Discussing HPV and oropharyngeal cancer in dental settings: gender and provider-type matter

ABSTRACT

Human papillomavirus (HPV) is the most common sexually transmitted infection in the US and the leading cause of oropharyngeal cancer (OPC), an oral cancer most often identified by dental providers. Given the rise in HPV-associated OPC and recent Food and Drug Administration (FDA) approval of the HPV vaccine to prevent OPC, dental providers have a unique role in HPV prevention. This study assessed US adults’ comfort levels discussing HPV and OPC with dental providers. An online survey platform was used to recruit a nationally representative sample of US adults (n = 300). The questionnaire assessed participants’ knowledge, acceptability, and comfort discussing HPV-related topics with dental providers. SPSS 24 was utilized for data analyses. In general, participants reported feeling comfortable discussing HPV and OPC with dental providers. Participants reported feeling more comfortable with dentists than dental hygienists when discussing (t = 2.85, p < .01) and receiving recommendations about the HPV vaccine (t = 2.09, p < .05). Participants were less comfortable discussing HPV as a risk factor for OPC compared to non-HPV related risk factors (t = 2.94, p < .01). Female participants preferred female providers, whereas male participants had no preference. Previous research has indicated dental providers recognize their role in HPV prevention, but research is needed to understand patients’ perceptions of dental providers’ role in HPV prevention. Findings demonstrate that US adults are comfortable discussing HPV and OPC with dental providers, which may be key to OPC-HPV prevention. Future research is needed to facilitate HPV communication between patients and dental providers.

KEYWORDS:

• HPV-related oropharyngeal cancer
• HPV vaccine
• dental providers
• oropharyngeal cancer risk factors

Introduction

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with 14 million new infections reported annually.¹ HPV has over 200 genotypes with the majority being low-risk and 14 being high-risk.^2,3 While most HPV infections are asymptomatic and resolve within two years,⁴ persistent low-risk HPV types are associated with genital warts and persistent high-risk HPV types are associated with a range of cancers including cervical, anal, penile, vulvar, vaginal, and oropharyngeal.⁵ HPV is known to be a necessary cause of cervical cancer and until 2015, cervical cancer was the most common HPV-associated cancer.⁶

Oropharyngeal cancer (OPC), also known as head and neck cancer, has surpassed cervical cancer as the most common HPV-associated cancer with rates nearly doubling over the past 30 years.^6,7 There were 18,917 cases of OPC in 2015 with 82% of the cases occurring in males.⁶ Previously, OPCs were mainly caused by tobacco and alcohol use; however, recent studies now show that approximately 70% of OPCs are associated with HPV.^8,9 HPV-positive OPC cases have an overall better prognosis and survival than HPV-negative OPC.¹⁰

The HPV vaccine, Gardasil 9, protects against nine types of HPV and is approved to prevent HPV-related cancers (e.g., cervical, vulvar, vaginal, and anal cancer) and was most recently approved for the prevention of OPC and other head and neck cancers.¹¹ The vaccine is given in a series of two or three shots depending on when it is initiated. The Centers for Disease Control and Prevention (CDC) routinely recommends the vaccine for youth 11–12 years of age, but it can be administered to children as young as 9 years. Recently, the HPV vaccine has been approved through mid-adulthood ages 27–45, with an emphasis on shared clinical decision making between adult patients and providers.¹²

Despite proven safety and efficacy, HPV vaccine rates in the US remain well below the Healthy People 2020 target vaccine rate of 80%. In 2018, 68.1% of US adolescents ages 13–17 received at least one dose of the HPV vaccine series, but only 51.1% were up-to-date on the vaccine.¹³ Moreover, in 2018, only 53.6% of females and 27.0% of males ages 18 to 26 years reported receipt of at least one dose of the HPV vaccine.¹⁴ With HPV vaccine rates falling short of the Healthy People 2020 target and increasing OPC cancer rates, there is a critical need to target known predictors of HPV vaccine initiation in order to close this gap.

