Kissing: hullo hpv

Kissing: hullo hpv


Louis Z.G. Touyz, BDS MSc(Dent) MDent(Perio&OralMed)
Faculty of Dentistry, McGill University, Montreal, QC.

The Editor

Current Oncology

December 20, 2010

There are at least 5 types of kisses, including gestural, cultural, osculum, basium, saviolum, and orogenital. The physiology of these kisses, except the last, has been reviewed elsewhere 1. Traditionally, kissing has been associated with transmission of viruses, particularly the Epstein–Barr virus (ebv), which causes self-limiting lymphoproliferative infectious mononucleosis with polyclonal activation of B lymphocytes. A positive Paul–Bunnell test with raised titres for ebv antibodies is confirmatory of the “kissing disease” so prevalent among young adults. Hairy leukoplakia and Burkitt lymphoma are also putatively associated with ebv 2.

After World War II, but before 1960, sexual behavior was moderated by many socio-psychological factors, including greater personal restraint, premarital abstinent behavior, barrier contraceptive methods, and religiously infused directives and controls, with contraception focused mainly on males. Subsequent to the introduction, from 1960 onward, of hormone-based systemic female contraception, marked changes occurred in sexual behavior between the sexes in terms of demands, frequency, and interpersonal relationships. With successful contraception possible in women, premarital consensual sexual intercourse, live-in extramarital relationships as common-law spouses, and homosexual relationships are, in 2011, all more frequent. With this change in attitude, increasingly adventurous forms of sexual expression have become popular, with far more kissing prevalent between people. Consequently, oral receptivity and transmission of orally infective human papilloma viruses (hpvs) are more common because of more frequent kissing 3, 4.

KISSING: PROBLEMS ARISING AND DISCUSSION

Saviolum and oro-genital kissing both involve mutual mucosal contact 1, with small but infective exchanges of bodily fluids with incumbent microbes. In addition to transmission of ebv infections through adventurous kissing, progressively more hpv infections from this activity are being noted as causative factors in oropharyngeal and respiratory infections 3. The hpv viruses are medically important mucotropic pathogens that may be benign or that may induce hyperproliferative lesions of epithelia (variously called warts, papillomata, or condylomata depending on the site of manifestation) and head-and-neck carcinoma 4 [for example, focal epithelial hyperplasia with oral papillomatosis (fehp), formerly known as Heck disease]. Because fehp occurred in family groups, it was previously (but erroneously) believed to be an inherited trait; hpv-13 and -32 have been causally associated with fehp 5.

The association between adventurous sexual behavior and the risk of developing oropharyngeal cancer is strong 6. Not only is hpv-16 associated with oral, tonsillar, oropharyngeal, laryngeal, and base of tongue squamous cell carcinoma, but in addition, hpv-16 is positively associated with oral sexual activity, open-mouth kissing (saviolum), and development of upper aerodigestive carcinoma 47.

Vertical and horizontal transmission of hpv-6 and -11 from infected mothers to their offspring induces oral and genital condylomas 8, 9. Peri-conceptual, prenatal, perinatal, and horizontal transmission of the virus (from siblings, householders, relatives, and friends) are all probable from digital contact and kissing 10. Transmission from child sex abuse is also possible 11.

Vaccines against hpv-16 and -18 have been developed. Gardasil (Sanofi Pasteur MSD, Lyon, France) is a quadrivalent vaccine against hpv-16 and -18, which are oncogenic, and also hpv-6 and -11. The Cervarix vaccine (GlaxoSmithKline, Brentford, U.K.) protects against hpv-16 and -18. These vaccines, which target mainly girls from 11 years of age to before sexual debut are available in Canada and the European Union 7, 8.

There are other hpvs: more than 120 genotypes are known, and finding hpvs in cancer demands a variety of lab techniques such as real-time polymerase chain reaction, polymerase chain reaction, in situ hybridization, and immunohistochemistry 7. Not all hpvs have been shown to be carcinogenic, and many are deemed benign in latent form in healthy human tissue. But use of the foregoing techniques has shown that hpv-16 is highly prevalent in head-and-neck neoplastic lesions, and hpv-6, -11, -18, -30, -33, -35, -52, and -59 have also all been reported to be present. The hpvs are variously classified as high-risk (h-hpv) and low-risk. To recognize h-hpvs in biopsies and exfoliated cell assays, dnarna hybrids, with specific antibodies, are used 8.

Respiratory papillomatosis is caused by hpvs. Recurrent respiratory papillomatosis (rrp) has a bimodal distribution—namely, juvenile and adult-onset. Juvenile rrp presents in prepubertal children, commonly around the age of 5 years; adult-onset rrp is prevalent in the 20-to-40 age group. The viruses mostly responsible are hpv-6 and -11, with adult rrp transmission often occurring through kissing. Recurrent respiratory papillomatosis is often progressive and fatal, because mucosal papillomata increase in number and size, leading to total respiratory collapse and insurmountable therapeutic challenges in the advanced stage of the disease 10.

