Establish a Pro-HPV Vaccine Practice

The rates of oropharyngeal cancers are increasing rapidly in the United States and pose a major public health challenge.^1,2 Primary anatomical sites for oral cancers include the side of tongue and below the tongue, while primary sites for oropharyngeal cancers include the tonsils and base of tongue or oropharynx. However, these cancers can encompass all areas of the oral cavity, including the gingiva and floor of the mouth.³ The American Cancer Society estimates that 53,000 new cases of oral and oropharyngeal cancers will be diagnosed in 2019, resulting in 10,860 deaths.³ Previously, major risk factors for oral cancers included tobacco and alcohol use; however, current research has established that 70% of oral and oropharyngeal cancers are caused by the human papillomavirus (HPV).^4,5 Whether alcohol and tobacco use impacts HPV is not clearly understood. However, smoking may support the progression of HPV infection to carcinogenesis.⁶ Fortunately, HPV-related cancers can be prevented through immunization with the HPV vaccine.

Collectively, HPV comprises more than 150 viruses, with some types responsible for cancers of the cervix, vulva, vagina, penis, anus, mouth and throat.² In addition, HPV is the most common sexually transmitted disease. The U.S. Centers for Disease Control and Prevention (CDC) estimates that approximately 80 million Americans are currently infected, and 14 million will acquire the virus each year.⁷ In fact, almost all sexually active people will have HPV at some point in their life.⁷ Most HPV infections resolve within 12 to 24 months following infection and do not cause cancer. However, persistent infections with high-risk types (such as HPV16 and HPV18) can lead to cellular changes and cancer; for example, HPV16, the type responsible for cervical cancer, also is linked to oropharyngeal cancer.² Furthermore, research indicates that HPV-related oropharyngeal cancers have been increasing at an alarming rate and have surpassed HPV-related cervical cancers.¹

The U.S. Food and Drug Administration (FDA) has approved three vaccines to prevent HPV-related viruses: Gardasil, Cervarix and Gardasil 9. All three protect against HPV16 and HPV18; however, as of May 2017, only Gardasil 9 is available in the United States.⁸

The HPV vaccine has been available for girls ages 9 to 26 since 2005, and for boys since 2011. Currently, it is recommended that all children ages 9 to 13 receive two doses of Gardasil 9, with the second dose given six to 12 months after the first. After age 13, youth should receive three doses, with the first two being given two months apart, and the third dose given six months after the second dose.

In 2018, the FDA approved the use of Gardasil 9 for individuals ages 27 through 45 to assist in preventing HPV-related diseases across a broader population.⁹ The CDC followed suit in 2019. Overall, the HPV vaccine is safe and has few adverse reactions, with the most frequent being similar to those experienced with other vaccinations, such as redness and soreness at the injection site. In addition, some individuals may experience an elevated temperature for up to 15 days following the injection.¹⁰

Despite the availability and proven safety and effectiveness of the HPV vaccine, uptake in the U.S. has been low compared with other childhood vaccines.¹¹ Factors contributing to low HPV vaccine uptake include low levels of knowledge regarding HPV and the vaccine, misconceptions and concerns among parents and caregivers, lack of recommendations from health care providers, and lack of supportive systems and polices — such as not requiring the vaccine for school entry.^11,12 Moreover, suboptimal uptake of the HPV vaccine could be attributable in part to the feminization of HPV.¹³ Specifically, support for HPV prevention activities has struggled due to its association with sexual activity, early research conducted only among females and focused solely on cervical cancer (thus positioning HPV as a female-specific disease), and the lag in vaccine approval for males. In addition, both vaccine hesitancy and anti-vaccine attitudes have become more prevalent in recent years, limiting optimal HPV immunization.¹⁴

