Interprofessional Collaboration: HPV Infection and Oral Cancer – PediaCast CME 097

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Description

  • Drs Homa Amini, Mary Ann Abrams, and Kyulim Lee visit the studio as we explore human papillomavirus (HPV) infections, the cancers they cause, and prevention strategies for reducing risk. We hope you can join us!

Instructions to obtain CME/CE Credit

  1. Read this information page.
  2. Listen to the podcast.
  3. Complete the post-test at Nationwide Children’s CloudCME.

Topics

  • Interprofessional Collaboration
  • Human Papillomavirus (HPV) Infection
  • HPV Vaccine
  • Oral Cancer

Presenters

Learning Objectives

At the end of this activity, participants should be able to:

  1. Describe the epidemiology of human papillomavirus (HPV).
  2. Understand the impact of HPV infection and associated sequela.
  3. Discuss the importance of and recommendation for HPV vaccination.
  4. Outline opportunities for interprofessional collaboration between medical and dental professionals for HPV education and vaccination.

Links

Disclosure Statement

  • No one in a position to control content has any relationships with commercial interests.

Commercial Support

  • Nationwide Children’s has not received any commercial support for this activity.

CME/CE Information

  • In support of improving patient care, Nationwide Children’s Hospital is jointly accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for the healthcare team. (1.0 ANCC contact hours; 1.0 ACPE hours; 1.0 CME hours)
  • Nationwide Children's Hospital has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. Approval is valid for 2 years from the date of the activity. PAs should only claim credit commensurate with the extent of their participation.
  • As a Jointly Accredited Organization, Nationwide Children's Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Nationwide Children's Hospital maintains responsibility for this course. Social workers completing this course receive 1.0 continuing education credits.
  • Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.

Contact Us

  • CMEOffice@nationwidechildrens.org

 

Episode Transcript

Announcer:     This is Pediacast CME. Welcome to Pediacast CME, a pediatric podcast for providers. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr Mike Patrick:     Hello, everyone, and welcome once again to Pediacast CME. It is a continuing medical education podcast for healthcare providers. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.

Dr Mike Patrick:     It's Episode 97. We're calling this 1 Interprofessional Collaboration, HPV Infection, and Oral Cancer. I want to welcome all of you to the program. Yes, our title today is a mouthful, but it's all going to make sense and come together here in just a couple of minutes. We have talked about our joint accreditation on this program frequently.

Dr Mike Patrick:     So you understand that we offer continuing medical education credits for physicians, of course, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And we really do our best to take a deep dive on every topic that we present, because our goal is to make the content relevant to everyone who takes care of kids, regardless of your role in the medical machine. And I think this works best when we do have multidisciplinary collaboration or interprofessional collaboration. And in the past, we have had nurse practitioners and pharmacists, psychologists, social workers, athletic trainers, and dentists all have made contributions to this program in the past. And today we have a really important collaboration between dentistry and primary care pediatrics as we consider HPV infections, the cancers they cause, and prevention tips that we should all be embracing as we care for kids, teenagers, and their families.

Dr Mike Patrick:     So that's the reason for the title. We really wanted to hammer home the interprofessional collaboration piece of this because you know, when different disciplines come together and have a message for parents and families, and when that message is aligned with 1 another, and so parents and families and our patients are getting the same information regardless of if they're at the dentist office, if they're at their primary care, if they're in an urgent care, in an emergency department. We are all using evidence and current standards of care to operate in a manner that is easy for parents to understand when they get different viewpoints. And this is especially important when you consider how much misinformation is out on the internet and how it how easy it is for families to really get confused, especially when messages are not lining up. So in this case, messaging is a very important part of interprofessional collaboration.

Dr Mike Patrick:     And today we're going to talk about HPV infections because they're not only associated with cervical cancer, but also cancers of the oral cavity. And that is why the dentists are also very interested in preventing HPV infections so that we can also prevent cancers in the oral cavity. It's important to screen for these cancers and even in childhood because from the onset of an HPV infection until that infection actually turns into malignant cancer, typically is about 10 years. And so, you know, if you have a baby who's infected with HPV through the birth canal, they may end up being a 10 year old with a cancerous lesion in their mouth. And so that's why it's really important, even though we don't see oral cavity cancers very often in children, it is still possible and something that we should really be screening for, not only by your medical doctor, but also by your dentist.

Dr Mike Patrick:     And in fact, oral cancer screenings are now really an important part of routine dental care, even in the pediatric population. So today we're going to explore more on the topic of HPV, oral cancers and their prevention again in the pediatric population. We have a couple of terrific guests this week. Dr. Mary Ann Abrams is with Primary Care Pediatrics at Nationwide Children's Hospital And Dr.

Dr Mike Patrick:     Q. Lee is a pediatric dentist at Nationwide Children's. And we have a fantastic co-host this week as well, Dr. Homa Amini. She is also with pediatric dentistry at Nationwide Children's Hospital.

Dr Mike Patrick:     Few quick reminders, Don't forget you can find us wherever podcasts are found and we really like it when you leave reviews For the podcast or the others who come along looking for free continuing medical education credit in the world of pediatrics They'll know what to expect. So those reviews are helpful and speaking of that CME credits really easy to claim yours Simply listen to the podcast which you are about to do and then head over to the show notes for this episode, episode 97, over at pdacastcme.org. You'll find a link to the post-test in the show notes. Follow that link to Cloud CME, take and pass the post-test, and the Category 1 credit is yours. So pretty easy.

Dr Mike Patrick:     When you get to Cloud CME, you're going to need an account, and it's free to sign up for that account And then when you hit the landing page for a particular episode You're gonna want to click on the materials link up at the top and once you're in the materials That's where you'll find the post test So try to make it as easy as we could but there's not a way to link Directly to the post test without going through that materials link first and I should mention you know, we do offer credit to all of these professionals that I have mentioned, physicians, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And since Nationwide Children's is jointly accredited by all of those professional organizations, It's likely we offer the credits you need to fulfill your state's continuing medical education requirements. Of course, you want to be sure the content of the episode matches your scope of practice. Complete details are available at pediacastcme.org. Also want to remind you the information presented in every episode of our podcast is for general educational purposes only.