In the United States, provider recommendation has shown to be a strong predictor of receiving the HPV vaccination and inconsistent or weak provider recommendation may contribute to low HPV vaccine uptake.¹⁵ HPV vaccine recommendation is critical, approximately 70% of those who receive a recommendation from their healthcare provider initiate the vaccine series.¹⁶ Family practice providers, pediatricians, and obstetricians-gynecologists make the majority of HPV vaccine recommendations.^17,18 However, research shows that dental providers know they have a central role in the prevention of HPV-related cancers with dental hygienists seeing themselves as “prevention specialists.”¹⁹ In collaboration with the National HPV Vaccination Roundtable, the American Dental Association now states that dental providers should advocate for, and strongly and clearly recommend the HPV vaccine as well as screen all patients for oral cancer.^20,21

Little research has been done on patient comfort with dental providers discussing the prevention of HPV and OPC. Rindal et al.²² found that 69% of patients were comfortable when being asked about their sexual behavior, but that study focused on feasibility and acceptability of oral HPV detection, not discussing HPV as a risk factor for OPC or the HPV vaccine. Another study found that only one-quarter of parents would be comfortable with dentists administering the HPV vaccine, yet parents reported higher comfort levels with dentists discussing HPV or providing written HPV prevention materials.²³

Furthermore, previous studies regarding patient preferences for dental providers of the same gender (gender concordance) have shown mixed results. Gender concordance refers to the alignment of the gender of patient and provider. For example, Bender²⁴ found that most dental patients generally had no preference for gender concordance. A study conducted by Cooper-Patrick²⁵ found a strong correlation between patient satisfaction and provider gender concordance and Hardie et al.²⁶ found that patients with high dental anxiety were more likely to prefer a gender concordant dental provider. Gender concordance is also present in primary care settings; one study found that female patients prefer female OB/GYN providers over male OB/GYN providers.²⁷ Additionally, a study on HPV vaccine recommendations found that Latina women reported being more likely to receive the vaccine if the recommending provider was of the same race/ethnicity and gender.²⁸ Gender concordance in the dental setting may facilitate communication regarding HPV.

Given the rise in HPV-associated OPC and the recent approval of the HPV vaccine to prevent OPC, dental providers have a unique role in HPV-prevention. The broad purpose of the current study was to assess self-reported comfort levels when discussing OPC and HPV with dental providers among US adults ages 18–45. In particular, we examine comfort levels when discussing established OPC risk factors, such as tobacco and alcohol use, to comfort levels when discussing HPV as an OPC risk factor. Then we test the gender-concordance hypothesis by comparing comfort ratings made by male and female participants regarding discussions with male and female dental providers.

Methods

This study was approved by the University of South Florida Institutional Review Board. Institutional Review Board. Prior to participation, participants provided informed consent.

Data collection

A nationally representative sample was recruited using Qualtrics, an online survey company that maintains market research panels. As this study was exploratory, sample size (n = 300) was based on testing the significance of small to moderate effects. Qualtrics utilized their market research panels to recruit participants (n = 300) based on our target audience, sample size, survey length, and inclusion/exclusion criteria. To ensure the highest quality of data and fulfil the desired sample size, Qualtrics ensures all respondents complete the questionnaire and will replace any respondents who do not complete the questionnaire. Questionnaires were administered via the Qualtrics platform. On average, participants took 11 minutes to complete the questionnaire. The inclusion criteria were: (1) 18 to 45 years of age and (2) able to read/speak English. Data were collected in February 2019. Participants received no financial compensation for their time.

This study uses items from a larger questionnaire that assessed US adults’ knowledge, attitudes, and awareness of HPV and risk factors for oropharyngeal cancer (referred to as “head and neck cancer”), as well as dental providers’ role in HPV-OPC prevention. This questionnaire was constructed based on components of the Health Belief Model and the Information-Motivation-Behavioral Skills Model. The questionnaire included items on participants’ socio-demographic characteristics (i.e., age, gender, race/ethnicity, education, income, religion, relationship status, etc.) and participants’ comfort levels when discussing HPV-related information with dental providers. Items assessing comfort were measured using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree).