CONTRAINDICATIONS

Overall, the HPV vaccine is safe and has few adverse reactions; however, there are a few contradictions for the vaccine. While data on vaccination during pregnancy are limited, pregnant women should not receive the HPV vaccine. However, no adverse effects have been reported on the developing fetus in cases in which the woman was vaccinated but unaware she was pregnant. In addition, individuals allergic to latex should not receive the HPV vaccine via a prefilled syringe, as the syringe tip may contain latex. Furthermore, individuals who have an acute illness should wait until their symptoms have passed.¹⁰

DENTAL TEAM’S ROLE

The American Dental Association (ADA) and American Academy of Pediatric Dentistry (AAPD) both recognize the important role oral health professionals play in increasing HPV vaccination. The ADA states that dental teams “should strongly and clearly recommend HPV vaccination to all age-eligible patients,”¹⁵ while the AAPD suggests oral care providers should “advocate for HPV vaccination as cancer prevention.”¹⁶ It is important for all members of the dental team to recognize their role in HPV prevention and discuss HPV with their family, friends, patients and communities.¹⁷

Together, dentists and dental hygienists are leaders in health education and promotion, both in their clinic setting and also within the community. As such, these professionals are uniquely positioned to increase uptake of the HPV vaccine, especially when they work in a practice that includes children and youth. Among their duties, dental hygienists are trained to provide oral cancer examinations; thus, educating patients about preventing cancers and providing oral cancer examinations are within dental hygienists’ scope of practice. Additionally, because at least one state has legislation allowing dentists to provide HPV vaccinations, others are likely to follow — which strengthens the call to action on the part of oral health professionals.¹⁸

Nonetheless, studies have shown neither dentists nor dental hygienists are especially knowledgeable about HPV or its prevention. For the most part, dental teams have not been receptive to educating patients about the need for HPV vaccination, and for a variety of reasons. For instance, although dental providers strongly believe it is within their role to prevent HPV-related diseases, noted barriers to discussing HPV prevention include patient characteristics (such as age), low HPV-related health literacy, a practice environment with open operatories and reduced privacy, concerns about liability, and the sensitive nature of the topic.^19–21 In addition, new research results are continuing to change recommendations for this vaccine, requiring health care providers to always be alert to understand and share the most recent findings.

PROMOTE HPV VACCINE UPTAKE

It is incumbent on health care professionals to be health literate about this vaccine, the cancers it prevents, and its connection to oral health. First, be well informed about oral and oropharyngeal cancers. Ensure the use of the most recent research findings from the most reliable sources, such as the FDA, National Institutes of Health, CDC, National HPV Vaccine Roundtable, President’s Cancer Panel, and ADA. Sign up for current list serves from these organizations. Second, ensure all staff members are thoroughly trained and that appropriate personnel are comfortable providing comprehensive oral cancer examinations.

Once armed with current information and skills, each member of the team is encouraged to take a lead role in promoting HPV vaccination. This proactive approach dovetails with goals established by the President’s Cancer Panel to:

• Reduce missed clinical opportunities to recommend and administer the HPV vaccine
• Increase parents’ and caregivers’ acceptance of the vaccine
• Maximize access to HPV vaccination

To accomplish these goals, dental teams must work collaboratively to create and maintain a pro-immunization environment. A pivotal step to being pro-HPV vaccine is to obtain an immunization history as part of the patient’s health history, and to update it at each appointment. Use of a tracking system is essential to identifying patients who are due for vaccination. Tracking systems are relatively easy to embed into electronic health records. Further, when working in a health maintenance organization or federally qualified health center in which dental and medical electronic health records are interoperable, it provides even greater opportunity to increase access to vaccination. For example, with a 10-year-old patient, the provider can check whether he or she has received the HPV vaccine. If not, the clinician can educate the parent/caregiver about the need for the vaccine, and also send a prompt to the child’s physician.

Dental team members also need to know where patients can obtain the HPV vaccine (assuming the dentist is not allowed to provide the vaccination directly). In addition to physicians’ offices, patients can obtain the HPV vaccination at pharmacies that have walk-in or minute clinics. Patients also need to understand that while most insurance plans cover the vaccine, it is expensive ($240 per injection) and there may be a co-pay. Remind those who are concerned about cost that the vaccine prevents five types of cancers.

