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How to reduce the risk of cunnilingus-related oral cancer

The fact that cunnilingus increases a man’s risk of developing oral cancer has been all over the Internet this week with Michael Douglas’s disclosure that he had an HPV-positive tumor.

Human Papilloma Virus (HPV)

Human Papilloma Virus (HPV)

To recap: some strains of Human Papilloma Virus (HPV) are oncogenic, meaning they induce changes in a cell’s DNA that can lead to cancer. The same strains of HPV that are oncogenic in the genital tract for women, causing both cervical cancer and anal cancer, can also wreak havoc on cells in the oral cavity. As an aside, HPV can also cause anal cancer for men.

The association between cervical cancer and HPV has been known for a while; in fact the Nobel prize in 2008 was given to the scientist who proved the link. However, even before we knew about HPV women were getting Pap smears to diagnose pre-cancers, dramatically reducing the risk of death from cervical cancer. Now that we know about HPV and have tests that can detect it, cervical cancer screening has become very refined and if every woman had access to health care HPV-related cervical cancer could become a disease that we “used to see.”

Keep in mind that Pap smears and HPV testing for women are after-the-exposure surveillance. These methods prevent cancer by catching the infection before it causes cancer, they don’t prevent acquiring the cancer causing HPV virus in the first place. So, cervical cancer prevention for women also includes HPV vaccination and safe sex practices. Condoms reduce the risk of HPV transmission, but they are far from 100% effective as HPV infection is not limited to the vagina or penis (HPV infection causes what is known as a field effect, meaning the virus is often multiple places in the reproductive tract, penis and scrotum for men and cervix, vagina, and vulva for women). Safe sex practices also include limiting partners. The more partners you have, the greater your risk of exposure.

So what about preventing HPV related oral cancer? Well, here are some strategies…

1) Don’t smoke. It doubles the risk of head and neck cancer.

2) Think of oral sex as sex. Because it is. Many people think they are being safer if they “just” have oral sex, but the reality is oral sex is an effective way to transmit sexually transmitted infections. Also, many people who use condoms for penetrative sex don’t for oral sex, so in many ways it has become and even riskier behavior. Six heterosexual oral sex partners increases a mans risk of oral cancer 8 fold.

3) Consider using a dental dam for oral sex if you are not in a long-term relationship. If you would use a condom with that partner for disease protection, then you should be considering what you can catch from other orifices as well. Although keep in mind no one knows how well a dental dam actually works in reducing exposures.

4) Go to a dentist regularly. Studies show this reduces the risk of invasive cancer as your dentist can often identify a lesion when it is small and hopefully pre-cancerous. There is no oral Pap yet or HPV test, but I wouldn’t be surprised if we started seeing some kind of screening test down the road.

5) Maintain good oral health. In one study bad dentition was an additional risk factor (distinct from dental visits). This could be that chronic inflammation from gum disease or missing teeth may increase the risk of catching the virus if exposed.

6) If you are in the right age group, get the HPV vaccine. While there are no studies that show it reduces oral cancer for men (we won’t know that for 10-20 more years at least), it does reduce the burden of HPV related genital tract diseases. The vaccine could possibly help men in two ways: reduce their risk of exposure if their partners have been vaccinated (a vaccinated woman is less likely to shed the virus) and reduce the risk of a man catching the HPV virus if exposed through oral contact.

Discussion

14 thoughts on “How to reduce the risk of cunnilingus-related oral cancer

  1. Nice article…a few comments from a HPV researcher:

    1. There is now a bit evidence that vaccination may prevalent oral HPV infection. I don’t think it has been published yet, but there was an abstract/presentation on this at the last HPV meeting with promising data.

    2. HPV-associated oral cancer is relatively rare so a screening test (that would reduce mortality) is going to be tough to develop.There’s research in this area looking at different biomarkers, but the sensitivity and specificity would have to be very very high for a screening test to be beneficial. The chances of developing an oral pap doesn’t look great because of issues of what the abnormal cells often develop (the tonsillar crypts) (http://www.ncbi.nlm.nih.gov/pubmed/21836021).

    3. Your comment on going to the dentist is interesting to me – do you have a citation? HPV+ oral cancer is in the back of throat and often in tonsillar crypts so it is difficult to detect visually. I’ve read HPV-negative oral cancer mortality may be reduced by screening of heavy lifetime smokers/drinkers, but that evidence isn’t strong and it’s not recommended by the USPSTF.

