C.E. Credit. Assessment of Pre-Doctoral Dental Students’ Knowledge, Attitudes, and Beliefs of HPV-Related Diseases and Vaccination Trends

ABSTRACT

Background

The dental team is uniquely positioned to prevent HPV-positive oropharyngeal squamous cell carcinoma (OPSCC-HPV) and other HPV-related diseases. Provider educational interventions may accelerate HPV vaccinations and decrease OPSCC-HPV rates.

Methods

Surveys before and after educational interventions were deployed. Year 1 – Year 4 students at WesternU College of Dental Medicine completed 129 pre- and 109 posttest surveys. Statistical analyses were conducted utilizing two-sided Crosstab Chi-square tests assessing pre- and post-survey responses. P-value <.05 was considered to be statistically significant.

Results

Knowledge levels of HPV-related diseases varied amongst cohorts, but improved post – intervention. Knowledge and preparedness for discussing high-risk HPV risk factors and vaccination increased amongst all cohorts. Understanding the importance of oral healthcare providers administering HPV vaccines in the dental office setting (69.8% vs 87.3%, p = .0068) was significant post-intervention.

Conclusions

After educational interventions, dental students reported they were capable of discussing and administering HPV vaccinations. Dentists should consider administering HPV vaccinations to reduce incidence of OPSCC-HPV and HPV-related diseases.

Practical Implications

Dental teams can prevent OPSCC-HPV by educating patients about disease’s risk factors and promoting HPV vaccination. HPV vaccinations in dental settings could improve HPV vaccination rates and decrease development of HPV-related diseases including OPSCC-HPV.

Continuing Education Credit Available: The practice worksheet is available online in the supplementary material tab for this article. A CDA Continuing Education quiz is online for this article: https://www.cdapresents360.com/learn/catalog/view/20.

KEYWORDS:

• Human papilloma virus
• dental education
• oral pharyngeal squamous cell carcinoma
• vaccination

Introduction

Among the 63,000 annual cases of head and neck cancer in the United States, oropharyngeal squamous cell carcinoma (OPSCC) represents a large portion of these cases, with the most common areas being the soft palate, base of tongue, and palatine tonsils.¹ Alcohol consumption and tobacco use have long been identified as risk factors for OPSCC, but an overlooked risk factor is now emerging; high-risk strains of the Human Papilloma Virus (HPV). The Centers for Disease Control and Prevention reported 18,917 cases of OPSCC with the majority, 15,479, reported amongst the male population.¹ The significance of HPV in the development of OPSCC is that 70% of diagnosed OPSCCs are associated with high-risk HPV (OPSCC-HPV). OPSCC-HPV is associated with significantly better survival rates than HPV-negative OPSCC as the HPV positive cases tend to respond better to treatment.

Treatment of OPSCC-HPV is focused on radiation and chemotherapy, but surgery at an earlier point in treatment is often indicated to help with prognosis. The oropharynx functions in breathing, speech, and swallowing. Any alteration to this vital structure can lead to significant morbidity, despite the high success rate of treatment for cancer in this area.¹ General oral effects of treatment to the oropharynx include dysphagia, xerostomia, progression of caries and periodontal disease, and potential osteoradionecrosis of the mandible.¹ The physical, mental, and emotional toll the treatment of oropharyngeal cancers can have on the individual and their social support network is compounded by the financial costs these patients incur.

Annual estimates of all HPV-related diseases reach upward of $8 billion. According to one study, costs associated with all HPV-related diseases significantly increased after 2012.² One study, completed in Texas patients diagnosed with OPSCC-HPV, evaluated medical billing claims for treatment of OPSCC-HPV prior to 2012, and between 2012 to 2018. Prior to 2012, treatment costs for OPSCC were upwards of $64,700. After 2012, the costs for OPSCC increased to an average of $146,100.³ This finding demonstrates a 125% increase in the costs associated with the treatment of oropharyngeal cancers in the state of Texas. It is important to note, most studies evaluating the cost of medical expenses related to OPSCC-HPV do not account for additional costs associated with lost wages and benefits. The actual financial costs associated with HPV-related OPC are higher than those reported in the literature. One way to combat the high medical costs associated with OPSCC-HPV is to investigate the screening protocols, or lack thereof, currently used in clinical practice.

