Dental Professionals and Human Papillomavirus Vaccinations

Alessandro Villa, DDS, PhD, MPH, is the chief of the Sol Silverman Oral Medicine Clinic and the program director for the oral medicine residency program at the University of California, San Francisco. He is a fellow of the Royal College of Surgeons of Edinburgh. Conflict of Interest Disclosure: None reported.

Dalton Pham, DMD, is a graduate of the Harvard School of Dental Medicine and is a resident in New York City. He has worked on HPV prevention with Dr. Villa for two years. Conflict of Interest Disclosure: None reported

ABSTRACT: Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Highrisk type HPV infections can cause many types of cancers, including oropharyngeal cancer. The HPV vaccine is the most effective method for the prevention of HPV-related cancers. However, HPV vaccination rates remain low in the United States. Dental professionals are well positioned to be at the forefront of educating patients about HPV, discussing the HPV vaccine and promoting vaccination with their patients.

Keywords: Human papillomavirus, HPV, vaccinations

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Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with approximately 80 million people, most in their late teens and early 20s, infected. HPV is transmitted through skin-to-skin contact.[1] Almost every person who is sexually active who does not get the HPV vaccine will be infected with HPV in their lifetime, usually with no signs or symptoms. Most HPV infections clear spontaneously in one year, and only persistent high-risk HPV infections lead to multiple types of cancers, including oropharyngeal, cervical, anal, vaginal, vulvar and penile cancers. Recent data from the Centers for Disease Control and Prevention (CDC) report an annual average of nearly 45,300 HPV-related cancers in the U.S., with oropharyngeal cancer being the most prevalent (19,775), followed by cervical (12,143) and anal (7,083) cancers.[2] The incidence of HPV-related oropharyngeal cancer has been increasing significantly over the past 30 years, especially among males. Men are almost three times more likely to have an oral HPV infection compared to women.[3]

The goal of this review is to provide a general overview of the current preventive strategies available for HPV-associated oropharyngeal cancer and discuss the role of dental professionals.

HPV Vaccination and Cancer Prevention

Most HPV-associated cancers are caused by persistent infection with HPV types 16, 18, 31, 33, 45, 52 and 58. Over 90% of HPV-related cancers are preventable through HPV vaccination, including oropharyngeal cancers (Gardasil 9 HPV 9 valentvaccine, recombinant, Merck & Co. Inc., West Point, Penn.). [2] In addition, HPV vaccination protects from HPV types 6 and 11 that can cause warts (e.g., papilloma, verruca vulgaris and condyloma) in the oral cavity, the genital area, anus and oropharynx. Gardasil 9 is a recombinant vaccine that contains virus-like proteins (VLP) that resemble the HPV virus. Following administration, the HPV vaccine induces the humoral immune response to target HPV-16, -18, -31, -33, -45, -52, -58, -6 and -11.

The Advisory Committee on Immunization Practices (ACIP) recommends routine HPV vaccination at ages 11 or 12. However, vaccination can start at age 9 and the series should finish by age 13. The ACIP also recommends HPV vaccinations for everyone aged 13 to 26 who were not adequately vaccinated previously. Depending on the age of initial vaccination, the series may be either two doses (for individuals starting the series before their 15th birthday) or three doses (for individuals who start the series at ages 15 through 26 years and for immunocompromised individuals). Shared clinical decisionmaking regarding HPV vaccination is recommended for some adults aged 27 to 45 who are not adequately vaccinated. [4]

The American Dental Association (ADA) adopted a policy on HPV vaccination that “urges dentists to support the use and administration of the HPV vaccine” and encourages research efforts to improve the understanding of the natural history of oral HPV infection, transmission risks, prevention, screening and testing. [5] The HPV vaccine has a reassuring safety record backed by 10 years of monitoring and research, and the 9-valent HPV vaccine currently available protects against nine HPV types, including seven types that can cause cancer. Despite the recommendations endorsed by the ACIP, HPV vaccine uptake in the U.S. remains lower than the goal of 80% proposed by the Healthy People 2020 initiative. [6] In 2019, only 54% of adolescents in the U.S. were reported to be up to date with HPV vaccination. [7] Compared to the 80% vaccination goal, only 56% of adolescents in California are up to date with HPV vaccination. [8] In California, the rate of HPV vaccination varies by geographic location, with the lowest vaccination rates tending to be in counties in the northern third of the state as well as more rural counties. The rates of initiation and completion of the HPV vaccine series were reported to be as low as 16% and 8%, respectively, among 13-yearolds in some California counties. [9]

HPV vaccination stands to be the most effective preventive measure against HPV-related cancers.

With the exception of cervical cancer, recommended screening tests for HPVrelated oropharyngeal cancers do not yet exist. [10] These cancers may go undetected for years until they cause significant health problems, deteriorate quality of life and even decrease life expectancy. In addition to the negative impact of HPV-related cancers on patients, significant health care costs are incurred for the treatment of these cancers. [11] An estimated 10% of HPV-related cancers in the U.S. occur in California. [2] It has been projected that if 99.5% of 20-yearold individuals in California were to be vaccinated against HPV, the state could avoid spending a total of $52.2 million that would be needed to treat the cancer cases, with $21.3 million of the cost attributed to treating male oropharyngeal cancer and $16.1 million to treating cervical cancer. [11] Therefore, in order to curtail the substantial cost of treatment and until more reliable recommended screening tests are developed for detecting HPV-related cancers, greater emphasis should be placed on preventive practices, namely vaccination.

