Dental-Medical Integration: An Innovative Approach to Immunizations
By Lisa Waiwaiole, Project Director
The Dental Care Program at Kaiser Permanente Northwest proves to be a great laboratory for immunization research.
Immunizations aren’t just for infants—teens and tweens need them, too. But while national immunization rates are fairly high for adolescent vaccines such as Tdap (tetanus, diphtheria, pertussis) (88%) and MCV4 (meningococcal conjugate vaccine) (79%), rates for human papillomavirus (HPV) and influenza are much lower. Current national HPV immunization rates for completing the series are 42% for girls and 28% for boys, and the influenza vaccination rate stands at 59%.
Any attempt to boost coverage rates for teens and preteens will have to reckon with one major obstacle: this group simply does not seek medical care as frequently as their younger counterparts. Furthermore, unlike single-dose adolescent vaccines, up until very recently a complete HPV vaccine required three doses. As of October 2016, the Advisory Committee on Immunization Practice recommends two doses, six months apart.
As a working mother, I have spoken to more than one colleague who admitted struggling to get our own kids to the doctor for all of the required doses of this important cancer prevention vaccine.
How could dental clinics be part of the solution?
The HPV vaccination is of particular concern to the dental care community since there is a link between HPV and oropharyngeal cancers (cancers of the head and neck). According to the American Dental Association, about 63 percent of oropharyngeal cancers each year—more than 11,000 cases—are associated with HPV infection, and the incidence is rising. (You can read the ADA’s full Statement on Human Papillomavirus and Squamous Cell Cancers of the Oropharynx online.)
Knowing this, CHR epidemiologists (Sheila Weinmann and Allison Naleway) and dental researchers (Jeff Fellows and I) met to discuss research opportunities in this area. We agreed that there was strong potential for dentists to play a larger role in improving HPV immunization rates and other aspects of preventive care. Dental clinics at Kaiser Permanente Northwest (KPNW) were already routinely giving patients a printed, individualized list of recommended vaccinations. We wanted to design a study that would build on that success and focus on adolescent immunizations specifically.
Dental Adolescent Immunization Study
With a grant from the Pfizer Independent Grants for Learning & Change, Allison Naleway developed an intervention and study plan along with Dan Pihlstrom, Michelle Henninger, David Mosen, and me. We randomized eight KPNW dental clinics to an intervention arm and eight KPNW dental clinics to usual care. The intervention itself was straightforward, building on what was already in place in the dental program. We asked dental team members in intervention clinics to:
- Provide all 11-17 yr olds and/or their parents with a printed, individualized list of vaccinations due (i.e., “care gap report”).
- Verbally recommend that the adolescent get the vaccine(s), using scripts that we provided.
- Provide a study brochure that described adolescent vaccines, how and where to get vaccinated at KPNW (no appointment required), and the locations of nurse treatment room throughout the region.
As part of the study, we also surveyed providers about their knowledge and comfort with recommending vaccines and we surveyed parents about their comfort receiving a recommendation from a dental provider.
As the only Kaiser Permanente region with its own dental care program, KPNW is an ideal setting for this type of research. In fact, the program has its roots in research, having begun as a demonstration project in the 1960s under the leadership of CHR’s first director, Mitch Greenlick. Our dental care program has always been ahead of the curve in integrating medical and dental care.
Did It Work?
We are encouraged by what we’ve learned so far, though many of our findings are still to be determined. Using KP’s electronic medical record system, we will compare the vaccine coverage of adolescents in the intervention clinics to that of adolescents in the usual care clinics. From our surveys, we have found:
About 80% of dental providers agreed that they should be discussing preventive medical care with their patients. Hygienists tended to have the highest vaccine knowledge compared to dentists or dental assistants. Dental providers said the biggest barriers to discussing vaccines were parents’ concerns about vaccine safety and providers’ own vaccine knowledge.
Almost 75% of parents were comfortable or neutral about receiving vaccine recommendations from dental providers. Acceptance from dental staff was mixed. One staff member said, “If everybody had this conversation [about vaccinations] every chance they got, then this intervention would be effective.” Some staff shared concerns they had about viewing members’ private health information. Dental staff agreed that most parents appreciated the vaccine reminder.
At a National Immunization Conference, representatives from several state organizations approached Allison Naleway with questions about how to enlist dental providers to promote the HPV vaccination. Incorporating dentists in overall health just makes sense—especially on a topic like HPV, where there is so much medical and dental overlap. Since Kaiser Permanente is already leading the way in so many aspects of preventive medical care, it is not surprising to be out ahead in this area of medical-dental integration as well.