Since 1943, the Papanicolaou smear (Pap smear) has demonstrated high sensitivity to pre-cancerous cellular changes in the cervix during a routine gynecologic visit for females. In 2018, 66% of women over the age of 18 had a Pap smear within the last 3 years.⁴ The development of this screening tool has dramatically reduced the mortality rates associated with cervical cancer.⁵ The implementation of the Pap smear has contributed to the identification and treatment of HPV-positive cervical cancer and an increase in favorable prognosis once treatment is rendered. OPSCC should be viewed no differently; that is earlier detection would lead to earlier treatment and better outcomes for the patient. Systematic visual examinations of the oral cavity are a viable screening tool, but there has been no officially endorsed laboratory screening methodology of OPSCC-HPV by a national organization. The lack of an endorsed laboratory methodology could be due to no evidence that screening, via an oral visual examination leads to a decline in the morbidity and mortality of OPSCC.⁶ The lack of a supported screening examination, for all individuals, equates to only high-risk populations receiving a quantitative type-specific PCR test for HPV E6/E7 mRNA.⁷ As there is no standard screening protocol, efforts should focus on cancer prevention including the HPV vaccine.

The HPV vaccine reduces the risk of OPSCC-HPV development in male and females. In 2006, the Food and Drug Administration approved the quadrivalent vaccine against HPV strains 6, 11, 16, and 18 for use among females aged 9–26 years in the United States. The vaccination series was approved to include males in 2009. Advertisement of the vaccine was originally targeted toward female populations to decrease the risk of HPV-related cervical cancer. There was a missed opportunity to potentially prevent an increase in HPV incidence in the public, but more specifically, prevention was not addressed in the male population.⁸ Previous studies reported that male populations had an earlier exposure and higher risk factors associated with contracting HPV.⁸ Recent public health efforts have now placed emphasis on vaccinating all adolescent individuals.¹⁰ Studies report 14–44% of United States adolescent males being fully vaccinated.¹¹ If adolescents, or any high-risk individual is at risk of not receiving an HPV vaccine in a medical setting, the idea of involving the dental healthcare team becomes a viable option.

Fifty percent of adolescents, annually, had no primary care physician visit.¹² In 2019, 86.9% of adolescents (2–17 years old), had a dental examination within the last 12 months.¹³ The dental team consists of the following oral healthcare providers (OHP); dentists, dental therapists, dental hygienists, and dental assistants and other auxiliaries. Because the OHP, is seeing a high percentage of the population during the recommended vaccination time, any OHP, that is certified to provide an injection through their training and scope of practice, becomes a viable option to consider administering the vaccine to patients. OHPs are well versed in the anatomy, clinical features, and recognition of high-risk behaviors of OPSCC-HPV. However, there are many factors limiting OHP’s capabilities in addressing HPV-related diseases and vaccination in the dental setting. For example, one study reported that OHP’s were hesitant to initiate discussions around the patient’s sexual behaviors, in relation to HPV.¹⁴ An additional barrier that deserves attention is the logistics of the OHP’s administering vaccines.

The COVID-19 pandemic and efforts to disseminate the vaccination to all individuals prompted swift discussions around the idea of OHPs administering vaccines in the dental office. The American Dental Association found that 55% of dentists are willing to administer vaccines other than the COVID-19 vaccine.¹⁵ There is support within the dental community to administer additional vaccines. As a health care provider administering intra-oral local anesthesia, there is legitimacy around the conversation of dentists administering vaccinations. The Dental Board of California has sought approval to make an emergency regulation (1066) permanent. This regulation would allow the dentist to administer the COVID-19 and influenza vaccines in the state of California.¹⁶ While the HPV vaccine is not included currently, this legislative step is acknowledged as one in the right direction.¹⁷

To further address the feasibility of OHP administering HPV vaccine in the dental setting, this study aims to: (1) to assess current dental students’ knowledge of HPV-related disease, (2) assess preparedness of the OHP in discussing HPV and vaccination with patients, and (3) to measure attitudes on the idea of dentists giving HPV vaccinations in the dental office setting. This study would add more evidence to the scientific community in regard to future dentists’ knowledge and preparedness to reduce this disease.

