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HPV: Oral Cancer Facts

HPV oral and oropharyngeal cancers are harder to discover than tobacco related cancers because the symptoms are not always obvious to the individual who is developing the disease, or to professionals that are looking for it. They can be very subtle and painless. A dentist or doctor should evaluate any symptoms that you are concerned with, and certainly anything that has persisted for two or more weeks. Although there are many adjunctive oral cancer screening devices and tests, currently none of them can find HPV positive oral and oropharyngeal cancers early. There are oral HPV infection tests on the dental market, and while they will find an oral HPV infection which as many as 26 million Americans have on any given day, (NHANES study, ongoing), that is no indicator that a person will cascade into an oral/oropharyngeal cancer. The foundation feels that while these tests find infections through a well-recognized testing protocol (PCR testing), since only about 1% of individuals that develop a high risk type oral HPV infection ever cascade into cancer, and that most often occurs decades after infection, that the utility of the test is highly in question when in it comes to providing meaningful and actionable information.  

The best way to screen for HPV related oral and oropharyngeal cancer today is through a visual and tactile exam given by a medical or dental professional, who will also do an oral history taking to ask about signs and symptoms that cover things that are not visible or palpable. Most of the symptoms of a developing HPV positive infection are discovered by asking questions not using a test, a light or other device to do so. Like other cancer screenings you engage in, such as cervical, skin, prostate, colon and breast examinations, opportunistic oral cancer screenings are an effective means of finding cancer at its early, highly curable stages. However like many other cancer screening techniques, this process is not 100% effective, is highly problematic in HPV origin disease, and any screening technique or technology can miss things. This is why it is so important that persistent problems, those which do not resolve in a short period of time like 2-3 weeks, are pursued until a definitive diagnosis of what it is, is established. Most of the time these will be issues that are not cancer, but persistent problems need to be addressed, cancer or not.

HPV Facts:

  • HPV is the most common sexually transmitted virus and infection in the US.
  • There are nearly 200 different strains of HPV, most of which are harmless and do not cancer. Out of all these, 9 are known to cause cancers, and another 6 are suspected of causing cancers as they are commonly found along with one of the nine we know to be oncogenic. In oral cancers, we are primarily concerned with HPV number 16 which is also associated with cervical, anal, and penile cancers besides those of the oropharynx.
  • You can have HPV without ever knowing it because the virus often produces no signs or symptoms that you will notice, and the immune response to clear it is not a process that you will be aware of.
  • Every day in the US, about 12,000 people ages 15 to 24 are infected with HPV. According to data from the ongoing NHANES study, approximately 26 million Americans on any given day have an oral HPV infection. Of those approximately 2600 are HPV16. The vast majority of individuals will clear the virus naturally through their own immune response, and never know that they were exposed or had it.
  • If you test positive for HPV, there is no sure way to know when you were infected with HPV, or who gave it to you. A person can have HPV for many years, even decades, before it is detected or it develops into something serious like a cancer. In the vast majority of infected people, even with a high-risk version of HPV known to cause cancers, they will not develop cancer.
  • Testing positive for an HPV infection does not mean that you or your partner is having sex outside of your relationship. It is believed to have long periods of inactivity or dormancy that may even cover decades; these are periods of time that you will test negative for it.
  • Sexual partners who have been together for a while tend to share all types of sexual infections. Typically if one partner has a fungal infection like Candida, the other partner has it as well, even though they may appear to be asymptomatic. The same is true of other common sexual infections like Chlamydia, a bacterial infection. HPV viral infections also are commonly shared. This means that the partner of someone who tests positive for HPV likely has HPV already, even though they may have no signs or symptoms. Like most Americans, their immune system will customarily clear it in under 2 years.
  • Condoms may lower your chances of contracting or passing the virus to your sexual partners if used all the time and the right way. However, HPV can infect areas that are not covered by a condom- so condoms may not fully protect against HPV.
  • Because of its ubiquitous nature, the CDC says that more than 80% of Americans will have an HPV infection in their lifetimes. For most of us, this occurs late in our teens and twenties when our sexual activity is the highest and the number of partners is likely the greatest.