Data analysis

Given the exploratory nature of our study, we set out to detect modest associations between variables. G*Power²⁹ version 3.1.9.7 was used to determine that a sample size of n = 300 was needed to achieve 80% power at the α = .05 level assuming an average effect size of η² = .03. Descriptive statistics were calculated for sociodemographic variables. Independent-groups t-tests were used to compare the responses of male and female participants regarding comfort talking about and receiving an HPV recommendation by provider type (dentist vs dental hygienist). Equality of variances were evaluated using Levene’s test and corrections were applied where this assumption was violated. Comparisons of responses to different items (e.g., comfort discussing HPV-related OPC risk factors vs. established risk factors such as tobacco use) were made using paired-sample t-tests. Based on research on gender concordance,^24,26 it was hypothesized that the gender of the participant might interact with the gender of the provider and the type of provider (dentist vs. hygienist) when discussing HPV. To assess this complex relation, a 3-way mixed analysis of variance (ANOVA) consisting of respondent gender x (provider type x provider gender) was used to analyze comfort responses to four items.: I All statistical analyses were conducted using SPSS version 24. For all tests of significance, a p value of .05 or smaller was considered statistically significant.

Results

A total of 300 participants completed the questionnaire. Two participants did not identify as being male or female leaving 298 for analysis (159 females and 139 males). The majority of participants were between the ages of 18 and 24 (41%), white/Caucasian (57%), heterosexual (85%), and single (52%). A summary of the sociodemographic characteristics of the sample is provided in Table 1.

Table 1. Summary of demographic variables

	N	(%)
Age
18–24	121	40.6%
25–34	102	34.2%
35–45	75	25.2%
Gender
Female	159	53.4%
Male	139	46.6%
Race
American Indian/Alaskan Native	3	1.0%
Asian	15	5.0%
Native Hawaiian or Pacific Islander	1	0.3%
Black or African American	79	26.5%
White or Caucasian	171	57.4%
Multiracial	8	2.7%
Other	21	7.0%
Ethnicity
Hispanic or Latino	74	24.7%
Sexual Orientation
Straight/Heterosexual	254	85.2%
Sexual Minority	44	14.8%
Relationship Status
Single, dating or uncommitted	154	51.7%
Committed or married	131	44.0%
Separated/divorced or Widowed/widower	13	4.4%

N = 298.

Participants were generally comfortable talking with both dentists and dental hygienists about HPV and established risk factors (alcohol, tobacco, sun exposure) for OPC. Paired t-tests were conducted to compare participants’ comfort levels when discussing established risk factors and HPV as a risk factor (see Table 2). Results from the paired t-tests revealed that participants were significantly less comfortable discussing HPV as a risk factor compared to alcohol (t = 2.839, p = .005), tobacco (t = 2.972, p = .003), and sun damage (t = 2.214, p = .028). Overall, participants were significantly more comfortable discussing established risk factors for OPC with dental providers compared to HPV as a risk factor.

Table 2. Mean responses (SD) of survey items pertaining to OPC risk factors

Statement	Total
I would feel comfortable if my dentist or dental hygienist …
… talked to me about alcohol as a risk factor for head and neck cancers.	3.85
	(0.98)
… talked to me about tobacco as a risk factor for head and neck cancers.	3.86
	(0.95)
… talked to me about sun damage as a risk factor for head and neck cancers.	3.81
	(0.98)
… talked to me about HPV as a risk factor for head and neck cancers.	3.71
	(1.07)

Scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree. Males (n = 139) and females (n = 159). Paired t-test results: alcohol vs HPV (t = 2.839, p = .005), tobacco vs HPV (t = 2.972, p = .003), sun damage vs HPV (t = 2.214, p = .028).