Dr Mike Patrick:     We do not diagnose medical conditions or formulate treatment plans for specific individuals. And your use of this audio program is subject to the Pediacast CME Terms of Use Agreement, which you can find at pediacastcme.org. So let's take a quick break. We'll get our expert guests and co-hosts settled into the studio. And then we will be back to talk about interprofessional collaboration, HPV infections, and oral cancer.

Dr Mike Patrick:     All of that is coming up right after this. Dr. Mary Ann Abrams is a primary care pediatrician at Nationwide Children's Hospital and an assistant professor of pediatrics at The Ohio State University College of Medicine. Dr. Q.

Dr Mike Patrick:     Lee is a pediatric dentist at Nationwide Children's and an assistant professor of dentistry at Ohio State. They both have a passion for preventing cancers caused by human papillomavirus and are strong advocates for the prevention of these cancers with the HPV vaccine. Our discussion today will be led by Dr. Homa Amini. She is also a pediatric dentist at Nationwide Children's and a professor of dentistry at Ohio State.

Dr Mike Patrick:     So let's give a warm Pediacast welcome to our guests, Dr. Marianne Abrams and Dr. Kyu Lee. Thank you both so much for being here today.

Dr Mary Ann Abrams:     Hi, Mike. It's great to be here again. Good to see you.

Dr Kyulim Lee:     Thank you for having me.

Dr Mike Patrick:     Yeah, absolutely. We are really, really excited to talk to you guys. And then before we get into it, let's welcome our guest co-host today, Dr. Homa Amini. Thank you so much for your hard work pulling this episode together.

Dr Homa Amini:     Thank you so much, Mike. It's a pleasure to be co-hosting this episode of PDICast with you.

Dr Mike Patrick:     Yes, I'm really excited about it. We have worked together on other educational endeavors over the years, and I'm really excited that we're able to put this 1 together. So, Homa, without further ado, I will hand the reins over to you and let's get to it.

Dr Homa Amini:     Homo Abedegian Thank you for the invitation, Mike, and it's a pleasure to be co-hosting this episode of Pediacast with you. Just a bit of background about the HPV and dental arena that in the past couple of years, many professional dental associations like American Academy of Pediatric Dentistry and American Dental Associations have really put effort in promoting HPV and increasing the awareness among dental providers. Also, at the national level, we know that the Congress has introduced legislations related to prevent HPV cancers, which is focused on public awareness campaign and also increasing the education for healthcare providers in prevention and treatment. And this is our, Peter Kast today is focused on interprofessional collaboration with having our pediatrician and a dentist here to talk about it. So Marianne, let's start with some of the basics and talk about what is HPV and how is it transmitted?

Dr Mary Ann Abrams:     Well, great, thanks. HPV, I think it was relatively new to non-lab people, et cetera, 15, 20 more years ago, and then emerged once we started to realize how it could potentially be prevented. Now, I don't mean that we weren't studying it and paying attention to it, because it's a very important virus that causes and can lead to serious cancers. But to back up just a little bit, it's helpful to know that HPV is a DNA virus. And 1 of the challenges related to that is that it has over 200 serotypes, meaning there's more than 200 different kinds of the viruses that can affect different parts of the body and different kinds of living organisms.

Dr Mary Ann Abrams:     Fortunately, HPV itself is the only 1 that affects humans, but it still has a lot of serotypes. And It is a major cause of infection, but 1 of the most important things to differentiate is that it's the disease that it can lead to that causes our health burden. So there are these different serotypes of HPV that tend to gravitate to different parts of the body. Generally, those are the skin, the anogenital area, and then oral mucosa, and sometimes the respiratory epithelium for young children. It's transmitted, primarily it's a sexually transmitted disease.

Dr Mary Ann Abrams:     It's transmitted also by skin to skin contact, deep kissing, occasionally by fomites. But that is very uncommon and certainly not a major concern in terms of serious disease and outcomes. But it's important, I think, to keep in mind that it's this infection versus disease that makes HPV so important and what we're gonna be talking about later in terms of screening and preventing it and our work together with our dental colleagues and others. Just by way of a little bit more background on transmission, the infection, most people are infected by sexual activity and infected pretty relatively quickly after their sexual activity debut. So that within a year or 2, depending on when people become sexually active, chances are quite good that they've acquired 1 of the HPV viruses.

Dr Mary Ann Abrams:     And seldom do they have symptoms unless they develop rest-aneogenable warts, which we'll talk about in just a minute. And most of those infections clear up on their own. Half of them are gone within a year. Most of them are gone in 2 to 5 years. And it takes about 10 years for the more serious outcome of HPV infection, which is cancer and precancerous lesions to start to show up in the body.

Dr Mike Patrick:     Marianne, if I could interject really quickly with transmission, is transmission from mother during childbirth to the baby, is that an issue? Because then, you know, 10 years later, the kid's 10 years old and maybe they have an oral cancer that we need to be watching for.

Dr Mary Ann Abrams:     I think it's more related to acquiring it during the birth canal, during the delivery process in the birth canal. They can have respiratory papillomatosis, which involves these papules that can cause respiratory symptoms and compromise. It can be something that occurs a little bit later. They may present with hoarseness or other symptoms. And they're still looking at, you know, whether amniotic fluid, it's been detected in amniotic fluid, So is there some in utero transmission, et cetera?

Dr Mike Patrick:     Yeah. So it's not something we can just discount in the pediatric population. Even if someone's not sexually active, there is still the potential for transmission and disease.

Dr Mary Ann Abrams:     Yes. And I guess it's helpful to know that people have different descriptions for what sexual activity is. It's not just intercourse. It can be like we've talked about deep kissing and lots of all other behaviors related to sexual activity. It's the closeness, the proximity of the skin to skin contact, the skin to mucosa contact.

Dr Homa Amini:     Thank you, Maryann. So can we talk a bit about the epidemiology and the clinical manifestation, how prevalent it is, who gets it, and that information.

