Julian Perez, J.D., Chief Legal Officer, dentalcorp; Michelle Budd, D.D.S, Patient Safety Consultant, dentalcorp
Oral and pharyngeal cancer, also known as head and neck cancer, poses a significant (if somewhat underappreciated) global public health issue, with over 50,000 North Americans diagnosed each year (1). The 2019 Canadian Cancer Statistics report indicated that 5,300 Canadians were diagnosed with oral cancer (3,700 men and 1,600 women), of which 1,480 died (1,050 men and 430 women) (1). Approximately three Canadians die each day from oral cancer, with Ontario having the highest oral cancer incidence and related death prevalence.
“Early diagnosis of oral cancer through screening and early detection is critical”[1] of course. But for dentists and other primary oral healthcare providers focusing on detection may no longer be enough. According to the Canadian Cancer Society, it is estimated that in 2022:
- 7,500 Canadians will be diagnosed with head and neck cancer.
- 2,100 Canadians will die from head and neck cancer.
- 5,400 men will be diagnosed with head and neck cancer and 1,500 will die from it.
- 2,000 women will be diagnosed with head and neck cancer and 560 will die from it.[2]
According to the Public Health Agency of Canada (PHAC), up to 35% of mouth and throat cancers (a broader set of cancers which includes oral and pharyngeal cancer) are related to previous Human Papilloma Virus (HPV) infection. Sadly, this number is increasing steadily over time (3). The incidence rate of HPV-associated oropharyngeal cancer is almost five times higher in males than females (2,4) and is mostly seen in the 40-59 years age group. Over the past several decades, oropharyngeal cancer has surpassed cervical cancer as the most common HPV-associated cancer with rates nearly doubling (5,6). Historically, the primary risk factors for oropharyngeal cancers were tobacco and alcohol use (4), but recent studies now show that approximately 70% are associated with HPV (7,8).
When discussing HPV and other sexually transmitted infections (STIs), their impact on oral health is generally not top of mind. HPV is very common and very contagious – more than 70% of sexually active Canadian men and women will have a sexually transmitted HPV infection at some point in their lives (9). While most people will contract this virus in their genital area, it can also be contracted in the mouth and throat (10). This is where a significant gap exists in addressing the upsurge of HPV-associated oropharyngeal cancer, and consideration for an interprofessional approach that includes oral health care professionals in cancer prevention (e.g., vaccination) is of utmost importance. With the rise of HPV-associated oropharyngeal cancer, there may be a significant impact on the Canadian healthcare system and resources if this issue is not adequately addressed (11).
Prevention versus detection and the HPV vaccine
There is currently no routine screening program for head and neck cancers in Ontario. Even if such a program existed, “14.5% of Canadians … reported that they did not have a regular health care provider they see or talk to when they need care or advice for their health.”4 Also, a sizeable portion of Canadians visit their oral healthcare provider more often than their primary care physician. (12,13) As a result, the early detection of such cancers becomes, in large part, the responsibility of dental care providers during routine patient examinations. This is an important role for dental care providers. There is evidence indicating that early detection of precancerous and early-stage lesions can significantly improve the survival rate and quality of life of oral cancer patients (1), but possible prevention is far superior on all counts.
While dental care providers are actively checking patients for oral cancer, the conversations around risk factors and prevention may not be discussed nearly as much as they should be. Risk factors such as smoking and alcohol use are already being discussed, as many medical history forms ask questions about these risk factors. But most dentists are not asking about other important risk factors for oropharyngeal cancer such as HPV infections and their known causes. While dentists may not feel comfortable having such discussions, it has been shown that the more knowledge dentists possess about HPV, the more comfortable they are having these conversations and offering preventive recommendations to their patients (14).