Methods

The authors conducted a literature review of publications on assessing parents, medical providers, dentists, and dental students’ knowledge, attitudes, and beliefs on OPSCC-HPV and the prospect of delivering vaccinations in the dental setting from June to September 2022. This search identified sixteen published articles. Additional resources from the HPV Vaccination Roundtable, the American Dental Association, and Health.gov were also used to gain a deeper understanding of HPV and vaccination.

Oral health students receive varied amounts of training during their education on the HPV and OPSCC-HPV. Dental students in this study included first year students who had two hours of virus specific education and an hour of education on oral cancer. The second-year students had 17 hours in the second year for a total of 20 hours of education on HPV and OPSCC. The third- and fourth-year students had variable clinical experiences beyond the didactic training described for the first and second year students.

A questionnaire, with 24 items, was adapted from others and utilized in this study.^1,18 Questions ranged from demographics to rating knowledge and preparedness relating to HPV and vaccination. Questions asking comfort levels were also included as part of the survey. Predoctoral dental students were surveyed as to their HPV and OPSCC knowledge prior to the educational intervention. An informational, one-hour lecture was delivered to the participants. First and second year students had an in-person lecture as part of their pre-clinical didactic course time. Third- and fourth-year students were invited via e-mail to attend an online Zoom presentation. Contents of the lecture included reviewing current statistics of OPSCC-HPV disease, history of and current vaccination trends, as well a review of how the OHP can aid in the reducing of the prevalence of disease. The same group of participants were surveyed again using the same instrument. Data was collected from December 2022 to February 2023. Data from the Qualtrics survey was evaluated and changes between the pre- and post-survey assessments were identified. This study, IRB # 1954258–1, was approved by the Western University of Health Sciences IRB.

All statistical analyses were conducted using the SAS software for Windows version 9.3 (Cary, North Carolina, USA). Descriptive statistics were presented as frequencies with percentages. Crosstab Chi-square analyses were conducted to assess the response to questions pre- and post-survey. All statistical analyses were two-sided. P-value <.05 was considered to be statistically significant.

Results

A total of 236 responses were collected between the pre- and post-survey assessment times. More than half (54.2%, n = 128) of the responses were from the pre-survey, and the other (45.8%, n = 108) were from the post-survey. Majority (72.5%, n = 171) of the response were within the 24 to 29 age group, 49.6% (n = 117) were Asian, Pacific Islander, or Hawaiian, 50.2% (n = 117) being females, 92.3% (n-215) being heterosexual, 69.1% (n = 169) being single, 72% (n = 170) has bachelor’s degree, and 50.9% in the Doctor of Dental Medicine (DMD) 2026 cohort. There was no statistically significant difference on the demographic variables between the pre- and post-survey period (all p-values >.05). Table 1 presented the detailed analysis results of demographic variables between pre- and post-survey.

Table 1. Comparison of demographic variables between pre and post survey.

	Overall (N = 236)	Pre (n = 128)	Post (n = 108)	p-value
Age				.893
18–20	14 (5.9%)	9 (7%)	5 (4.6%)
24–29	171 (72.5%)	90 (70.3%)	81 (75%)
30–35	45 (19.1%)	25 (19.5%)	20 (18.5%)
36–40	5 (2.1%)	3 (2.3%)	2 (1.9%)
41+	1 (0.4%)	1 (0.8%)	0 (0%)
Race/Ethnicity				.995
Asian, Pacific Islander, or Hawaiian	117 (49.6%)	65 (50.8%)	52 (48.2%)
Black	15 (6.4%)	8 (6.3%)	7 (6.5%)
Hispanic	27 (11.4%)	14 (10.9%)	13 (12%)
White	57 (24.2%)	30 (23.4%)	27 (25%)
Other	20 (8.5%)	11 (8.6%)	9 (8.3%)
Gender				.943
Female	117 (50.2%)	63 (50%)	54 (50.5%)
Male	116 (49.8%)	63 (50%)	53 (49.5%)
Frequency Missing = 3		126 (0%)	107 (0%)
Sexual Orientation				.87
Bisexual	10 (4.3%)	5 (3.9%)	5 (4.7%)
Heterosexual	215 (92.3%)	117 (92.1%)	98 (92.5%)
Homosexual	8 (3.4%)	5 (3.9%)	3 (2.8%)
Frequency Missing = 3
Marital Status				.867
Single	163 (69.1%)	89 (69.5%)	74 (68.5%)
Married	73 (30.9%)	39 (30.5%)	34 (31.5%)
Degree				.963
Bachelor’s degree	170 (72%)	93 (72.7%)	77 (71.3%)
Master’s degree	60 (25.4%)	32 (25%)	28 (25.9%)
Doctorate Degree	6 (2.5%)	3 (2.3%)	3 (2.8%)
Program				.944
DMD 2023	10 (4.2%)	5 (3.9%)	5 (4.6%)
DMD 2024	15 (6.4%)	9 (7%)	6 (5.6%)
DMD 2025	91 (38.6%)	48 (37.5%)	43 (39.8%)
DMD 2026	120 (50.9%)	66 (51.6%)	54 (50%)