Dr Mary Ann Abrams:     Yeah, as I mentioned earlier, the different types of HPV have that predisposition. So the skin, the cutaneous exposure can lead to a variety of warts, the common warts that we talk about, other serotypes predisposed to the anogenital area, and can lead to benign genital warts or condyloma acuminata, which are not pleasant, but They are also benign. And then there's a variety of inogenital cancers, the vaginal, vulvar, cervical, anal, and the penis. And then oral mucosa, which I know Dr. Q is going to talk about quite a bit in a few minutes, along with that respiratory papillomatosis that we just touched on.

Dr Mary Ann Abrams:     The biggest area that we tend to focus on is cervical cancer, and that is a very prominent disease worldwide and in the US. What happens is some of the serotypes have a gene that, or proteins that integrate into the genome, and that's what leads to the cancer. So those subtypes are type 16 and type 18. They account for 50% and 20% of cervical cancers. And then there's about a dozen other subtypes, some of which we can also address when we talk a little bit more about the vaccine.

Dr Mary Ann Abrams:     So those integrate into the host genome. In the United States, there's about 36,000 plus females and males who are diagnosed with HPV-related cancer each year, 11,000 cervical cancers diagnosed per year, and about 4,000 female women die of cervical cancer each year. Some good news, and we're getting a little bit ahead here because we're going to be talking about the vaccine is we're starting to see some decreasing trends when we look at the presence of high-risk HPV and precancerous lesions among young women in their 20s and basically mostly in their 20s and starting to see some decrease in that prevalence since the vaccination has been introduced and is increasingly being used although not as often as we would like.

Dr Homa Amini:     Focusing on oral cavity, Q, would you please explain how does HPV affect the oral cavity and what would we expect to see?

Dr Kyulim Lee:     Yeah, so Mary-Ann did a really good background on HPV in general. I'd like to sort of add to that and focus a little bit more on the oral cavity presentation. So from the 200 types of HPV that's been identified, and you know, we just discussed by Mary Ann, from those, more than 40 types can spread through direct sexual contact to the genital areas. And This includes, in addition to that, to the mouth and the throat. Most common way of oral HPV transmission is through oral sex, so genital oral method, or through that deep kissing method that Marianne mentioned.

Dr Kyulim Lee:     But it can be transmitted through non-sexual ways. And we talked about how a lot of people are exposed to HPV in their lifetime and have that oral HPV infection. So majority of these sexually active individuals can get infected with HPV at least once in their lifetime. But again, most of the infections are transient, they're subclinical, they resolve 1 or 2 years after without the individuals being even aware with any symptoms. But others will have HPV infections that will persist.

Dr Kyulim Lee:     And so the HPV presentation in the oral cavity then can vary. So it could range from asymptomatic infections to benign warty lesions or potentially malignant lesions. And this is really dependent on the HPV type. So whether that is from that low-risk type or the high-risk type. So for example, we have the low-risk mucosal HPV types like the HPV6 or HPV11.

Dr Kyulim Lee:     Those cause the benign lesions. Squamous papilloma is 1 of the most frequently seen benign oral epithelial lesions in both children and adults. These present as like these whitish exophytic projections. They're also sometimes described as cauliflower-like. These present in the oral cavity, specifically in the palate or the tongue.

Dr Kyulim Lee:     Another HPV benign lesion that Marianne alluded to is chondyloma cumulonimbum. This presents mostly as an anogenital wart, but it can actually present in the oral cavity as well, although it's not really common. The high-risk HPV types can cause various cancers. Total, there's about 12 high-risk types, and among these, the HPV16 and HPV18 is the 1 that's mostly been associated with HPV-related cancers. This includes the squamous cell carcinoma in the oropharyngeal region.

Dr Kyulim Lee:     HPV-16 is known to cause over 80% of oropharyngeal squamous cell carcinoma, And this specifically refers to the cancers in the back of the throat, which involves the base of the tongue, the tonsils, the uvula, as well as the south palate.

Dr Homa Amini:     Thank you. So what are some of the risk factors that are associated with HPV-related oropharyngeal cancers?

Dr Kyulim Lee:     So the major risk factors for oral cancers and oropharyngeal cancers are alcohol consumption, tobacco use, as well as heavy use of the combination of both. But for oropharyngeal cancer specifically, HPV infection is the major risk factor. If you look at the data now, approximately 70% of cancers and the oropharynx are caused by HPV infection. And if you look at the incidence trend of oral and oropharyngeal cancer, It's pretty interesting because the incidence of non-HPV-related oral cancer is actually decreasing and this is thought to be partially due to the decreasing rate of smoking. But on contrary, we're actually seeing an increase in HPV-related cancers specifically.

Dr Homa Amini:     Talking about the health consequences, can you expand on some of the oral health consequences associated with oral cancer and oral pharyngeal cancers?

Dr Kyulim Lee:     So once you're infected with the high-risk type of HPV, it can take years for that HPV-infected cells to become precancerous or cancerous. It really depends on the type of the HPV, the presence of the risk factors that we just talked about, the ones, you know, medical history, their immune status. But there are several symptoms that individuals can experience when they have oropharyngeal cancers, such as having that, like, feeling of persistent mass in the throat or the neck, having a sore throat that doesn't go away, difficulty in swallowing, speaking, chewing, changes in the voice that they feel or having that hoarseness of the voice. Differently, oral cancers can also present as lumps, bumps, and lesions in the mouth. And these can present as precursor oral lesions at first.

Dr Kyulim Lee:     Some of them present as leukoplakia, which are like white lesions or white patches. Sometimes they can be erythroplagic, which are more of the red lesions. Some lesions can be combinations of these 2 features. And these oral mucosal lesions have a risk of becoming cancerous or may already be cancerous. So it's really important to get those lesions evaluated or biopsied, especially if it doesn't resolve in 2 weeks.

Dr Kyulim Lee:     Now if we're talking about treatment, treatment for oral and oropharyngeal cancers can involve like the surgical excision with radiation therapy and a combination of that with chemotherapy. Another newer type of treatment is the targeted therapy, which is like use of drugs that precisely target the cancer cells. There's also immunotherapy, which is a treatment that will work with the body's immune system to improve their immune function and sort of attack the cancer cells. The treatment route is then really dependent on the location of the cancer, the size, the type of the tumor, whether it has metastasized or not, and the overall health of the patient. And because head and neck cancer, so that includes oral and oropharyngeal cancers, because these are really hard to detect in its early stages, it's often advanced when it's diagnosed.

