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My View: Could vaccines come from your dentist? Not yet

October 21, 2019

By Joseph Kwan-Ho Yun, D.D.S.


Joseph Kwan-Ho Yun, D.D.S.
On May 6, Oregon House Bill 2220 was signed into law, enabling licensed dentists to prescribe and administer vaccines. The policy is scheduled for implementation in 2020 pending review and protocol design by the Oregon State Dental Board. With its passage, Oregon joins Minnesota and Illinois as the third state to permit vaccinations in dental offices. Minnesota and Illinois allow flu vaccines to be administered.

In the wake of growing antivaccination movements and the largest measles outbreak in the United States since 1994, expanding the number of providers offers a modest strategy to improving vaccination rates and mitigate disinformation. Dentists remain an untapped source of primary care and can provide screening services for a variety of chronic issues including diabetes and hypertension. However, statewide implementation of a dental vaccine program poses several barriers that make widespread adoption unlikely.

1. Lack of training. The current Commission on Dental Accreditation has no outlined dental education standards regarding the training and usage of vaccines. This means there is no national dental curriculum to safely and adequately supply, administer and dispose of vaccines. Dentists receive formal training on properly handling local anesthetics, needles and performing injections, but preservation and handling of vaccines differs greatly from analgesic chemicals. Vaccines often require adequate temperature control in storage and transportation known as the Cold Chain. Local anesthetics, meanwhile, can be left at room temperature and stored in a dry area. An even greater area of concern is the lack of communication training: dentists must learn how to communicate with patients and parents about vaccines to properly obtain informed consent.

With increasing distrust towards medical professionals, communication becomes paramount towards success. One such study found when health care providers engage and discuss parental concerns regarding human papilloma virus vaccines, vaccinations occurred that same day. Proper training improves compliance and outcomes.

Without it, clinicians may exacerbate vaccine hesitation and resistance from patients and providers.

2. Lack of adequate medical history. Patients, for a variety of reasons, may have medical exemptions from vaccinations. Infants younger than twelve months, individuals with allergies and immunocompromised individuals are unable to receive certain vaccines. If dentists seek to administer vaccines, then they must also do proper due diligence with physicians, as parents themselves may not have a clear understanding or memory about their child’s vaccine schedule. This increases the administrative burden of dental offices and staff and may deter oral health providers from engaging in vaccinations.

3. Cost-inefficiency. Private practice dentists would need to find means to supply, house and properly dispose of their vaccines. Dental offices must allocate space and resources to properly store vaccines. Per the Centers for Disease Control and Prevention, household refrigerators are inadequate and frozen and refrigerated vaccines should have separate, stand-alone units. Vaccines also have varying shelf lives, meaning inventory must be regularly monitored and restocked. Disposal of vaccines also varies by state-based regulations and may require coordination with local medical waste companies.

4. Payment and billing practices. The majority of health insurance plans cover several vaccines without the need of copayment or coinsurance so long as they are delivered by an in-network provider. As vaccinations are under the domain of medicine, there is a financial incentive for patients to seek vaccine delivery from their physicians and disincentives for dentists to formally train and establish billing infrastructure through their offices. There is also no guarantee that insurance companies will pay for vaccines administered through dental offices.

Despite the pressing obstacles facing implementation of a vaccine policy among dentists, Oregon’s new policy provides several opportunities for providing greater care and promoting public health. Dentists may find it beneficial to focus on seasonal and targeted interventions such as the flu and HPV vaccines.

Seasonal flu vaccines may reduce the administrative burden of regularly restocking inventory for more than the illness of the season.

Dentists may also be more comfortable discussing and administering the HPV vaccine, as they possess domain expertise and ethical obligation to prevent and screen for oral cancers, of which HPV is the leading cause. Administration of HPV vaccinations also possess logistical alignment. Gardasil’s dosing schedule for children between the ages of 9-14 is every six months, which coincides with the recommended timing of dental recall examinations.

What might be the most promising result of this policy change is that dentists are empowered to have conversations about vaccinations. Joint efforts of both dentists and physicians to encourage immunizations will be far more persuasive. As dental offices typically see healthy patients twice a year, frequency of exposure and conversation can drive greater outcomes for patients to comply with their vaccine schedules.

