OHNEP is at the vanguard of helping nurse practitioners, nurse-midwives, nurses, and other health professionals incorporate oral health into clinical education and patient care. Show
Why? Oral health and overall health are connected. Research evidence links poor oral health like periodontal disease with diabetes, cancer, heart and lung diseases, and progression of dementia and Alzheimer’s, among many others. Yet, few health professionals integrate oral health in their clinical practice. OHNEP is changing that. As a national voice promoting interprofessional oral health integration and oral health equity, OHNEP advocates, educates, creates and promotes interprofessional resources that educators and clinicians can use to improve the quality of oral health care in their patients. The OHNEP website serves as a knowledge center and portal for best practices. To stay up-to-date on OHNEP resources and initiatives, and more oral health news from our partners, subscribe to our email list by contacting ! Learning Outcome
IntroductionThe Human Papillomavirus (HPV) is the initiating force behind multiple epithelial lesions and cancers, predominantly cutaneous and mucosal surfaces.[1][2][3] More than 100 subtypes of HPV and individuals with persistent HPV infection and those who have multiple sexual partners are at very high risk for acquiring more HPV subtypes. The current classification of HPV infection is as follows:
The clinical lesions may be visibly obvious, but in some cases (latent lesions) may require testing for viral DNA. The majority of HPV infections are latent, and most clinical lesions present as warts rather than a malignancy. Today, HPV has been implicated as a cause of laryngeal, oral, lung, and anogenital cancer. Subtypes 6 and 11 are low risk and usually present with the formation of condylomata and low-grade precancerous lesions. HPV subtypes 16 and 18 are high risk and are responsible for high-grade intraepithelial lesions that progress to malignancies. It is important to understand that HPV alone does not cause cancer but requires triggers like smoking, folate deficiency, UV light exposure, immunosuppression, and pregnancy. Nursing Diagnosis
CausesHPV is a non-enveloped, double-stranded, circular DNA virus of the Papillomaviridae family. The virus enters the epithelium through disruption to the skin/mucosa and infects basal stem cells. Its genome contains seven early (E) and two late (L) phase genes required for viral propagation. The viral DNA may remain as an independent episome for a period before integrating into the host’s genome. HPV preferentially integrates at fragile sites in the human DNA where the strand is prone to breakages.[4] Risk FactorsHPV subtypes show a predilection for body sites they most commonly infect, and disease manifestations that result from infection may vary. Over 180 subtypes of HPV have been identified. Cutaneous warts of the hands and feet, such as verruca vulgaris or verruca plantaris, are most commonly caused by HPV subtypes 1, 2, 4, 27, or 57. Most anogenital warts, such as condyloma acuminatum, are caused by HPV subtypes 6 or 11 and termed low-risk HPV; these subtypes also are responsible for juvenile and adult recurrent respiratory papillomatosis. Pre-cancerous and cancerous lesions of the cervix, male and female anogenital areas, and oropharyngeal area are most commonly caused by HPV subtypes 16 and 18. However, subtypes 31, 33, 35, 45, 52, and 58 also fall in the high-risk HPV group as they are associated with cervical cancer development. The HPV subtypes which cause cutaneous verrucae are spread by contact between skin with microscopic or macroscopic epidermal damage and a fomite-harboring HPV. The prototypical location for contracting warts of the feet is a locker room. Both low-risk and high-risk HPV (sometimes referred to as alpha-papillomaviruses) are considered to be sexually transmitted but may be spread by other forms of intimate contact. According to the Center for Disease Control and Prevention (CDC), the most recent studies show the prevalence of genital HPV for adults aged 18 to 59 to be approximately 45.2% in men and 39.9% in women.[5][6] AssessmentEvaluation and treatment of HPV infection vary by body site and disease manifestation. For a more in-depth examination of each disease entity, please visit those specific topics. History
Physical examination
