Only one vaccine exists which has the power to prevent oral human papillomavirus (HPV): the HPV vaccine.

Every hour, someone dies of oral or oropharyngeal cancer. An estimated 54,000 cases will be diagnosed this year in the U.S. Of that number, 43% will not survive beyond five years, largely because these cancers are often discovered late in development. Those who do survive regularly face long-term consequences, such as facial disfigurement or trouble eating or speaking.

HPV is a commonplace disease. In the U.S., 80% will be infected with HPV at some point in their lives, and 43 million Americans have it now. Each year brings 13 million new infections. It is spread through skin-to-skin contact, and many may never know they are infected, as it often causes no symptoms. For the majority of people, HPV will go away without causing any problems — but it is impossible to tell who will develop complications and who will not.

HPV can lead to over six types of cancer. In addition to cancers it is associated with, such as cervical cancer, it is the leading cause of oropharyngeal cancer, 70% of which HPV causes in the U.S. With smoking on the decline, HPV is at fault for an increasing portion of oral cancers, too.

More than 150 different strains of HPV exist, but HPV-16 causes 60% of the oral cancers. Gardasil 9 has been the only HPV vaccine given in the U.S. It protects against type 6 and 11, which cause 90% of genital warts; types 16 and 18, high-risk strains that cause 70% of cervical cancers and an even higher percentage of other HPV-related cancers; and types 31, 33, 45, 52, and 58, which are all high-risk HPVs that account for another 10%-20% of cervical cancers. In short, it covers the majority of the HPV strains that cause cancers.

The CDC recommends giving the HPV vaccine routinely to children ages 11 to 12 and as early as age 9. If it is given on time between 9 and 14 years of age, two doses are recommended six to 12 months apart, ideally six. On or after 15 years, a three-dose regimen is recommended, with the second dose one to two months after the first, and the third dose six months after the first.

However, while most people associate this time frame purely with when they expect a child to become sexually active, and therefore conclude that 11 to 12 years old is too young, immune response is another key reason why the HPV vaccine is best given at such a young age. It’s best to receive the vaccine between the ages of 9 and 12 because the immune system at that age responds better, so better coverage is achieved. According to the National Foundation of Infectious Diseases, people below 15 years have twofold to threefold higher HPV antibody levels after HPV vaccination compared to those 16-26 years old. Despite this data, people older than 26 are still encouraged to get the vaccine, as they can still derive benefit.

The first HPV vaccine was given in 2006, and under careful watch from scientists and medical professionals alike, it has performed without incident since. In the U.S. 120 million doses have been given. No serious side effects have ever been recorded, and cervical cancer has dropped 88% since the vaccines became commonplace. The vaccine is effective prevention against 6 types of cancer, meaning about 34,000 cancers are prevented each year because of HPV vaccination.

Vaccination rates vary by state, with a high of 79% of adolescents up to date on HPV vaccination in Rhode Island. Missouri’s rate is only 53.6%, well below the national average of 58.6%, making Missouri 27th in the nation for HPV vaccination.

“Think about this for a moment,” said Dr. Jacqueline Miller, DDS. “What if you, as the dental professional, can be part of preventing cancers versus just diagnosing cancers?”

Recently, the Missouri Coalition for Oral Health hosted a webinar featuring speaker Dr. Miller, wherein she advocated for the role of dental health professionals in championing the HPV vaccine. A 2020 study in he Journal of the American Dental Association shows that 73% of parents feel that dental providers are trusted and qualified to discuss HPV. The American Academy of Pediatric Dentistry and the American Dental Association recommend educating patients, parents, and caregivers about the relationship between HPV and oral cancer and urge all dental personnel to support the use of the HPV vaccine. Dental providers already screen for oral cancer, Dr. Miller said, so why not take a more active role in preventing it?

Dr. Miller described a dental office where all personnel, from dentists to hygienists to assistants to front office staff, are on board with an HPV vaccination program. Dental clinics find success in these HPV vaccination programs when they make a plan and organize around engaging the patient with every person in the clinic. Plans can include steps like making informational pamphlets and posters available in the clinic and reviewing medical records to find patients who haven’t started or finished their HPV vaccinations and marking them for motivational interviewing.

What is motivational interviewing?

Motivational Interviewing (MI) is a patient-centered method which provides a collaborative approach to behavior change and provides a safe, non-judgmental, supportive environment. The role of the provider is to guide the patient in their decision and support the patient in achieving their goal. Patients can take control of their behaviors, and are therefore more likely to succeed in subsequent behavior changes. It helps patients accept responsibility for their health, with the goal of evoking a positive change within the patient, and is more likely to evoke lasting behavior changes in the patient. “MI is done for and with, not to and on,” said Dr. Miller.

