by Jake Holtzmann

The Warmup

This morning, before I sat down at my ‘work from home’ desk to write this piece for my friends and colleagues at CU, the U.S. death toll from the COVID-19 Pandemic officially reached 100,000 lives lost.   To preface my thoughts on the topic of this blog post, I’d like to acknowledge our community during this difficult time.  My thoughts are with each of you, hoping that you’re well, and hoping that those you love are safe.  I hope that today, if even for just a moment, you can free your mind to dream with me – of life after COVID-19, of our future role as oral healthcare providers, and of the lives that we could save with dental administration of critical vaccines – perhaps even a future SARS-CoV-2 vaccine. 

As dental students, we have joined the world on an unprecedented journey into uncharted territory.  A journey that none of us thought we’d ever have to take, but one that requires us to be bold, collaborative, and forward thinking.  If you’re like I was two months before I sat down to write this piece, you’d never considered the possibility of dentists giving the vaccinations that you’re so accustomed to receiving from your primary care provider.  However, as I hope to share with you today, when you dig deeper into the literature, policies, and legislation fueling this growing push to expand our profession’s scope of practice, you begin to consider, “maybe this is possible.”

The Supporting Literature

After reviewing the literature re: Dental Administration of Vaccines, I think it’s important to note the scarcity and specificity of the literature currently available.  Because our current scope of practice already includes preventative screenings for, and education about, head and neck cancer, studies have largely been specific to the potential role of dental providers in HPV (Human Papillomavirus) vaccine administration.  This specificity within the research should help us focus our advocacy efforts in the future as the dental profession takes small steps toward this noted dental scope expansion.

Specifically, HPV continues to be implicated in oropharyngeal cancer oncogenesis (Pinatti et al., 2018).  Following the development of the new Gardasil-9 HPV vaccine, which is expected to protect against the “HPV types that cause ∼93% of head and neck cancers” (Zhai & Tumban, 2016), Primary Care Providers (PCPs) have been taking steps to educate and vaccinate their patients using recommended dosing schedules – which, depending on the patient’s age, typically involves two or three separate doses administered within a much shorter timeframe than a typical yearly check-up at their PCP’s office.

As of 2015, high rates of HPV vaccination had not yet been achieved despite strong endorsements by the medical community (Sussman et al., 2015). While completion rates of the scheduled dosing sequences are already thought to be low (Elsamadicy et al., 2019), completion rates have been found to be significantly lower in racial and ethnic minority populations (Agenor et al., 2020, Spencer et al., 2019), serving as yet another striking example of the systemic inequality in our healthcare system that contributes to the disparate health outcomes of marginalized communities. Studies have found that challenges associated with healthcare delivery (Sussman et al., 2015) such as the consistent scheduling of patients to complete their HPV vaccination dosing outside of their yearly check-ups remains the greatest barrier to community HPV vaccination.

Current literature specifically related to the dental profession has explored the dental community’s willingness to be educated and integrated into the effort to vaccinate against the virus. Promisingly, “a majority of oral health students may be open to receiving training to administer the HPV vaccine and to administer the HPV vaccine once they are trained” (Kepka et al., 2019).  The literature also notes that any such expansion of our scope of practice “would require a strong statement of support by professional organizations” (Young et al., 2015) like the American Dental Association and, yours truly, the American Student Dental Association.

Before moving on, as studies have concluded that some dentists might be hesitant to administer HPV vaccines due to a perceived increase in liability (Daley et al., 2014), I wanted to note that after rigorous analysis, the CDC concluded that there is no evidence to suggest any causal link between the Gardasil-9 vaccine and any deaths reported to the Vaccine Adverse Event Reporting System (VAERS).

The Policies and Legislation

Figure 1

Following publication of the noted literature, the American Dental Association acted accordingly in 2018 by authoring a new policy designed to push dentistry forward into the space of HPV vaccinations (see Figure 1).  To date, the American Student Dental Association has not yet put forth their own policy encouraging dental schools to include vaccination sciences and training into their curriculums.