EvaluationPatients with cutaneous, anogenital, and/or oropharyngeal warts may have them excised and submitted for histopathological examination if there is any question about the diagnosis or concern for dysplasia.[6][7] Screening for cervical dysplasia/malignancy is typically accomplished through speculum examination and Pap smear with concurrent or reflex HPV testing, an assay test performed on cervical cells to evaluate the most common HPV subtypes associated with dysplasia. Treatment protocols stratify patients by age, HPV status, and Pap smear results. Depending on treatment stratification, patients with results concerning intraepithelial squamous or glandular lesions may proceed to colposcopy (a procedure in which the cervix is coated with acetic acid, acetowhite areas are evaluated with a colposcope, and concerning areas are biopsied to examine for histopathologic evidence of dysplasia or malignancy). Medical ManagementIndividuals with cutaneous warts have numerous treatment options available, including surgical removal, cryotherapy (freezing the infected tissue), irritant or immunomodulating medications, and laser removal. Many of these treatments' overarching purpose is to manually or chemically irritate the area, thereby invoking a host immune response to assist in clearing the infected tissue.[8][9][10] To prevent lower anogenital tract HPV infection by the most common high-risk and low-risk subtypes, the CDC recommends that boys and girls be vaccinated for HPV starting at ages 11 to 12. It is further recommended that women get vaccinated through the age of 26 and men through the age of 21. Anogenital and oropharyngeal warts may be treated similarly to cutaneous warts as long as the patient is immunocompetent. Development of HPV-related carcinoma at these sites may require resection, chemotherapy, and/or radiation. Cervical HPV-driven lesions may regress without any intervention. Young immunocompetent women with dysplasia are usually monitored at shortened intervals through Pap smears, HPV testing, and colposcopic examination. Persistent cervical dysplasia at any age, or high-grade dysplasia in older women, is treated with cryotherapy, loop electrosurgical excision procedure (LEEP), or cold knife cone (CKC) excision. Both surgical procedures (LEEP, CKC) involve resection of the cervical os and transformation zone. If the patient progresses to malignancy (e.g., squamous cell carcinoma, endocervical adenocarcinoma), further resection, chemotherapy, and/or radiation may be required.[11][12] For a fuller explanation of the disease entities associated with HPV infection, please visit those topics specifically. Nursing Management
When To Seek Help
Outcome Identification
Monitoring
Coordination of CareHPV is known to cause lesions of the mucous membranes and skin. There are over 100 subtypes of HPV, and some are associated with an increased risk of malignancy. For the most part, HPV is sexually acquired, and one of the best ways to decrease the morbidity of this infection is the patient's education. Both the nurse and the pharmacist are in a prime position to educate patients about safe sex, the use of condoms, and the avoidance of multiple sex partners. Further, women should be encouraged to undergo the Pap smear to screen for cervical dysplasia and the presence of HPV. More importantly, patients should be told that if they have genital warts, sexual activity should be avoided until the lesions have been treated or have resolved. The pharmacists should also encourage the patients to be vaccinated against HPV. Finally, patients need to be educated that if they have HPV, they should be screened for other sexually transmitted infections.[13][14][15](Level II) Health Teaching and Health Promotion
Risk ManagementLong term follow up is essential as recurrence of warts is common. In addition, all treatments for warts have side effects that need to be monitored. The sexual partner also needs to be examined for condylomata. Because of the risk of cancer, DNA testing and screening is required in high-risk patients. Discharge Planning
The 9 valent HPV vaccine is available to prevent certain cancerous lesions in males and females. The HPV vaccine covers HPV subtypes 6,11,16,18,31,33,45,52 and 58. The effectiveness of the vaccine has been inferred from several studies. It has been shown to prevent anal cancer, genital warts, cervical intraepithelial neoplasia, vulvar intraepithelial neoplasia, and anal intraepithelial neoplasia. The vaccine is most effective when administered before initiating sexual activity at ages 9-12. Evidence-Based IssuesOutcomes Once HPV is acquired, recurrences are common. However, for most patients with genital warts, there are treatments. In about 60% of cases, genital warts resolve spontaneously. Irrespective of the treatment of genital warts, the risk of cervical cancer is not altered. The biggest concern with genital warts is the risk of cervical cancer. HPV is also known to be associated with anal and head and neck cancers. Individuals who are immunocompromised are also at risk for developing dysplasia or cancer of the vagina and vulva. Finally, in at least one-third of patients with HPV, there is the presence of other sexually transmitted infections.[16][1][17](Level II) Pearls and Other issues