HPV vaccination stands to be the most effective preventive measure against HPV-related cancers. While multiple factors influence HPV vaccination uptake, vaccine recommendation by a health care provider is one of the most important and consistent predictors of vaccination. [12–15] Dental providers have a unique opportunity as health care professionals to build relationships with patients and facilitate conversations to promote education and practices for improving their health. Recent reports from the CDC show that while 54.5% of people in the U.S. made a visit to their primary physician, 65% of adults aged 18 and older visited the dentist in the past year. [16,17] For children aged 2 to 17, that number was even higher at 85%. [18] This large proportion of pediatric dental visits presents a great opportunity to start the conversation with parents regarding HPV, prevention and vaccination. Furthermore, considering the recommended six-month recall schedule for dental check-ups and cleanings, it is likely that patients see their dentists more frequently than physicians. According to the ADA, almost 10% of the U.S. population visits a dentist, but not a physician, annually. [19,20] These routine visits allow dental providers to build rapport with their patients and would help patients feel more comfortable discussing HPV and vaccination.

Addressing HPV With Patients

Dental providers have demonstrated success in interventional and preventive measures with their patients, as seen by the effectiveness of oral cancer screenings as well as smoking-cessation efforts in the dental office. [21–23] Resources such as guidelines for how to conduct systematic oral cancer screening exams have enhanced early detection rates.[24] Additionally, recommendations for how to discuss smoking cessation through methods such as motivational interviewing have been instrumental in the success of interventions that begin in the dental office.[25] Along these same lines, studies show that the majority of dentists feel comfortable speaking to patients about HPV and even feel comfortable providing HPV vaccinations as well. [26] However, of the dental providers who do not discuss the HPV vaccine with patients, the most common reasons include believing it is a topic better suited for other health care professionals, not knowing how to address it and feeling uncomfortable discussing HPV as a sexually transmitted infection. [26] Studies have shown that dental providers who underwent training programs designed to increase HPV knowledge reported feeling more comfortable and prepared to discuss HPV and prevention with patients. [27–29]

Research has demonstrated that if dentists recommend the HPV vaccine, there is a significant increase in vaccination uptake by patients.

In order to better facilitate the discussion of HPV and vaccination with patients, especially adolescent patients and their parents, providers should frame the vaccine by incorporating it within the set of age-appropriate routine vaccinations for the child. Doing so has demonstrated greater parental acceptance of the vaccine for their children. [30–32] Parental concern about HPV, the vaccine and its implications regarding their child’s sexual activity can be effectively addressed by informing parents that the administration of the vaccine is not about sex, but rather cancer prevention, and that the HPV vaccine has a stronger immune response when administered at younger ages. [31,33] Moreover, the quality of the provider’s recommendation plays a role in the patient’s acceptance of the vaccine. Stronger provider recommendations for HPV vaccination are associated with greater uptake by parents and patients. [34] Additionally, in the decision-making process, parents of adolescents reported wanting more detailed communication regarding logistics of the vaccine, namely the schedule of dosing, number of doses, recommended age and cost of the vaccination series. [32,35] Patient-centered materials such as pamphlets in the waiting room may serve to not only educate patients about HPV prevention but also prompt patients to initiate the conversation with specific questions for their dental providers. [36] Organizations such as Team Maureen, the ADA and the National HPV Roundtable offer a dental toolkit of HPV resources, including patient brochures and office posters that can be distributed and displayed in a dental office. [37]

Dental Professionals and Vaccines

Dental providers acknowledge and are in favor of their role and responsibility in HPV prevention efforts. [38,39] Research has demonstrated that if dentists recommend the HPV vaccine, there is a significant increase in vaccination uptake by patients. [40] Interestingly, in Oregon, dentists are approved to administer any vaccine, and in Minnesota and Illinois, dentists can administer the flu vaccine to adults. [41–43] Further, due to the COVID-19 pandemic, dentists in all states have been approved to administer COVID-19 vaccines. [44–46] In the context of HPV, dental providers who participated in educational programs to increase HPV knowledge reported feeling more comfortable not only discussing prevention with patients, but also with administering the HPV vaccine as well.[29] Studies have shown that a majority of parents are receptive to speaking about HPV and vaccination with dental providers, and even expect dental providers to communicate and recommend HPV vaccination. [47,48] Moreover, a majority of parents have also reported feeling comfortable with their children receiving the HPV vaccine from dental providers. [47,48]

Conclusion

Dental professionals’ knowledge, training and demonstrated success in prevention make them well positioned to be at the forefront of increasing patient knowledge and prevention of HPV. Patients and parents are receptive to speaking with their dental providers about HPV and to receiving vaccination in a dental setting. As such, emphasizing the role of dental professionals in HPV education and prevention stands to be an effective preventive measure against HPV and HPV-related cancers.

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THE CORRESPONDING AUTHOR, Alessandro Villa, DDS, PhD, MPH, can be reached at Alessandro.Villa@ucsf.edu.