Dr Kyulim Lee:     And when you look at the survival rate, the relative survival rate, according to American Dental Association or ADA, the five-year relative survival rate for those with localized oral and oropharyngeal cancer diagnosis is 85% compared to only like 40% in patients whose cancer has already metastasized. So early diagnosis has a significant impact on the treatment route, as well as the outcome, but most importantly, the overall quality of the life of these patients.

Dr Homa Amini:     It sounds like it has significant morbidity and mortality associated with HPV-related cancers. So talking, you mentioned detection, switching gears, talking about the detection and diagnosis. Maryann, what are some of the screening methods that are available right now for cervical cancer or oral cancer detection?

Dr Mary Ann Abrams:     Well, for HPV-related cervical cancer, which is about 90% of the cervical cancers in the US, we are fortunate that we do have good screening techniques and they've been in place for some time. And there are recommendations for screening put out by the US Preventive Services Task Force, the National Cancer Institute, and those are all reconciled with ACOG and CDC and other professional associations and bodies. The 2 main ways to screen are the Pap test or Pap smear. That's if you use it by itself, it's recommended every 3 years and that obtains cervical cells and that cytology is examined to look for cell changes, precancers, that would then lead to further evaluation like colposcopy and biopsy and staging if indeed it's a malignant or precancerous lesion. So that is a well-known screening tool, very effective, and is recommended to start at 21 years regardless of sexual activity and regardless of HPV vaccination status.

Dr Mary Ann Abrams:     And the reason it can start when somebody's in their 20s is it takes about 10 years or longer for these changes, these cancerous, pre-cancerous and cancerous changes to start to show up and reveal themselves. The other screening test is HPV testing, which is collected basically the same way, And it actually tests for infection of those cells with the high-risk HPV serotypes that directly cause cervical cancer, especially type 16 and 18. And then some people do co-testing every 5 years, looking at the PEP and the HPV tests. And that's another way to add some additional perspective, I suppose, on the risk of cervical cancer or pre-cancer. Again, some people, there are some recommendations for more frequent screening for some people if they're HIV positive, have a weakened immune system or a recent abnormal biopsy or screening test or a history of cervical cancer or diethylstilbestrol exposure before birth, which took place mostly in the 1970s, so probably not a high-impact issue in pediatrics at this point.

Dr Homa Amini:     Great. So How about in dentistry, Q, what do we have as far as screening methods that are available to the dentists who can use in diagnosing oral cancer?

Dr Kyulim Lee:     So currently there are no standard screening tests for oral pharyngeal cancer. But over the years, there has been more like emphasis from the dental community and playing for us to play a role in promoting prevention and early detection of oral and oropharyngeal cancers. Again, 2019, the American Dental Association actually adopted a policy for this specifically. So recommending education and doing routine visual exams to screen for these cancers in all of the patients. So this is a change from previous recommendations, which were limited to doing all of this in patients that were more just at risk of getting oral cancer based on their history of tobacco and alcohol use.

Dr Kyulim Lee:     But now it's recommended that the dental team performs these routine general oral cancer screening exams in all patients. And that involves like evaluating various parts of the mouth very thoroughly, including the lips, all the intraoral mucosal tissues, all the gingival tissues, all of the surface of the tongue, the floor of the mouth, heart and soft palate, trying to see as much as to the back of the mouth as well. And if something is concerning, like I mentioned before, it's really important to get it evaluated and biopsy to get a definitive diagnosis. And you know, we keep emphasizing the importance of early detection of these cancers, and this push is not really only from American Dental Association. There has been more recent initiatives at the NIH level, where National Institute for of Dental and Craniofacial Research and National Cancer Institute has partnered together to share resources and support research to help improve early detection of all head and neck cancer.

Dr Kyulim Lee:     So these are all very important advances to improve the treatment and outcomes of our patients, especially given that, you know, we don't really have a standardized screening tool at this time.

Dr Homa Amini:     Yeah, now that you made the point that we really, sometimes it can be challenging to diagnose, especially for oral cancers and oropharyngeal cancers because we don't have that tool. Let's talk about prevention. It seems like the prevention is very important. And, Mary Ann, can you talk about the HPV vaccination, a little bit about the history, its efficacy, and when should the patient get the vaccine, and what are the possible common side effects?

Dr Mary Ann Abrams:     Happy to do that. We're very fortunate that we have a very effective, very safe HPV vaccine. We've had the initial 1 had covered 2 serotypes, then 4, and the current vaccine, which was licensed in 2015, covers 9 serotypes and is the only 1 that's available now in the US. And it's known as Gardasil 9, which is the trade name. And the nice thing about Gardasil 9 is that it covers the main serotypes that are related to the high-risk cancer-causing serotypes, HPV 16 and 18, and then 6 and 11, which also cause a lot of disease, and then 5 other serotypes that are also more likely to cause serious disease.

Dr Mary Ann Abrams:     It's important to know that the vaccine is for prevention. And a lot of people probably in the lay community probably view it as perhaps even a treatment. So maybe I can get it after I've got HPV infection or HPV-related disease and cancer, but it has no treatment effect, no therapeutic effect. It doesn't hasten getting rid of any of the serotypes that would go away on their own, and it doesn't prevent progression of disease. But it is excellent at prevention, which is what we're talking about.

Dr Mary Ann Abrams:     The many studies have been done with thousands of people enrolled in those studies that have looked at its efficacy, its immunogenicity, and when they look at seroconversion by antibody, those seroconversion rates range in the 90 to 90, 93 to almost 100% seroconversion. The younger the vaccinated person is, the higher and the more likely that seroconversion is. And it's also what we've seen in terms of efficacy, we are starting to see decreases in cervical cancer incidence and other HPV-related disease. And there's a really positive, there are data to support another positive part of this, that we are seeing some evidence perhaps of herd immunity. So we're starting to see some decrease rates among people who have not been vaccinated, which is a really positive thing.

