Abstract

Introduction

Dental clinicians are in a position to educate their patients on the subject of HPV as part of a primary healthcare multidisciplinary team and to detect HPV-related disease. Attention needs to be paid to dental undergraduate teaching on the topic. This study aims to ascertain awareness and opinions of our dental undergraduate students about HPV, its relation to oral health and its vaccine.

Method

A questionnaire was distributed to undergraduate dental students in clinical years 3, 4 and 5 of the BDS programme at Bristol Dental School.

Results

Dental students demonstrated an understanding of HPV and oropharyngeal cancer and expressed that they felt dentists should play a role in health promotion in relation to oropharyngeal cancers. They also wished for more teaching on the subject and suggested topic areas that they wished to know more about.

Conclusion

New teaching strategies on the topic of HPV should be considered for inclusion into undergraduate dental programmes and encompass both knowledge and communication skills training to prepare future dentists for their role in confronting this preventable disease.

Introduction

The human papilloma virus (HPV) is established as an aetiological risk factor for oropharyngeal cancer.1 The number of cases of oropharyngeal cancer in the UK has risen significantly over the last two decades with the age-specific greatest increase in incidence seen in the 40–69 year old age group2 and a similar increase in cases has been noted in other countries.3 HPV, in particular HPV–16, has seen a significant rise in association with oropharyngeal cancer over the last decade4 and is identified in approximately 50–60% of cases.2,4,5,6 HPV is thought to explain the pattern of oropharyngeal cases in the under 60, heterosexual, non-smoking, low alcohol drinking male cohort. Evidence suggests transmission of HPV is via high-risk sexual activity7 and is associated with the number of sexual partners and oral sex partners over a lifetime.8,9,10 Tumour HPV status is considered to be a major prognostic factor for patients with oropharyngeal carcinoma11 with survival for patients with HPV positive tumours being better.12,13 Management of patients with HPV-related oropharyngeal cancer is a high interest area of current research14 as effective treatment modalities differ from their non-HPV-related counterparts.

Oral health professionals can play a role in the prevention of HPV-related oropharyngeal cancers by educating patients about the risks of HPV transmission, instructing about lifestyle change and by encouraging patients and their relatives to participate in HPV vaccination programmes.15,16,17 There is a view in the United States that dental healthcare providers should be involved in education of their patients about HPV and its link to oropharyngeal cancers18,19 and some suggest oral health professionals should be at the forefront of confronting the 'HPV related oropharyngeal cancer epidemic'.18 Given that 28.9 million people accessed NHS dental care in the 24 months ending 31 December 2016,20 dental teams have a real opportunity to engage with a significant number of people about this escalating disease.

Since 2008, the current HPV vaccination programme in the UK has included girls aged 11–13, aimed at prevention of cervical cancers. Thus far, it is reported to have decreased cancer rates by 86% in those women eligible for the vaccination as adolescents.21 Many organisations, including the British Dental Association22 have successfully campaigned to include vaccinations for adolescent boys as well. The HPV vaccination became available for men who have sex with men in April 2018 after successful pilots in the UK23 and, most recently, the HPV vaccine has been proved to be cost effective in teenage boys and it is now to be offered to those in this cohort.24

Articles on the subject of HPV have been presented more recently in dental literature in the UK25,26,27,28 and a recent study concluded that UK dental students lack confidence in communicating with patients about HPV.29 It is clear that educational interventions are required to keep all dental professionals up to date with the rapidly changing landscape of oral and oropharyngeal cancer,30 in addition to training in communication skills to connect sensitively with their patients about potentially delicate subjects around sexual activity.

The present study has been conducted, as part of our teaching evaluation and development process, with an aim to ascertain the current awareness and opinions of HPV and its vaccine among our dental undergraduate students. The outcome of the study will inform the undergraduate dental teaching programme review process to ensure our students graduate to carry out effective health promotion on this subject.

Methods

A cross-sectional study was performed among undergraduate dental students in years 3, 4 and 5 of the five-year Bachelor of Dental Surgery programme at Bristol Dental School. A questionnaire (Appendix 1) was developed using previous literature8,29 and validated by means of a round table discussion. Ethical approval was obtained via the University of Bristol, Faculty of Medicine and Dentistry Ethics Committee.