Participants were then asked more detailed questions regarding their comfort levels discussing various HPV topics with dentists and dental hygienists. Topics included talking about head and neck cancer and the discussion and recommendation of the HPV vaccine. Comparisons between parallel items (one referring to dentists and the other referring to dental hygienists) revealed participants were more comfortable talking to dentists compared to dental hygienists about head and neck cancers (t = 3.17, p < .01) and about the HPV vaccine (t = 2.85, p < .01). Participants were also more comfortable with dentists recommending the HPV vaccine than they were with dental hygienists (t = 2.09, p < .05).

Next, independent t-tests were conducted to determine whether comfort levels differed between male and female respondents. These results indicated there were no gender differences in responses except when the content of discussion pertained to HPV. Female participants were significantly less comfortable than male participants discussing HPV as a risk factor for head and neck cancers with dental hygienists (t = 2.00, p < .05). Furthermore, male participants were significantly more comfortable receiving an HPV vaccine recommendation from dentists (t = 2.67, p < .01) and from dental hygienists (t = 2.98, p < .01) than were female participants.

While the previous survey items focus on specific aspects of HPV and cancer, they do not address gender concordance. The structure of four additional survey items permitted exploration of an interaction between the gender of the participant, the gender of the provider, and the type of provider on comfort ratings when discussing HPV. These items include: ‘I would feel comfortable if a male dentist talked to me about HPV,’ ‘I would feel comfortable if a male dental hygienist talked to me about HPV,’ ‘I would feel comfortable if a female dentist talked to me about HPV,’ and ‘I would feel comfortable if a female dental hygienist talked to me about HPV.’ Gender concordance, if present, should manifest as male participants being more comfortable in discussions with male providers, while female participants are more comfortable in discussions with female providers. This was examined using a 3-way ANOVA, respondent gender x (provider type x provider gender), the results of which are summarized in Table 3. There was a main effect of provider gender [F (1,296) = 10.181, p = .002, η² = .033], however, this effect was qualified by a significant interaction between provider gender and participant gender [F (1,296) = 14.035, p < .001, η² = .045]. Note that η² is a measure of effect size, indicating the proportion of variance in the outcome variable accounted for by the source in the analysis. An η² = .045 indicates a small-to-medium effect size. None of the other interactions in the ANOVA were significant. Among male participants, comfort discussing HPV with male and female dental providers was 3.72 and 3.69, respectively (p > .05). Female participants were significantly (p < .05) more comfortable discussing HPV with female providers (mean comfort = 3.65) compared to male providers (mean comfort = 3.34). Mean comfort scores by respondent gender and provider gender are presented in Figure 1. The nature of the interaction was such that when discussing HPV, the gender of the provider did not matter to male participants, but female participants were more comfortable having these discussions with female providers than with male providers.

Table 3. Results of 3-way analysis of variance by participant and provider gender and by provider type

Source	F	η^2	p
Participant gender	3.265	.011	.072
Provider gender	10.181	.033	.002
Provider type	0.545	.002	.461
Provider gender x participant gender	14.035	.045	<.001
Provider type x participant gender	0.000	.000	1.000
Provider type x provider gender	1.652	.006	.200
Provider gender x participant gender x provider type	0.607	.002	.436

df for all F-tests are 1, 296. We included race in the ANOVA. It was not significant nor were any of its interactions. Therefore, in the interest of parsimony, it is not reported in this model.

Figure 1. Comfort discussing HPV with dental providers by respondent gender and provider gender.

Discussion

HPV-related oropharyngeal cancers are increasing, and while dental providers affirm the importance of their role in HPV-related cancer prevention, research is needed on patient preferences for HPV-related communication with dental providers.¹⁹ This study assessed participants’ comfort levels in discussing HPV and the HPV vaccine with dental providers. Specifically, questions were designed to elicit patient preferences for OPC-related discussions with both dentists and with dental hygienists.