The h-hpv–positive head-and-neck cancers seem to have a better prognosis than do the h-hpv–negative ones, and also a better prognosis than is seen with the cancers associated with smoking either tobacco or marijuana 1214, findings that may be attributable to the sensitivity of hpvs to chemoradiation therapy. Also, hpv precipitates oncogenesis at sites different from those affected by various carcinogenic chemicals involving other vulnerable genome sites 13, 14.

CONCLUDING REMARKS

Kissing is not as innocent as it is universally accepted to be 15. Young males act as a reservoir for hpvs, and whether the current policy of unisex (targeted to women) protection will be successful in society as a whole remains unknown 1, 7, 16. Lips are generally taken for granted by the public, and consequently not only is microbial transmission prevalent, but transmission of many viruses is also common. The ebv, herpesvirus, hepatocellular virus, and hpvs can be transmitted 15, 17, 18. Greater awareness of kissing as a source of infection should be noted and included in all sex education classes for adolescents and adults. To minimize transmission of infections, saviolum kissing should be eschewed and reserved only for fully committed lifelong partners. Vaccination, as for all preventable viral disease, is desirable for hpv whenever possible for women and, when feasible, for young men too 1.

CONFLICT OF INTEREST DISCLOSURES

The author has no conflict of interests to declare.

REFERENCES

1. Touyz LZG. Lips, kissing and oral implications. J Aesthet Dent 2009;3:29–34.

2. Cawson RA, Odell EW. Essentials of Oral Pathology and Oral Medicine. 6th ed. New York: Churchill Livingston; 1998: 211,269,305–6.

3. Chow LT, Broker TR, Steinberg BM. The natural history of human papillomavirus infections of the mucosal epithelia. APMIS 2010;118:422–49.
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4. D’Souza G, Agrawal Y, Halpern J, Bodison S, Gillison ML. Oral sexual behaviors associated with prevalent oral human papillomavirus infection. J Infect Dis 2009;199:1263–9.
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5. Beaudenon S, Praetorius F, Kremsdorf D, et al. A new type of human papillomavirus associated with oral focal epithelial hyperplasia. J Invest Dermatol 1987;88:130–5.
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6. D’Souza G, Kreimer AR, Viscidi R, et al. Case–control study of human papillomavirus and oropharyngeal cancer. N Engl J Med 2007;356:1944–56.
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7. Lajer CB, von Buchwald C. The role of human papillomavirus in head and neck cancer. APMIS 2010;118:510–19.
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8. Snijders PJF, Heideman DAM, Meijer CJLM. Methods for hpv detection in exfoliated cell and tissue specimens. APMIS 2010;118:520–8.
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9. Puranen M, Yliskoski M, Saarikoski S, Syrjänen K, Syrjänen S. Vertical transmission of human papillomavirus from infected mothers to their newborn babies and persistence of the virus in childhood. Am J Obstet Gynecol 1996;174:694–9.
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10. Derkay CS, Wiatrak B. Recurrent respiratory papillomatosis: a review. Laryngoscope 2008;118:1236–47.
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11. Syrjänen S. Current concepts on human papillomavirus infections in children. APMIS 2010;118:494–509.
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12. Mendenhall WM, Logan HLC. Human papilloma virus and head and neck cancer. Am J Clin Oncol 2009;32:535–9.
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13. Hafkamp HC, Manni JJ, Haesevoets A, et al. Marked differences in survival rate between smokers and nonsmokers with hpv 16–associated tonsillar carcinomas. Int J Cancer 2008;122:2656–64.
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14. Gillison ML, D’Souza G, Westra W, et al. Distinct risk factor profiles for human papillomavirus type 16–positive and human papillomavirus type 16–negative head and neck cancers. J Natl Cancer Inst 2008;100:407–20.
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15. Donovan B. Sexually transmissible infections other than hiv. Lancet 2004;363:545–56.
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16. Touyz LZ. Human papilloma virus inoculation: why only girls? Curr Oncol 2009;16:2.
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17. Crawford DH, Macsween KF, Higgins CD, et al. A cohort study among university students: identification of risk factors for Epstein–Barr virus seroconversion and infectious mononucleosis. Clin Infect Dis 2006;43:276–82. [Erratum in: Clin Infect Dis 2006;43:805]
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18. Zacks S, Beavers K, Theodore D, et al. Social stigmatization and hepatitis C virus infection. J Clin Gastroenterol 2006;40:220–4.
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louis.touyz@mcgill.ca

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Current Oncology, VOLUME 18, NUMBER 4, 2011








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