2013 self-study course four course

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ABOUT this FREQUENTLY asked COURSE… QUESTIONS… Q: Who can earn FREE CE credits? . READ the MATERIALS. Read and review the course materials. A: EVERYONE - All dental professionals in your office may earn free CE contact . COMPLETE the TEST. Answer the credits. Each person must read the eight question test. A total of 6/8 course materials and submit an questions must be answered correctly online answer form independently. for credit. us . SUBMIT the ANSWER FORM Q: What if I did not receive a ONLINE. You MUST submit your confirmation ID? answers ONLINE at: A: Once you have fully completed your p h o n e http://dent.osu.edu/sterilization/ce answer form and click “submit” you will be directed to a page with a 614-292-6737 . RECORD or PRINT THE unique confirmation ID. CONFIRMATION ID This unique ID is displayed upon successful submission Q: Where can I find my SMS number? of your answer form. t o l l f r e e A: Your SMS number can be found in the upper right hand corner of your

1-888-476-7678 monthly reports, or, imprinted on the back of your test envelopes. The SMS number is the account number for ABOUT your your office only, and, is the same for f a x FREE CE… everyone in the office. 614-292-8752 Q: How often are these courses . TWO CREDIT HOURS are issued for available? successful completion of this self- A: FOUR TIMES PER YEAR (8 CE credits). e - m a i l study course for the OSDB 2012-2013 [email protected] biennium totals. . CERTIFICATE of COMPLETION is used to document your CE credit and is mailed to your office. w e b . ALLOW 2 WEEKS for processing and www.dent.osu.edu/ mailing of your certificate. sterilization Page 1 HUMAN PAPILLOMAVIRUS 2013 Dental health professionals encounter HPV derived processes on a daily course basis. There are more than 40 types of HPV that can infect the genital areas as well as the mouth and throat. The objective is to equip dental four health professionals with the basic knowledge of the infection, its clinical manifestations, diagnostic procedures, prevention and management.

INTRODUCTION Human papillomavirus (HPV) is a DNA that has the ability to infect epithelial cells of the skin and mucous membranes. More than one hundred types of the virus have been identified. Each type has a unique genetic sequence of the outer capsule. Most forms of HPV are recognized to infect the mucosa and are classified as high risk or low risk based on their ability or inability to cause . in Oral Cavity Source: Paul A. Volberding, MD, University High risk HPV is associated with of California in San Francisco almost all forms of cervical cancers, is the most common sexually 50% of vulvar cancers, 65% of transmitted disease in the U.S. at vaginal cancers, 35% of penile present, with over 20 million cancers, 95% of anal cancers and people currently infected and 60% of oropharyngeal cancers. Low increasing by 6.2 million infections risk human papillomaviruses are every year. 64% of sexually active common, harmless, non-cancerous, females between the ages of 15-24 and, are primarily responsible for are affected. inducing benign and warts. Over 30 types of HPV have been identified in the mouth. Most HPV infects the basal layer of the lesions produced by the virus are . For most people, the benign and of little significance. written by infection is asymptomatic and While HPV has been identified in a amber kiyani, dds resolves spontaneously. However, in significant number of oral cancers, a small percentage of people, the there is doubt about the virus may persist causing warts, significance of its role in the papillomas and, in rare cases, edited by pathogenesis. cancers. rachel flad, bs According to the Centers of Disease HPV can be transmitted through karen k. daw, mba, cecm Control and Prevention, about sexual contact, non-sexual human 8,400 people in the United States contact, saliva, breast milk or, very are diagnosed with oropharyngeal rarely, though vertical transmission. cancers that may have been caused Approximately 79 million Americans by HPV. These cancers are three are currently infected with HPV and times more common in men than about 14 million people become women. infected each year. Anogenital HPV Page 2

SQUAMOUS Squamous papilloma is a benign papillary process of the oral cavity that is linked to HPV. It is one of the more common lesions of the oral mucosa and is attributed to low risk HPV subtypes 6 and 11. Squamous papillomas have low virulence and infectivity. The incubation period for the virus can be up to 12 months before any visible signs of infection are seen.

