Running head: Oral Cancer and HPV

Oral Cancer and HPV

by

Kari Burdick, Whitney Copenhaver, and Stephanie Olesen

Lake Washington Institute of Technology

In partial fulfillment

of the requirements for

DHYG 248: Research I Fall Quarter

Agatha Stavnesli, RDH, BS, ©MS

November 21st, 2017

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Introduction

“HPV (human papillomavirus) is a virus that can cause certain cancers and diseases in

both males and females.” (HPV.com). In the past, the main risk factors for oropharyngeal

cancers were commonly older patients who frequently used tobacco products and consumed

excessive amounts of alcohol. This is no longer the case, both men and women are now getting

oropharyngeal cancers without being heavy smokers/drinkers. Charles et al. (2017) states 80

percent of oropharyngeal cancer cases may be caused by HPV. Many people are not aware that

HPV can be contracted orally, and therefore, do not realize they are at risk for oral cancer. HPV

vaccinations are recommended for adolescents ages 9 to 26. Hirth, Chang, Resto, Guo, &

Berenson (2017) found participants who have been vaccinated have a much lower occurrence of

HPV compared to those who have not had the vaccine. Because of the increase in HPV-related

oral cancers, dentists and hygienists are becoming “prevention specialists” to not only inform

their patients on the importance of getting vaccinated and tested, but also to perform thorough

extraoral and intraoral examinations.

The oral manifestation of human papillomavirus was first documented in 1967 (Sand &

Jalouli, 2014). Since then research has shown HPV can integrate into the host DNA and remain

dormant with low copies in the nucleus of the cell. The virus then is able to disrupt the tumor

suppressor gene through alterations or inactivation thus allowing “HPV-induced carcinogenesis”.

There are hundreds of types of HPV, but the types associated with high risk for oral

carcinogenesis in the form of squamous cell carcinoma have been identified as types 16, and 18.

The progression from HPV infection to oral cancer is not immediate, but has been observed to
Oral Cancer and HPV 3

occur more than 15 years after the initial HPV exposure and infection. Due to this lapse in time

between infection and tumor growth, many are unaware that HPV is the causative factor.

The upper digestive tract is highly susceptible to HPV due to the easy access to basal

cells, such as in the tonsillar crypt and glottis regions (Campisi & Giovannelli, 2009). The

virions are able to find safe harbor in these areas and are much harder for the infected individual

to detect lesions in this area. In a US based study published in 2011 it was noted that those at

highest risk of developing HPV related oral cancers are “young individuals (< 60 years of age),

men, and white” (Chaturvedi et al., 2011). There are many proposed modes of transmission for

HPV in the oral region with oral sex being the main suspect, but even mouth-to-mouth (kissing)

transmission is possible. Based on statistical data it is anticipated that “ the annual number of

HPV-positive oropharyngeal cancers is expected to surpass the annual number of cervical

cancers by the year 2020” (Chaturvedi, et al., 2011). In light of this, all potential methods of

transmission should be included in the education of HPV with an emphasis on the value of the

HPV vaccine.

In 2017, Hirth, Chang, Resto, Guo, and Berenson reported human papillomavirus (HPV)

type 16 is responsible for most head and neck squamous cell carcinoma cancers with oropharynx

being the most prevalent. The cancers related to HPV have increased dramatically since the

1980s when only 16% of all oropharyngeal squamous cell carcinoma cancers were related to

HPV. In the 2000s that percentage increased to >70%, indicating a high demand to prevent the

disease (Introduction, para. 1). The purpose of this investigation was to compare the prevalence

of HPV between vaccinated and unvaccinated young adults who participated in the 2009-2014
Oral Cancer and HPV 4

cycles of the National Health and Nutrition Examination Survey (NHANES). Hirth et al. (2017)

analyzed the data of several surveys regarding the frequency of HPV vaccines administered and

occurrences of oral HPV. All participants (18-30 years old) answered a questionnaire they

received about the HPV vaccine, had medical exams conducted during the study period and had

an oral sample collected. Out of over three thousand participants, the ones that were vaccinated

had a lower occurrence of HPV compared to those that had not been vaccinated. According to

researchers, if both partners are vaccinated against HPV it is unlikely they will be exposed to it,

increasing the odds that the vaccine will work. This investigation was the first to offer evidence

that the HPV vaccine provided protection against vaccine-type oral HPV infection. The evidence

in this article suggests the vaccine may provide protection against oral HPV. Hirth et al. (2017),

also believes vaccination induces antibodies in the oral cavity but they are unsure whether the

antibody levels are at a high enough level to offer long-term protection. According to this study,

the HPV vaccination appears to provide protection against oral HPV infection but research using

a larger sample is needed to confirm these findings. It is recommended, for adolescents age 9 to