While no push has been made at the federal level to educate, equip, and empower dentists to provide HPV vaccines to our patients, so far three states have passed such legislation.  To date, the states of Minnesota (150A.055 Administration of Influenza Immunizations) and Illinois (1220.403 Dentists Administering Flu Vaccines) allow licensed dentists, who undergo additional training, to administer Influenza vaccines to patients that are 19 years or older and 18 years or older, respectively. 

In response to their state’s low vaccination rates, the state of Oregon set the bar even higher in 2019 by passing House Bill 2220, enabling qualified dentists to administer any type of vaccine.  In order to implement this legislation, the Oregon Board of Dentistry is expected to develop rules and guidelines, while the sole dental school in Oregon (Oregon Health & Science University) is expected to provide training to dentists interested in administering in-office vaccinations.  As a sponsor of House Bill 2220, the Oregon Dental Association President James McMahan stated that “We sponsored House Bill 2220 to increase access to care, providing additional opportunities for patients to receive life-saving vaccines from highly trained practitioners they already know and trust.”

The Challenges Ahead

While appreciating the progress that some states have made in passing promising legislation, it would be irresponsible of us to ignore the challenges that must certainly be overcome before a nationwide effort to include the dental profession in vaccine administration is realized.

As noted in an opinion piece published by Dr. Joseph Kwan-Ho in the ADA News, “statewide implementation of a dental vaccine program poses several barriers.”  Most notably, I’ve reasoned that a few such barriers could include: a lack of standardized training to address the logistical and financial difficulties of supplying, storing, and administering vaccines in a “cold chain”, whether warranted or not, perceived liability resultant from vaccine administration, and lastly, a lack of universally standardized medical record interoperability, which was exacerbated by the high number of different digital record companies born from the Health Information Technology for Economic and Clinical Health Act of 2009.

The Endgame

Progress on this scale – implementing vaccination protocols, infrastructure, and practices in dental offices all around the country – is slow.  So where can we start?  The literature, American Dental Association, and expert testimony all point us in the same direction: HPV vaccination.

As healthcare providers that claim the oral cavity as “our” domain, and as healthcare providers that have the unique opportunity to build trusting relationships with our patients through more frequent appointments than Primary Care Providers, no one should be more qualified and equipped to discuss, recommend, and administer HPV vaccines to prevent the future development of oral cancer than us.  Every year, around 10,000 Americans die from oral or oral pharyngeal cancer (The Oral Cancer Foundation).  Of those that die from oropharyngeal cancer, 70% die due to the Human Papillomavirus (National Cancer Institute).  A strong, collective commitment by dental organizations, dental schools, and dental practices to future advocacy efforts at the state and federal levels could change that.

When I chose to pursue a career in healthcare, just like you, I did so to care for my future patients.  Every day, I’m inspired by our colleagues and our mentors that care for their whole patient, not just their teeth.  During a pandemic of such devastating proportions, we’re reminded of the importance of public health.  While we scramble to keep up with our clinic requirements and stay “Safer at Home” for online learning, I hope that we can all renew our commitment to the public health of, and advocacy for, our communities and the public healthcare system that was so nearly overrun by COVID-19.  In the event that an effective vaccine is developed for the SARS-CoV-2 virus, I believe that policies like the one put forth by the ADA and legislation similar to what has been passed in Oregon could serve as a foundation for us to supplement and alleviate the stress on our public healthcare system by administering SARS-CoV-2 vaccines.

So, is the dental profession ready today to partner with our medical colleagues to distribute life-saving vaccines?

Not yet.  But we can change that.

About the Author

As a former University of Denver Pioneer and current second-year dental student at CU, Jake Holtzmann currently serves in several capacities within the American Student Dental Association.  In one of his roles, a Legislative Coordinator for the Council on Advocacy, Jake employs his passions for public health, research, and organized dentistry to coordinate advocacy efforts by dental schools in Colorado, Texas, Oklahoma, Nebraska, Missouri, Iowa, and Minnesota.  A Colorado native, Jake loves to ski, travel, and visit breweries in his free time.  Oh, and one time he attempted to eat a massive cheeseburger made of eight half-pound patties… he failed.