The clinical dental undergraduate students were selected because all these students had received some teaching about HPV, the extent of which depending on which year of the programme they were enrolled in. The students were advised by email one week ahead of questionnaire distribution that they would be surveyed using a hard copy of the questionnaire at the end of a specified lecture. Students in all years were given the opportunity to leave without completing the survey. Questionnaires were deposited by students in a drop box after they had completed them. Completed questionnaires were immediately entered in to a secure password protected university accessed database. Descriptive analysis was applied to the data.

Questions were developed to acquire qualitative data to assess dental students':

  • Current awareness about HPV and its link to oropharyngeal cancer (yes/no answers)

  • Knowledge of the methods of HPV transmission (single best answer)

  • Knowledge of the current UK vaccination schedule (single best answer)

  • Opinions on the importance of the role that general dental practitioners play in health promotion related to oral and oropharyngeal cancer (four point Likert scale)

  • Views on how much more information regarding HPV and its vaccine they would like to be taught (4-point Likert scale).

In addition, a free text area was included to gain further information regarding what else students would like to know about HPV.

Results

Response rates

A total of 167 questionnaires were returned from the 211 students across the three clinical years, giving a response rate across all years of 79%. Students from third year responded highest with a 92% response rate, followed by year 5 at 74% and then year 4 with a response rate of 72%. The absolute number of responses follows this trend with 61, 55 and 51 responses respectively.

Responses to questions regarding HPV awareness

The results to the questions relating to students' awareness of HPV and its link to oropharyngeal cancer, awareness of HPV transmission and the HPV vaccine are illustrated in Figures 1, 2 and 3. There was a slight decrease in responses to individual questions. The questions represented by Figure 1 had two respondents not answer and Figure 3 lacked one answer. In summary: 93% of students knew HPV can cause oropharyngeal cancer, 71% knew it could be contracted via oral-genital sex and 83% correctly identified the cohort eligible for the vaccine under the NHS at the time. With regard to the latter point, half of those who responded incorrectly chose answers that included the correct cohort.

Figure 1
figure 1

Can HPV cause oropharyngeal cancer?

Figure 2
figure 2

How is HPV contracted?

Figure 3
figure 3

Who do you think receives the HPV vaccine in programmes within the UK?

Role of the dentist

Students were asked how important they thought the role of the dentist is in health promotion related to oropharyngeal cancer. In total 143 (86%) students responded that the role of the dentist was either important or very important. Only two students, both from year 3, responded that the dentist's role was not important at all. The results are illustrated in Figure 4.

Figure 4
figure 4

How important is the role of the dentist in health promotion regarding oral and oropharyngeal cancer?

Dental education

When the students were asked how much more they felt they needed to know about HPV and its vaccine, 139 (83%) of 167 responders answered 'some more' or 'lots more' as illustrated in Figure 5. Only three students (2%) felt they knew enough about HPV and its vaccine.

Figure 5
figure 5

How much more do you feel you need to know about HPV and its vaccine to inform your patients?

The free text answers to 'What more would you like to know about HPV and its relation to oral health?' were categorised into 'knowledge' and 'communication' themed comments. The responses are summarised in Table 1. Across all three years, there is a rough 2:1 ratio between students' desire for more knowledge of HPV and its vaccine and teaching in communication of these topics with their patients.

Table 1 Tabulated free text responses by year group as received verbatim

Respondents tended to show a desire for more knowledge in prevention, vaccination and risk management. With regards to communication, students desired teaching about how and what to be advising to their patients about HPV and its vaccination.

Discussion

The position that the oral healthcare professional has a role to play in health promotion regarding HPV, oral and oropharyngeal cancers and its vaccine, clearly resonates with our undergraduate dental students – all but one registered that it has importance. It follows that for this to be possible, knowledge of the virus and its sequelae should be taught to students so they can adopt this role when they begin to practice. It is worth noting that the question did not have an answer for equally important (that is, a shared responsibility) between the dental and medical team.