14 years old, to have 2 doses of the HPV vaccine. And, it is recommended for people who are

vaccinated between 15 and 26 years old to receive 3 doses. The researchers associated with this

study concluded there were limitations because the information was self-reported and there could

be discrepancies between what was reported on the survey and what actually transpired.

Vaccines are important in oral HPV prevention but good oral hygiene could also play a

role according to Sun et al. (2017). They studied the correlation between oral HPV infection and

poor oral health. The study included a group of 223 unvaccinated participants who were selected

from the University of Queensland Dental School, between October 2014 and October 2015. The
Oral Cancer and HPV 5

participants were all over the age of 18 and had no history of cancer, or other systemic conditions

that would affect oral health, they were not taking any medications and they all had at least 20

teeth remaining in their mouths. Sun et al. (2017) specifically looked at the oral HPV-16

infection and tested the oral rinse of the participants. Their research found that 10 of the 223

participants tested positive for the HPV-16 infection. Of the 10 positive cases, 7 had poor oral

hygiene and 3 had periodontal disease. According to their research there is a positive correlation

between HPV-16 and poor oral hygiene. These studies represent the need for dentists and

hygienists to be aware of HPV infection and how it correlates with head and neck cancer.

It has been estimated that 63 percent of oropharyngeal cancers are linked to HPV

infection (ADA Council on Scientific Affairs, 2012). HPV related oropharyngeal cancers have

smaller rates of death or recurrence than non-HPV cancers, if it is caught in the early stages.

This shows the importance of dentists and hygienists performing thorough extraoral and intraoral

examinations at every check up. Due to the rise in HPV related oral cancer cases, dentists have

the opportunity to play a large role in preventing the spread of oral HPV, just by speaking to

their patients and educating them on the vaccine available for prevention. The ADA is

encouraging dentists to talk to their patients about the correlation between HPV and

oropharyngeal cancer with both younger and older patients. Daley et al. (2014) found

approximately 97 percent of dentists are hesitant to speak with their patients about the HPV

vaccination. The two main reasons for this is their perceived role and liability. The public do not

see dentists as health care providers; therefore patients may not take medical advice from their

dentists. With the rapid rise of HPV related oral cancer, the ADA is working to change the
Oral Cancer and HPV 6

public’s view of dentists so they are recognized as health care providers. They are also working

to train dentists on how to speak with their patients about sensitive health care topics.

Conclusion​:

HPV related cancers are becoming more prevalent than ever before. The virus's ability to lay

dormant in the host cells means that we will continue to see a rise in HPV related oral cancers in

patients who have been exposed to the virus prior to the introduction of the vaccine. Dental

professionals can play a role in identifying, preventing and increasing awareness of oral HPV in

all their patients. Dental professionals are in a unique position to help with early detection of

HPV and oral cancer as oral cancer screenings is a critical part of comprehensive patient care.

Early detection by a dental professional allows for a less aggressive radiation treatment and

better long-term prognosis for the patient (Campisi &Giovannelli, 2009). Dental professionals

can also advocate prevention by educating patients on their risk of HPV. For example, as

unvaccinated patients get older and immune systems decline due to other health concerns, they

have an increased risk of contracting HPV. Younger patients may have misconceptions about the

transmission of HPV and who the HPV vaccine is designed for, possibly assuming it is only to

protect women against cervical cancers. In all cases, with the help and support of organizations

like the ADA, hygienists can educate patients on the risks of HPV and promote common

preventative measures that can be followed to reduce the patient’s risk of exposure to HPV.
Oral Cancer and HPV 7

References

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& Neck Oncology​, ​1​, 8. http://doi.org/10.1186/1758-3284-1-8

Charles, X.S., Bennet, N., Tran, P., Kai, D.T., Lim, Y., Frazer, I., … Punyadeera, C. (2017). A

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