Three domains were assessed for changes in the pre- and post-informational lecture material. The first domain is the HPV assessment comparison between pre and post-survey. There was a statistically significant improvement on the correct answer for HPV induced infection (79.7% vs 91.4%, p = .014), and the recall of HPV lecture information (66.1% vs 80.8%, p = .041). Table 2 provided more detailed information on the first domain.

Table 2. Comparison of HPV assessment variables between pre and post survey.

	Overall (N = 236)	Pre (n = 128)	Post (n = 108)	p-value
HPV infection is the most common sexually transmitted infection in the United States				.0784
Yes	203 (92.7%)	106 (89.8%)	97 (96%)
No	16 (7.3%)	12 (10.2%)	4 (4%)
Frequency Missing = 17
HPV infection can produce which type(s) of infection				.0136
Correct Answer	197 (84.9%)	102 (79.7%)	95 (91.4%)
Wrong Answer	35 (15.1%)	26 (20.3%)	9 (8.7%)
Frequency Missing = 4
HPV can contribute to other disease/illness later in life				1
Correct Answer	222 (99.6%)	119 (99.2%)	103 (100%)
Wrong Answer	1 (0.5%)	1 (0.8%)	0 (0%)
Frequency Missing = 13
Do you recall receiving information about HPV and subsequent illnesses at Western U				.0407
Yes	168 (72.7%)	84 (66.1%)	84 (80.8%)
No	25 (10.8%)	18 (14.2%)	7 (6.7%)
I can’t recall	38 (16.5%)	25 (19.7%)	13 (12.5%)
Frequency Missing = 5

The second domain compares the HPV knowledge pre- and post-survey. There was a statistically significant increase in the percentage of males worrying about HPV and the associated comorbidity later in life (47.8% vs 76.3%, p = .005). No other statistically significant difference was detected. Table 3 provided more detailed information on the second domain.

Table 3. Comparison of HPV knowledge variables between pre and post survey. P-value not available due to the small count in each category.

	Overall (N = 236)	Pre (n = 128)	Post (n = 108)	p-value
A vaccine exists that protects against infection from HPV				.2174
Yes	209 (97.2%)	109 (95.6%)	100 (99%)
No	6 (2.8%)	5 (4.4%)	1 (1%)
Frequency Missing = 21
HPV vaccines are currently approved by the Federal Drug Administration				.0645
Yes	185 (89.8%)	90 (85.7%)	95 (94.1%)
No	21 (10.2%)	15 (14.3%)	6 (5.9%)
Frequency Missing = 30
At what age(s) should the HPV vaccine be administered?				.6259
Correct Answer	158 (76.3%)	80 (74.8%)	78 (78%)
Wrong Answer	49 (23.7%)	27 (25.2%)	22 (22%)
Frequency Missing = 29
Have you received any dose(s) of the HPV vaccination?				1
Yes	123 (71.5%)	65 (71.4%)	58 (71.6%)
No	49 (28.5%)	26 (28.6%)	23 (28.4%)
Frequency Missing = 64
what would be the main reason for NOT receiving the HPV vaccine				N/A
Cost/Insurance coverage	5 (5%)	2 (3.3%)	3 (7.3%)
Do not know where to get the vaccine	28 (27.7%)	19 (31.7%)	9 (22%)
HPV infections do not produce health problems	1 (1%)	0 (0%)	1 (2.4%)
Medical provider has not approached the topic of my risk for HPV infection	25 (24.8%)	12 (20%)	13 (31.7%)
Not at risk for contracting HPV	19 (18.8%)	12 (20%)	7 (17.1%)
Safety of the vaccine	7 (6.9%)	5 (8.3%)	2 (4.9%)
Other	16 (15.8%)	10 (16.7%)	6 (14.6%)
Frequency Missing = 135
what would persuade you to receive the vaccine if you have NOT received the HPV vaccine				N/A
Dentist Recommendation	10 (14.7%)	3 (7.9%)	7 (23.3%)
Doctors Recommendation	47 (69.1%)	27 (71.1%)	20 (66.7%)
Family/Friend Recommend	1 (1.5%)	0 (0%)	1 (3.3%)
Parental Recommendation	3 (4.4%)	3 (7.9%)	0 (0%)
Other	7 (10.3%)	5 (13.2%)	2 (6.7%)
Frequency Missing = 168
Males only: worrying about HPV and the associated comorbidity later in life among				.0045
Agree	77 (61.1%)	32 (47.8%)	45 (76.3%)
Neutral	37 (29.4%)	26 (38.8%)	11 (18.6%)
Disagree	12 (9.5%)	9 (13.4%)	3 (5.1%)
Frequency Missing = 110