Recent regulatory changes require oral healthcare professionals to reconsider their role in the prevention of oropharyngeal cancer. Indeed, in April 2022, Health Canada approved an expanded indication of certain HPV vaccines to prevent not just cervical cancer but oropharyngeal and other head and neck cancers.4
Challenges can and should be overcome
In Ontario, the scope of practice of dentists includes “The … treatment and prevention of any disease, disorder or dysfunction of the oral-facial complex”. Under the Dentistry Act, 1991 dentists are permitted to perform the controlled act of “administering a substance by injection or inhalation”. An argument could be made, therefore, that administering vaccines to prevent head and neck cancer would fall within the scope of practice of dentistry in Ontario. Indeed, the same could be said of the practice of dentistry in most provinces as dentists universally are tasked with preventing diseases of the orofacial complex and granted the right to administer substances through injection. Still, in Ontario it is not clear that dentists have the statutory authority to administer vaccinations. Without a clear statement from the provincial regulatory authority acknowledging vaccination as inherent to the practice of dentistry, it is unlikely a critical mass of dentists will add this to the services they offer and advertise. Accordingly, the administration of vaccines has not been something dentists or patients expect during a routine dental visit. So, although dentists are charged with providing oral health care, the responsibility for administering vaccines that can prevent oral cancer has been left with physicians and nurses. Logically, the possibility exists that the administration of HPV vaccinations in dental offices could help to increase vaccination rates and in turn reduce the morbidity and mortality rates of oropharyngeal cancer (15).
Another potential obstacle for dentists getting involved in discussions around HPV and oropharyngeal cancer with their patients is that even if the patient understands their risks and wants to have the HPV vaccine, dental care providers are limited in what they can do next. They cannot provide the vaccine, at least that’s a commonly held perception, and so an opportunity has been missed. The patient now has to seek out a medical provider and schedule a separate appointment. How often will that get forgotten? But if the dentist could provide the vaccine and schedule the second dose, this would most likely have a positive impact on the amount of people who ultimately receive the HPV vaccine.
And finally, there may be questions around logistics, including the ability to access and update a patient’s electronic medical record (EMR) and vaccination status, as well as considerations regarding fees and reimbursement for administering vaccines in dental practice, as most dentists are not set up to access health records and bill for treatment under OHIP the way that their medical counterparts are. This is something that should be addressed, as it would allow dentists to provide services related to their roles in the management of the orofacial complex, but with the financial coverage that patients are entitled to under their provincial health plan for such services.
Taking action in your practice and beyond
Despite the proven safety and efficacy of HPV vaccines, the vaccination rates are falling short, which may be related to inconsistent or weak provider recommendation. Provider recommendation has shown to be a strong predictor of patients receiving the HPV vaccination (16). The American Dental Association states that dental care providers should advocate for, and strongly and clearly recommend the HPV vaccine in addition to screening all patients for oral cancer (17). Dentists recommending the HPV vaccine alone may result in a more educated population and indirectly prevent some cancers; however, allowing dentists to provide HPV vaccines will undoubtedly result in even higher vaccination rates and ultimately save lives.
What can dental care providers do right now to help address this important issue? (18):
- Stay current on evidence related to HPV infection and oral cancers
- Conduct head and neck (including oropharyngeal) cancer screening at regular dental check-ups
- Recognize signs and symptoms at an early stage, and monitor any abnormal or suspicious lesion(s)
- Explore the possibility of collecting samples at the dental office (e.g. oral rinses or swabs) for HPV
- Engage yourself and your team to explain to patients the links between HPV and oral cancer
- Share evidence-based information about known risk factors (such as tobacco use) and modes of transmission, including sexual practices and behaviours
- Promote the HPV vaccine as a safe and effective way to help prevent the infection and make referrals where appropriate
- Advocate to the provincial regulatory body, for provinces where it is not currently within the standard of care, for a clear statement that dentists have the ability to and should administer HPV vaccines in dental offices.
Originally published in Oral Health journal.
1. Oral Cavity and Oropharyngeal Cancer Surveillance and Control in Alberta: A Scoping Review Parvaneh Badri, DDS, MSc; Seema Ganatra, DDS, MSD, FRCD(C); Vickie Baracos, PhD; Hollis Lai, PhD; Maryam Amin, DMD, MSc, PhD Cite this as: J Can Dent Assoc 2021;87:l4
2. GARDASIL® 9 Product Monograph. Merck & Co. Inc. Updated April 6, 2022
3. https://www.cmaj.ca/content/189/32/E1030
4. https://cancer.ca/en/cancer-information/cancer-types/oropharyngeal/risks
5. Van Dyne EA, Henley SJ, Saraiya M, Thomas CC, Markowitz LE, Benard VB. Trends in human papillomavirusassociated cancers – United States, 1999–2015. MMWR Morb Mortal Wkly. 2018;67(33):918–24. PMID: 30138307. doi:10.1 5585/mmwr.mm6733a2
6. National Cancer Institute. Head and neck cancers. Bethesda (MD): U.S. Department of Health and Human Services; 2021 May 15 [accessed 2021 Jul 18]. https://www.cancer.gov/types/head-andneck/head-neck-fact-sheet .
