Sexual health and the mouth

Sexual healthBenjamin Tighe breaks down some common sexually transmitted diseases, explains how they transmit and the treatments available.

What did your dental training teach you about sexual health? For many of us the answer is nothing.

Syphilis and gonorrhoea are on the rise in the UK. A recent study by Drake et al suggested HPV may become the number one cause of oropharyngeal cancer overtaking traditional causes like smoking and alcohol.

One of our roles as dental professionals is to educate the patient on the risks of their behaviour. We’ve done this for years about smoking and more recently about alcohol.

But why is sex so different?

What is oral sex?

Oral sex refers to the sexual act of genital stimulation by the use of the mouth, tongue or throat (Saini et al, 2010).

Common among people of all sexual orientations, it can be practised as part of foreplay before, during or following sexual intercourse.

Kumar et al, (2015) suggests teenagers have engaged in oral sex before sexual intercourse. And they have more unprotected oral sex than vaginal sex.

The various types of oral sex performed are:

  • Analingus – oral-anal contact: stimulation of the anus with tongue or lips
  • Cunnilingus – oral-vaginal contact: stimulation of a vagina and/or vulva and/or clitoris with the lips and tongue
  • Fellatio – oral-penile contact: stimulation of a penis by the tongue, lips or throat.

One of the main problems we face is lack of education around oral sex.

Many adolescents don’t see oral sex in the same light as penile/vaginal sex. Therefore they often perceive the risks associated to be much lower or non existent (Nguyen et al, 2016).

Studies (Brondani et al, 2019; Guadiana et al, 2021) showed that dental professionals were perfectly placed to provide the correct preventative advice and could become leaders in preventing HPV-related cancers and oral STIs.

However, one main barrier that was identified was the profession’s lack of knowledge around oral sex.

This article aims to break down some common sexually transmitted diseases.

HPV (transmitted through all modes of oral sex)

Transmission

HPV is one of the most common sexually-transmitted infections in the UK.

There are over 150 subtypes of HPV. With more than 40 being transmitted through sexual contact. They infect the anogenital region and oral cavity (Kim, 2016).

An estimated 80% of all sexually active people are infected with some strain of HPV (Satterwhite et al, 2013).

In 2012, the International Agency of Research of Cancer (IARC) declared that there was sufficient evidence to associate a subtype of HPV 16 with oral cancers.

The human papillomavirus 16 (HPV16) is associated with the development of head and neck cancer. Particularly in the oropharynx (tonsils, base of the tongue, and throat) and floor of the mouth (Satterwhite et al, 2013).

Epidemiologically, HPV-associated head and neck cancers occur more frequently in patients below the age of 50 (Kim, 2016).

Heck et al (2009) stated that HPV head and neck cancer is associated with:

  • A history of six or more lifetime sexual partners
  • Four or more lifetime oral sex partners
  • A younger sexual debut.

Symptoms

HPV has no symptoms so often goes undiagnosed. But it can present as small warts in the mouth, throat, genitals or anus.

If you spot these during your examination then refer the patient to Oral Med for further investigation.

HPV sexual health

Preventing HPV

Condom and barrier use for all sexual encounters including oral sex is recommended. But the best way to prevent HPV is to get vaccinated.

The advent of the HPV vaccine has also shown to decrease the incidence of HPV infections in young girls and more recently young boys.

The HPV vaccine is currently free for all under 25s. Men who have sex with men (MSM) are able to access the vaccine from their local sexual health centre for free up until the age of 45 in England.

Herpes (transmitted through all modes of oral sex)

Transmission

Genital herpes is caused by one of the herpes simplex viruses (HSV).

There are two types, HSV-1 and HSV-2. Both types can infect the genital and anal area (genital herpes), the mouth and nose (cold sores).

It is highly contagious and tends to be more contagious during an active outbreak.

HSV-1 is mainly transmitted via contact with the virus in sores, saliva or surfaces in or around the mouth.

Although less common, HSV-1 is transmitted to the genital area through oral-genital contact to cause genital herpes if you receive oral sex from someone who has a cold sore or is just about to get one.

The virus enters the body through small abrasions in the skin. Or through the moist mucous membranes of the mouth, vagina, rectum, urethra and under the foreskin.

Symptoms

The primary symptom of herpes is the appearance of blister-like sores on or around the genitals or anus. It often coincides with general malaise and fever.

They may also affect the mouth, tongue, and lips, depending on the type of herpes.

Preventing herpes

For sexually active people, consistent and correct use of condoms is the best way to prevent genital herpes and other STIs.

People with symptoms of oral herpes should avoid oral contact with others (including oral sex) and sharing objects that touched saliva.

Even condoms and other barrier protection methods may not prevent the virus from spreading. Particularly if someone has a sore or a blister that is not completely covered by a condom or dental dam.

Herpes is not curable. But medications can manage symptoms, reducing the frequency and severity of the attacks.

If you present to your doctor within five days they can prescribe an antiviral called Aciclovir – 200mg for five days.

If you experience six or more ‘attacks’ in one year or it is severely affecting your quality of life then you can have long-term treatment, which is Acilcovir 400mg x twice daily for 12 months.

Medication for facial cold sores isn’t suitable for genital herpes.

Syphilis (transmitted through all modes of oral sex)

Transmission

Syphilis is a sexually transmitted infection that is caused by the bacteria treponema pallidum.

Over time syphilis destroys blood vessels and nerves.

The bacteria live in the sores that are present in the genital areas as well as around the mouth.

Syphilis is mainly spread through close contact with an infected sore. It spreads usually during vaginal, anal or oral sex. Or by sharing sex toys with someone who’s infected.