Review QuestionsReferences1.Bradbury M, Xercavins N, García-Jiménez Á, Pérez-Benavente A, Franco-Camps S, Cabrera S, Sánchez-Iglesias JL, De La Torre J, Díaz-Feijoo B, Gil-Moreno A, Centeno-Mediavilla C. Vaginal Intraepithelial Neoplasia: Clinical Presentation, Management, and Outcomes in Relation to HIV Infection Status. J Low Genit Tract Dis. 2019 Jan;23(1):7-12. [PubMed: 30161052] 2.Hirth J. Disparities in HPV vaccination rates and HPV prevalence in the United States: a review of the literature. Hum Vaccin Immunother. 2019;15(1):146-155. [PMC free article: PMC6363146] [PubMed: 30148974] 3.Kobayashi K, Hisamatsu K, Suzui N, Hara A, Tomita H, Miyazaki T. A Review of HPV-Related Head and Neck Cancer. J Clin Med. 2018 Aug 27;7(9) [PMC free article: PMC6162868] [PubMed: 30150513] 4.Araldi RP, Sant'Ana TA, Módolo DG, de Melo TC, Spadacci-Morena DD, de Cassia Stocco R, Cerutti JM, de Souza EB. The human papillomavirus (HPV)-related cancer biology: An overview. Biomed Pharmacother. 2018 Oct;106:1537-1556. [PubMed: 30119229] 5.Van Dyne EA, Henley SJ, Saraiya M, Thomas CC, Markowitz LE, Benard VB. Trends in Human Papillomavirus-Associated Cancers - United States, 1999-2015. MMWR Morb Mortal Wkly Rep. 2018 Aug 24;67(33):918-924. [PMC free article: PMC6107321] [PubMed: 30138307] 6.Nunes EM, Talpe-Nunes V, Sichero L. Epidemiology and biology of cutaneous human papillomavirus. Clinics (Sao Paulo). 2018 Aug 20;73(suppl 1):e489s. [PMC free article: PMC6097087] [PubMed: 30133564] 7.Heo I, Kwak HJ, Nah EH, Cho S, Kim S, Cho HI. Evaluation of the LC-1000 Flow Cytometry Screening System for Cervical Cancer Screening in Routine Health Checkups. Acta Cytol. 2018;62(4):279-287. [PubMed: 29843120] 8.Kim JJ, Burger EA, Regan C, Sy S. Screening for Cervical Cancer in Primary Care: A Decision Analysis for the US Preventive Services Task Force. JAMA. 2018 Aug 21;320(7):706-714. [PMC free article: PMC8653579] [PubMed: 30140882] 9.Deutsch SA, Benyo S, Xie S, Carlin E, Andalaro B, Clagg B, De Jong A. Addressing Human Papillomavirus Prevention During Pediatric Acute Sexual Assault Care. J Forensic Nurs. 2018 Jul/Sep;14(3):154-161. [PMC free article: PMC6114142] [PubMed: 30130316] 10.Soe NN, Ong JJ, Ma X, Fairley CK, Latt PM, Jing J, Cheng F, Zhang L. Should human papillomavirus vaccination target women over age 26, heterosexual men and men who have sex with men? A targeted literature review of cost-effectiveness. Hum Vaccin Immunother. 2018;14(12):3010-3018. [PMC free article: PMC6343618] [PubMed: 30024823] 11.Buzard CL, Rizzolo D. An overview of anal intraepithelial neoplasia. JAAPA. 2018 Jul;31(7):1-5. [PubMed: 29957613] 12.Cooper CP, Saraiya M. Cervical Cancer Screening Intervals Preferred by U.S. Women. Am J Prev Med. 2018 Sep;55(3):389-394. [PMC free article: PMC6102077] [PubMed: 30033024] 13.Rositch AF, Krakow M. Invited Commentary: Moving From Evidence to Impact for Human Papillomavirus Vaccination-The Critical Role of Translation and Communication in Epidemiology. Am J Epidemiol. 2018 Jun 01;187(6):1277-1280. [PMC free article: PMC6248451] [PubMed: 29860471] 14.Arrossi S, Temin S, Garland S, Eckert LO, Bhatla N, Castellsagué X, Alkaff SE, Felder T, Hammouda D, Konno R, Lopes G, Mugisha E, Murillo R, Scarinci IC, Stanley M, Tsu V, Wheeler CM, Adewole IF, de Sanjosé S. Primary Prevention of Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Guideline. J Glob Oncol. 2017 Oct;3(5):611-634. [PMC free article: PMC5646902] [PubMed: 29094100] 15.Ouh YT, Lee JK. Proposal for cervical cancer screening in the era of HPV vaccination. Obstet Gynecol Sci. 2018 May;61(3):298-308. [PMC free article: PMC5956112] [PubMed: 29780771] 16.Cheraghlou S, Torabi SJ, Husain ZA, Otremba MD, Osborn HA, Mehra S, Yarbrough WG, Burtness BA, Judson BL. HPV status in unknown primary head and neck cancer: Prognosis and treatment outcomes. Laryngoscope. 2019 Mar;129(3):684-691. [PubMed: 30151832] 17.Donken R, Ogilvie GS, Bettinger JA, Sadarangani M, Goldman RD. Effect of human papillomavirus vaccination on sexual behaviour among young females. Can Fam Physician. 2018 Jul;64(7):509-513. [PMC free article: PMC6042675] [PubMed: 30002026] Which risk factors are known to contribute to atrial fibrillation select all that apply?Common causes of Afib include:. high blood pressure – the most common risk factor for Afib.. heart failure.. coronary artery disease which has led to a heart attack.. coronary artery bypass surgery.. cardiomyopathy.. diabetes.. myocarditis or pericarditis – infection or inflammation of the heart.. Which substance will the home care nurse instruct the client to use after laryngectomy to cleanse the stoma site?You'll want to clean the edges of the stoma with gauze and mild soap and water. Gently remove crusting and excess mucus. Salt water spray can help with this.
Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider?Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention? Facial edema and septal deviation indicate that the client has sustained facial injuries.
Which reported clinical manifestations would the nurse expect from a client with ulcerative colitis?They include diarrhea, weight loss, abdominal cramping, anemia, and blood or pus in bowel movements. There's no cure for ulcerative colitis.
|