Transmission of oral HPV Mechanism of transfer
skin-to-skin or skin-to mucosal contact other means of transmission such as vertical transmission from mother to newborn, self-inoculation or horizontal transmission should be the subject of continued research (Petca, et al., 2020). Viral clearance In most cases, without treatment, the viral infection will clear to undetectable levels between 12 and 24 months after infection, depending on the virus type and the status of the individual’s immune system (WebMD, n.d.b; Bacaj and Burch, 2018). In some cases, such as infection with high-risk HPV types, the virus persists and its presence becomes a precursor for cancer (Taberna et al., 2017). The virus type, viral load, and health of the individual’s immune system affect the length of time required for the virus to clear with viral clearance requiring an effective cell-mediated response (Abebarnowo, et al., 2018). Low-risk HPV types clear more rapidly than high-risk types. However, clearance of a naturally-acquired virus does not confer immunity from future infection (Nunes, et al., 2018). Screening tests are available to detect the presence of oral HPV, but the implications of viral detection in asymptomatic people are currently unknown, as is the clinical value of such knowledge (Candotto, et al., 2017). A “positive HPV test” in the mouth would have limited clinical usefulness as there would be little for a practitioner to do. Not everyone who is a carrier of high-risk HPV will develop cancer (as in the case of HPV infection of genital mucosa), and there is no current method for detecting an “HPV positive premalignant” lesion (Candotto et al., 2017). Nonetheless, as with cervical cancer, ongoing research may provide a rationale for routine oral HPV screening. Although routine screening for oral HPV is not currently recommended or ADA approved, some patients may request testing. The risk profile for oral HPV includes anyone older than age 12 who is sexually active, has had more than three sexual partners (oral, anal, and/or genital (Candotto, et al., 2017), and has a weakened immune system (Oral Cancer Foundation, 2022). In reality, most sexually active adolescent or adult patients are at risk for HPV infection. Although testing for oral HPV is not a recommended practice for dental patients, test kits are available, and testing is available in some dental practices. Dental professionals who provide oral HPV testing for their patients should be prepared to answer both the clinical and emotional questions that come with a positive test result and should be equipped to respond to psychosocial issues that may arise (You, et al., 2019). Patient concerns about screening Any patient tested for oral HPV should be aware of the limited clinical value of the findings. Since viral clearance is probable, patients testing positive for oral HPV should have follow-up tests to determine viral persistence. All patients should be informed of the need to consistently practice safe sex. When assessing a patient’s HPV risk status, sexual behaviors must be explored. Educating patients about the prevalence of HPV and its relationship to oral cancer can provide a nonthreatening introduction to a discussion of personal risks and the importance of oral cancer examinations (American Dental Association, 2022). The subject of oral sex can be introduced in a nonspecific and nonjudgmental way by starting with a discussion of oral viral infections, such as HPV (Rehan, 2017). Because the number of past sexual partners is a risk factor for acquiring HPV, asking questions relating to past and present sexual behaviors, including the number of past sexual partners
HPV infections are acquired mainly through close contact. The infections spread easily during sexual contact, but can also move vertically (such as during delivery when a fetus moves through the birth canal of a mother infected with HPV), through autoinoculation, and via viral presence on objects used during sexual encounters (Syrjanen, 2018). Poor oral health can be an independent risk factor for oral HPV infection. Carious lesions, gingivitis, periodontal disease and ulcerative lesions from iatrogenic trauma during brushing, eating or from irritation from a prosthesis facilitate the entry of the HPV into the oral tissues (CDC, 2021g). Although HPV can be found on fomites such as utensils, medical instruments, environmental surfaces and various objects, transmission of HPV from a fomite has never been documented. However, HPV transmission from fomites is remotely possible as some studies have found that the HPV can occasionally survive the standard disinfection regimens of medical instruments (Petca, et al.,2020). Although the primary means of the transmission of the (HPV) is through Screening for oral HPV In recent years, HPV salivary diagnostic tests have become commercially available to dentists and there is ample evidence which supports the use of saliva as a diagnostic testing fluid for the detection of HPV DNA in patients with oropharyngeal cancer (OPC) (Tang, et al., 2019). Increasing evidence reveals that salivary HPV DNA can provide a biomarker which can monitor disease progression and tumor recurrence in (OPC) patients (Qureishi, et al., 2018). While these tests cannot determine the origin of HPV infection, salivary diagnostic testing can determine who caries HPV-16 and HPV 18 (Rehan, 2017). Since viral clearing is common, positive test results would require additional testing over time to determine if there is viral persistence or if the immune system has cleared the HPV infection (Rehan, 2017) and viral load (Tang, 2019). Other considerations regarding oral HPV screening include the impact of a positive test on the patient as well as patient care and management (Rehan, 2017). In its Statement on Human Papillomavirus and Squamous Cell Cancers of the Oropharynx, the American Dental Association Council on Scientific Affairs noted approval of the two existing HPV vaccines for the prevention of HPV-related cancers of the cervix and vulvar, vaginal, and anal mucosa and acknowledged that the vaccines may be effective for the prevention of HPV-related oropharyngeal cancers (ADA, n.d.). However, the statement does not include approval related to the use of saliva testing to detect the presence of HPV in the oral cavity. Who, when, and how to screen Currently, HPV screening is approved by the United States Food and Drug Administration only for cervical cancer (American Cancer Society, 2020). Guidelines recommend that women over the age of 30 receive the HPV test in conjunction with their Pap test (CDC, 2021h). The rationale behind this HPV screening recommendation is based on the ability of the Pap test to exclusively detect cervical cell changes. If cervical cell changes are occurring, the HPV test will allow clinicians to know which HPV type is responsible for the changes with positive cytology and HPV tests indicating cervical precancerous lesions (CDC, 2021h). If both tests are negative, the risk of cancer is low, and women can wait 5 years before another HPV screening. However, Pap tests should continue to be performed every 3 years. Currently there are no routine HPV screening tests for other anatomic locations, including the oral cavity and the pharyngeal region (American Cancer Society, 2021b).
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