Original ResearchPrevention of HPV-related oral cancer: assessing dentists' readiness
Introduction
Human Papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the US1 and is associated with a subset of oropharyngeal cancers (OPC) and oral cavity cancers (OC).2, 3 More than 90% of OPC and OC diagnosed each year are oral squamous cell carcinomas (OSCC).4 Although the majority of OC and OPC are typically attributed to tobacco and alcohol use4 within the past decade research has confirmed oral HPV infection as an additional risk factor, particularly for OPC.5 The most recent national prevalence study found that oral HPV infection is present in 6.9% of males and females ages 14–69, with higher prevalence found among individuals ages 30–34 (7.3%) and 60–64 (11.4%) and among men (10.1%).6 A review of HPV-related OPC demonstrated that HPV was present in ∼22–26% of the cases, and of those cases, ∼90–95% were attributable to HPV types 16 and 18.7 Other sources have reported even higher proportions (38–65%) of HPV-related OSCC.8, 9
Due to the growing link between OSCC and specific HPV types 16 and 18, researchers have hypothesized that use of the two available HPV vaccines may cause a reduction in the increasing incidence of OPC.7, 10, 11 Plausibility of this hypothesis is strengthened through published studies demonstrating evidence of the HPV vaccine's ability to prevent other cancers, such as anal cancer and HPV-related non-cervical cancers, such as vulvar and vaginal lesions.12 Moreover, the two Food and Drug Administration—approved HPV vaccines, Gardisil™ and Cervarix™, have been shown to prevent transmission of HPV 16 and 18—the same two strains attributable to 90–95% of HPV-related OPC.7 In 2006, the Advisory Committee on Immunization Practices13 recommended the HPV vaccine for the prevention of cervical cancer and genital warts among females age 9–26 years;13 and in 2011, recommendations extended to the prevention of anal cancer among males age 11–26 years.14 While there is currently no conclusive data on the effectiveness of HPV vaccines in preventing OC or OPC, as the research continues to build, it is anticipated that the HPV vaccine will be shown to be effective in preventing a range of cancer, including oral cancer.
While physicians primarily administer HPV vaccines, dentists typically perform oral cancer screening examinations, inspecting the face, neck, lips, gums, mucous membranes and floor of the mouth, alveolar ridge, hard and soft palates, and the tongue for lesions or other signs of cancer.15 Additionally, dentists are among the most frequently visited health provider.16 This regular interaction with patients offers dentists a unique opportunity to contribute to primary prevention of HPV-related oral cancer by discussing the HPV vaccine with their patients. This is a promising arena for increasing vaccine uptake, as a recent systematic review of HPV vaccine acceptability indicated the important role that health providers have in increasing vaccine coverage among their patients.17 Furthermore, evidence of dentists playing this preventative role has been demonstrated in the area of tobacco cessation.18, 19 Moreover, the public health significance of primary and secondary prevention performed by dentists has been noted in the newly developed Healthy People 2020 Oral Health Objective: ‘Increase the proportion of adults who receive preventive interventions in dental offices’.20 Engaging OHPs in HPV-related prevention activities may be a meaningful strategy to reduce HPV-related cancer incidence.
Previous studies employing psychological models have shown utility in explaining and predicting dental providers' clinical behaviours.21, 22, 23, 24, 25 Contributing to this research on theory-guided behaviour change research among dental providers, the purpose of this exploratory study was to: (a) assess dentists' readiness to discuss HPV vaccines as a prevention measure against HPV-related OSCC with adult patients and/or parents of underage patients during routine visits; and (b) determine processes of change associated with increasing readiness to discuss HPV vaccines as a prevention measure against HPV-related OSCC. A priori hypotheses stated the majority of dentists would not be willing or ‘ready’ to discuss the HPV vaccine or the HPV–OSCC link with their patients. This paper presents findings from a larger mixed-methods study assessing oral health providers' (OHP) intention and capacity for engaging in primary and secondary prevention of HPV-related OSCC.26
Section snippets
Theoretical framework
This research was guided by the Transtheoretical Model (TTM),21 specifically, the Stages of Change and Processes of Change constructs. The Stages of Change construct extracted from the TTM was used to segment dentists into distinct stages of behavioural adoption. Reed and colleagues28 suggest assessing behavioural readiness represented by current stage of behaviour is most effectively examined by using a four-item algorithm corresponding to a criterion-specific behaviour. As such, individuals
Participants
Of the 4480 surveys emailed, 368 surveys were returned. A response rate could be calculated by simply dividing the number of responses from the number of emails sent to the Florida Dental Association membership (368/4480 = 8.2%). However, this would likely lead to a gross underestimate of the response rate, as it does not account of the high number of invalid email addresses and undelivered messages. Therefore, it was not possible to calculate an actual final response rate for this study. Of
Discussion
As awareness of HPV-related OC increases, dentists may be a key healthcare provider for discussing the HPV vaccine with their patients, demonstrating how OHPs may be important in future HPV prevention efforts. Although dentists may play a crucial role in primary prevention of HPV-related OSCC, results suggest the majority of dentists are not ‘ready’ to do so. Additionally, results suggest dramatic relief and self-revaluation as two processes of change that may be effective in moving dentists
Acknowledgements
This study was supported through a joint pilot project funded by the H. Lee Moffitt Cancer Center and the University of Florida. The authors are grateful for their support.
Ethical approval
Not required.
Funding
None declared.
Competing interests
The authors have no financial or competing interests related to this study.
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