HPV and Oral Cancer:

  • HPV is the leading cause of oropharyngeal cancers; primarily the tonsils, tonsillar crypt, the base of the tongue (the very back of the mouth and part of what in lay terms might be called a part of the throat), and a very small number of front of the mouth, oral cavity cancers. HPV16 is the version most responsible, and affects both males and females.
  • More males than females will develop oropharyngeal cancers. This understanding was elucidated and the reason revealed for it in a published study by Gillison et. al. Through conventional genital sex, females acquire infection early in their sexual experiences, and rapidly within very few partners, seroconvert that infection into a systemic antibody that protects them through life. Males take a far greater number of sexual partners to seroconvert an infection into a systemic protective antibody. This increased number of partners and exposure before the development of a protective antibody against the invading virus is most likely the reason that more males will later in life develop oropharyngeal cancers than females. 
  • In public messages for simplicity, OCF frequently speaks about oral cancers in general. Scientifically, this is actually anatomically divided up into the oral cavity and the oropharynx; two distinct anatomical sites though they are one continuous space. Each anatomical site has different statistics, infections, disease etiologies which dominate that location, and outcomes from treatment are different in each location. The fastest growing segment of the oral and oropharyngeal cancer population are otherwise healthy, non-smoking individuals in the 35-55 age range. When you consider both anatomical sites, the growth is in oropharyngeal HPV positive cancers primarily. 
  • White, non-smoking males age 35 to 55 are most at risk, 4 to 1 over females.
  • In the oral/oropharyngeal environment, HPV16 manifests itself primarily in the posterior regions (the oropharynx) such as the base of the tongue, the back of the throat, the tonsils, the tonsillar crypts, and tonsillar pillars.

Risk Factors:

  • Number of sexual partners- The greater your number of sexual partners, the more likely you are to contract a genital HPV infection; and when engaging in oral sex, this also holds true for oral infections. Having sex with a partner who has had multiple sex partners also increases your risk.
  • Weakened Immune Systems- People who have weakened immune systems are at greater risk of HPV infections. Immune systems can be weakened by HIV/AIDS or by immune system-suppressing drugs used after organ transplants.

Oral Cancer Signs and Symptoms:

This list considers both oral cancers from HPV and those from tobacco and alcohol

  • An ulcer or sore that does not heal within 2-3 weeks
  • A red, white, or black discoloration on the soft tissues in the mouth
  • Difficult or painful swallowing. A sensation that things are sticking in the throat when swallowing
  • A swollen but painless tonsil. When looking in the mouth, tonsils on both sides should be symmetrical in size
  • Pain when chewing
  • A persistent sore throat or hoarse voice
  • A swelling or lump in the mouth
  • A painless lump felt on the outside of the neck, which has been there for at least two weeks.
  • A numb feeling in the mouth or lips
  • Constant coughing
  • An ear ache on one side (unilateral) which persists for more than a few days.

How do people get HPV?

  • HPV is passed on through skin to skin genital contact, most often during vaginal, anal and oral sex.
  • You are more likely to get HPV if you have many sex partners or a sex partner who has had many partners.
  • Many people don’t have symptoms and are unaware that they have HPV. They will be equally unaware when the clear it through natural immune responses to it. 
  • The virus may be inactive for weeks, months and for some people possibly even years after infection.

What does that mean for my health?

Partners usually share HPV. If you have been with your partner for a long time, you probably have HPV already. Although HPV is the most commonly transferred sexual infection, in most people it is cleared by the immune system in under 2 years. Individuals with persistent infections are at risk for several types of cancers depending on the location of the infection. When considering the entire US population of over 300 million people, the incidence rate of oral cancers from it are still relatively rare mathematically, though the media frequently likes to state that this is an epidemic. In terms of oral and oropharyngeal cancers (which in 2017 about 50,000 Americans will get) the rapid increase in them is certainly alarming. The trend line since the early 1970’s has been a steep upward climb. With proper use of the HPV vaccination in our youth, we should see progress against this trend in future generations. 

