2010 was the year that the oral HPV/oral cancer connection
made the headlines. It took a celebrity's oral cancer
diagnosis to prompt several reporters to dig deeper and
inform consumers that not all oral cancers are caused by
tobacco and alcohol.
Physicians and dentists alike know that oral cancer can be
disfiguring and deadly, particularly when presenting in its
later stages. For generations, clinicians have been trained to
look at alcohol and tobacco use as two of the main factors,
other than family history, that put their patients in the high risk
category. And for generations, we've been evangelical
about explaining these risk factors to our patients.
But now there's a new villain in the lineup; one that is
running pace with smoking and drinking as a putative cause
for oral cancer. This suspect is human papillomavirus, or
HPV. In fact, of the 34,000 cases of oropharyngeal cancers
diagnosed each year, HPV is now found in up to 50 percent
Whatever the cause, oral cancer at its earliest stages is difficult
to discern from healthy tissue. By the time the lesion is
visually apparent or symptomatic, it is likely to require surgical
There are about 1,700 more people developing HPV-related
oral cancers each year.¹ The risk profile for oral HPV
includes anyone older than age 12 who is sexually active or
who has had more than three sexual partners.² These statistics
are now being cited in the mainstream media.
Like it or not, the fast-forward button has been pushed on
the progress of oral medicine, which presents dentists with
the two-edged sword of both great responsibility and opportunity.
As the gatekeepers of oral health, don't dentists have a
responsibility to their patients to look for cancers that originate
and/or reside in the oral cavity at their earliest and most
There are several devices available to assist dental professionals
in detecting possible cancerous lesions in the mouth.
Tissue fluorescence devices shine light of a specific wavelength
onto the oral mucosa. The light interacts with dysplastic
tissue differently than with normal tissue, and therefore
fluoresces differently than normal tissue. Depending on the
individual risk factors of the patient, the suspect lesion can be
monitored over time for changes or symptoms, or a biopsy
can be taken and tested for cancer.
Brush biopsy devices employ tiny wire brushes that scrape
off the top layers of skin of suspect lesions, the cells of which are
analyzed in a laboratory and described on a pathology report.
It must be noted that these two methods are used to
screen for oral cancer, which might be attributed to the oral
HPV virus. They do not directly screen for HPV as a potential
precursor to oral cancer. Currently, the most convenient
noninvasive way to definitively detect oral HPV is through a
salivary diagnostic test.
OralDNA Labs recently introduced the OraRisk HPV
test, a noninvasive, easy-to-use screening tool for identifying the various types and levels of oral HPV infection, especially
HPV-16 and HPV-18, which are the variants most commonly
linked to oral cancer.3,4
Using salivary diagnostic testing, today's dental professional
is in a unique position to not only save lives, but to play an
important public health role in minimizing the spread of a sexually
transmitted disease – the rationale being that once a
patient knows he or she is oral HPV-positive, he or she might
take the initiative to be more responsible and practice safe sex.
This opportunity to save lives and control the spread of
sexually transmitted diseases is achieved through skillful
patient communication, accurate diagnosis and prompt referral.
There are four main questions that need to be answered
before incorporating salivary diagnostic testing for oral HPV
into your oral cancer screening protocol.
How to Discuss HPV
For most dentists and hygienists, the most probing question
they ask their patients is, "Do you floss?" Now, in order
to be a "mouth physician" testing for persistent HPV infection,
much more personal questions need to be asked to
patients who fit the following profile:
The oral HPV discussion is one that can be rehearsed and
that over time will become more comfortable for dentists,
hygienists and patients who will begin to accept the dental
clinician's expanding role as a health care provider. The following
is a sample script excerpt from the OralDNA patient
education kit that can be used as a general guide on how to
discuss oral HPV testing with your patients:
- Family history of oral cancer
- Signs and symptoms of oral cancer
- Traditional risk factors for oral cancer
- Suspicious oral lesions
Doctor: "As part of our regular oral cancer screening, we
now incorporate an oral HPV test that helps us in several ways.
It enables us to determine if HPV is present in your mouth and,
if so, which types of HPV are present. This helps us determine if
you are at increased risk for developing oral cancer and allows
us to implement a plan for earlier detection and prevention of
How to Test For HPV
As the patient education script explains, it's pretty easy:
The patient is instructed to swish a saline solution around
the entire mouth, gargle deeply and expectorate into a specimen
collection tube. This process takes 30 seconds.
The collection tube is then placed into its own plastic
specimen transport bag and shipped from the dental office via
prepaid FedEx envelope to OralDNA Labs in Brentwood,
Tennessee for DNA analysis.