The last domain assesses the HPV related questions as a future dentist. A significant increase was detected in the preparedness level of discussing HPV risk and vaccines with patients (47.5% vs 84%, p < .0001). Additionally, a significant increase was detected in agreeing with OHPs should approach the topic of HPV more than medical providers (64.3% vs 86.3%, p = .0007). Lastly, there was a significant increase in the preparedness level of administering the HPV vaccine in the dental office setting (69.8% vs 87.3%, p = .0068). Table 4 provided more detailed information on the last domain.

Table 4. Comparison of HPV future patient variables between pre and post survey.

	Overall (N = 236)	Pre (n = 128)	Post (n = 108)	p-value
“I feel comfortable and prepared to address HPV risks and vaccines with patients				<.0001
Agree	142 (64%)	58 (47.5%)	84 (84%)
Neutral	52 (23.4%)	41 (33.6%)	11 (11%)
Disagree	28 (12.6%)	23 (18.9%)	5 (5%)
Frequency Missing = 14
All oral health care professionals, regardless of specialty, should perform an intra-oral examination on patients?”				.2325
Agree	198 (86.8%)	105 (83.3%)	93 (91.2%)
Neutral	25 (11%)	17 (13.5%)	8 (7.8%)
Disagree	5 (2.2%)	4 (3.2%)	1 (1%)
Frequency Missing = 8
Oral Healthcare Providers should approach the topic of HPV more than medical providers				.0007
Agree	169 (74.1%)	81 (64.3%)	88 (86.3%)
Neutral	47 (20.6%)	35 (27.8%)	12 (11.8%)
Disagree	12 (5.3%)	10 (7.9%)	2 (2%)
Frequency Missing = 8
As a dentist, I would feel comfortable administering the HPV vaccine in the dental office setting				.0068
Agree	177 (77.6%)	88 (69.8%)	89 (87.3%)
Neutral	41 (18%)	30 (23.8%)	11 (10.8%)
Disagree	10 (4.4%)	8 (6.4%)	2 (2%)
Frequency Missing = 8
I feel comfortable utilizing interprofessional collaboration to provide information to medical colleagues about the importance of HPV and Oropharyngeal Cancer (OPC)?”				.0502
Agree	193 (84.7%)	101 (80.2%)	92 (90.2%)
Neutral	32 (14%)	22 (17.5%)	10 (9.8%)
DISAGREE	3 (1.3%)	3 (2.4%)	0 (0%)
Frequency Missing = 8

Discussion

This study assessed pre-doctoral dental students’ preparedness to discuss HPV-related diseases and vaccines with patients. Oral health students receive varied amounts of training during their education on the HPV and HPV OPSCC. Studies indicate a range of two to twelve hours of training on the topic.^19,20 Dental students assessed in this study reported an increased preparedness level when discussing these topics with patients and medical colleagues after they received the educational intervention. An increase from 32% to 51% of respondents strongly agree that the OHP should approach the topic of HPV more often than medical providers. The intra-oral examination completed by the OHP can be a gateway to discussing risk factors and diseases related to HPV.