Dr Mary Ann Abrams:     And the other pieces, and we'll talk about this in a little bit too, there's a fair amount of vaccine, HPV vaccine hesitancy. And so we haven't achieved the target goals for HPV vaccination among adolescents. But even though we're not there yet, we are seeing these positive signs of declines in serious disease. So that's all really positive. It's important to recognize that the vaccine is most effective at a younger age and prior to the sexual debut of people becoming sexually active.

Dr Mary Ann Abrams:     It's more effective, and because people tend to get, to acquire HPV infections so soon after starting sexual activity, the idea of giving it at a younger age is to provide that immunity before they're exposed. And that's a little bit of a complex thing to think about, but it does, if we can communicate that clearly, I think that really does help with some of the questions that people ask about, well, why are you talking about this with my 9 or 10 or 11 year old? And we will talk a little bit more about that. So the vaccine is routinely recommended on the US Advisory Committee for Immunization Practices endorsed by the American Academy of Pediatrics and Family Medicine and ACOG and CDC and all those associations that it's part of the U.S. Vaccine schedule.

Dr Mary Ann Abrams:     So we should start young adolescents at 11 to 12 years of age as part of routine vaccination. But we can also start it as young as 9. And there's nothing wrong with doing that. The persistence of protection does not seem to be affected, and there's no data at this point to show loss of protection. The good news, if you start before you're 15, you only need 2 doses at 0.0 and then 6 or 12 months later.

Dr Mary Ann Abrams:     And if you're 15 years or older, then you need a three-dose schedule so you get an extra dose in there. So that's a universal recommendation. There's also a universal recommendation to do catch-up vaccination for anybody who's not adequately vaccinated up through age 26 years old. So say somebody's an older adolescent or young adult and they've not been vaccinated or They only got 1 dose, catch them up through age 26. Starting at age 27, the benefit of vaccinating people at that age declines because most of them have been exposed already, but the recommendation is to use shared decision-making to provide the vaccine.

Dr Mary Ann Abrams:     And there are some groups that should probably more strongly consider it. And that would be people who have not been sexually active or are maybe changing to a new or constantly acquiring new sexual partner, so their risk of being exposed goes back up. And there are some recommendations that some healthcare workers who might have repeated exposure to the vapors involved with surgical excision or ablation of HPV-associated lesions should consider vaccination. The vaccine is not licensed over the age of 45, so there's no recommendations for providing it at a later age. And if you do get into that little bit, that shared decision-making range, there may be some insurance coverage questions as well.

Dr Mary Ann Abrams:     In general, the vaccine is not recommended during pregnancy, but for women who've been inadvertently vaccinated during pregnancy, there are no data to show any problems with an impact on the fetus or the baby. There's a registry for tracking those patients long-term to confirm those data. It's okay to get the vaccine during if you're breastfeeding and it's very safe. So it's not a live vaccine. That's 1 thing.

Dr Mary Ann Abrams:     There were lots of stories and misinformation on the internet about death and loss of fertility and premature ovarian failure. And no studies have demonstrated any association of the vaccine with those kinds of outcomes. That's in thousands of people in very long-term clinical trials and with over 100 million vaccine doses distributed in the US. So the most common side effects really relate to redness and erythema, swelling and pain at the vaccination site, and the risk of fainting and syncope following a vaccine. So the recommendation is to watch someone, have them wait for about 15 minutes after the vaccine before they leave.

Dr Mary Ann Abrams:     So you don't have an inadvertent chance of somebody fainting and falling and hitting their head. But the syncope piece has been observed, I think, with HPV vaccine, but some people faint when they get a vaccine of any kind or a needle stick. So we also have ongoing monitoring for safety. So the US has a whole lot of half dozen different vaccine safety monitoring systems, the VAERS and others. And no serious safety events associated with the vaccine have been detected.

Dr Mary Ann Abrams:     And I know we'll talk a little bit more about some of those other concerns about vaccine hesitancy as well.

Dr Homa Amini:     It's great that we have such an effective and safe vaccine available to us. How are we doing with HPV vaccination in the U.S.?

Dr Mary Ann Abrams:     Well, we're making slow strides, but we're moving forward. The data that we look at for teen vaccine coverage is the National Immunization Survey, and there's a specific survey that looks at adolescents. So we are trying to achieve an 80 percent vaccination target among the adolescents who are age 13 to 15 who have received the recommended number of doses of the vaccine. So whether it's 2 or 3, and we've looked initially at just having 1 dose, but the main Healthy People 2030 goal is to look at fully vaccinated. And what we've seen in the data from 2018 through 2021, an increase overall from 48% up to 58.5% in 2021.

Dr Mary Ann Abrams:     And that's what makes some of those results that we're seeing in terms of seeing some declines in those precancerous and cancerous lesions already showing up even with suboptimal vaccination.

Dr Homa Amini:     So given that we still have a way to go with our vaccination rate, what are the barriers and challenges and how can we improve HIV vaccination rates?

Dr Mary Ann Abrams:     So as we know, there's general, there's quite a bit of vaccine hesitancy and vaccine resistance in the U.S. At this point. But there are some specific concerns that people have and had about HPV. And some of their studies, they looked at what were those main concerns. And there were sort of 5 areas of HPV vaccination that concerned parents and caregivers.

Dr Mary Ann Abrams:     The safety, I've already talked about a lot of those unfounded concerns that don't get borne out by the data, that they don't perceive the vaccine as needed. It's like, what's this new vaccine? I haven't heard of it. I don't know anything about it. And that's coupled with the third reason, which is the healthcare provider never recommended it, or if they did recommend it, it was sort of half-hearted, or yeah, there's this new vaccine, do you wanna get it?

Dr Mary Ann Abrams:     Okay, we can talk about it later. Not giving our full endorsement the way we would to some of our other vaccines that are very important as well. And then back to some of those points that I made earlier about its effectiveness at younger ages and for prevention. Our role in conveying that knowledge to the parents has not been well fulfilled, I would say, because not knowing and understanding the relationship of the vaccine and the relationship of timing and how you can really make a long-term impact on cancer rates, especially cervical cancer, wasn't meshing for parents to really understand its importance. And then the final area is sort of concerned about my child isn't sexually active or can't we deal with that when they're older, they're too young to start talking about it.

