Human Papilloma Virus Vaccinations: Primary Prevention by Dentists
Matthew Sun, BSc; Thomas P. Sollecito, DMD; and Eric T. Stoopler, DMD
Human papilloma virus (HPV) is the most common sexually transmitted infection in the United States, and the HPV vaccination prevents HPV infections associated with oropharyngeal, genital, and rectal cancers.1 Physicians and dentists recommend HPV vaccines during adolescence to promote public health, and the US Food and Drug Administration recently expanded use of Gardasil 9 (Merck) up to age 45.2-6 Although HPV immunization rates have increased, only 51% of adolescents have completed the vaccine series, which is 30% to 40% lower than similar multidose immunizations.7-9
Considering the 80% lifetime exposure risk to HPV and significant morbidity of HPV-associated cancers, dentists can play a major role in primary prevention against HPV-associated cancers to help reduce national disease burden.10-14 Concern exists that administration of HPV vaccinations by dentists exceeds the scope of dental practice, is unfeasible within the current healthcare system, and may not fully address the low HPV immunization rates.15-19 Let's examine these assumptions and explore rationales for this approach to address the public health problem.
Dentists are primary oral healthcare providers with expertise of the oral maxillofacial complex who hold an ethical obligation to "advance the overall oral health of their patients" and "fight oral cancer."20 Dentists perform detailed extraoral and intraoral evaluations and routinely identify common local diseases (eg, dental caries and periodontal disease). In addition, they may detect oral manifestations of systemic diseases (eg, diabetes, anemia, and HIV infection), and identify systemic conditions (eg, hypertension and arrhythmias) through assessment of vital signs. Physicians consult dentists for specialized knowledge of the oral cavity and conditions affecting the head and neck regions. Collaborative care between dentistry and medicine is often underutilized; however, oral and systemic health are indisputably interconnected. As health systems evolve toward integrated care, coordinating care for HPV immunization opens interprofessional dialogue to collectively improve systemic health through oral health services.21,22
Spanning medicine and dentistry, the American Medical Association and American Dental Association advocate for patient education on oropharyngeal cancer. Prevention of HPV-associated oropharyngeal cancer aligns with the professional ethos of dentistry, but HPV immunizations are administered primarily by physicians, nurses, and pharmacists. However, dental and medical professions hold shared responsibility over the multidisciplinary diagnosis and management of oropharyngeal cancer, yet most dentists lack practice authority to deliver HPV vaccines.23,24
Adding HPV vaccinations to dentists' armamentarium will expand patient access to HPV preventive care and potentially reduce HPV-associated oropharyngeal cancer rates, as 84.6% of adolescents visit dentists annually in the United States.25-27 Dentists can have even greater impact by administering HPV vaccines in patients up to age 45, as the median age of diagnosis for HPV-associated oropharyngeal cancers occurs during the early sixth decade for men and women.28
Dentists are qualified to administer HPV vaccinations because they possess translatable clinical skills to safely perform intramuscular injections and manage patients' medical complications. However, standardized training should be required before certifying dentists to administer HPV vaccines to ensure appropriate levels of knowledge and familiarity with associated patient management protocols.29 Although permitting dentists to administer HPV vaccinations is congruent with the ethical responsibility and clinical scope of dentistry, this health measure challenges the financial structure and culture of the current US healthcare system.
State legislatures should grant dentists practice authority to administer HPV vaccines because HPV immunization reasonably falls within the scope of dental practice. Oregon recently passed House Bill 2220 to extend immunization privileges to dentists and aims to reimburse vaccinations by dentists similar to authorized provider coverage.30 To improve oral health, dentists perform medically indicated procedures (eg, cone-beam computed tomography, sleep apnea oral appliances, and temporomandibular disorder treatments), which are reimbursable under the "Nondiscrimination in health care" provision in Section 2706 of the Affordable Care Act.31 Therefore, dentists certified to administer HPV vaccinations would act within professional practice standards and should be subject to medical insurance reimbursement.