CLINICAL FEATURES: The lesions are seen in both men and women with an equal frequency. The lesions can be identified in individuals of any age group. Tongue, lips and soft palate are commonly involved. Verruca Vulgaris Source: Dr. Carl Allen, The Ohio State University College of Dentistry The lesions appear as small, solitary, painless papules or nodules with finger-like projections that may appear either pink or white in the oral cavity. papillary projections. Verruca vulgaris grows Their bases may either be pedunculated (growing rather quickly until a final size is attained. The off of a stem) or sessile (attached directly). The lesions are usually small and may have a lesions may grow up to 3.0 cm in rare instances. pedunculated or a sessile base. It is not unusual TREATMENT: to have cutaneous warts simultaneously. Although the lesions are benign and have no TREATMENT: reports of malignant transformation, conservative Conservative excision is the treatment of choice surgical excision is the recommended form of for oral lesions. Cutaneous warts may resolve treatment to rule out lesions of significance spontaneously, however, persistent warts may mimicking this benign process. The excised tissue require excision, removal by cryotherapy or must be submitted for histologic examination. keratolytic agents. VERRUCA VULGARIS Oral lesions must be submitted for histopathology. This helps in attaining a (COMMON ) definitive diagnosis and rules out presence of Verruca vulgaris is a common cutaneous epithelial more significant pathology. process of the skin that is rarely seen in the oral cavity. It is associated with virus subtypes 2, 4, 6, CONDYLOMA ACUMINATUM and 40. Because the lesions are highly infectious, Condyloma acuminatum, also known as venereal the transmission of the virus to the oral cavity is wart or anogental wart, is primarily acquired usually by self-inoculation. through sexual contact and accounts for over CLINICAL FEATURES: 20% of all sexually transmitted infections. Low risk human papillomavirus types 2, 6, 11, 53, and While the lesions are seen across all age groups, 54 are commonly found in these lesions. High risk they are most commonly encountered in young types 16, 18, and 31 may also be identified less children. Fingers, arms and feet are common sites frequently. The prevalence of condylomas of cutaneous infection. appears to be higher in immuno-compromised In the oral cavity, lips, labial mucosa and the tongue individuals such as those with HIV. Please refer to are frequent sites of involvement. The oral lesions the section “HPV in Patients with HIV, beginning appear as painless, white nodules with rough on page 6, for more details.

Page 3 HECK’S DISEASE (MULTIFOCAL EPITHELIAL HYPERPLASIA): Multifocal epithelial hyperplasia is a HPV-derived epithelial process. Human papillomavirus types 13 and 32 are linked to this condition.

DEMOGRAPHICS: It is seen more commonly in Native Americans and Inuit. It is usually seen in children, and females appear to be more affected than males.

CLINICAL FEATURES: The lesions associated with Heck’s disease characteristically appear as small, round papules Condyloma Acuminatum Source: Dr. Carl Allen, The Ohio State University College arranged in clusters that imparts a cobblestone of Dentistry appearance to the mucosa. Sometimes a papillary CLINICAL FEATURES: architecture may be noted. The papules are Oral infection may result through oral sexual symptomatic. Labial, buccal and lingual mucosa practices and, in rare instances, through vertical are commonly involved. The lesions may also be transmission. The incubation period for the virus is seen less frequently on the gingiva, palate and between 1 to 3 months. The lesions are seen most tonsils. In rare instances, conjunctival frequently on the labial mucosa, soft palate and involvement has also been reported. lingual frenum. They appear as pink, exophytic, TREATMENT: (outward growing) masses with sessile bases and short, blunted papillary projections. Multiple Most of the patients with this condition undergo lesions may be present at one time, usually in the spontaneous regression. For persistent lesions form of clusters. The lesions are usually much larger and cosmetic purposes, surgical removal, laser than a papilloma and may attain sizes as large as 3 ablation or cryotherapy can be employed. cm. DIAGNOSIS: LARYNGEAL PAPILLOMATOSIS A of the lesion and submission of the excised Laryngeal papillomatosis is an extremely rare specimen is necessary in order to confirm diagnosis. condition attributed to human papillomavirus While the histopathologic features are quite types 6 and 11. Papillomas develop in the distinct, a definitive diagnosis cannot be made until over a period of time. If the condition is not HPV testing is performed. treated in a timely manner, obstruction of the airway may result in death. Recurrent lesions are TREATMENT: common and the condition requires long term The lesions are usually surgically excised or laser follow-up with multiple surgical procedures. It is ablated. currently not understood why only a small percentage of people exposed to HPV types 6 and CONDYLOMA ACUMINATUM IN CHILDREN: 11 develop this condition. Vertical transmission is It is important to note that condyloma acuminatum listed as a potential source of transmission of the is a sexually transmitted disease. Presence of this virus. lesion in a child is indicative of sexual abuse and needs to be reported to the authorities. The report CLINICAL FEATURES: should only be made once the diagnosis is Most of the people affected by the condition are confirmed by histopathology since some sessile children. Difficulty in breathing, swallowing and squamous papillomas may show resemblance to inability to make sounds should raise alarm and this process. warrant further investigation. Page 4 In adults, laryngeal papillomatosis may present itself periodontal disease, use of mouthwash to treat a as voice changes. Difficulty breathing is usually not dental problem in the past week and the number seen in adults. of missing teeth. An appropriate age and sex DIAGNOSIS: matched control population was also evaluated. is performed by an otolaryngologist to A higher prevalence of oral disease was seen in view the area. If laryngeal papillomatosis is individuals who were HPV-positive compared to a suspected, an endoscopic or open biopsy is control population. The study also noted a higher performed and sent for histopathologic evaluation to prevalence of HPV in men, individuals who establish a definitive diagnosis. The biopsy specimen smoked, and those who have had multiple oral is tested for presence of low risk HPV. sexual partners. TREATMENT: OROPHARYNGEAL Conservative excision or laser ablation of the Oropharynx is made up of the base of tongue, soft papillomas is necessary to ensure a clear airway. palate, tonsils and the walls of . Laser is preferred over conventional surgery because Oropharyngeal cancers can sometimes be a it prevents scarring and damage to the tissue. human papillomavirus derived process. It is Periodic procedures are usually necessary because of estimated that about 63% of oropharyngeal the recurrent nature of this disease. cancers are HPV-related. High risk HPV type 16 and 18 is linked to the development 90% of these Antiviral drugs have been used to treat this lesions. condition. The efficacy of these antivirals is however unclear. They appear to slow down the process of TRANSMISSION: papilloma formation but they are unable to provide The virus is usually transmitted through sexual complete resolution of the condition. contact. Oral sexual practices allow transmission of the organisms from the anogenital area to the oral