Dr Mary Ann Abrams:     So there's been a lot of work done to improve vaccine uptake and acceptance. And some of the things we found that are really important, and I just alluded to this, is our role as healthcare providers to make a clear, strong, and affirmative, presumptive recommendation for the vaccine. So instead of saying, well, we've got several vaccines, what do you want to do about them? To say, your son or daughter is due for their tetanus and diphtheria booster and their HPV vaccine today. And to be clear that it's just like any other vaccine.

Dr Mary Ann Abrams:     Also things like making sure that everybody on your team is conveying the same message that it's important, it's safe, it's effective, and millions of people have gotten it without any problem. And that consistent messaging I think is very reassuring. I personally witnessed healthcare settings where some staff kind of say, I wouldn't get it if it was my child, which goes a long way toward discouraging acceptance. If people have concerns, answer them honestly and clearly. You can use motivational interviewing if they're still resisting vaccine.

Dr Mary Ann Abrams:     Having standing orders or policies for your practice like standing orders can be helpful, and then looking at motivating providers with some of our other motivating and reminding, you know, giving reminders, having EMR alerts, looking at your vaccination coverage data and tracking that and giving feedback over time are some other ideas.

Dr Mike Patrick:     Maryann, when this vaccine first came out, it was only recommended for females. And then a few years later, the recommendation came out that this really should be for everyone and as we think about oral cavity cancers, obviously, you know, both men and women can get those. So can you just comment, it's a really strong recommendation for both women and men, correct?

Dr Mary Ann Abrams:     Yes, that's a really good point. The overall effectiveness of the vaccine in decreasing primarily cervical cancer, but other cancers, because men also get anal genital cancers and oral cancers. The analysis looking at the cost effectiveness and the disease burden, etc., clearly recommend that adolescents of all genders receive the vaccine for their own health benefits and to protect the health of their partners and other, and we're seeing the benefits of that in the data that we talked about earlier, where we're seeing some reduction in these infections and diseases, even among people who aren't vaccinated. So the role of transmission looks like it's impacted as well.

Dr Homa Amini:     So talking, I mean, we've been trying to promote HPV vaccine by all professionals, healthcare professionals, and specifically talking about the dental professionals. Q, what do you foresee as the challenges that are present in a dental setting, and what can we do to help address those barriers?

Dr Kyulim Lee:     So I think oral health professionals are very well positioned to play an important role in HPV education and having that discussion about HPV vaccination. We see our patients way more frequently throughout the year, which gives us the opportunity to more frequently educate our patients on the HPV infection as well as to talk about the vaccine. But, of course, like Maryann mentioned about the barriers that are present in the medical setting, we also have that as well. There was a study that was published in Journal of American Dental Association last year that specifically looked at the barriers to HPV-related discussions in the dental setting. And what we found there is that, you know, although it is recommended by the American Dental Association, as well as the American Academy of Pediatric Dentistry to counsel our patients for the HPV vaccine early on, generally The oral health care team felt like there was just lack of training and knowledge to be able to do this appropriately.

Dr Kyulim Lee:     So we're generally not involved in the actual vaccination process. So historically, we don't get that adequate training to engage patients in conversations about the HPV vaccination. We also feel like we don't know, we may not know enough about the vaccine itself or answer questions about cost or insurance coverage if those questions were asked by the parents. Some also felt like they didn't know enough about the misinformation on the side effects and the risks associated with the vaccine, or even know enough about where to refer or guide our patients if they were to express interest in getting the vaccine. Some other barriers that were reported in that study and that we see in our practices is providers generally feel uncomfortable talking about sexual history with our patients and the families.

Dr Kyulim Lee:     There's also reports of fear of offending the patients and the parents while you're having that conversation. Another important barrier that we see and that was reported, and 1 of the reasons why we're doing this today, is about the perceived roles. So generally, oral health professionals were and are unaware or they're unsure whether they can play that role in discussing and recommending the HPV vaccine because, you know, we think that the physicians would be doing this. And in addition to that, time is also a factor. Having that conversation or incorporating that conversation about the HPV vaccination to an already busy clinic flow, there was some hesitancy about that as well.

Dr Kyulim Lee:     But I think there are many opportunities that we can work on to improve this. I think 1 of the very first steps is now shifting and thinking that the dentist and the dental team have, they have that role to help promote HPV vaccination and also, you know, educate our patients about this. 1 way we can start already is, you know, doing this when you're doing the oral cancer screenings. So, this can be a great opportunity to educate our families and our patients and why we're doing this oral cancer screening exam, talk about HPV infection in general. And this all sort of very closely ties into our efforts in promoting the oral health of our patients and emphasizing that oral and systemic connection, health connection, is you know, really important.

Dr Kyulim Lee:     Another way that we can address some of the barriers is setting the culture in your office about the topic of HPV infection and HPV vaccination. It's like Maryann talked about it. It's also very important that we send the consistent message about the HPV vaccine. The same message should be emphasized and reinforced by all members of the dental team that includes like dental assistants, dental hygienists, the front desk staff. I think that's very important to be able to consistently see the message about how HPV vaccination is important.

Dr Kyulim Lee:     Having like posters, brochures, or pamphlets, like educational materials that we can share with our patients and families, that could also be very helpful. And we can go over a little bit of those more in detail later on.

Dr Homa Amini:     Great, so we're talking about the role of dental providers and medical providers, and our focus is also on interprofessional collaboration. So what does interprofessional collaboration look like within the medical and dental fields? Maryann, if you wanna take it first or Q.

Dr Mary Ann Abrams:     Sure. I think what we're doing today is a perfect example. You invited me to join you for this podcast and working, I've already had the pleasure of working with you, but working together on this particular aspect, I think has provided us with a lot of conversations about, well, what does this look like? How could we do this? How can we foster this?

Dr Mary Ann Abrams:     How can we help each other? And how can we help figure out how to work this into an already busy workflow. And I know Helma is going to describe some of the work that she's done to help with that. But just like we say, we want to make sure everybody on our own healthcare or dental care team is consistent and on the same page. I think there's a lot of value in the medical, the pediatricians and family medicine docs and the dentists and our colleagues, our teams saying the same thing.