The OraRisk HPV lab report is then sent back to the
ordering dentist via the secure Web site, so that he or she can
share the information with the patient and develop a personalized
treatment plan based on their test results.
How to Explain the Results of the
OralDNA has created helpful patient education scripts for
virtually every OraRisk HPV test result scenario:
Negative result: Doctor: Good news, your OraRisk HPV results came back
negative, so there's nothing more to do at this time. On an ongoing
basis, we would like to continue monitoring for new risks or
changes in current risk factors. There are no current established
guidelines for retesting, however; conventional wisdom or clinical
judgment suggests one year is a reasonable time frame for repeat
testing (similar to annual HPV testing of genital tract).
Positive result with no lesion:
Doctor: Your OraRisk HPV results came back positive for
HPV (HPV type 16, 18, etc.). You have no lesions or areas in
your mouth of concern that we can see. However, to be safe, I recommend
you have an examination of your complete throat area
by an ENT, After that exam, we will discuss whether or not additional
testing will be needed. By then, the virus may clear itself from your body on its own, as is usually the case, and our test will
provide certainty. Research has not determined the exact time
frame for re-testing, but we suggest six to 12 months.
Positive with a lesion: Doctor: "Your OraRisk HPV results came back positive for
HPV (HPV type 16, 18, etc.). Because you have a small lesion
here (show patient the spot with an intraoral camera), I recommend
you see a specialist who has experience in diagnosing these."
Patient: "What will s/he do?"
Doctor: "In many cases, they can tell just by looking if a
biopsy is necessary. Biopsies these days are simple and painless.
They will numb you in the area with an anesthetic, just like
I do before a dental procedure. Then they may take a small
brush and gently brush the area with it. This collects cells
from the area that are sent to a lab for identification. Or, they
may remove a very tiny part of the lesion and send it to a lab
Patient: "What if the biopsy is positive for cancer?"
Doctor: "Whenever we notice a lesion that does not get
better on its own within 2 weeks, it's best to have it checked out
by a specialist who will be able to provide the necessary treatment.
The good thing is that we noticed it early. Treatment at
the earliest stages is the most advantageous time to do something
What to Do Next
OralDNA Labs recommends that the treating clinician
follow standardized follow-up protocols, and has created helpful
workflow charts to map out the referral process for
patients who test oral HPV-positive but present no visible
lesions, and those who test oral HPV-positive and present visible
Armed with salivary diagnostic tests, dentists and hygienists
are in a perfect position to diagnose oral HPV early, and
not only have a positive impact on patient outcomes, but also
on reducing the spread of oral HPV. As a New Year's
Resolution, perhaps you can resolve 2011 to be the year you'll
choose to update your oral cancer screening protocol.
- Saraiya M, Kawaoka K. Incidence of human papillomavirus (HPV)-related head and neck cancers in
the US from 1998-2003: Pre-HPV vaccine licensure. Proc Am Soc Clin Oncol. 2007;25:299s.
- Heck JE, Berthiller J, Vaccarella S, Winn DM, Smith EM, Shan'gina O, Schwartz SM, Purdue MP,
et. al. Sexual behaviours and the risk of head and neck cancers: a pooled analysis in the International
Head and Neck Cancer Epidemiology (INHANCE) consortium. Int J Epidemiol. 2010
Feb;39(1):166-81. Epub 2009 Dec 18.
- Herrero R, Castallsague X, Pawlita M, et al. Human papillomavirus and oral cancer: The
International Agency for Research on Cancer multicenter study. J Natl Cancer Inst. 2003; 95:
- Kreimer AR, Clifford GM, Boyle P. Human papillomavirus types in head and neck squamous cell carcinomas
worldwide: a systematic review. Cancer Epidemiol Biomarkers Prev. 2005; 14:467-475.
|Ronald C. McGlennen, MD, is the medical director of OralDNA
Labs, Inc., a leading provider of salivary diagnostic tests to the dental
profession, and a subsidiary of Quest Diagnostics, Incorporated.
Dr. McGlennen is board certified in anatomic and clinical pathology,
and also board certified by the American Board of Medical Genetics,
with a specialty in clinical molecular genetics. He is internationally
recognized as an expert in molecular biology and genetics.
Thomas W. Nabors, DDS, FACD, was a practicing dentist for
more than 38 years. He treated periodontal patients using a variety
of treatment philosophies: nonsurgical, surgical, laser therapy,
as well as antimicrobial models. He has a rich background in the
clinical application of current therapy philosophies and the application
of clinical laboratory testing. He is a distinguished lecturer
at the national and state levels on personalized periodontal disease
treatment and the application of molecular testing methodologies
within oral medicine. He has authored numerous articles
on the subject. He co-founded OralDNA Labs in 2008 and serves
as the company's chief dental officer.