You may wonder if it’s appropriate to talk about such a taboo subject as oral sex in your preventive dental appointment, but as a primary care oral health care professional, the answer is YES! It’s not only appropriate but conscientious.
With the incidence of HPV Oral Pharyngeal Cancers (HPV-OPC) on such a rambunctious rise, increasing at about 30% per year, we need to be doing a better job at screening, preventive recommendations, and at discussing the root cause—oral sex. We will get to tips on that dialoged in a minute.
The American Cancer Society reported in 2024 that the incidence of oral cavity and oropharyngeal cancer from HPV is currently towering at 58,450 new cancers a year! How is that possible?
You may be surprised to learn that our bodies are a cesspool of virus—hosting about TEN viral particles per human cell! HPV alone is so ubiquitous that if you put a piece of scotch tape anywhere on your arm and picked it up, you’d find HPV. Fortunately, most of the 200+ strains of Human Papilloma Virus are not a serious threat to us. Some strains cause the menacing warts we experience on our hands and feet, but some go on to cause cancers—mostly of the oral pharynx, cervix, anus, penis and vagina.
Historically, we have considered tobacco (smoke and smokeless) and alcohol (a co-carcinogen) as the primary culprits of oral cancer. Not anymore! HPV-OPC accounts for about 73% of all oral pharyngeal cancers. These cancers are also exacerbated by smoke, booze and our all-too-commonplace acid reflux, but certain strains of HPV are much more pernicious in their invasion. A handful are aggressive and virulent! They can distort human cells into malignancy, even while patients remain asymptomatic.
Sadly, these cancers that are rarely detected in our traditional 8-point oral cavity “cancer screening”. They take root behind the scenes—in the back in the throat (base of the tongue, tonsillar pillars, posterior pharyngeal wall, tonsils, etc.).
More sadly, the most common way HPV-OPC is detected is from an enlarged neck node. We call this “neck disease”. My take on the oral cancer screening exam is this: since 73% of the oral cancers are HPV-OPC and the first place they show up is in the neck, then 73% of the time we devote to oral cancer detection should be focused on a very thorough neck exam. There are professional videos your clinical team might watch on how to accomplish a good neck exam.
As opposed to most sexually transmitted infections, HPV infection is more prevalent in men than women. Hence the HPV oral pharyngeal cancer rate is more than two times greater form men. Interestingly, white, middle-aged men are the predominant demographic. Why? It is thought that is because white men have the highest number of lifetime oral sex partners and report first performing oral sex at a younger age compared with other racial/ethnic groups.
Keep in mind that 50% of all new HPV infections occur between the ages of 15 and 24. That shocking fact behooves us to learn about the current trends in oral sexual behaviors.
As opposed to 50 years ago, today oral sex is often viewed as casual body contact, much like kissing—and it has become increasingly popular. More than 85% of sexually active adults aged 18-44 years reported having had oral sex with a partner of the opposite sex. It’s also reported that the average age for first body-part sex (including oral sex) is 11-13 years old. That is precisely the reason the HPV vaccine series targets 11- and 12-year-old children.
HPV is our number one most prevalent sexually transmitted infection, and more than two-thirds of sexually active men and women will have HPV infection at some point in their lives.
The nuance is in the oncogenic (cancer causing) strain(s) you contact. Of the 200+ HPV strains, 25 have been associated with oral pharyngeal cancer, with 9 strains responsible for about 73-90% of the associated malignancies.
We have an awesome opportunity to detect the presence of these strains in a simple saliva test—and the technology is nothing short of amazing. In a single drop of saliva, we can accurately detect the collective presence of 51 HPV strains with exact specificity. If the most virulent strains (HPV-6,11,16, 18, 31, 33, 45, 52 or 48) are present, we can test again in 12-18 months to see if our patients have “cleared” the virus, for it is the persistent infection that brings on the burden of cancer risk.
It’s true! Unlike some viruses we are familiar with, such as Herpes (HSV-1, HSV-2) or HIV, Human Papilloma Virus can be cleared. Think of the nagging plantar wart on your foot that suddenly disappears without treatment after being present for years.
Clearing a virus depends on strong host immunity. In other words, generalized health. A positive HPV saliva test gives us the opportunity to counsel our patient toward a more healthful lifestyle: better quality and quantity sleep, nutrition, hydration, exercise and stress reduction. I advise my patients with any chronic disease, including periodontal disease, to treat their body like a temple while they are trying to shift that microbiome toward health and stability.
Meanwhile, if I was hosting a persistent HPV infection in my oropharynx, you can bet I’d be seeking out my trusted Otolaryngologist (ENT) to perform an oropharyngeal exam using a flexible laryngoscope with regular frequency. Early detection is still critical in reducing the horrific sequalae of OPC cancer and cancer treatment.
Many of our patients are gun-shy about vaccination these days but be assured that the Gardasil 9 series (carrying the 9 most oncogenic strains) is covered up to age 45 years old and will reduce the risk of HPV infections and HPV cancers by 80%. Still today, less than 50% of 11- and 12-year-olds receive even the first inoculation. Research shows that most parents follow the vaccination recommendations of their physicians. Please be the physician of the oral cavity by asking about their history and advising toward protection.
Lastly, don’t forget to point out the root cause. We must get the word out that oral sex is not safe sex. It’s true that oral sex performed on males wearing a condom and females using a dental dam is less risky, but let’s face it—that’s not what’s happening.
My recommendation is, while the hygienist is focusing on a thorough neck exam, it gives us a minute to say something like this:
“You might wonder why I’m spending more time on your neck today. Oral pharyngeal cancer from the HPV virus—predominantly introduced by oral sex—is increasing at a very scary rate. These cancers take root in the back of the throat area, beyond what I’m able see in your mouth. So, the first sign of this disease is usually a little neck bump that can often be detected with the tips of our fingers. The bottom line is, if you ever notice a lump in your own neck, please don’t blow it off. And if you haven’t been vaccinated or had your kids vaccinated, please consider that too. Cancer prevention rocks!”
Meanwhile, I have a question printed on our adult health history form that reads: “HPV from oral sexual transmission is the primary cause of oral pharyngeal cancer. Would you like to have a saliva test for the presence of HPV?”
On our pediatric health history form a similar question reads:
“HPV is the primary cause of oral pharyngeal cancer. Has your adolescent (or older) child completed their Gardasil 9 vaccination series? (It reduces cancer risk by 80%.)
If you’ve been close to a friend, family member or patient suffering with HPV-OPC, you already know the treatment is brutal. That’s a subject for another day. Meanwhile, it’s time to do our part better. With a few changes in our practices and dialogue, we can be part of the change we want to see in the world.
