gardasil_logo_tcm1908-197175There are over 200 known serotypes of Human Papilloma Virus (HPV). About 79 million Americans are currently infected with HPV. About 7% of adults have HPV in their oral cavity. Only about 3,000 to 13,000 patients in the United States have Recurrent Respiratory Papilllomatosis (RRP). Virtually all of them have active HPV in thier oral cavity. These patients are afflicted with HPV 6 and 11, which affects primarily mucous membranes. It is looking more and more like oral to oral transmission trumps oral genital transmission. It seems to be a different animal all together than cervical HPV. Serotypes 16 and 18 are the types associated with carcinogenesis. There currently is no evidence that spouses should be vaccinated and it does not really seem to be easily transmitted between adults.  Cervarix is a bivalent 16 &18 only vaccine.

This disease has become epidemic, however the treatments and the preventative measures are also gaining momentum.  HPV is the whole reason we really did PAP smears.  The viral changes led to cervical uterine dysplasian and even carcinogenesis.  It was even suggested to consider C-section in women with active infections.

The disease is really divided into the more problematic juvenille onset (>20 lifetime surgeries) vs adult onset (<5 lifetime surgeries).  There may be some correlation with sexual behavior in adult onset, however, this is still controversial. There is no role for vaccination or even counseling or testing partners.

images-1Recurrent Laryngeal RRP may require multiple surgeries.  It seems the best initial response is with the CO2 Laser, however use of the microdebrider (PIPE) may actually give better voice outcomes

Adjuvant therapies such as Acyclovir, MTX, Ribavarin, Mumps vaccine, PPI, Alpha Interferon, Hsp E7, Retinoids, and Intralesional Cidofovir have been touted, but lack strong prospective efficacy studies.  Typically I use the CO2 laser.  Have patients eat green leafy vegetables (Indole-3-carbinols) modulates estrogen metabolism and 1/3 of patients respond.  Inject about 75 mg of Cidofovir in 1 cc after the resection.  I may consider placing on Celebrex (Cox 2 inhibitor) which modulates the over expression of epidermal growth factor by inhibiting cyclooxygenase-2 and prostaglandin E2.   I also may consider injecting Avastin (Bevacizumab) recombinant monoclonal antibody against vascular endothelial growth factor.

Lip Tie

Labial Frenulectomy

Frenum_composite 1106CFP_PC_Frenum_AB-1A labial frenectomy is a form of frenectomy performed on the lip.

The labial frenulum often attaches to the center of the upper lip and between the upper two front teeth. This can cause a large gap and gum recession by pulling the gums off the bone. A labial frenectomy removes the labial frenulum. Orthodontic patients often have this procedure done to assist with closing a front tooth gap. When a denture patient’s lips move, the frenulum pulls and loosens the denture which can be uncomfortable. This surgery is often done to help dentures fit better.

The removal of the frenulum does not cause any adverse effects to the lip and mouth.  The real question is if it has any beneficial effects.

“Potential” benefits include better feeding, diminished decay of the front incisors, and avoiding a central diastema (gap in the front teeth).  I remain a bit skeptical that the benefits exist.

Tongue Tie (Ankyloglossia)

tounge_tie_mediumBefore we are born, a strong cord of tissue (the frenulum) that guides development of mouth structures is positioned in the center of the mouth. After birth, the frenulum continues to guide the position of incoming teeth. As we grow, it recedes and thins.

This frenulum is visible and easily felt if you look in the mirror under your tongue. In some children, the frenulum is especially tight or fails to recede and may cause tongue mobility problems.

The tongue is one of the most important muscles for speech and swallowing. For this reason, having tongue tie can lead to eating or speech problems, which may be serious in some individuals.  Posterior tongue tie is a nebulous term that lacks a clear definition or treatment.