It is on the rise across the UK, especially amongst men.

Symptoms

This first stage of infection is early (primary) syphilis.

Although rare, the initial signs are painless. Hard sores or ulcers that don’t bleed on or inside the genitals, mouth, or throat within the first three months after infection.

Early (secondary) symptoms may also include red, flat patches across the body. Especially on the palms of the hands and soles of the feet.

Late (tertiary) syphilis then occurs many years or even decades after initial infection. This is because it affects the blood vessels and nerves. Tertiary syphilis can cause serious problems with bones, the brain and the large vessels near the heart.

Blindness, numbness and brain damage can also occur.

Preventing syphilis

Fortunately, syphilis complication is rare within the UK due to regular testing. However, it is on the rise.

To reduce the risk of infection, it is encouraged to regularly test and use condoms or barriers when engaging in sex.

Shigella (transmitted through analingus or fellatio following unprotected anal sex)

Transmission

Shigella infection (shigellosis) is caused by a bacteria (S sonnei and S flexneri) that lives in faeces.

Although normally caused by food contamination it can be passed through sex that involves contact with faeces (this can be fingers to mouth or analingus) and is more common in men who have sex with men.

Symptoms

Symptoms usually begin one to two days after you become infected and can last up to a week.

Not all cases display symptoms. But most people get diarrhoea and abdominal cramps. Some may also have a high temperature and vomiting.

Preventing shigella

To reduce the risk of catching shigella, it is important to reduce the risk of coming into contact with any faecal matter.

Always wear a condom for anal sex; use a barrier (condom or dental dam) when performing analingus; ensure you’re washing your hands during or after sex, especially if you’re performing analingus or touching someone’s anus and shower after sex.

Gonorrhoea (transmitted through all modes of oral sex)

Transmission

Gonorrhoea is a bacterial sexually-transmitted infection caused by neisseria gonorrhoeae.

It is the second most common bacterial sexually transmitted infection (STI) in the UK.

It is spread easily through unprotected vaginal, anal or oral sex.

Oral gonorrhea also spreads through oral sex performed on the genitals or anus of someone who has gonorrhea.

Government statistics show that MSM in England accounted for over 80% of all pharyngeal infections.

Symptoms

Gonorrhea of the mouth is often asymptomatic. However, it can present several symptoms, including swelling of the lymph nodes in the neck, painful swallowing, a sore throat, nausea/vomiting and a fever.

Bacteria transmitted orally also has a higher chance of infecting the eyes. This leads to pain and increased sensitivity to light.

Depending on the patient’s level of sexual activity, the infection might spread to other areas of the body and cause other symptoms like a thick green or yellow discharge from the vagina or penis.

Preventing gonorrhoea

We can prevent gonorrhoea by using condoms when having vaginal and anal sex.

Using a condom to cover the penis or a dental dam to cover the vagina or anus if you have oral sex.

Conclusion

Due to its importance, we have now included sexual health within our undergraduate dental hygiene and therapy curriculum at The Eastman.

References

Brondani MA, Siqueira AB and Alves CM (2019) Exploring lay public and dental professional knowledge around HPV transmission via oral sex and Oral Cancer Development. BMC Public Health 19(1)

Drake VE, Fakhry C, Windon M, Stewart CM, Akst L, Hillel A, Chien W, Ha P, Miles B, Gourin C, Mandal R, Mydlarz WK, Rooper L, Troy T, Yavvari S, Waterboer T, Brenner N, Eisele D and D’Souza G (2021) Timing, number, and type of sexual partners associated with risk of oropharyngeal cancer. Cancer 127(7): 1029-38

Guadiana D, Kavanagh NM and Squarize CH (2021) Oral health care professionals recommending and administering the HPV vaccine: Understanding the strengths and assessing the barriers. PLOS ONE 16(3)

Heck JE, Berthiller J, Vaccarella S, Winn D, Smith E, Shan’gina O, Schwartz SM, Purdue M, Pilarska A, Eluf-Neto J, Menezes A, McClean M, Matos E, Koifman S, Kelsey KT, Herrero R, Hayes RB, Franceschi S, Wünsch-Filho V, Fernández L, Daudt AW, Paula Curado M, Chen C, Castellsagué X, Ferro G, Brennan P, Boffetta P and Hashibe M (2009) Sexual behaviours and the risk of head and neck cancers: A pooled analysis in the international head and Neck Cancer Epidemiology (INHANCE) consortium. International Journal of Epidemiology 39(1): 166-81

IARC Working Group on the Evaluation of Carcinogenic Risks to Humans (2012) IARC monographs on the evaluation of carcinogenic risks to humans: IARC monographs, volume 100B. A review of human carcinogens. B. Biological agents. Lyon: International Agency for Research on Cancer. 278–280

Kim SM (2016) Human papilloma virus in oral cancer. Journal of the Korean Association of Oral and Maxillofacial Surgeons 42(6): 327

Nguyen NP,  Nguyen LM, Thomas S, Hong-Ly B, Chi A, Vos P, Karlsson U and Vinh-Hung V (2016) Oral sex and oropharyngeal cancer. Medicine 95(28)

Saini R, Saini S and Sharma S (2010) Oral sex, Oral Health and Orogenital infections. Journal of Global Infectious Diseases 2(1): 57

Satterwhite CL, Torrone E, Meites E, Dunne EF, Mahajan R, Ocfemia RCB, Su J, Xu F and Weinstock H (2013) Sexually transmitted infections among us women and men. Sexually Transmitted Diseases 40(3): 187-93

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