    For me – the big picture is that the absolute risk of this cancer is very low for all groups, so changing your behavior based solely on the risk of this cancer may not be recommended. That being said, there are other strong benefits of Dr. Gunter’s recommendations – particularly not smoking and vaccination.

    Posted by danbeachler (@danbeachler) | June 5, 2013, 8:46 am
    • Hi Dan. Thanks for posting.

      I haven”t seen the unpublished data, but it seems intuitive that the vaccine would help reduce the oral risk. However, you never know until you see the paper!

      As DNA testing becomes so much more affordable you never know what might happen. There is certainly nothing available for oral testing prime time, however, I remember people thinking HPV testing for women would be ridiculously expensive and here we are. I also don’t know if it’s HPV persistence for oral cancer, like it is for cervix (although I assume that it is), so would there be a possibility of screening men at the age of 40 for the virus and then following those who are positive? Don’t know.

      The dentist reference comes from an obscure journal (Swed Dent J Suppl. 2005;(179):1-66). I don’t kwow if men who go to the dentist are also likely to have fewer lifetime partners, so it may not be a result of going to the dentist or something that going to the dentist is associated with. However, we do know that trauma is definitely a co factor for genital HPV so having the best oral hygiene, which typically includes dental visits, is probably a good idea! So, I stand by the regular dental check-ups recommendation.

      The risk of cancer is low, and hopefully it will stay that was with the vaccine. But we also don’t have enough longitudinal studies with the vaccine to look at people 20 years or more post vaccination.

      Thanks for contributing! Much appreciated.

      Jen

      Posted by Dr. Jen Gunter | June 5, 2013, 6:18 pm
  2. Nice info Jen,

    Just wondering, as a man with HPV is it worth getting the Gardasil injection although I’m already exposed?

    Posted by Studiosound | June 5, 2013, 6:10 pm
  3. Jen,
    as always good advice. I don’t see the dental dam as really helping cut down contact the way a condom does, though…but I’ve never tried it. The key is to see oral sex as sex, as you said.

    Posted by bob99901 | June 7, 2013, 1:23 am
  4. i have a17 year old son not yet sexually active who is an athlete en route to becoming professional should I give him the gardasil shots

    Posted by suzanne | June 8, 2013, 11:55 pm
  5. sadly most parents are scared that if their daughter or son receive the HPV vaccine it would promote sex at an early age – it is best advice that a boy or a girl ages 11 and above should be vaccinated- plus the fact that there are no proven record that being vaccinated would really help prevent oral cancer.

    as for visiting your dentist regularly, it really does help prevent oral cancer formed from other factors such as smoking, infection etc, i don’t think, and haven’t heard anyone else said, “oh boy, you’ve got oral cancer, its because you’ve got infected by doing oral sex”

    Posted by St. Lawrence Dentist (@StLawrenceDDS) | June 11, 2013, 2:00 am
  6. I’m sad to see that you, like so many MD’s, ignore the fact that women also practice cunnilingus. This blog piece focuses solely on men, ignoring that women are at least as much at risk. Women’s sexuality and STD risks need to be taken serioiusly as well.

    Posted by NJ | June 13, 2013, 12:42 pm
  7. i would like to receive a reply from Dr Jen please re my son the athlete

    Posted by suzanne | June 16, 2013, 12:48 pm
  8. People need to be adequately educated regarding the risks . They know nothing virtually about oral sex and hpv associated cancer. Time is now for younger people who feel invincible. Beware there are over 100 serovars not many being proved to be definitely associated with oral cancer, but not enough true studies completed in people with multiple partners and not enough immunohistochemistry specific or even nonspecific performed on small and papilloma like oral lesions to confirm anything or neggate anything.regarding significant associations between HPV SPCIFIC SEROVARS. Physicians need to wake up and educate their patients in a very touchie subject. No pun intended.

    Posted by Thomas B Burkhardt MD | June 27, 2016, 4:53 pm

Trackbacks/Pingbacks

  1. Pingback: I’ve already had HPV, should I still get the vaccine? | Dr. Jen Gunter - June 6, 2013

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