cavity where the virus gains access to the mucosa

HUMAN PAPILLOMAVIRUS AND through a site of injury. The virus then makes its DENTAL DISEASE way to the basal cell layer of the epithelium. Patients with multiple sexual partners are at a A recent research study from the University of Texas higher risk for oropharyngeal cancers. reported an increased incidence of dental disease in Immunosuppression or iatrogenic exposures patients who were at risk for acquiring oral HPV predispose an individual to acquiring HPV. infection. The oral health status of about 3,500 patients who were positive for low or high risk HPV Interestingly, while tobacco is not involved in the was evaluated on the basis of four parameters oncogenic process, its proinflammatory and including self ranking of oral health, presence of immunosuppressive effects may present with a higher risk of infection and persistence.

The incubation period of the virus can be up to several years. Certain studies have reported that it may take up to 15 years to develop this form of cancer.

EPIDEMIOLOGY: Oral human papillomavirus can be found in up to 7% of sexually active individuals. About 75% of the infected individuals are males. However, only 1% of these people harbor HPV type 16, most of which are young Caucasian males.

Papilloma on Lingual Frenum Source: Dr. Carl Allen, The Ohio State University College of Dentistry Page 5 CLINICAL FEATURES: DENTAL PROFESSIONALS AND Oropharyngeal cancer can present as persistent pain OROPHARYNGEAL CANCERS in the throat, painful swallowing, voice changes, neck lump and unexplained weight loss. Less Dental health professionals see patients at regular frequently, ear pain, sternal lump, pain behind the 6-month intervals. This puts them in a unique sternum and a persistent cough is noted. position to monitor any abnormal growths in the oral cavity and the oropharyngeal area. This is why DIAGNOSIS: it is necessary to perform a comprehensive oral A thorough clinical examination is performed by an examination that includes palpation of the neck otolaryngologist that includes an endoscopic and visualization of the oropharynx. Dental health evaluation. If an obvious mass is visualized during professional are not required to diagnose the the endoscopic exam, are performed and oropharyngeal pathology, they are simply sent for histopathological examination. Once the expected to note any asymmetric enlargements. diagnosis of oropharyngeal cancer is made, the The enlargements identified during the oral exam tissue is sent for testing for high risk types of human require further evaluation by an otolaryngologist. papillomavirus. A positive result will influence the course of treatment. ORAL CANCER AND HPV PREVENTION: The most common type of cancer in the oral cavity is squamous cell . Like non-HPV forms of Dental dams and condoms help prevent infection oropharyngeal cancer, tobacco related products, with the virus. A is now available that may alcohol and genetic mutations are the major provide protection against high risk strains of human etiology for the development of these lesions. papillomavirus, however the efficacy of this vaccine against oropharyngeal cancers is still undetermined. The prevalence of HPV in squamous cell It is discussed in more detail in the section on is low. It is estimated that about 5% of “Prevention” on page 7. the oral cavity cancers may harbor high risk types of HPV, with some studies claiming rates as high as TREATMENT: 35% available. The role of the virus in the Early diagnosis is the key to successful treatment. oncogenic process is unknown and the popular The cancer is treated with by surgery followed by opinion is that the virus is just a secondary radiation or radiation alone. The disease appears to occupant in the area. have a good prognosis and longer survival rates. It In rare instances, extension of HPV-related has an extremely low rate of occurrence. oropharyngeal cancers may be seen in the oral NON-HPV OROPHARYNGEAL CANCER: cavity. Such lesions are usually seen at the posterior aspect of the tongue and the soft palate About 40% of oropharyngeal cancers are not may also be involved. A biopsy with a associated with high risk human papillomavirus. characteristic histopathologic appearance and a These types of cancers are linked to: positive HPV probe will warrant further 1. Use of tobacco products investigation by an otolaryngologist. An 2. Excessive alcohol intake endoscopic examination will be required to locate the primary lesion in the oropharynx. 