To begin, the provider asks permission to broach the topic with the patient. “Try something like, ‘I see your daughter is due for her HPV vaccine. Would it be alright if we talked about that a little bit?’” said Dr. Miller. In doing so, the provider establishes a partnership with the patient by reinforcing that the patient retains control of the conversation and their own health. If a patient says they do not wish to talk about it, it is important to respect their decision instead of pushing the subject.

Partnership, acceptance, compassion, and evocation are key to MI. Partnership means communication with a patient as a partner to collaborate toward a goal; acceptance of the patient’s autonomy is understanding the patient’s perspective and not being judgmental, focusing on positive health behaviors and supporting them to change; and compassion is a deliberate commitment to actively promote the patient’s welfare and give priority to their needs. None of these principles are possible if the provider tries to steer the conversation against the patient’s will. Instead, the provider should focus on evocation, which is exploring what is important to the patient and how they would like to make a change, acting on what wishes are already present, rather than instilling an external mindset. In doing so, the provider is much more likely to facilitate lasting positive change in a patient’s behavior.

Of course, positive connections can be complicated to establish. Reflective listening is one useful tool to help a patient maintain an open and trusting mindset with a provider during MI. Reflective listening involves reflecting back to the patient the content and feeling that the provider is hearing from them, clarifying assumptions by using phrases like “so you mean” or “I hear you saying that” to ensure they understand the patient’s point of view. By repeating or rephrasing their comments, the provider expresses understanding and lack of judgment. It builds empathy while ensuring the provider can confirm that they understand what the patient is saying.

MI is also a particularly good tool for addressing any hesitancy around the vaccine. There are different levels of vaccine hesitancy among patients, ranging from minimal to extreme. The most common reasons for the greatest hesitation are, in order, concerns about safety and side effects, lack of necessity, mistakenly believing they are up to date, believing their child was too young to be sexually active and therefore didn’t need the vaccine, and lack of provider recommendation. Moderately hesitant patients listed safety concerns as their primary reason, but lack of provider recommendation came second, and in fact came first in minimally hesitant patients.

Tailoring conversations to the level of hesitancy may be more effective than addressing all patients with the same approach. Providers need to have information ready to answer many of these reasons for hesitation and common questions, such as why the vaccine is recommended for both genders, why it’s recommended so young, how it has performed over the millions of doses given, why it’s so important, and more. It is also important to ensure that information is presented in a way that considers the culture of the patient population.

Dr. Miller recommended paying attention to change talk, which is when the patient mentions their desire, ability, reason, and need to change their behavior. A person is more likely to make long-term change if they are invested in their own plan to make that happen. If a provider hears a patient or caretaker using language about their wants, needs, ability, or reasons for getting the HPV vaccine, that’s a green light to continue with making a vaccination plan.

However, if the provider hears discordant language instead, Dr. Miller said that needs to be addressed and resolved before trying to move ahead with a vaccination plan. Arguing, challenging, hostility, ignoring, non-answers, interrupting, negating, and pseudo-compliance are all examples of discord. If a provider hears these signals, they need to redirect the discussion so the focus stays on mutual, positive ground between patient and provider before continuing on with making a plan.

MI can sound complicated and intimidating, but in practice it is easier to understand. Dr. Miller showed a clip of a conversation demonstrating these techniques, which can be found at this link at 48:33.

Barriers and resources

Black women are commonly undervaccinated for HPV because providers do not recommend it to them as often as other women. Consider making whatever brochures or information that are available in the office about the HPV vaccine specifically address any local demographics that face similar challenges, said Dr. Miller.

Other barriers she acknowledged included political and time-based barriers. In more conservative areas of Missouri, all vaccinations have become politically charged, even vaccines which had been accepted in the past. Staff turnover can also be a problem when new members are not as informed as previous members were and may need training, and finding the time to plan and execute a whole-office HPV vaccination advocacy program can be challenging. However, with a full office committed to making a difference, Dr. Miller said, change is possible.

For parents with financial or insurance barriers to getting vaccines for their kids, Missouri has a Vaccines for Children program funded by the CDC. More information for providers and parents can be found here.

Examples and resources about creating an HPV immunization program and information in your dental clinic can be found here, including flyers and posters on page 7 that can be printed out and put around the office.