Currently, most medical insurances fully cover HPV vaccinations under age 18, and adopting medical reimbursement for dentists can address patients' financial concerns and incentivize preventive services by dentists. Incorporating HPV vaccinations into dental visits can add value to dental practices, reinforce the relationship of dental care for overall health, and stimulate the public consciousness of dentists as oral physicians.32,33
Hospital-based dentists, pediatric dentists, oral and maxillofacial surgeons, and oral medicine specialists who practice within existing medical centers are primed to be early adopters of HPV vaccinations, because they have established access to patients' medical records, immunization registry, and infrastructure to coordinate insurance. Similarly, public health dentists practice in integrated care teams at community-based federally qualified health centers (FQHCs). Hospitals and FQHCs address patients' financial limitations by accepting public and private health insurances, and these dental specialists directly confront disparities in healthcare access for referred patients with medically complex needs who would gain substantial benefit from HPV vaccination.7,34,35 Therefore, initial implementation of HPV vaccinations by dentists in these settings may be appropriate.
Because some patients visit dentists more often than their physicians, dentists can increase patient access to HPV vaccinations.36 By establishing greater accessibility for patients, dentists can help increase HPV vaccination rates. Even one dose of the HPV vaccine can deliver significant preventive benefit and protect previously infected patients from other HPV serotypes.37 HPV 16 is highly associated with oropharyngeal cancers and commonly diagnosed in the early sixth decade, so the importance of HPV immunization for public health benefit cannot be overstated.38-40
Solely recruiting dentists, however, may not completely address low HPV immunization rates because barriers of cost, awareness, and stigma of the HPV vaccine must be overcome.41 This multifaceted public health issue requires concerted coordination among healthcare professions in diagnostic screening, educational intervention, and primary prevention for HPV-associated cancers.
As oral health experts, dentists are in an ideal position to address poor rates of HPV immunization by detaching stigma surrounding HPV. Conversations about sexual health related to oral-systemic health matters can productively educate patients about HPV-associated cancers.42,43 Reports indicate patients are comfortable with dentists asking about sexual health as part of performing a standard medical history.44-47 Dentists can help remove stigma around HPV by recontextualizing the dialogue as oropharyngeal cancer prevention. Dentists want training to facilitate discussions about HPV vaccines, and training can enhance dentists' knowledge of HPV immunizations and their ability to converse with patients about HPV.16,48,49
Although oral and systemic health are closely intertwined, the historical division between medicine and dentistry may place patients in a healthcare void, and prevention of HPV-associated oropharyngeal cancer may occupy this space. Traditional notions of dentists as "tooth doctors" do not accurately reflect contemporary clinical practice, which emphasizes dental medicine for comprehensive health, and this paradigm shift challenges those outdated perceptions of dentistry.50,51 Integrating electronic health records, insurance billing, and appropriate training will help bridge the gap between dentists and medical communities, facilitate interprofessional communication, and coordinate oral health with primary medical care as a multidisciplinary team.52-55
Dentists hold a professional responsibility to address oral public health needs, as they are equipped with the clinical skills to change the educational and stigma barriers affecting HPV-oropharyngeal cancer vaccination. Dentists administering HPV vaccines can potentially reduce the global burden of HPV-related disease and enhance the public health impact of dental medicine.18,28,56,57
About the Authors
Matthew Sun, BSc
DMD/MBE Candidate, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
Thomas P. Sollecito, DMD
Professor and Chairman of Oral Medicine, Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania; Fellowship in Dental Surgery of the Royal College of Surgeons of Edinburgh (FDS RCSEd)
Eric T. Stoopler, DMD
Professor of Oral Medicine, Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania; Fellowship in Dental Surgery of the Royal College of Surgeons of Edinburgh and England (FDSRCS); Fellowship in Dental Surgery of the Royal College of Physicians and Surgeons of Glasgow (FDSRCPS)
References
1. Van Dyne EA, Henley SJ, Saraiya M, et al. Trends in human papillomavirus-associated cancers - United States, 1999-2015. MMWR Morb Mortal Wkly Rep. 2018;67(33):918-924.