3. Genetic factors Management has already been discussed in the 4. Epstein-Barr Virus section on oropharyngeal cancers. The presentation, diagnosis and treatment of the HPV IN HIV PATIENTS disease are very similar to HPV-related cancers. The prognosis for these cancers depends on the extent Patients with HIV are at a higher risk for acquiring of disease and is generally worse than HPV-related HPV infections. The increased frequency of warty oropharyngeal carcinomas. Rate of recurrence is lesions in HIV patients is linked to the use of anti- high, so regular follow-ups are necessary in these retrovirals. It is speculated that the use of these patients. drugs generates an altered immune response

Page 6 of HPV identified and the level of risk of associated against the latent virus that leads to its activation with each of the types. Positive results do not and production of epithelial changes. The mean that the infection will persist. For most arguments used in favor of this theory are the individuals, the virus is cleared out from the system constantly rising rates of cervical and anal cancers within 2 years. Since most HPV infections are in patients with HIV since the introduction of asymptomatic, clinical examination provides no Highly Active AntiRetroviral Therapy (HAART). assistance.

The HPV-associated warts are commonly seen in According to a study carried out by the the anogenital areas, but oral involvement may International Agency of Research and the National also occur. HPV strains linked to these lesions Cancer Institute, antibodies to human include common types 2, ,4, 6 and 11, and less papillomavirus type 16 were identified in 35% of frequent types 7 and 32. The oral lesions seen in blood specimens taken from individuals up to 12 patients with HIV appear as condyloma years before they developed oropharyngeal acuminatum; multiple, irregularly surfaced, white cancers. It is expected that in the future, detection or pink plaques. Labial and buccal mucosa, tongue of these antibodies may be used as a and gingiva are common sites of involvement. tool or a risk factor for oropharyngeal cancers. Excision is usually the preferred form of treatment because it allows for histopathologic evaluation of PREVENTION the tissue. Laser ablation may also be used. The excised specimen requires HPV probing in order to VACCINE: establish definitive diagnosis. Since cancers are a concern in patients with HIV and these lesions tend The HPV vaccine provides protection against high to exhibit some degree of dysplasia, close clinical risk strains; type 16 and 18. It can protect an follow-up is usually mandatory in these patients. individual from most forms of HPV-related cancers and genital warts. It’s marketed under the trade- DIAGNOSING ORAL HPV names and . It is delivered as a three-dose regimen over a 6-month period at 0, 2 Diagnosis of HPV is not a simple process. While and 6 months. Only a completed regimen will several commercial tests are available for use in the provide effective protection against the virus. market, the efficacy of these tests is still Studies have shown that the protective antibodies undetermined. In 2010, OraDNA labs introduced a remain in the bloodstream for over 5 years. non-invasive and easy to use salivary test called Though the HPV vaccine provides protection OraRisk HPV. The patient swishes and gargles a against anogenital disease and cancers, its role in saline solution for about 30 seconds and protection against oropharyngeal cancers is still expectorates in a tube. The specimen is then unknown. shipped to the lab to complete the testing process. The World Health Organization has recommended The virus is detected using a PCR technique. The vaccination of young women between the ages 9 final report includes information about the types and 26 to protect against . Studies have shown that women up to the age of 45 can safely receive this vaccine. Since the vaccine is directed against two strains of the virus only, the women are still advised to have regular pap smears. The vaccine has been approved by the FDA for use in males between the ages 9 and 26 as well. It can protect against genital warts, anal cancers, and penile cancers. The efficacy of the vaccine for people with HIV is currently undetermined. Since this group is at a significant risk with high risk HPV types, studies are underway to determine the effectiveness.