The question arises as to what dentists need to know about HPV, how they are expected to use that information to care for their patients, and indeed how much time is dedicated to this topic in a busy undergraduate dental curriculum. A learning outcome relating to health promotion and disease prevention in the GDC's dental undergraduate curriculum document Preparing for practice states that dentists are expected to 'provide patients with comprehensive and accurate preventive education' and 'underpin all patient care with a preventive approach that contributes to the patient's long-term oral and general health.'31 With no specific guidance available, some authors have attempted to propose a level of knowledge about HPV that dentists should aim for, focusing on understanding the pathophysiology of HPV and oropharyngeal cancer, associated risk factors and on available vaccination programmes.1,7,8 Others advocate that national organisations representing oral health professionals should develop campaigns to offer education on HPV as part of continuing professional development.18,30

In light of no reliable screening tools for oral HPV, prevention and early detection of disease is paramount. Education about lifestyle risk factors, vaccination programmes and the virus itself should be available to patients if they enquire, especially if the patient falls within the ever-expanding cohort of those who are offered the vaccination on the NHS. With respect to detection, practitioners should be able to identify oral and oropharyngeal carcinomas at their early stage and provide appropriate referral and council.

Most of the students (93%) surveyed had an understanding that HPV and oropharyngeal cancers are causally linked, however, just under a third – across all year groups – did not know that it could be contracted via oral-genital sex. This is significant as lack of knowledge about transmission may lead to patients being misinformed about their actual risk of the disease. Van der Valk and Walker17 found similar results in 2014, finding that two-thirds of newly qualified dentists in the Berkshire area felt poorly trained on discussing HPV with their patients. It is apparent then that there is a need for further education around this topic. A wider-reaching study including multiple institutions would be beneficial and may highlight places where students are very well prepared to deal with HPV.

Fortunately, the vaccination programme in the UK was better understood with 91% of respondents choosing an answer including the correct cohort. This is important because the danger with poor knowledge of vaccination programmes is lack of referral and education, not over-education or over-referral. However, this should not lead to complacency as new developments in the eligible vaccination cohort mean continued education is needed.

It is not just the author's opinion, however, that more teaching is needed here. The majority of our students expressed that they felt they needed to know 'some more' or 'lots more' about HPV and its vaccine (Fig. 5) to inform patients. There were many knowledge themed free text comments supporting this (Table 1) such as what are the 'risks and prevalence?' of HPV and 'what can we do to reduce the risk?' Acquiring this data about gaps in our students' knowledge is key to improving our teaching programme so that students are given the information they need to help educate their patients in the future.

Dental students are conventionally well trained in discussing risk factors related to oral cancer with patients, such as tobacco use and alcohol consumption,29 however, HPV and its relation to oropharyngeal cancer is a relatively new topic in the dental programme. There were several communication themed free text comments that demonstrated students may not be confident in communicating with patients about HPV, for example 'how do you talk to patients about HPV?' and 'when appropriate to bring this up with patients?' (Table 1). A recent study found that only 14% of dental students felt confident in discussing the risks of HPV in relation to oral health and 16% felt confident in advising on HPV vaccination programmes.29 It is not clear, however, that this is a function of students' lack of knowledge more than the fact that discussion of oral-genital sex, cancer and high-risk lifestyles is inherently difficult. Particularly when those patients are young girls and boys under the age of 18. The ability to broach these topics professionally and with confidence is unlikely to come from the classroom and more from dedication to communications teaching and experience in practice.

It is beneficial for patients and practitioners alike that dental education does not lag behind its practice, as some authors have alluded to in other areas of dentistry.32 Given that this is a quickly changing field, there is potential here for more modern and alternative teaching methods, such as online courses or seminars, that can be easily spread, digested at leisure and updated with new developments remotely. Further research into why students and dentists are not comfortable discussing the above topics, and indeed whether this feeling persists with veteran oral healthcare professionals, would help guide both content and teaching methods and delivery.

Conclusion

The rise in HPV-related oropharyngeal cancer is recognised by the dental profession and attention must be given to training in this topic in contemporary dental undergraduate programmes. The study highlights that, despite a good acknowledgement of the disease and its sequelae, students from the Bristol Dental Hospital would like further teaching regarding the communication and prevention of HPV. Undergraduate dental programmes should aim to incorporate training in knowledge about HPV, as well as communication skills teaching, focused on prevention, referring patients appropriately and answering patients' questions in order to educate them as part of a multidisciplinary primary healthcare approach to tackling this preventable disease. Future studies should assess novel ways to improve dental students' knowledge and awareness of oral and oropharyngeal cancer, including HPV as a risk factor, and examine methods to develop dental students' confidence in communicating with patients on the subject.