How to have the awkward conversation

New research into the link between oral sex and oral cancer could see dentists playing a pivotal role in treating and informing their patients. But what is the best way to approach this sensitive matter? By Zoe Meunier

Oral cancer—or, specifically, oro-pharyngeal squamous cell carcinoma (OPSCC)— is a condition causing significant morbidity and mortality. Its occurrence can be broadly divided into those linked to behavioural and oral-hygiene factors such as smoking and drinking, and those resulting from infection with high-risk Human Papilloma Virus (HPV), which is transmitted through oral sex.

“Exposure to, and transmission of, the Human Papilloma Virus through oral sex increases the risk of oro-pharyngeal cancer, and the rate of HPV causing oro-pharyngeal cancer is increasing,” says Professor Michael McCullough from the Australian Dental Association.

Dr Beata Rumianek, a Sydney dentist with a Masters in sexual health who specialises in this area, says the increase rate is dramatic.

“In the largest study conducted on the subject in the United States between 1988 and 2004, the incidence of OPSCC related to HPV increased by 225 per cent, but even this may be under-reported, with the Centre for Disease Control estimating 72 per cent of OPSCC may be associated with HPV,” says Dr Rumianek.

In a pilot study of 300 of her own patients, Dr Rumianek discovered two per cent of them tested positive for oral HPV, which is exactly the same virus that causes cervical cancer in women. In both cases, Dr Rumianek explains, the HPV virus normally gets cleared by the system in around one to two years, but for reasons unknown, in some instances it perseveres and can become cancerous.

Dr Rumianek says it’s too early to tell if the HPV vaccine is also protective against OPSCC and currently, there is no test available to diagnose oral HPV, which often displays no symptoms. Dr Rumianek is working on devising a test such as a rinse and gargle method to be able to screen for the disease, much like a pap smear does.

“If we develop a screening method for HPV in the oral cavity, this is where the dentists’ roles could become critical in the future, because we are often the only ones looking into the oral cavity unless the patient is complaining of a sore throat and has gone to a GP.”

“The dentists’ roles could become critical in the future, because we are often the only ones looking into the oral cavity unless the patient is complaining of a sore throat and has gone to a GP.”—Dr Beata Rumianek

Despite the lack of testing for HPV, dentists today still play a critical role in oral cancer screening, says Professor McCullough, with Dr Rumaniek urging dentists to be on the lookout when inspecting the oral cavity.

“Be aware and check the soft tissue. Look as far down the mouth as you can, the tonsils, the uvula, the phylangeal wall or the soft palate,” she says, explaining that any strange lesion that’s not healing should be considered suspicious and be biopsied, as opposed to the “typical benign HPV benign lesions, [which] have a warty, cauliflower appearance and can be present in the mouth, lips or tongue”.

Initiating the conversation

Requesting permission to perform an oral cancer screening can provide the ideal scenario for initiating what can be an awkward conversation about patients’ sexual health.

“The oral-cancer exam is a great opportunity to open the door for patient education… it is important that we talk to our patients about lifestyle risks that increase the risk of oral cancers,” says Professor McCullough.

“Talking your patients through the exam not only makes them aware of the high level of care you are providing, but allows you to discuss what you are looking for and the lifestyle factors that place them at risk.”

This also extends to other STDs of the mouth, with other common ones including herpes, chlamydia, gonorrhoea and syphilis.

Ask to learn, not teach

Naturally, talking about such intimate matters can be disconcerting for dentists, but Dr Mary Stewart from Family Planning NSW explains it should simply be expressed as a necessary facet of the patient’s overall health and wellbeing.

“I think as health professionals, dentists should gain confidence in asking a sexual history just as they ask a medical history when it is relevant. However, I don’t necessarily think it is the dentist’s role to educate their patients about safe sex.”—Dr Mary Stewart, Family Planning NSW

“I think as health professionals, dentists should gain confidence in asking a sexual history just as they ask a medical history when it is relevant,” she says. “However, I don’t necessarily think it is the dentist’s role to educate their patients about safe sex,” she adds.

“If a patient has a lesion that may be related to an STI, e.g. a primary syphilitic lesion, oral HPV or HSV, it is important to raise it in context. The simple strategies of normalising, justifying and asking permission can be achieved by saying something as simple as: ‘Sometimes lesions like this might be related to infections that might be transmitted sexually; I would like to ask you some questions about your sexual health; do you mind if I ask you some questions about your sexual health?’”

Dr Rumaniek had to ask some intimate questions of her patients in the course of her study and found to her surprise that her patients, were, on the whole, receptive and open to discussion.

“I was really worried about how people would react when I asked them about their oral sex practices for the study, but out of 309 patients that I approached, only nine refused,” she reveals. “I think dentists needn’t be worried that patients will react badly—people are understanding and when it comes to their health, they can accept a lot of things. If you explain what’s happening, why it is relevant and what it can cause, people will understand. I even had a lot of elderly patients, and everyone understood.”

Know your boundaries

While the role of the dentist is clearly growing and evolving, Professor Michael McCullough says it’s also important to understand the limits of what a dentist is able to examine and diagnose.

“There are three parts to the pharynx: the naso-pharynx, the oro-pharynx and the hypo-pharynx, which is also known as the larynx-pharynx,” he says. “None of these are the oral cavity and none of these are areas where a dentist can examine. Therefore, if patients complain about throat symptoms they should be recommended to see their doctor, or referred directly to an otolaryngologist for an examination.”


Invitation

If you would like to participate or assist Dr Beata Rumaniek in her upcoming study by contributing details about your patient population, please contact her on beata_rumianek@hotmail.com. She is particularly interested in hearing from dentists who have a high indigenous population. Participating dentists can be listed as co-authors of the study or can simply assist by allowing Dr Rumaniek access to their patient population.

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