Oral HPV in an HIV-Positive Source: Centers for Disease Patient Control and Prevention Page 7 The vaccine is not recommended for people who are sensitive to yeast, have an ongoing serious illness and pregnant women. It is only linked to minor side effects such as fainting, pain, swelling to the area, headache and nausea. However, there have been occasional reports of death, permanent disability, hypersensitivity reactions and thromboembolism. While private insurance companies are reluctant to pay for the vaccine (the cost is over $360) federal and state insurances are liable to provide complete coverage.

CONDOMS:

Condoms may lower the risk of HPV transmission. Michael Douglas Source: www.usatoday.com Since male condoms still allow for some contact, CONCLUSION they provide less protection than female condoms. Continued use of condoms can limit the spread of A few important points to keep in mind: infection to other sites. It can also allow for swifter clearance of infection. 1. Human papillomavirus is the most common sexual transmitted infection in the United States. DENTAL DAMS: 2. More than 120 types of HPV have been identified Dental dams are barrier devices that provide but only a few have been linked with cancers. protection against sexually transmitted infections 3. Most of the lesions associated with HPV are such as HPV and HIV. They are recommended for common, harmless and non-cancerous. individuals that engage in practices and if 4. Over 60% of oropharyngeal cancers have been used consistently, can significantly reduce the linked to HPV but the link between oral cancers and possibility of infection. HPV is still undetermined. MICROBICIDES: 5. The HPV vaccine provides protection against anogenital disease and cancers, however, its role in Certain antimicrobial chemicals can provide protection against oropharyngeal cancers is still protection against the organism if applied to the unknown. genitals before intimate contact. These products are inexpensive but are still currently undergoing clinical trials. MICHAEL DOUGLAS AND HUMAN PAPILLOMAVIRUS In 2010, human papillomavirus came under spotlight ORIGINATING FROM PAKISTAN, DR. KIYANI WENT TO RIPHAH when Michael Douglas, an American television and UNIVERSITY FOR THEIR 5-YEAR DENTAL SCHOOL PROGRAM. movie producer and actor, announced that he had GRADUATING WITH A 4.0 GPA, SHE CAME TO THE OHIO STATE been diagnosed with throat cancer caused by the UNIVERSITY IN ORDER TO FURTHER HER STUDIES FOCUSING ON ORAL virus. He was treated with radiation and AND MAXILLOFACIAL PATHOLOGY. SHE PLANS TO TAKE THE INFORMATION SHE LEARNS BACK TO PAKISTAN FOR BOTH chemotherapy. In October 2013, Douglas DIAGNOSTIC AND TEACHING PURPOSES. announced that he had been diagnosed with tongue cancer, rather than throat cancer. The decision to HER CURRENT RESEARCH STUDIES AS A FELLOW AT OSU INVOLVE EVALUATING THE ORAL CHANGES ASSOCIATED WITH initially not reveal the true diagnosis was made by GASTROINTESTINAL DISEASES. Douglas and his doctor to protect his career. The 68 year old is now actively involved in spreading DR. AMBER KIYANI CAN BE CONTACTED awareness about sexually transmitted viruses. AT: [email protected] Page 8 post-test instructions - answer each question ONLINE - press “submit” - record your confirmation id - deadline is November 22, 2013

High risk types of human papillomavirus 1 T F have been linked to cervical, vulvar, anal, penile and oropharyngeal cancers.

HIV patients are at a higher risk of acquiring 2 T F HPV infections. SUBMIT Difficulty in breathing, swallowing, and 3 T F inability to make sounds are signs of squamous papilloma in children.

Condyloma acuminatum is a sexually transmitted infection, and when confirmed in 4 T F ONLINEyoung children, requires alerting the authorities.

Dental health professionals are expected to 5 T F diagnose oropharyngeal cancers. d i r e c t o r john r. kalmar, dmd, phd According to a recent study, a higher [email protected] prevalence of HPV was found in men, 6 SUBMITT F individuals who smoked, and those who had a s s i s t a n t d i r e c t o r multiple sexual partners. karen k. daw, mba, cecm [email protected] There are over 40 types of HPV that can infect 7 T F the genital areas, as well as the mouth and channel coordinator throat. rachel flad, bs [email protected]

ONLINEThe HPV vaccine provides effective 8 T F protection against oropharyngeal cancers.

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