In general, participants reported feeling comfortable with dental providers discussing HPV and OPC, although participants were more comfortable receiving an HPV vaccine recommendation from dentists relative to dental hygienists. These results align with what has been previously reported in the medical literature, wherein patients prefer seeing physicians rather than “lower level” practitioners,^30,31 especially when they perceive their medical condition to be severe.^32,33 However, a 2008 study found that while patients prefer physicians when dealing with medical aspects of care (e.g., treatment and diagnostics), they prefer talking with nurse practitioners for information and advice on how to deal with a disease.³⁴ Findings from our study may be similar in that patients reported feeling more comfortable speaking with dentists but may feel comfortable getting additional information or advice from dental hygienists.

There were important differences between male and female participants. Female participants showed a stronger preference for discussing HPV with female providers, whereas male participants showed no such gender preference. There have been mixed findings related to gender concordance and the HPV vaccine,^24,28 and given the results of this study and the recent FDA approval for the prevention of OPC, pursuing this line of inquiry may be timely.

Participants were more comfortable discussing established risk factors for OPC (tobacco, alcohol, sun damage) than HPV as a risk factor for OPC. This finding may be explained, in part, because the general public is largely unaware of the association between HPV and OPC,³⁵ and also because tobacco and alcohol have received media attention as risk factors since the 1980s (e.g., Blot).³⁶ In 1997, only 33% of dentists asked their patients about tobacco use,³⁷ but this figure has increased to 74% during 2004 through 2008.³⁸ Recent studies conducted in Canada have suggested that OPC prevention discussions centering on tobacco and alcohol should be expanded to incorporate the association of HPV with OPC.^35,39

While dentists, rather than dental hygienists, may be perceived as the more appropriate/trusted source of OPC and HPV-related information and messaging, the gender-by-gender interaction observed in this study may inform a practical/optimal approach to prevention. Considering that while 93.9% of dental hygienists are female, only 28.7% of practicing dentists are female,⁴⁰ thus suggesting that a patient is more likely to encounter a female hygienist and a male dentist. If the patient in question is female, she may be more comfortable discussing OPC and HPV with the hygienist, who might introduce the topics, and ask the patient if she would like to discuss the details with the (male) dentist. If the patient says “no” then the hygienist could continue the conversation and provide details. This has implications for curriculum development in dental and dental hygienist education programs. Both types of professionals ought to receive instruction on HPV-related topics including appropriate communication strategies. Such an approach is in line with the interdisciplinary philosophy of public health, and public health education, and may further increase HPV vaccination rates and decrease rates of HPV-related cancers.

This study showed that US adults are comfortable with dental providers discussing HPV and recommending the HPV vaccine. These findings are key to HPV prevention because provider recommendation is the strongest predictor of HPV vaccination uptake. Additional research should be conducted with larger samples of participants to represent the diversity of beliefs and preferences of the US population more accurately. Understanding that male and female patients differ in the social dynamics of these topics of communication is a critical first step. Future research could focus on optimizing communication channels between patients and providers and on sequencing the content to maximize patient understanding.

As in any article that attempts to make substantive claims, there are some limitations to bear in mind. First, as with all survey-based research, the data were obtained from self-reports, and consequently, may reflect bias in reporting certain feelings and beliefs. Second, despite the sampling methods used by Qualtrics to recruit a representative sample of the US population, the sample obtained was one of convenience, and so findings may not generalize to the US population at large. Third, the effects of omitted variables (e.g., personality traits, stressful life events related to cancer, or beliefs about sexually transmitted infections) are unpredictable. Their absence could lead to misleading conclusions with regard the variables examined.

Nonetheless, we believe that the findings reported above add greater understanding of the role of dental providers in HPV-related cancer prevention. To the best of our knowledge, this is the first study to assess patient comfort with discussing non-HPV risk factors compared to HPV risk factors.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.