Elsevier

Oral Oncology

Volume 50, Issue 5, May 2014, Pages 364-369
Oral Oncology

Epidemiology of oral human papillomavirus infection

https://doi.org/10.1016/j.oraloncology.2013.09.003Get rights and content

Summary

Objective

To describe what is known about the epidemiology of oral human papillomavirus (HPV) infection.

Methods

In this article we review current data on HPV prevalence, natural history, mode of acquisition, and risk factors for oral HPV infection.

Results & Conclusion

Over the past several years new studies have informed our understanding of oral HPV infection. These data suggest oral HPV prevalence is higher in men than women and support the sexual transmission of HPV to the mouth by oral sex. Data is emerging suggesting that most oral HPV infections usually clear within a year on and describing risk factors for prevalent and persistent infection. Recent data support likely efficacy of the HPV vaccine for oral HPV, suggesting vaccination may reduce risk of HPV-related oropharyngeal cancer.

Introduction

Human papillomavirus (HPV) infection accounts for approximately 5.2% of the worldwide human cancer burden including the cancers of the anus, genital tract and oropharynx [1], [2]. While the epidemiology, natural history and molecular biology of the HPV infection and subsequent development of cancers in the genital tract have been extensively studied in the past, there are many unknowns in oral HPV infection and its role in development of oropharynx cancer. The etiologic role of HPV infection in oropharynx cancer has now been firmly established [2], [3], [4], [5]. In the US, HPV now causes the majority of oropharynx cancer and the total number of the cases is expected to surpass the number of cervical cancers by the year 2020, if the current trend of increasing incidence of oropharynx cancer continues [2].

In this review, we will highlight lessons learned from investigations of HPV infection of the genital tract and provide insight into interpretation of the current data in prevalence, incidence, natural history, mode of acquisition and risk factors of oral HPV infection. Because molecular mechanism, epidemiology, screening and prevention specific to HPV-related oropharynx cancer are reviewed in separate sections of this special issue, we will only briefly summarize the pertinent points in these topics for completeness of this review. Further understanding of epidemiology and natural history of the oral HPV infection can inform prevention strategies and screening of oropharynx cancer.

Section snippets

Biology of HPV infection

There are over 150 types of HPV, which have been categorized into “high-risk” and “low-risk” types based on their potential to induce malignancy in cervical cancer. The eleven HPV types currently classified as high-risk include: HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, while oncogenic potential of 7 additional HPV types has been suggested in some studies, but not established [6], [7]. A single type, HPV 16, is responsible for the majority of HPV-associated cancers, and causes more than

Prevalence of oral HPV infection

Epidemiology and natural history of oral HPV infection have not been well established. However, recent studies suggest oral HPV prevalence is substantially lower than genital HPV infection [24], [25], [26], [27], [28], [29]. In epidemiologic studies cervical HPV prevalence ranges from 27% to 43% among US females aged 14–59 years [26], [28]. While oral HPV infection in the comparable age group is lower ranging 0.9–7.5% (Table 1) [25], [30], [31], [32], [33], [34]. In a systemic review of the

Oral HPV transmission

It is not yet fully understood how oral HPV infections are transmitted, although data strongly support sexual transmission. Cross sectional data suggests oral HPV infection is usually spread from performing oral sex on an infected genitals, or rimming an infected anus [36]. It is not clear whether HPV can be spread through deep kissing (French kissing). Some initial evidence suggests that vertical transmission might be possible. For example, persistent oral HPV infection in mothers was

Natural history of oral HPV infection

Natural history of oral HPV infection such as incidence, duration of infection and ultimate development of oropharynx cancer is not yet well understood. Initial studies suggest that most oral HPV infection are likely cleared within a year [25], [29], [30], [36], [45]. In a study of college students, followed at a 3 month interval, oral HPV incidence was 5.67 per 1000 person-months (95% CI, 3.12–8.16/1000 person-months) [30]. In a recent prospective cohort study of 404 HIV-infected men incidence

Risk factors for oral HPV infection

Numerous cross sectional studies which have explored oral HPV prevalence have also examined risk factors associated with oral HPV infection [25], [29], [30]. The most consistent risk factors associated with prevalent oral HPV infection in these cross sectional studies are male gender, sexual behaviors and tobacco exposure. In the NHANES study, oral HPV prevalence was notably higher in men than women (10.1% vs. 3.6%) [25].

Prospective studies suggest that HPV acquisition increases around sexual

Common risk factors between oral HPV infection and oropharynx cancer

Several studies have also looked at the prevalence of oral HPV infection among patients with oropharynx cancer. HPV16 DNA is detected in oral rinses of ∼50% of cases with HPV-16-positive oropharynx cancer patients [49]. Patients with HPV-positive oropharynx cancer in particular are significantly more likely than individuals without cancer to have oral infection (OR ∼ 12), and the association is even stronger for HPV type 16 (OR ∼ 15) [4]. Higher number of sexual partners is associated with

Trends in oropharynx cancer incidence

The incidence of HPV-related oropharynx cancer has significantly increased over the last three decades in several countries [2], [57], [58], [59], [60]. A US cancer registry study found that the incidence of HPV-negative head and neck cancer declined by 50% from 2.0 cases per 100,000 to 1.0 per 100,000 between 1988 and 2004 [2]. Over the same time period, the incidence of HPV-positive HNSCC instead increased by 225% from 0.8 per 100,000 to 2.6 per 100,000. This increase was only observed among

Prevention of oral HPV infection

There is currently no validated screening method for HPV-related oropharynx cancer which has been shown to be effective. Although HPV DNA can be detected in oral rinses, and is associated with increased odds of HPV-related oropharynx cancer in case-control studies, cohort studies suggest most oral HPV infections clear quickly and thus may not be useful for screening. In the cervical cancer model, persistent HPV infection is an established risk factor for developing high-grade cervical

Summary

It is clear that the disease burden caused by HPV infection in certain subgroups is significant [1]. Increasing amounts of data indicate that oral HPV infection is relatively common, but that like anogenital HPV infections, most oral HPV infections likely clear on their own within a year or two. While our current knowledge of epidemiology, natural history and prevention of oral HPV infection remains limited, studies show that oral HPV infection is sexually transmitted and that male gender,

Conflict of interest statement

CHC served on an ad hoc scientific advisory board for Merck and received an honorarium. GD has research support from Merck.

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