2. Centers for Disease Control and Prevention. HPV Vaccine Recommendations. Centers for Disease Control and Prevention website. 2017. https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html. Accessed January 16, 2019.
3. American Dental Association. ADA Adopts Policy on HPV Vaccination for the Prevention of Oral HPV Infection. American Dental Association News Releases. 2018. https://www.ada.org/en/press-room/news-releases/2018-archives/october/ada-adopts-policy-on-hpv-vaccination-for-the-prevention-of-oral-hpv-infection. Accessed January 16, 2019.
4. American Cancer Society. Nearly 14 Million Additional Adolescents Need to Be Vaccinated against HPV to Reach Public Health Goal. American Cancer Society web site. 2018. https://pressroom.cancer.org/FedewayHPVburden2018. Accessed May 7, 2019.
5. U.S. Food and Drug Administration. FDA approves expanded use of Gardasil 9 to include individuals 27 through 45 years old. U.S. Food and Drug News Release. 2018. https://www.fda.gov/news-events/press-announcements/fda-approves-expanded-use-gardasil-9-include-individuals-27-through-45-years-old. Accessed May 7, 2019.
6. American Dental Association. CDC committee: HPV vaccine could benefit adults up to 45. American Dental Association News. 2019. https://www.ada.org/en/publications/ada-news/2019-archive/june/hpv-vaccine-could-benefit-adults-up-to-45. Accessed June 27, 2019.
7. Walker TY, Elam-Evans LD, Yankey D, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 Years - United States, 2017. MMWR Morb Mortal Wkly Rep. 2018;67(33):909-917.
8. Centers for Disease Control and Prevention. HPV Vaccination Coverage Data. Centers for Disease Control and Prevention web site. 2019. https://www.cdc.gov/hpv/hcp/vacc-coverage/index.html. Accessed May 8, 2019.
9. Centers for Disease Control and Prevention. CDC reports show encouraging signs for preventing future cancers. Centers for Disease Control and prevention web site. 2019. https://www.cdc.gov/media/releases/2018/p0823-HPV-vaccination.html. Accessed April 11, 2019.
10. McQuillan G, Kruszon-Moran D, Markowitz LE, et al. Prevalence of HPV in adults aged 18-69: United States, 2011-2014. NCHS Data Brief. 2017;(280):1-8.
11. Centers for Disease Control and Prevention. Reasons to Get Vaccinated. Centers for Disease Control and Prevention web site. 2019. https://www.cdc.gov/hpv/parents/vaccine/six-reasons.html. Accessed May 7, 2019.
12. Ward G, Mehta V, Moore M. Morbidity, mortality and cost from HPV-related oropharyngeal cancer: impact of 2-, 4- and 9-valent vaccines. Hum Vaccin Immunother. 2016;12(6):1343-1347.
13. D'Souza G, Kreimer AR, Viscidi R, et al. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007;356(19):1944-1956.
14. Glick M. Why don't dentists provide immunizations?: a missed opportunity. J Am Dent Assoc. 2013;144(10):1098-1100.
15. Speer WB. Dentists and vaccinations. J Am Dent Assoc. 2014;145(1):17.
16. Stull CL, Lunos S. Knowledge, attitudes and practices regarding human papilloma virus communication and vaccine advocacy among Minnesota dentists and dental hygienists. J Dent Hyg. 2019;93(1):33-42.
17. Lazalde GE, Gilkey MB, Kornides ML, McRee AL. Parent perceptions of dentists' role in HPV vaccination. Vaccine. 2018;36(4):461-466.
18. Kline N, Vamos C, Thompson E, et al. Are dental providers the next line of HPV-related prevention? Providers' perceived role and needs. Papillomavirus Res. 2018;5:104-108.