Additionally, this policy furthers integration of dentistry and medicine. Many — if not most — dentists will likely find a more productive means of increasing immunization rates by collaborating with physicians. If dentists find their patients are behind in their vaccine schedules, they can notify doctors. By engaging in screening efforts of both public and chronic health issues, both patients and the general population will benefit from increased health literacy and earlier medical intervention to prevent and reduce the burden of disease.

While the effects of Oregon’s new vaccination policy will not be seen for quite some time, passage of such a plan signals a greater commitment towards advancing public health and should be lauded as such.
Efforts to curtail the misinformation of vaccines, empowering dentists to participate in overall wellness and collaborations between different health disciplines all result in a stronger community and positively influence generations to come.

REFERENCES
1. Relating to Vaccines Administered by Dentists; and Declaring an Emergency. HB2220 2019 Regular Sess. (2019). Available at: https://olis.leg.state.or.us/liz/2019R1/Measures/Overview/HB2220. Accessed Ocrtober 15, 2019.
2. Immunizations and Vaccinations. IMCare Provider Manual. Available at: www.co.itasca.mn.us/DocumentCenter/View/725/Chapter-9A-Immunizations-and-Vaccinations-PDF. Accessed October 15, 2019.
3. Illinois General Assembly, Joint Committee on Administrative Rules. Administrative Code: Title 68: Professions and Occupations. Chapter VII: Department of Financial and Professional Regulation Subchapter b: Professions and Occupations Part 1220 Illinois Dental Practice Act Section 1220.403 Dentists Administering Flu Vaccines. Available at: www.ilga.gov/commission/jcar/admincode/068/068012200D04030R.html. Accessed October 15, 2019.
4. Centers for Disease Control and Prevention. Measles Cases and Outbreaks: Cases in 2019. Available at: https://www.cdc.gov/measles/cases-outbreaks.html. Accessed October 15, 2019.
5. Gambhir RS. Primary care in dentistry: an untapped potential. J Family Med Prim Care. 2015;4(1):13-18.
6. Commission on Dental Accreditation, American Dental Association. Accreditation Standards for Dental Education Programs. Available at: www.ada.org/~/media/CODA/Files/pde.pdf?la=en. Accessed October 15, 2019.
7. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Vaccine Storage and Handling Toolkit. Available at: https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf. Accessed October 15, 2019.
8. Taifour, ML, Terezhalmy GT. Pharmacology of Local Anesthetics: Clinical Implications | Technical Issues, Sterilization, and Storage. Available at: www.dentalcare.com/en-us/professional-education/ce-courses/ce449/technical-issues-sterilization-and-storage. Accessed October 15, 2019.
9. Malone C. Americans Don’t Trust Their Institutions Anymore. Available at: https://fivethirtyeight.com/features/americans-dont-trust-their-institutions-anymore/. Accessed October 15, 2019.
10. Shay LA, Baldwin AS, Betts AC, et al. Parent-provider communication of HPV vaccine hesitancy. Pediatrics. 2018;141(6):e20172312.
11. Immunization Action Coalition. Storage and Handling. Available at: https://www.immunize.org/askexperts/storage-handling.asp. Accessed October 15, 2019.
12. Centers for Disease Control and Prevention. Vaccine Storage and Handling. Available at: https://www.cdc.gov/vaccines/pubs/pinkbook/vac-storage.html. Accessed October 15, 2019.
13. Centers for Disease Control and Prevention. Resources for Adults Vaccination Insurance and Payment. Available at: https://www.cdc.gov/vaccines/hcp/adults/for-practice/insurance-payment.html. Accessed October 15, 2019.
14. The Oral Cancer Foundation. HPV/Oral Cancer Facts. Available at: https://oralcancerfoundation.org/understanding/hpv/hpv-oral-cancer-facts/. Accessed October 15, 2019.
15. Merck Vaccines, Gardasil. Dosage and Administration for GARDASIL 9. https://www.merckvaccines.com/Products/Gardasil9/dosing-administration. Accessed October 15, 2019.


Joseph Kwan-Ho Yun is currently a pediatric dental resident at the Children’s Medical Center of Dallas/Texas A&M College of Dentistry.