How common is HPV?

HPV is the most commonly sexually transmitted infection. The CDC estimates that there are 6.2 million new infections each year in the United States. The vast majority of Americans will have some form of HPV early in their sexual experiences. Since it is so common, there is nothing to be ashamed about. If you are diagnosed with HPV, talk to your health care provider about it. HPV’s are divided into 9 high risk types and more than 150 others that either cause benign warts, or do nothing at all that we know of at all.

How do I know if I have HPV?

The only way to know if you have an HPV infection is if your health care provider tests you for the virus. For females, in relationship to cervical discovery, this may be done directly from the Pap test cervical exam or by using an additional swab at the time of the Pap test. The CDC now recommends an HPV test for women along with the pap test as a matter of routine. Oral HPV testing in both men and women is problematic. While there have been some commercial tests available in the dental community, the value of this testing is not clear, and testing positive on any given day for an oral HPV does not prove persistence of the infection, which is what we are really concerned about. There are no visible oral signs of an HPV infection. There are no viricides or other drugs to kill it. There are also no established genital tests for men. There are anal brush cytology tests for those that engage in anal sexual practices. Those tests can be early predictors of HPV caused anal cancers.

Is there a cure for HPV?

There is no cure for the virus. Most of the time, HPV goes away by itself within two years and does not cause health problems. It is only when HPV stays in the body for many years, usually decades, that it might cause these oral cancers. Even then, it is a very small number of people that will have an HPV infection cascade all the way into an oral malignancy, though that number is increasing every year by about 10%. It is not known why HPV goes away in most, but not all cases. For unknown reasons there is a small percentage of the population whose immune system does not recognize this as a threat and it is allowed to prosper. Although HPV can increase the risk of developing some types of cancer, most people who have HPV do NOT develop cancer.

HPV Vaccines

Two vaccines known as Gardasil and Cervarix protect against the strains of HPV that cause cervical cancers (HPV16 and 18), Gardasil also protects against other versions that cause genital warts (HPV6 and 11). A new version of the Gardasil vaccine protects against 9 versions of HPV. Millions of young girls in the US and in developed countries around the world have been safely vaccinated with an HPV vaccine. Because the original clinical trials were done only on cervical cancers, the FDA restricts the manufacturers from talking about other potential positive implications of these vaccines in different anatomical sites that HPV is known to infect. Since these vaccines block people from ever getting HPV16, it is not much of a scientific leap to extrapolate that to “if you can’t get the virus, you can’t get things the virus might cause”. Using this logic, many in the science community, including the CDC, and every major cancer treatment center in America, recommend vaccinating to protect people from the various different cancers associated with the virus such as oropharyngeal and anal cancers. The foundation also believes this to be highly worthy of doing, and has advocated at the CDC for vaccination of boys (finally winning their approval for pediatricians and other doctors to do so), not only to more quickly help reach the point of “herd immunity” in our country; protecting our next generation from HPV caused cervical cancers, but also to offer protection from other HPV cancers as well including oropharyngeal.

The National Advisory Committee on Immunization Practices recommends routine HPV vaccination for girls and boys ages 11 and 12, as well as individuals ages 13 to 26 if they haven’t received the vaccine already. While not part of the original approval for use, today the Gardasil vaccine has also been approved for use in boys and men, ages 9 through 26 years old. For adults the age range has been extended from 27 to 45 years old. The value of vaccination at a later stage of life might be higher in those who have had a limited number of sexual partners in their lifetime than others. These vaccines are most effective if given to children before they become sexually active. If you have already been exposed to a particular version of HPV, the vaccines will not work for you in preventing issues from that version, though if you have had few sexual partners there is a chance that one of the versions of HPV that the vaccine covers, you have not been exposed to yet.  So vaccination at pre-sexual ages brings the most protection.

Source: https://oralcancerfoundation.org/understanding/hpv/hpv-oral-cancer-facts/

HPV Center of America and Dr. Abbadessa
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HPV Center of America
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