19. Daley EM, Vamos CA, Thompson E, et al. The role of dental providers in preventing HPV-related diseases: a systems perspective. J Dent Educ. 2019;83(2):161-172.
20. American Dental Association. About the ADA. American Dental Association web site. 2019. https://www.ada.org/en/about-the-ada. Accessed May 7, 2019.
21. Ajwani S, Jayanti S, Burkolter N, et al. Integrated oral health care for stroke patients - a scoping review. J Clin Nurs. 2017;26(7-8):891-901.
22. Glurich I, Nycz G, Acharya A. Status update on translation of integrated primary dental-medical care delivery for management of diabetic patients. Clin Med Res. 2017;15(1-2):21-32.
23. Migliorati CA, Mendes RA. The intersection of oral medicine and interprofessional education. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;117(6):787-790.
24. Windon MJ, D'Souza G, Rettig EM, et al. Increasing prevalence of human papillomavirus-positive oropharyngeal cancers among older adults. Cancer. 2018;124(14):2993-2999.
25. Chaturvedi AK, Zumsteg ZS. A snapshot of the evolving epidemiology of oropharynx cancers. Cancer. 2018;124(14):2893-2896.
26. Centers for Disease Control and Prevention. Oral and Dental Health. Centers for Disease Control and Prevention web site. 2017. https://www.cdc.gov/nchs/fastats/dental.htm. Accessed February 26, 2019.
27. Daley EM, Thompson EL, Vamos CA, et al. HPV-related knowledge among dentists and dental hygienists. J Cancer Educ. 2018;33(4):901-906.
28. Viens LJ, Henley SJ, Watson M, et al. Human papillomavirus-associated cancers - United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2016;65(26):661-666.
29. Daley E, Dodd V, DeBate R, et al. Prevention of HPV-related oral cancer: Assessing dentists' readiness. Public Health. 2014;128(3):231-238.
30. Oregon State Legislature. HB2220. Oregon State Legislature web site. 2019. https://olis.leg.state.or.us/liz/2019R1/Measures/Overview/HB2220. Accessed June 9, 2019.
31. Centers for Medicare and Medicaid Services. Affordable Care Act Implementation FAQs - Set 15. The Center for Consumer Information and Insurance Oversight web site. 2019. https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs15.html. Accessed May 7, 2019.
32. Stoopler ET, Sollecito TP. Focusing on the medicine in dental medicine. Spec Care Dentist. 2016;36(2):59.
33. Giddon DB, Swann B, Donoff RB, Hertzman-Miller R. Dentists as oral physicians: the overlooked primary health care resource. J Prim Prev. 2013;34(4):279-291.
34. Hirth J, McGrath CJ, Kuo YF, et al. Impact of human papillomavirus vaccination on racial/ethnic disparities in vaccine-type human papillomavirus prevalence among 14-26 year old females in the U.S. Vaccine. 2018;36(50):7682-7688.
35. Moriarty S. Investigating how geography, citizenship, and insurance influence HPV vaccination. AMA J Ethics. 2019;21(3):E269-E272.
36. American Academy of Pediatric Dentistry. Policy on Human Papilloma Virus Vaccinations. American Academy of Pediatric Dentistry web site. 2017. https://www.aapd.org/research/oral-health-policies--recommendations/human-papilloma-virus-vaccinations/. Accessed May 7, 2019.
37. Safaeian M, Porras C, Pan Y, et al. Durable antibody responses following one dose of the bivalent human papillomavirus L1 virus-like particle vaccine in the Costa Rica vaccine trial. Cancer Prev Res (Phila). 2013;6(11):1242-1250.
38. Fakhry C, Blackford AL, Neuner G, et al. Association of oral human papillomavirus DNA persistence with cancer progression after primary treatment for oral cavity and oropharyngeal squamous cell carcinoma. JAMA Oncol. 2019. doi: 10.1001/jamaoncol.2019.0439.
39. Guo T, Eisele DW, Fakhry C. The potential impact of prophylactic human papillomavirus vaccination on oropharyngeal cancer. Cancer. 2016;122(15):2313-2323.
