HPV-associated squamous cell carcinoma. Photo from Wikimedia Commons.
HPV-associated squamous cell carcinoma. Photo from Wikimedia Commons.


The Journal of the American Dental Association

By Emma Yasinski

Earlier this year, The Journal of the American Dental Association published a study by Ellen M. Daley, MD, PhD and her colleagues that examined the level of understanding that dentists have when it comes to the HPV (human papillomavirus)vaccine, as well as their attitudes about discussing it with their patients in an effort to prevent oropharyngeal cancer.

According to the Centers for Disease Control and Prevention (CDC), HPV is the most common sexually transmitted infection, commonly spread during vaginal, anal, or oral sex. Seventy-nine million Americans, most in their late teens and early 20s, are infected with HPV.

Incisor sat down with Dr. Daley, associate dean for research and practice at the University of South Florida College of Public Health, to figure out what exactly dentists and oral health professionals need to know about the HPV vaccine


Incisor: What led you to conduct the study?

Dr. Daley: Well, I had done a lot of research already on HPV because my background is in women's health. About eight or nine years ago, someone said to me, "Did you hear a study just came out that they think HPV is associated with oropharyngeal cancer?" By that point, they had known it was [associated with] cervical and anal cancer as well. So really, it just makes you think it [has to do with] mucosal tissue.

Then there’s the HPV vaccine, which is very effective. It's been around for over a decade. We should have very good vaccination rates in the U.S., but the way the vaccine program was rolled out has made it really ineffective. It's almost solely dependent on provider recommendation. It's not a school-based program like (the ones for) kids who are going to middle school and have to get TDAP [tetanus, diphtheria, and pertussis] before they can go. Because it's provider dependent, and we were used to OBGYNs, and pediatricians, and family practice doctors being the ones who really needed to make sure their patients got it, my first thought was, “if it's oropharyngeal, where are patients going to hear this? Well, then it's going to be dentists."


Dr. Ellen M. Daley of the University of South Florida College of Public Health
Dr. Ellen M. Daley of the University of South Florida College of Public Health


Incisor: Can you give me a brief description of what exactly you did in the study?

Dr. Daley: We talked to three groups. We talked to opinion leaders, and we did two sets of focus groups. One was with dentists, and one was with dental hygienists at big national conferences.

We not only did the focus groups, but we asked if we could collect data on knowledge of HPV and its relationship to cancers, including oropharyngeal. We collected interviews from the opinion leaders and then we got some great information from these focus groups that talked about … did they think that HPV-related cancers, oropharyngeal cancers… did the oral health providers think that they had a role in the prevention and education related to that? The thing that was so great about that is that absolutely every single one of them said yes.

“One way that HPV is transmitted is sexually,
but it's also transmitted in other ways”


Incisor: Was that surprising?

Dr. Daley: Well, it was. I was really happy to see that. When we did the pilot test five years earlier, there was a lot of hesitation there. "I don't know." "I don't know enough about it." "I don't know if this is something that we should be talking to our patients about." The other thing in the preliminary study, they said, and they were absolutely correct, "There's no statement, no policy statement from the American Dental Association to say whether we should be doing this. If you don't have the backup of your professional organization,” they just said, "Until there's something there, I just don't see upsetting my patients about that."

We did have to wait until the ADA put a statement out and the statement said that it was the responsibility of dentists to educate themselves and their patients about HPV and oropharyngeal cancers. That's pretty much all we needed. Mostly what they wanted though, was for us to tell them how to do it.


Incisor: What would that conversation ideally sound like? Do you have something in mind?

Dr. Daley: The thing that was so interesting about the feedback we got from them was some providers said, "Okay, I would be willing to talk to patients about it, but I want them to bring it up. I don't want to be the one to bring it up." Is there a way that the conversation could be started somehow and I would happy to answer questions? How could we get patients to say, "So, what is that? I heard this thing on the news and what does that mean?" Or, "I saw this poster in your waiting room." Or, "There's a question on the medical history that asks me if I had the vaccine. Why are you asking me that?" Anything that would just start that kind of conversation.

We're going to be doing a study that looks at coming up with a toolbox for them. Here are different ways that you can display this in your practice, and patients are more likely to ask you.

We did see differences in the number of years in practice and also gender. If you're a male dentist and you're uncomfortable talking to a female patient about it and vice versa, how do we come up with a different kind of way for you to do it? There were all those other factors as well.

One of the questions I was surprised by was “Would you be willing to talk to your patients about the vaccine?” What they said was, "Yes, we'd be willing to, but we've never had that kind of conversation before, and we need you to help us introduce that in a way that's not upsetting to people." They're very concerned. They don't want their patients to be upset.

“Okay, I would be willing to talk to patients about it, but I want them to bring it up. I don't want to be the one to bring it up”


Incisor: Without straight up guidelines just yet, what should dentists take away from the study? What should they know?

Dr. Daley: Well, the takeaway from the study is that the vaccine is approved for the prevention of anal and genital cancers. It is not approved by the FDA for oropharyngeal cancers. That being said, the type of HPV that causes all those cancers is HPV-16 (along with other types). That's the type that causes the majority of oropharyngeal cancers.

They can't say, "The vaccine will prevent the type of cancer that I'm going to screen you for," but, "It prevents any cancers that are caused by that type of HPV." That's an important distinction for them to be able to say to their patients. We would want them to talk about the vaccine to their patients. Also, we would want all of them to conduct a really thorough screening for oropharyngeal cancer that includes the screening of the oral cavity and the throat and the lymph nodes.

If they're conducting that screening, that also gives them a conversation point. Because one of the things that we found is that people get that screening and the dentists don't tell them what they're doing. There's a missed opportunity. You have that opportunity to say, "Well, I'm checking for this type of cancer and it's caused by HPV and there's a vaccine." Or, the dentists or the dental hygienists can say, "So now I'm doing this and this is why I'm doing it." There's your opening to start talking about this.


Incisor: Several headlines about your study mentioned that dentists are going to start having to ask their patients about their sex lives. How is the HPV that causes oropharyngeal cancer transmitted?

Dr. Daley: One way that HPV is transmitted is sexually, but it's also transmitted in other ways. One of the things that researchers are looking at pretty extensively now is something called autoinoculation, which is where we infect ourselves, like you may get it on your hands if you're touching the genital area. You get it on your hands and then you touch your mouth. There’s more and more evidence that that's one way that we do it. That would be nice to take that stigma away.


Author: Contributing writer Emma Yasinski received her Master of Science (MS) in science and medical journalism from Boston University. Her articles have also appeared at TheAtlantic.com, Kaiser Health News, NPR Shots, and Genetic Engineering and Biotechnology News.

Other Recent Incisor Articles by Emma Yasinski:

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