HPV is so common that most sexually active people get infected with at least one type of HPV at one point in their lives. The CDC estimates that 79 million Americans are currently infected with HPV and another 14 million become newly infected each year (CDC 2014). For many people with strong immune systems, the infection clears on its own.
What many people may not realize, however, is that HPV is also linked to oral health risks, including oropharyngeal cancers (tongue, tonsil and pharynx). In 2013, actor Michael Douglas set media ablaze with his announcement that his oral cancer was caused by HPV acquired through oral sex. In fact, according to the Oral Cancer Foundation, HPV is emerging as the leading cause of oropharyngeal cancers. It has been estimated that HPV will cause more oropharyngeal cancers than cervical cancers in the United States by 2020 (Chaturvedi, 2011).
Of the 100 HPV types (Munoz et al, 2003) , approximately 40 types are sexually transmitted, while about 60 types cause warts on hands or feet through simple contact with infected skin or even objects. While most oral HPV lesions are benign and may persist or relapse spontaneously, primary care providers should be aware of the various HPV-associated oral lesions– and their etiology!– in order to provide appropriate risk-management tips, education and treatment, depending on whether the HPV is sexually transmitted or not.
Condyloma acuminatum lesions are clustered and typically localize to the mucosa, soft palate, lingual frenum and tongue. Because these lesions are typically the result of oral-genital contact, these lesions are considered sexually-transmitted. Since they may cause disfigurement, surgical treatment is advisable, although recurrence is common. These lesions are commonly found in the HIV infected population.
Certain HPV strains may also cause oral and oropharyngeal carcinomas. According to Mount Sinai’s HPV Program, the U.S. has seen a four- to five-fold increase in the number of oropharynx cancers over the past decade, and this is likely due to an increased number of people engaging in oral sex with multiple partners. The most common symptom of oropharyngeal cancer is non-healing sore in the mouth or on the lip. Other symptoms may include red or white patches on the gums, tongue, tonsil or lining of the mouth, an unresolvable sore throat, trouble swallowing and coughing up blood, all of which necessitate referral to an otolaryngologist. Because it is often detected in the later stages, oral cancer’s mortality rate is higher than several other cancers, including cervical. Between 2007-2011 the mortality rate for oral cancers was 2.5 per 100,000 persons per year (National Cancer Institute, 2015). However, those with HPV-positive oropharyngeal cancers have a lower risk of dying or having recurrence than those with HPV-negative cancers (Fakhry, 2008).
Focal Hyperplasia, or Heck’s Disease, appears as soft, smooth lesions that cluster to the labial, buccal and lingual mucosa that have a cauliflower appearance. This condition appears most often among children of certain ethnic groups, such as indigenous peoples of North America, Central America and South America, but is also more frequently seen in HIV infected individuals. These lesions may spontaneously resolve, but may be removed surgically if cosmetically unpleasing. This oral infection appears to be the result of close contact between family members and fomite transmission (Davidova et al., 2013).
Verruca vulgaris are painless but contagious warts found commonly on the lip, gingiva and palate of the mouth. These lesions are typically small and cauliflower-shaped or exhibit fingerlike projections and are removed through surgical excision. Although these can infect all age groups, children most commonly show these lesions. Accidental skin contact with infected wart tissue may lead to development of this common wart.
Squamous papillomas are small, white projections that are generally benign and which arise from the stratified squamous epithelium of skin, lip, oral cavity, tongue, pharynx, larynx or the esophagus. These papillomas are considered curable with surgical excision, unless they reappear, which suggests the possibility of carcinogenicity.
While many oral manifestations of HPV are benign and resolve with time, it is important to educate pattens about transmission patterns, especially parents since many oral manifestations are often seen in children. Given the substantial burden of oral cancers caused by HPV, primary care providers must be able to diagnose, refer, and most importantly, educate their patients about safe sex habits. The CDC recommends that all boys and girls ages 11-12 years get vaccinated; catch-up vaccines are recommended for males through age 21 and for females through age 26, if they did not get vaccinated when they were younger. The vaccine is also recommended for gay and bisexual men (or any man who has sex with men) through age 26. It is also recommended for men and women with compromised immune systems through age 26.
In celebration of oral cancer awareness month, join students from NYU’s Colleges of Dentistry and Nursing, Columbia University College of Dental Medicine, Stony Brook Health Sciences Center, Rutgers University School of Dental Medicine, Bronx Lebanon Hospital Center, local chapters of the Student National Dental Association, the Oral Cancer Foundation, the Oral Cancer Consortium, the NYU Oral Cancer Center, Colgate and others in the 10th annual NYC Oral Cancer Walk on Sunday, April 19, 2015 to help raise awareness about oral cancer. NYU’s dental office on wheels, Smiling Faces, Going Places, will be onsite to offer free oral cancer screenings. Find out more here: http://www.oralcancerwalknyc.org/
Center for Disease Control. Genital HPV Infection – Fact Sheet.”23 Feb. 2015. Available on http://www.cdc.gov/std/hpv/stdfact-hpv.htm
Chaturvedi, A. K., Engels, E. A., Pfeiffer, R. M., Hernandez, B. Y., Xiao, W., Kim, E., … & Gillison, M. L. (2011). Human papillomavirus and rising oropharyngeal cancer incidence in the United States. Journal of Clinical Oncology, 29(32), 4294-4301.
Davidova, L. A., Sedghizadeh, P. P., Balouch, A., & Salek, H. (2013). Oral Multifocal Papillary Lesions in a Young Child: Clinico-Pathologic and Medico-Legal Considerations.
Fakhry, C., Westra, W. H., Li, S., Cmelak, A., Ridge, J. A., Pinto, H., … & Gillison, M. L. (2008). Improved survival of patients with human papillomavirus–positive head and neck squamous cell carcinoma in a prospective clinical trial. Journal of the National Cancer Institute, 100(4), 261-269.
Mount Sinai HPV Program. “Human HPV and Throat/Oral Cancer frequently Asked Questions” Available on http://www.mountsinai.org/patient-care/service-areas/ent/areas-of-care/head-and-neck-cancer/oral-cancer/hpv/hpv-faq
Munoz, N., Bosch, F. X., de Sanjose, S., Herrero, R., Castellsagué, X., Shah, K. V., … & Meijer, C. J. (2003). Epidemiologic classification of human papillomavirus types associated with cervical cancer. New England Journal of Medicine, 348(6), 518-527.
National Cancer Institute. (2015). “Oral Cancer Prevention.” Available on http://www.cancer.gov/cancertopics/pdq/prevention/oral/HealthProfessional/page2
The Oral Cancer Foundation. “The HPV Connection.” Available on http://oralcancerfoundation.org/hpv/
Weiss, A. and Dym, Harry. (2011). Oral Lesions Caused by Human Papillomavirus.” The Clinical Advisor. January Issue. Available on http://www.clinicaladvisor.com/oral-lesions-caused-by-human-papillomavirus/article/193918/