40. Tanaka TI, Alawi F. Human papilloma virus and oropharyngeal cancer. Dent Clin North Am. 2018;62(1):111-120.
41. Emberger J. The HPV vaccine: overcoming barriers to acceptance of a medical triumph. AMA J Ethics. 2015;17(9):854-857.
42. American Dental Association. Just-released ADA brochure educates patients about HPV vaccine. American Dental Association News. 2019. https://www.ada.org/en/publications/ada-news/2019-archive/april/ada-brochure-educates-about-hpv-vaccine. Accessed April 28, 2019.
43. Rindal DB, Gilbert GH, Carcelén C, et al. Feasibility and acceptance of oral human papillomavirus detection in the dental office: results from The National Dental Practice-Based Research Network. J Am Dent Assoc. 2019;150(2):130-139.
44. Vázquez-Otero C, Vamos CA, Thompson EL, et al. Assessing dentists' human papillomavirus-related health literacy for oropharyngeal cancer prevention. J Am Dent Assoc. 2018;149(1):9-17.
45. Griner SB, Thompson EL, Vamos CA, et al. Dental opinion leaders' perspectives on barriers and facilitators to HPV-related prevention. Hum Vaccin Immunother. 2019;15(7-8):1856-1862.
46. Walker KK, Jackson RD, Sommariva S, et al. USA dental health providers' role in HPV vaccine communication and HPV-OPC protection: a systematic review. Hum Vaccin Immunother. 2019;15(7-8):1863-1869.
47. Shukla A, Nyambose J, Vanucci R, et al. Evaluating the effectiveness of human papillomavirus educational intervention among oral health professionals. J Cancer Educ. 2018. doi: 10.1007/s13187-018-1391-z.
48. Pampena E, Vanucci R, Johnson LB, et al. Educational interventions on human papillomavirus for oral health providers. J Cancer Educ. 2019. doi: 10.1007/s13187-019-01512-7.
49. National HPV Vaccination Roundtable. Cancer Prevention Through HPV Vaccination: An Action Guide for Dental Health Care Providers. National HPV Vaccination Roundtable web site. 2018. https://hpvroundtable.org/wp-content/uploads/2018/04/DENTAL-Action-Guide-WEB.pdf. Accessed August 12, 2019.
50. American Dental Association. MyView: Does dentistry have a role in health care?. American Dental Association News. 2018. https://www.ada.org/en/publications/ada-news/viewpoint/my-view/2018/november/myview-does-dentistry-have-a-role-in-health-care. Accessed January 16, 2019.
51. Walker K, Jackson R, Edwards PC, Vadaparampil ST. HPV and oral cancer: the need to integrate oral health practices into nursing education. Clin J Oncol Nurs. 2018;22(6):E166-E173.
52. Simon L. Overcoming historical separation between oral and general health care: interprofessional collaboration for promoting health equity. AMA J Ethics. 2016;18(9):941-949.
53. Emami E, Harnagea H, Girard F, et al. Integration of oral health into primary care: a scoping review protocol. BMJ Open. 2016;6(10):e013807.
54. Manski RJ, Hoffmann D, Rowthorn V. Increasing access to dental and medical care by allowing greater flexibility in scope of practice. Am J Public Health. 2015;105(9):1755-1762.
55. Martin SA, Simon L. Oral health and medicine integration: overcoming historical artifact to relieve suffering. Am J Public Health. 2017;107(S1):S30-S31.
56. Chaturvedi AK, Graubard BI, Broutian T, et al. Effect of prophylactic human papillomavirus (HPV) vaccination on oral HPV infections among young adults in the United States. J Clin Oncol. 2018;36(3)262-267.
57. Chesson HW, Meites E, Ekwueme DU, et al. Updated medical care cost estimates for HPV-associated cancers: implications for cost-effectiveness analyses of HPV vaccination in the United States. Hum Vaccin Immunother. 2019;15(7-8):1942-1948.