Dr Mary Ann Abrams:     I think, I imagine it would be a surprise and pretty eye-opening for a parent or even an adolescent to have their dentist bring this up. Like, why are you talking about this? Oh, yeah, my other doctor said something about that, but I didn't know. And now you're talking about it and you're talking about cancer and blah, blah, blah. I think there's a lot

Dr Kyulim Lee:     of potential in that synergy and reinforcing and using some of these same resources and being comfortable talking about it and allaying people's fears. Yeah, there are a lot of educational resources that's on websites, and this is all helpful to sort of help promote HPV vaccinations, resources that we can use as providers and also the ones that we can provide to our families and patients, but also to educate our staff and providers as well about the HPV vaccine and a little background about that and about HPV infection in general. There are educational materials in like national federal agency websites like CDC. A lot of national organizations have a lot of information and materials like ADA, American Dental Association, AAP, AAPD, where you can directly download these pamphlets and educational materials and also like posters that you can put in your offices or share with the families and patients. There's also CE courses that's available through the CDC if you want to get that additional knowledge and training about the vaccine.

Dr Kyulim Lee:     I was actually going through the CDC website and I remember listening to this presentation on HPV recommending HPV vaccination. And there was an example that they gave about why we need to recommend HPV vaccine early on and how can we have that dialogue, that conversation with parents. And they gave a great metaphor that I still remember, which is how they compared HPV vaccination, why they need to get it at an early age for prevention purposes. And they compared that to a child, you know, when should they wear a bike helmet? And the question was, you know, why do you need the vaccine at age 11 or 12 years old, or even as early as 9?

Dr Kyulim Lee:     And that same thing as the question of, like, when should the kids wear the bike helmet? And the answers were, 1, you know, before they get on their bike. 2, as they're riding their bike in the street, 3, was when they see a car heading directly towards them, and 4, the fourth answer was after the car hits them. So I think that was a great example that I saw on the CDC website on 1 of the presentations they gave. So point of the story is there's a lot of great resources out there that you can use to train yourself as well as your staff and then also share with your patients as well.

Dr Kyulim Lee:     We can also take advantages of like the months and specific days that we have for like cervical cancer awareness day, awareness month actually, and that's in January. There's also international HPV awareness day, and I think that's like sometime in March. On those days specifically, you know, we can have providers or the dental teams or medical teams focus on highlighting HPV infections, raising awareness about it, motivate the staff and the team to sort of talk about that more with the families and maybe set goals or something like that. Another opportunity where interprofessional collaboration can happen is the actual referral part of the, for the HPV vaccination. So for patients who see that they would like to get vaccinated, you know, as dentists, we can 1, send them to their primary care physician or any public health clinics or pharmacies as well.

Dr Kyulim Lee:     But that all sort of depend on, I think, state regulations. If at that point they see that they haven't seen their PCP in a couple of years, or, you know, especially these like teenagers, then I think it's important for the dentist to have that conversation with those patients and families and reinforce that that's pretty important, you know, how about you go get a wellness check and then at the same time get that vaccine. And depending on where you practice, another way to explore interprofessional collaboration might be to work together to sort of streamline that direct referral between the dental and the medical teams if a patient wants to be vaccinated that day. So that could be sort of something that we can all brainstorm together to make that a little bit more easy for that patient.

Dr Homa Amini:     Thank you. This has been a very informative session. I know Maryann alluded to some of the things that we have done internally and locally to prepare our trainees for the future, specifically when it comes to talking about HPV. And I want to say that Maryann has been involved in almost all of them. 1 of them was developing some videos, videos that kind of depict, simulate the conversation between a dentist and a patient, a teenager patient and a mother who are talking about HPV and how do you bring it up and how do you talk about it and also engaging the staff in that conversation.

Dr Homa Amini:     That was 1 example. We also used simulated patients to get our residents trained and make them feel comfortable in talking about it. On a national level, the ADA, American Dental Association, had had a health literacy essay contest, and the goal of it was to bring attention to health literacy and HPV, specifically training the pre-doc dental students. And 1 of their topic was why your dentist wants you to get the HPV vaccine. And then other things that we have done internally was, or Miriam actually can chime on that, we had a health literacy conference, which was focused on oral health literacy.

Dr Homa Amini:     And I was 1 of the guest speakers on this panel. And we talked about oral diseases and specifically HPV and talking about how it impacts your body and your mouth and cancers and how we can use health literacy concepts to kind of bring that concept up. And Marianne, you can expand on all of this because I know you have been involved and also you are doing some QI projects internally within your department and primary care network to increase the rate of vaccination locally.

Dr Mary Ann Abrams:     Yeah, I just want to applaud Homa for her vision and leadership in all of these projects. And it's fun and great to work together, interprofessionally collaborating on those HPV dental videos, where we also integrated health literacy and plain language and teach-back when we were depicting those different scenarios and also conveyed some of the provider responses to the parent in that video who was very resistant to the vaccine and then ultimately, of course, accepted it because the dentist did a great job. Also, the panel discussion, it was a part of our work in health literacy, but it was put together by a colleague at Columbus Public Health, and it was attended, it was a hybrid, So there were in-person and virtual people. So it was a public health audience, an oral dental health audience, and a physician and medical group. And distinctly, I was virtual, but I still remember it was a really effective panel.

Dr Mary Ann Abrams:     And it covered a lot of topics, but the HPV discussion was quite good. And I think it probably opened the eyes of some of the other people that were there. Here at Nationwide Children's, our primary care network has improving HPV vaccination coverage as an important quality improvement goal and trying to take advantage of opportunities to vaccinate and have their applying evidence-based strategies using this announcement or this presumptive approach to providing the vaccine and also having what amounts to sort of standing orders to give the vaccine. And we're seeing increases just over a relatively short period of time in people given who accept and receive the vaccine. So that's been a really positive step.

Dr Mary Ann Abrams:     So I'll kind of pause there. I know I've also worked with you on some other projects like the Empathy Project, which also brings the perspective of a family who does not speak Spanish in a Spanish-speaking clinical setting to build empathy among the healthcare team about those struggles as well. So back to you, Huma.