7. Centers for Disease Control and Prevention. HPV and cancer. Atlanta (GA): United States Department of Health and Human Services; 2020 Sep 3 . https://www.cdc.gov/ cancer/hpv/statistics/index.htm .
8. Chaturvedi AK, Engels EA, Pfeiffer RM, Hernandez BY, Xiao W, Kim E, Jiang B, Goodman MT, Sibug-Saber M, Cozen W, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011;29(32):4294–301. PMID: 21969503. doi:10.1200/JCO.2011.36.4596.
9. Public Health Agency of Canada. Sexual Health and Sexually Transmitted Infections: Human Papillomavirus (HPV). Ottawa (ON): PHAC; 2020 (accessed 2020-06-11). https://www. canada.ca/en/public-health/services/infectious-diseases/ sexual-health-sexually-transmitted-infections/ human-papillomavirus-hpv.html
10. Canadian Cancer Society. HPV and Cancer. 2020 (accessed 2020-06-11). https://www.cancer.ca/en/prevention-andscreening/reduce-cancer-risk/make-informed-decisions/ get-vaccinated/hpv-and-cancer/?region=on
11. Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2016. Special Topic: HPV-Associated cancers. Toronto (ON): Canadian Cancer Society; 2016. https://www.cancer.ca/en/cancer-information/ cancer-101/canadian-cancer-statistics/?region=on
12. https://www.cda-adc.ca/stateoforalhealth/snap/#:~:text=The%20results%20showed%20that%2075,dentist%20on%20an%20annual%20basis.
13. https://www.statista.com/statistics/891832/doctors-visits-among-canadians/#:~:text=This%20statistic%20depicts%20the%20percentage,times%20per%20year%20or%20more.
14. Oral health care professionals recommending and administering the HPV vaccine: Understanding the strengths and assessing the barriers. Denise Guadiana, Nolan M. Kavanagh, Cristiane H. Squarize
15. Kwan-Ho Yu J. ADA News- My View: Could vaccines come from your dentist? Not yet. Oct 21, 2019. https://www.ada.org/en/publications/ada-news/viewpoint/ my-view/2019/october/my-view-could-vaccines-come-fro m-your-dentist-not-yet
16. Gilkey MB, Calo WA, Moss JL, Shah PD, Marciniak MW, Brewer NT. Provider communication and HPV vaccination: the impact of recommendation quality. Vaccine. 2016;34(9):1187–92. PMID: 26812078. doi:10.1016/j.vaccine.2016.01.023.
17. American Dental Association Center for Evidence-Based Dentistry. Cancer prevention through HPV vaccination: an action guide for dental health providers. Chicago (IL): American Dental Association; 2018 Feb [accessed 2021 Jul 01]. https://ebd.ada. org/~/media/EBD/Files/DENTAL-Action-Guide-WEB_ADA.pdf? la=en .
18. Human papillomavirus and oral health Office of the Chief Dental Officer of Canada. CCDR. November 5, 2020 • Vol. 46 No. 11/12
About the Authors
Julian Perez is Chief Legal Officer at dentalcorp, where he oversees legal, regulatory compliance, corporate governance, and enterprise risk functions to support practices in the delivery of optimal patient care. He earned his bachelor’s degree from Yale University and a JD from Columbia University’s School of Law.
Michelle Budd works with dentalcorp’s Compliance & Risk Management team as a Patient Safety Consultant. She graduated from Western University with a Doctor of Dental Surgery degree and subsequently earned a Master of Public Health degree. Michelle has travelled throughout Canada to help dental practices achieve and maintain professional compliance.