The day started out like a normal Wednesday, morning work and then a trip to Trader Joe’s. I almost didn’t go; My to-do list was long, and the 36-mile round trip would take some time to tick things off that list, but the little voice in my head was telling me to go.
There’s butter salad and then there’s Trader Joe’s butter salad, so it’s always first on my list. I moved through the aisles and filled my basket with other favorites. With a full shopping cart, I walked to the shortest checkout line. It was a pleasure to watch the two young men checking and packing the customers in front of me; They were engaged and obviously enjoying their day at work – you could feel the smiles under their masks. As the customers walked in front of me, the inspectors with bright eyes peering over their masks turned to me and said, “How are you today?” Thank you for coming!” After exchanging pleasantries, the inspector asked what I did for a living. I told him that I am a dental hygienist and that I speak and educate about oral cancer. With that, he stopped scanning my groceries and said, “That’s really specific; I never heard of it. I’m glad none of us smokes; We’ll never get this cancer. Do you have any fun or interesting oral cancer facts or information to share with us?”
From butter salad to oral sex
Now I knew why that little voice was telling me to go see Trader Joe that day. For reasons unknown to me, I was asked to share information with these young men. It was the perfect scenario: two young non-smoking white men who believe they are at no risk for oral cancer asked me to share information with them. They didn’t know my passion for it and certainly didn’t know what to share with them! I said, “I’d love to share! Thank you for your concern. What we now know is that human papillomavirus (HPV) is the leading cause of oropharyngeal cancer. It is cancer of the back of the mouth, typically of the tonsils and back of the tongue, and white non-smoking males are most at risk. We also know that HPV now causes more of this cancer than cervical cancer.”1
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By this time the young man who was packing my groceries had stopped packing. Both young men were keen to know more and were very surprised to find out about this cancer and that they might be at risk. They said they had heard about HPV and cervical cancer, but not that it causes cancer of the mouth. Both continued to ask questions and wanted more information, including how HPV gets into the mouth and specifically what they can do to reduce their risk of developing the cancer. I informed them that HPV is transmitted through skin-to-skin contact, orally through oral sex, and possibly through open-mouthed, deep, aggressive kissing. I recommended protection for oral sex as well as for conventional sex. We also talked about the HPV vaccine they both had; However, they didn’t know much about it and were unaware that it could help protect them from ongoing HPV infections, which could potentially lead to cancer. It wasn’t an uncomfortable conversation; They were really curious and wanted more information and I was thrilled to be able to share that information with them. Both say they go to the dentist regularly.
Lots of training opportunities
Over the past 12 years that I have been busy raising awareness about HPV and oral and oropharyngeal cancer, I wish I had kept track of the number of conversations of this nature that have taken place in and out of the office. There are just too many to remember. Another conversation took place recently while waiting in line for Donny Osmond’s VIP preshow in Las Vegas, again with a non-smoking male. He stood in line and reserved a seat for his wife while she got ready. He too had many questions and asked about transmission of HPV to the mouth. He explained that he knew HPV causes cervical cancer but not cancer of the mouth. He was very curious about what signs and symptoms to look out for and what to do if he noticed any of them. We discussed these and I recommended he see an ear, nose and throat (ENT) doctor for further evaluation if he ever experiences any persistent signs and symptoms.
As I was writing this article, a phone conversation with a business colleague in his 60s about my work in oral cancer prompted him to inquire further about HPV and how it gets into the mouth. He thought he knew but wanted a little more clarity. And just last week, while listening to a radio show with a distinguished doctor as a guest, the topic of HPV was raised. The doctor mentioned HPV and its connection to cervical cancer and mentioned the HPV vaccine. However, the vaccine was only mentioned in terms of preventing cervical cancer, not head and neck cancer or other cancers associated with persistent HPV infection. It was a missed opportunity for a large audience to learn about other HPV cancers.
That’s just my opinion, but I think people keep asking about oral cancer and HPV because they don’t hear much about it in the media or even in their doctor’s and dentist’s offices. The messages for cancers like breast cancer, colon cancer and cervical cancer are intended in the media and the respective doctor’s offices, but not so much for oral cancer. Dentistry needs to be more focused on education and awareness raising about HPV and oral and oropharyngeal cancer.