Dr Homa Amini:     Thank you, Maryann, and thank you, Q. And thank you, Mike, for allowing us to talk about this important topic. I think we still have a way to go to promote HPV vaccination, specifically in dentistry and for all my oral health professional colleagues that are out there. This is something we can do and we need to do. And this interprofessional collaboration should be ongoing and to make our kids better and healthier.

Dr Mike Patrick:     Yeah, I agree. This has been such a wonderful conversation. And I've actually learned a lot just listening to you guys talk about this. And I really didn't realize that there was so much of a push within the field of dentistry to think about this, but I love it. I just love that.

Dr Mike Patrick:     And when parents are getting the message from their primary care physician and from their dentist, you know, hopefully both of them being in sync with the message, then we can get more, more kids vaccinated. And you know, as I think about this, you know, from a parent point of view, when we talk about these vaccines, when they're resistant, oftentimes it's because they really do have their kids' best interest in mind. Like they're worried, is something going to go wrong with this vaccine? Or do we not know enough about it? And you know, who's making money off of it?

Dr Mike Patrick:     And then all these questions come up. And of course, regardless of what your thoughts are, you're going to find people with similar thoughts on the internet that kind of feed into what you already believe, whether that thing is true or not. And I think from a science standpoint, we're really seeing that, you know, vaccines are for sure the benefit outweighs the risk. And it's just a matter of, of trying to convey that to families. And I think the more of us that are, you know, have that message, regardless of if you're a physician or a dentist, the families are hearing the same thing and hopefully they will trust us and get the vaccines for their kids.

Dr Mike Patrick:     Because really, when we talk about all of these vaccines, we want them to be protected before the actual thing comes. So you could say like, why are we talking about this for a nine-year-old? But you know, why are we talking about measles for a 12-month-old? Because we don't know when in the future there's going to be exposure. And so we want kids to be protected before that exposure happens.

Dr Mike Patrick:     And of course that is the same, you know, with pre-adolescence. And as they're going into the age where they may become sexually active and there's a higher risk for the transmission of HPV. And then the other thing I wanted to mention is there 1 of the things that really kept people from getting it, I feel like was this whole, some kids would hold their breath and get have panic attacks and, and pass out. And then the more that you, that gets in the news, that this is something that happens and in parent boards and on YouTube and TikTok and all these things, if you think that maybe you're gonna get lightheaded when you get a shot, it's likely that that is gonna happen. And it doesn't mean that the shot did it, really being exposed to all that misinformation is what did it.

Dr Mike Patrick:     And so I think, especially 5 years ago or so, I feel like that was a really big problem, but I feel like maybe there is more acceptance. And hopefully that is just from this, the same message, you know, being pushed out over and over from all of us. And I think that's such such an important thing. And you guys did a wonderful job sort of conveying that message today. So I thank you very much.

Dr Mike Patrick:     So once again, Dr. Maryann Abrams with Primary Care Pediatrics at Nationwide Children's and Dr. Q. Lee with Pediatric Dentistry at Nationwide Children's. Thank you both so much for stopping by and chatting with us today.

Dr Mary Ann Abrams:     Thank you, Mike. It was great to be with my colleagues and you today.

Dr Kyulim Lee:     Thank you, Mike, as well. And thank you, Mary Ann. I learned a lot through you 2 and while preparing for this interview too. So overall, everything was very enjoyable. So I'm really grateful for this opportunity and to join this team.

Dr Kyulim Lee:     So thank you all.

Dr Mike Patrick:     And also Homa, Amini, thank you again so much for co-hosting. You did a fantastic job of guiding this conversation and getting everybody prepared for it. We really do appreciate your work as well.

Dr Homa Amini:     Thank you, Mike. It's been a pleasure and a pleasure working with my colleagues and we'll continue to chip at it.

Dr Mike Patrick:     We are back with just enough time to say thanks once again to all of you for taking time out of your day and making Pediacast CME a part of it. Really do appreciate that. Also thanks again to our guest co-host this week Dr. Homa Amini with Pediatric Dentistry at Nationwide Children's Hospital and also thanks to our guests Dr. Marianne Abrams with Primary Care Pediatrics and Dr.

Dr Mike Patrick:     Q Li with Pediatric Dentistry, both from Nationwide Children's. In our usual fashion, we are going to have lots of links for you in the show notes. So if you head over to pdacastcme.org, look for episode number 97, and you will find links to pediatric dentistry at Nationwide Children's also primary care pediatrics. And we have information for you from the centers for disease control and prevention on HPV infection and HPV vaccines. Also information from the American Cancer Society on human papillomavirus and also information from the Oral Cancer Foundation.

Dr Mike Patrick:     So lots of links. There'll be some other stuff there. So head over to the show notes at PDAcastCME.org and this is episode number 97. Also don't forget you can find us wherever podcasts are found. We're in the Apple and Google podcast apps.

Dr Mike Patrick:     I Heart Radio, Spotify, SoundCloud, Amazon Music, YouTube, and most other podcast apps for iOS and Android. Our landing site is PDA cast CME dot org. You'll find our entire archive of past programs there along with show notes our CME information our terms of use agreement and The handy contact page if you would like to suggest a future topic for the program reviews are helpful wherever you get your podcasts We always appreciate when you share your thoughts about the show. And we love connecting with you on social media. You'll find us on Facebook, Instagram threads, LinkedIn, and Twitter X.

Dr Mike Patrick:     Simply search for Pediacast. So you've listened to the podcast. Now be sure to claim your free category 1 continuing medical education credit. It's an easy thing to do. Simply head over to the show notes for this episode at pdacastcme.org.

Dr Mike Patrick:     You'll find a link to the post-test in the show notes. Follow that link to Cloud CME. Take and pass the post-test and the category 1 credit is yours. Once again, you do have to click the materials link to find that post-test. And again, we do offer credit to many pediatric professionals, including doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.

Dr Mike Patrick:     Of course, you want to be sure the content of this episode matches your scope of practice. Complete details are available at pediacastcme.org. Also don't forget about Plain Pediacast. It's our evidence-based podcast for moms and dads. Lots of pediatricians and other providers also tune in as we cover Pediatric news, answer listener questions, interview pediatric and parenting experts.

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