Lobbying on Capitol Hill is one of the most unique activities that happens in Washington D.C. Each year, the House of Representatives and Senate write bills that are passed into law by the President. As the political climate in Washington regularly fluctuates, it is essential that constituents address issues with consistency. Two weekends ago, we saw this in action. Thousands participated in the Tibet National Lobby Day, AIDS Foundation Lobby Day and ADA Dental Lobby Day. All were welcomed and given the ears and time of their elected officials.

For the past two decades, the American Dental Association (ADA) along with the American Dental Political Action Committee (ADPAC) have advocated for the dental profession on Capitol Hill. They have ensured that core concerns that effect our profession, providers and patients are voiced to our legislators. This year, for the first time, the American Student Dental Association (ASDA) joined with the ADA and ADPAC to voice the current issues important to our profession together. We took the following issues to our legislators; The Competitive Insurance Reform Act, the Student Loan Programs under the Higher Education Act and Health Care Reform: Supporting Oral Health.  

This year, a week before our Lobby Day, we saw years of the ADA’s hard work pay off as the 115th House of Representatives voted a 428 to 6 majority on H.R. 372. This repealed the Mccarran-Fergussan antitrust laws for medical and dental insurance companies. Since 1945, insurance companies have been exempt from the McCarran-Fergussan antitrust laws which prohibits companies and business owners to discuss and set similar prices for their products and services. Greater federal involvement in antitrust enforcement should encourage more competition in the healthcare insurance marketplace. More competition will promote lower prices and greater consumer choices for all Americans purchasing medical and dental insurance. This week, we thanked members of Congress for supporting this bipartisan bill and urged our senators to support or even sponsor a sister bill so that it can be passed in the senate as well. 

Rising student debt for undergraduate and graduate students is a prevalent concern for many of us. This concern is being voiced on Capitol Hill.  In 2016, the average student debt for recent dental graduates was $262,119. That is a 5% increase of average dental student debt in 2014. The weight of student debt limits many graduates’ professional pursuits, especially those who want to serve in public service, teaching and research positions. As Congress reauthorizes the Higher Education Act this year, we continued to voice our concerns regarding student debt as we met with members of Congress. Currently, there is a sponsored bill, H.R. 1614, that would allow students to refinance their graduate student loans at anytime through out the life of their loan. This would make keeping our student loans with the federal government more appealing and could save graduates thousands on accruing interest. Currently, the interest rate is fixed for the life of the loan. This week we tried to gather more representatives support for H.R. 1614 so that it will pass when it reaches the House floor. 

Since the instatement of The Affordable Care Act (ACA) the uninsured rate for Coloradans has dropped from 14.7% to 6.7%. Additionally the recent medicaid expansion in Colorado, passed in May of 2013, expanded coverage to more than 200,000 Colorado residents. As a direct result we have seen the number of hospital dental visits go from $11 million dollars to $1 million dollars annually in Colorado. We want to continue this progress as the expanding coverage reaches many of our small towns in eastern Colorado and in the Western slope. This was emphasized to our representatives by our doctors who practice in these areas. As health care is a hot topic on Capitol Hill right now we also discussed the importance and need for dental insurance transparency. Our doctors from the CDA have seen many patients who sign up for dental insurance and find out they aren’t covered until they pay for 24 months of premiums. Overall, we advocated for more transparent dental insurance plans so that our patients know what they are purchasing and what to expect from us.   

During our Lobby Day we were able to visit all 6 of our district representatives and both senator’s offices to discuss the issues above. It was great to see the impact we could make on organized dentistry by voicing our concerns to our legislators! It made me proud that we are included in a profession that stands united in protecting and advocating for our patients and doctors!

As a student of the Dental Medicine program of Colorado, I was lucky to have been chosen to attend the National ASDA Leadership Conference in Chicago. I had never even heard of ASDA before entering dental school, and was honestly apprehensive of the passion and excitement many showed for this organization. As an undergraduate, I was apart of the Biology and Chemistry club, but they were never the most exciting parts of my undergraduate career. I was really mostly excited to see Chicago, which was about to change.