The Agency for Health Research and Quality’s universal precautions are designed to reduce complexities within the clinic and across health systems, as well as support oral health professionals’ efforts to establish a pro-HPV vaccine practice.²² All operators should be educated about HPV, and teams should establish clear responsibilities for patient education about cancer prevention, including HPV vaccine recommendations and documentation in the patient’s dental record. Providers should receive ongoing training so they can effectively communicate the need for HPV vaccination. Further, all staff members should be able to address any questions patients and families may have. This may be challenging, however, as the virus is transmitted through vaginal, anal and oral sex. As such, the focus of the pro-vaccination culture should be that the vaccine prevents multiple cancers. In clinic, a priority should be to listen to any concerns the parent/caregiver may have, and to counsel parents/caregivers and children about the safety of the vaccine.

INCREASE ACCEPTANCE

Educating parents/caregivers about their children’s need for the HPV vaccine can be challenging, but the CDC has developed useful suggestions.²³ For example, the CDC provides helpful talking points, as well as excellent posters for download (Figure 1).²⁴

Previously, the FDA and CDC suggested different age ranges for Gardasil 9, which impacted whether health insurance payers would cover the vaccine at different age levels — a situation which some families found confusing. However, in June 2019, the CDC adopted the same age range (9 to 45) recommended by the FDA. The CDC also changed its age recommendation for catch-up vaccinations for both women and men to age 26, which is the same as the FDA’s recommendation.

In the dental setting, all relevant print and nonprint literature should be evidence-based, easy to understand and culturally appropriate. Established tools, such as the Patient Education Materials Assessment Tool or Clear Communication Index, should be used to evaluate print/audio-visual materials to ensure they are user friendly.^25,26

ACTIONS STEPS AND SUMMARY

Many oral health professionals also work in their communities, either as part of their position or as volunteers. Using these connections can be useful in maximizing access to the HPV vaccine. School nurses are usually excellent partners for educating teachers, staff and parents/caregivers about the need for vaccination. Other venues to consider include the 4-H network for children and youth, and boys and girls clubs. In addition, dental team members can increase awareness of HPV vaccination through local and state professional organizations. One example would be to put together a session on HPV and the HPV vaccine, or serve as a speaker on a panel that may discuss other vaccines, such as flu or measles vaccinations.

In conclusion, HPV is a common virus, and the prevalence of HPV-related oropharyngeal cancers is increasing rapidly. Preventing HPV-related cancers requires a multidisciplinary approach, and oral health professionals play a key role in promoting HPV vaccine uptake. As such, dental teams should become knowledgeable about HPV, its association with oropharyngeal cancers, and the importance of HPV vaccination. They can also champion system-level changes, such as improving patient education, organizational structures, and health care linkages that promote HPV vaccination. In so doing, dental providers can ultimately improve the health of their patients.

Acknowledgment: The authors thank Sydni Thomas for her assistance in related searches and reference management.

REFERENCES

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2. American Cancer Society. Risk Factors for Oral Cavity and Oropharyngeal Cancers. Available at: cancer.org/​​​​cancer/​​​​oral-cavity-and-oropharyngeal-cancer/​​​​causes-risks-prevention/​​​​risk-factors.html. Accessed September 6, 2019.
3. American Cancer Society. Key Statistics for Oral Cavity and Oropharyngeal Cancers. Available at: cancer.org/​​​​cancer/​​​​oral-cavity-and-oropharyngeal-cancer/​​​​about/​​​​key-statistics.html. Accessed September 6, 2019.
4. National Institute of Dental and Craniofacial Research. Oral Cancer. Available at: nidcr.nih.gov/​​​​health-info/​​​​oral-cancer/​​​​more-info. Accessed September 6, 2019.
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From Decisions in Dentistry. October 2019;5(9):41—44.