944-56.