Before attending, I had written a paper on the word “leadership” and what it meant to me; this put me in the running to be fully funded to Chicago NLC. I was then informed that my essay was chosen, and I was lucky enough to be fully funded. I was so ecstatic, but had no idea what to expect. With my anatomy exams the following week, I was worried that attending NLC would take away invaluable study time.

Nevertheless, I attended NLC and can truly say I regret nothing. I arrived at the gorgeous Hilton Chicago and I was in awe. I attended the sessions and it was so exciting to see so many dental students from so many places in one room. These people were like me, and all were hungry for knowledge of the career they are pursuing.

Sessions I attended included mostly post-grad options and ways to be smart financially while owning a business. While I still have a while until I have to worry about these things, it’s never too early to start having a plan. As a first year dental student, I think a lot of us lose sight of the reason why we’re here; many of our beginning classes have nothing to do with dentistry. It’s so easy to get bogged down in the day-to-day tests and studying that sometimes it becomes the question “why am I doing this”, rather than “I’m so excited I made the right career decision”.

NLC brought back the motivation I came into this semester with, fresh out of being accepted into dental school. I’ve heard many times that these conferences “aren’t for first years,” when ASDA NLC has so much for first year students. The great thing about this conference is that students of ALL CLASSES can take home information on study strategies, residencies, practices, budgeting, and so much more!

As if all of this information wasn’t good enough, I was able to attend  so many events to interact with other dental students from in and out of our district. Hearing that another student 2,000 miles away was going through the same worries and fears as me was comforting. I was also able to bond with my own classmates, reassuring each other that our missed study weekend was worth it.

Chicago NLC was one of the most fun, informational, and motivational trip I have ever attended.  I would recommend ANY dental student that has a desire to be successful to attend next year. I may have missed a weekend of studying (which ended up not mattering because I did great on my exams), but I gained a an endless amount of knowledge about dentistry and becoming a business owner.

Thank you ASDA!

This past October, I attended the ASDA National Leadership Conference.  Having recently been elected the ASDA Alternate Delegate for my class, I was sincerely excited and curious about this conference.  I knew I would be surrounded by others who shared my same enthusiasm about ASDA and my commitment to enhancing our dental school experience and future profession. Given my legal background, I am particularly interested in ASDA’s and the ADA’s role in legislative and legal issues regarding dental school education and the dental profession.  While I thought I had a good grasp of the issues regarding the profession, at the conference, I learned so much more about the various nuances within the law that affect dentists. I was thoroughly impressed by the commitment of ASDA and ADA to advocate on our behalf. For this blog post, I wanted to highlight three areas regarding the law and dentistry that were large topics of discussion at the conference.

1)  Pending U.S. Supreme Court Case about Dental Boards and Anti-Trust

Recently, the United States heard oral arguments for North Carolina Board of Dental Examiners v. Federal Trade Commission.  This case hinges upon whether the NC Board of Dental Examiners has the authority to send warning letters to non-dentists who offer dental services, such as teeth whitening.  For this case, the FTC is concerned that the Board is engaging in antitrust behavior.  The pivotal issue in this case is whether the Board of Dental Examiners is considered “private", as anti-trust laws only apply to private entities. While the NC Board of Dental Examiners is considered a public entity, the FTC argues that it is comprised of dentists who primarily make their living as private dentists, and thus, they are also affected by the market that they are attempting to regulate. The ADA submitted an Amicus Curiae brief to the Supreme Court for this case.  An Amicus Curiae brief is essentially an opinion of a third party that is not directly involved in the case but has a substantial interest in the outcome.  The final decision should be issued sometime in 2015. You can view the ADA’s brief here.