OHPs play a crucial role in the detection, prevention, and management of OPSCC-HPV. The increase in incidence of OPSCC-HPV provides a multi-disciplinary team opportunity for patient education of the HPV, HPV-related tumors, and HPV vaccinations in a dental setting.⁹ As part of the preventive interprofessional patient care team, it is essential that all members of the dental team feel capable and prepared to use their knowledge related to the epidemiology, etiology, localization, and clinical features of OPSCC-HPV. The dental team, specifically the dentists and providers that have a scope of practice that includes injections, should aim to recommend, and potentially administer HPV vaccines to eligible patients. Timely vaccination is paramount to long-term prevention of benign HPV-related lesions and HPV-related cancers.

Dentists routinely administer intra-oral local anesthesia and are well educated on the anatomy of the oral cavity and injection technique. The idea of dentists administering vaccines accelerated during the COVID-19 global pandemic as dentists administered COVID-19 vaccines to battle the pandemic.²¹ This demonstrated that dentists have the skillset and training to administer vaccines successfully. Furthermore, an increase of 16% (32% to 55%) in this study, demonstrates the openness of dental students to the idea of providing vaccines to patients. More research is needed to explore barriers to administer vaccines among pre-doctoral dental students. Examples of barriers would be logistics, reimbursement, regulatory standards, and general perceptions. These barriers may be addressed by future curriculum changes.²²

The current study reported that a focused educational intervention on the HPV, HPV-related lesions and cancers, and the HPV vaccine improved dental students’ knowledge and preparedness on the subject materials. The current study also noticed that first-year dental students have lower knowledge and preparedness levels with the subject material than fourth-year students. This discrepancy can be attributed to a lack of learning experience thus far in their training. Accordingly, the first-year students had the greatest percent change from pre- to post-survey assessment for this question. This significant finding provides support for an evidence-based recommendation to implement HPV vaccine education early in a student’s dental education.

The generalizability of the study’s findings may be limited by several factors. First, the participant population was from a single institution. These findings may not be applicable to other institutions different from Western University of Health Sciences. Future research is needed to assess the effectiveness of similar educational intervention amongst outside institutions to confirm these findings. Second, not all third and fourth year pre-doctoral dental students participated in this study. Endeavors were applied to recruit students into the study by sending out multiple e-mail reminders and class announcements. To further incentivize participation, a random drawing was offered with a chance to win a gift card for participation. Additional studies are needed to assess whether there was a significant change in the attitudes of preparedness of third and fourth year pre-doctoral dental students in regard to administering the HPV vaccine.

Conclusions

Patient education, routine head and neck examinations, and vaccinations are necessary for the ongoing prevention of OPSCC-HPV. The dental team plays a crucial role in the education, detection, and management of OPSCC-HPV. Overall, educational interventions on the HPV, OPSCC-HPV, and the HPV vaccination appear to improve pre-doctoral dental students’ knowledge and preparedness on these topics. Opportunities should be explored to deliver HPV vaccinations in a dental setting.

Disclosure statement

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

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/19424396.2023.2257340.

Additional information

Notes on contributors

Andrew Halverson

Andrew Halverson is a second year doctor of dental medicine student at Western University of Health Sciences. He received his master’s in dental therapy (MDT) from the University of Minnesota - School of Dentistry.

Mark Mintline

Mark Mintline received his D.D.S. from the UCLA School of Dentistry and certificate in Oral and Maxillofacial Pathology from the UF College of Dentistry. Dr Mintline is a Diplomate from the American Board of Oral and Maxillofacial Pathology. He currently serves as an Assistant Professor in College of Dental Medicine and is the Laboratory Director for WesternU Health Oral Pathology Laboratory.

Fanglong Dong

Fanglong Dong received his Ph.D. in Statistics from Bowling Green State University, an M.S. in Statistics from Southwest Jiaotong University, China. He currently serves as a Professor in the College of Podiatric Medicine and the Director of Biostatistics at Western University of Health Sciences.

Elizabeth Andrews

Elizabeth Andrews received her D.D.S. from the University of the Pacific, Arthur A. Dugoni School of Dentistry and MS in Oral and Maxillofacial Pathology at the University of North Carolina, Chapel Hill. She currently serves as an Associate Professor and Dean of the College of Dental Medicine, Western University of Health Sciences.