What we now know is this: the number of HPV-associated head and neck cancers has surpassed the number of HPV-associated cervical cancers. Unfortunately, the message about HPV is still focused on cervical cancer.2
I’ve learned a lot from talking to patients and the public over the years of working to raise awareness about HPV and oral cancer.
First, if the public is to be educated and informed about HPV and its association with head and neck/oropharyngeal cancer, it will come from dentists. In fact, it is our ethical responsibility to share this information about “our cancer”. If they don’t hear it from us, where else? It’s okay, even important, to talk about the transmission of HPV through oral sex, its link to head and neck cancer, and the availability of the HPV vaccine, which can help reduce persistent HPV infections that aren’t just related to oropharyngeal and cervical cancer, but also anal, penile, vaginal and vulvar cancer.
Society is open to this information. The public wants to know how to help prevent cancer and recognize the signs and symptoms for early detection. Most still believe that tobacco is the only risk factor for mouth, head and neck cancer. Patients and the public deserve to know this information so they can make informed decisions about their oral health. This doesn’t have to be a knee-to-knee conversation; The optimal time for the exchange of information is during the extraoral and intraoral evaluation (EOIO). Information can also be shared in newsletters that the dental office sends to patients, in social media posts, and in office brochures and flyers.
The public and some medical and dental professionals are misinformed about HPV. It is still widely believed that HPV is most commonly associated with causing cervical cancer, and the purpose of the HPV vaccine is to prevent cervical cancer in women. Statistics released by the US Cancer Statistics Data Briefs, #26 in December 2021, based on data from 2014-2018 show that approximately 10,600 cases of oropharyngeal cancer in men and 1,800 cases of oropharyngeal cancer in women occur each year Types 16 and 18 are due to HPV.2 The US FDA added prevention of oropharyngeal cancer to HPV vaccine indication: “Recombinant 9-valent human papillomavirus (HPV) vaccine (Gardasil 9) received FDA approval for an expanded indication covering the prevention of oropharyngeal cancer and other head and neck cancers caused by HPV types 16, 18, 31, 33, 45, 52 and 58.”3
People are listening! The public and our patients are listening, and they are looking for healthcare professionals who share our expertise and have bold conversations about important healthcare information. When I first started sharing information about HPV with my patients 12 years ago, I brought them up when I was palpating the occipital nodes behind them so I didn’t have to look at them. At first I found this conversation very uncomfortable; However, I knew it was vital information for my patients’ oral and systemic health that needed to be shared. Find the time and place that is most convenient for you during your clinical appointments.
Our work doesn’t end when we take off our smocks. Be open to spontaneous conversations about important information about HPV and oral cancer. In a recent conversation with Katrina Sanders, MEd, she said eloquently, “Irene Newman, the first dental hygienist – her job wasn’t to improve production and close more cases. Your job was to be a patient advocate and educate the community.” I encourage you to be like Irene Newman: be an advocate and educate the community about the tremendous amount of knowledge, expertise, and life-saving information you have about “our cancer ‘ to share not only with patients but also with the general public.
call to action
If you are uncomfortable or unsure about sharing information about HPV, or feel you need more knowledge, find a mentor, do your research, and be your own advocate to get the knowledge you need to get. Recruit your entire dental team or Dental Service Organization (DSO) to build a positive, informative culture around HPV and oral cancer. Make it your mission to save lives by sharing important information with patients and the public. Conduct a thorough EOIO assessment on each patient, share what you are doing, and use this time to efficiently share information and raise awareness of what we now know about HPV and oral cancer.
Start with an HPV fact sheet for practitioners and an HPV fact sheet for patients.
Editor’s note: This article appeared in the March 2022 print edition RDH Magazine. Dental hygienists in North America are entitled to a free print subscription. Sign up here.
- HPV/Oral Cancer Facts. The Oral Cancer Foundation. https://oralcancerfoundation.org/understanding/hpv/hpv-oral-cancer-facts/
- Cancers Associated with Human Papillomavirus, United States – 2014-2018. US Cancer Statistics Data Briefs, #26. Centers for Disease Control and Prevention. December 2021. https://www.cdc.gov/cancer/uscs/about/data-briefs/no26-hpv-asccancers-UnitedStates-2014-2018.htm
- FDA adds prevention of oropharyngeal cancer to HPV vaccine indication. AAP News. May 2021. https://www.fda.gov/media/150779/download