2)  Student Loans

The accumulation of significant student loans is a large source of stress for dental students.  While the rising costs of tuition are often unavoidable, ASDA and the ADA are advocating for students and recent graduates from a tax standpoint.  Currently, most dentists’ incomes are too high to have a student loan interest deduction on their taxes.  The ADA is actively lobbying the federal legislature to completely eliminate this income cap.  This way, interest on federal student loans can be considered a tax deduction, which can potentially save dentists up to thousands of dollars each year. To take action on Student Loans through ASDA's Action Site, Engage, CLICK HERE.

3)  Dental Mid-Level Providers

Unlike Colorado, other states in the country are allowing “mid-level” providers to provide some basic, yet irreversible dental procedures in order to increase access to dental care.  ASDA and the ADA are very concerned about this, as it allows individuals with less than four years of dental training to perform procedures that can permanently affect a patient’s tooth.  Additionally, the addition of mid-level providers dilutes the dental profession in these states, which can have a substantial impact on the quality of dental services and the salaries for dentists. ASDA seeks to ensure that only dentists provide irreversible dental procedures to patients.

These three issues are just some highlights of the myriad of issues and work that ASDA and the ADA do on our behalf.  In addition to attending the legislative sessions, I attended marketing, financial, and other sessions which my colleagues have already highlighted. This conference confirmed to me that ASDA is really looking out for us. I certainly caught the “ASDA fever”!

Many components have an effect on the profession and the day-to-day life of dentists, including changing technology and educational requirements, among others.  An often under-looked component regarding the dental profession, that may affect dentists and future dentists substantially, is the changing landscape of state and federal laws that impact the dental profession.

In most respects, state laws and policies have the most direct impact on dentists; the state regulates dentists who practice within it.  In Colorado, the State Board of Dental Examiners, a regulatory board under the Department of Regulatory Agencies (DORA), bears the authority for dental regulation.  The State Board of Dental Examiners is subject to the “Sunset Process”, meaning that the Board’s existence terminates if the state legislature does not act to continue the board by a certain date, usually after an extensive review of and often with modifications to how they operate.

The Colorado legislature completed its sunset review of the State Board of Dental Examiners earlier this year and voted to continue the Board through September 1, 2014 (Colorado House Bill 14-1227).  It also made changes to the Dental Practice Law of Colorado, many of them administrative or technical, but it also included changes which have a tangible impact on dentists.  For example, one change addresses discipline for certain, unauthorized anesthesia usage on patients; another change mandates 30 hours of continuing education, every 2 years, for dentists and dental hygienists.

The Colorado legislature implemented the changes, largely based on recommendations from DORA itself and other interested parties, such as the Colorado Dental Association.  One recommendation that the legislature did not address in its completed sunset review, however, was a recommendation from DORA to address potential alternatives for the clinical component of dental licensure testing.  In its recommendation to the legislature, DORA specifically requested the legislature to “Revise the clinical examination requirement to allow the Board to accept other methods of evaluating clinical competency….” In its recommendation, DORA noted that “[t]he notion that a clinical examination can be something other than a one-time, high-stakes examination performed on a real patient is gaining broader acceptance…the General Assembly should expand the law to allow the Board, at its discretion, to accept alternate methods of evaluating clinical competency…” (The entire DORA recommendation is available HERE.)

Despite DORA’s recommendation, the Colorado legislature failed to address changing certain clinical examination requirements.  The Colorado legislature may address this in a future piece of legislation; however, it is also possible that the legislature will not address this until the next sunset review deadline, around 2023.  If the Colorado legislature addressed this recommendation by DORA, the proposed changes to the clinical examination process would surely be in students’ best interest, as it could expand the opportunities for licensure applicants to demonstrate their clinical acumen.

This recent sunset review of the Colorado Board of Dental Examiners demonstrates how the law and legislature may have a large impact on our careers.

~Becky Bye, JD, Class of 2018, Colorado ASDA Alternate Delegate

The first time I heard about ASDA, I didn’t even realize I was hearing about ASDA. All I knew was that I wanted scrubs with the CU School of Dental Medicine logo on it. Since then, however, ASDA has completely changed my dental school experience for the better.

When ASDA was first introduced to our class, a lot of effort went into explaining what it was, and yet, I still found myself struggling to understand it. When I would ask different members about ASDA, they would all give me different answers. Finally, after about a year, I realize that the reason I was having trouble understanding ASDA is because ASDA is everything. It is so all-encompassing that sometimes it can be hard to explain. It wasn’t that nobody knew what ASDA was, it was just that ASDA was something different to everyone.

Simply put, ASDA is the American Student Dental Association which is the nation's largest student run association whose mission centers around protecting and advancing the rights, interests and welfare of dental students. But what does that mean exactly, and more specifically, what does that mean to you?

Well, to better explain ASDA and make its mission, purpose and benefits more clear to those who are less familiar with it, we have decided to literally spell it out for everyone. The letters "ASDA" stand for the American Student Dental Association. But to us, ASDA also stands for the four pillars of Colorado ASDA: Advocacy, Service, Dentistry and Activities. We have decided to focus on these four categories because everything within ASDA can fit into them (and it also conveniently spells out ASDA). We have tried to restructure the chapter's resources to follow this theme. You may notice that even our blog categories are set up to reflect this new focus, as will our website once we get that fully up and running. Of course ASDA is more than just this, but these four words are where everything starts.

Advocacy. Advocacy is what makes ASDA unique from any of the other dental student organizations out there. Locally, we work with the Metro Denver Dental Society and the Colorado Dental Association to educate our state representatives on current issues facing our profession and topics affecting us as students. Nationally, we represent about 92% of all dental students, so people listen to us when we vote in a new policy and take us seriously as an organization.

Service. Service is why most of us sought a career in dentistry in the first place. Our chapter is always organizing service and community outreach activities. From helping out at COMOM to volunteering at the Fifth Gear Kids events, there is always something that you can get involved in to help out the community around us.

Dentistry. I have had numerous people from my class ask me what ASDA is. Before now, the only way that I could really explain it is "everything dentistry outside of dental school." Even though that answer isn't as complete of an answer as I would have liked to give, it still is true. ASDA is where you learn everything about dentistry that you don't learn in dental school. ASDA teaches you to be a leader in your practice and in your community. ASDA shows you how to manage your finances while you are in dental school and ways to manage your business when you graduate. ASDA helps you to prepare for things that you might not even realize that you want to know yet, like integrating new technology into your practice without overdoing it and what things to look for when searching for an associate position.

Activities. The activities that Colorado ASDA puts on are awesome. If you participated in Thrush Week and the Amalgames (see our Facebook Page for pictures), then you know what I'm talking about. If you didn't, then it's not too late. We still have plenty of things coming up in the near future (be on the lookout for "Shimstock," our music and talent competition coming in October).

I got involved in ASDA without even fully understanding what it was because I could see potential-- not only in the chapter, but in myself through the chapter. ASDA was the only student organization, in my mind, that had everything... and best of all, it was free!

Since deciding to get involved, I have had some of the most amazing opportunities of my life. ASDA motivates me to step just far enough outside my comfort zone that I do things I have never done before, but not far enough that I regret my participation. It pushes me to meet people, helps me find mentors and gives me the resources that I need to succeed (and not just on boards).

ASDA is a lot of things to a lot of people and our chapter here at Colorado is expanding to become more than it has ever been before. To me, Colorado ASDA is opportunity. It is fun. It is my creative outlet. It is networking. It is the best experience I have had in dental school and it has become a big part of my life. I believe in everything that this organization stands for and choosing to become involved has been one of the best decision I have ever made. I can’t imagine dental school without ASDA, nor would I ever want to. ASDA is about getting involved and having a voice-- so get involved and say something. You might just be surprised at what can happen because of it.

http://www.youtube.com/watch?v=RY31ouvXfLU

Tell us what #CoASDAis to you in the comments below or use the tag #CoASDAis to tell us on Facebook, Instagram or Twitter by Aug 29th for your chance to win a $10 Target Gift Card!

~Kyle Luis Larsen, Class of 2017, Colorado ASDA President-Elect