1. Introduction
Human Papillomavirus infections are now implicated in the etiology of six cancers, including a subset of head and neck squamous cell carcinomas, specifically oropharyngeal cancers (OPCs) [1]. Although a safe and effective vaccine prevents over 90% of oncogenic HPV infections [2], only 62.6% of the adolescents aged 13–17 were up to date with the HPV vaccine nationally [3], which is well below the Healthy People 2030 target of 80% [4]. It is projected that a decreased incidence of HPV-related head and neck cancers may not be evident until 2045, when the disease pattern may change and be more common among older and unvaccinated individuals [5].
Given that HPV drives the majority of OPC cases, promoting HPV vaccination is a critical public health priority and is not solely the responsibility of physicians. Dentists, who routinely engage with adolescents through frequent and consistent patient interactions, are uniquely positioned to contribute significantly to vaccination advocacy and delivery. Dental visits provide excellent opportunities to gather patient vaccination data, deliver targeted educational interventions, and refer for or administer vaccinations, thereby promoting both oral and overall health. Advocacy of HPV vaccination as a cancer prevention strategy is endorsed by the American Academy of Pediatric Dentistry (AAPD) [6] and the American Dental Association (ADA) [7].
Previous studies have explored dental professionals’ knowledge, attitudes, and barriers regarding HPV vaccination. A survey of 208 parents on the knowledge and awareness of the HPV vaccine showed that most parents were comfortable with their child receiving counseling about HPV (68%) and HPV vaccinations (73%) from a dentist [8]. The literature reports on several studies assessing dental provider knowledge, barriers to promoting HPV vaccination, and the willingness to administer HPV vaccines if allowed by law [9,10,11,12,13]. A mixed-methods study [9] indicated that the majority of dental hygienists (78%) were not comfortable talking about the HPV vaccine with parents of their teenage patients. An extensive survey of 623 oral health professionals, including dental and dental hygiene students, showed that the majority would be willing to administer the HPV vaccine if permitted by law [11]. An online survey of licensed dentists in Indiana showed that 58% of dentists would offer vaccination if permitted by law; the percentage was higher among dentists working in federally qualified centers and academic institutions [12]. A common finding in these studies conducted in different states is the need to develop tailored continuing education for dental providers. In the United States, efforts are expanding toward authorizing dentists to administer vaccines. For example, dentists in Indiana, Kentucky, Louisiana, Mississippi, New Jersey, and Oregon can administer any vaccine, and in Massachusetts, dentists and dental hygienists can vaccinate patients [14]. Despite these insights, parental acceptance of HPV vaccination, specifically in dental school settings in the U.S., remains understudied.
To help improve HPV immunization coverage in Texas, the Texas Medical Association implemented evidence-based programs to help increase HPV vaccination rates [15]. More recently, the University of Texas MD Anderson Cancer Center funded 12 projects to support new initiatives, including HPV vaccination in dental offices, to increase awareness and improve vaccine uptake [16]. The present study addresses this research gap by assessing pediatric dental patients’ HPV vaccination status within a dental academic institution, evaluating parents’ willingness to initiate or complete HPV vaccination in a dental setting, and categorizing reasons for parental refusal. The goal is to identify critical intervention points and barriers to optimizing HPV vaccination uptake through enhanced interdisciplinary collaborations and tailored educational strategies, thereby contributing to a reduction in HPV-related cancer incidences.
2. Materials and Methods
2.1. Study Design and Setting
This observational, cross-sectional study was conducted in the Pediatric Dentistry clinics at the UTHealth Houston School of Dentistry between April 2022 and April 2023. The clinics provide care to children and adolescents aged 6 months to 18 years, including those who are age-eligible (9–18 years) to receive the HPV vaccine.
2.2. Ethical Approval
The study was conducted in accordance with the Declaration of Helsinki and approved by the UTHealth Committee for Protection of Human Subjects (CPHS) institutional review board (IRB) with exempt status for the study HSC-DB-22-0323. The information obtained was recorded in a format that allowed study participants not to be identified directly or through identifiers linked to patients, and was stored on an encrypted, password-protected institutional server. The study offered no risk or was at minimal risk (e.g., loss of confidentiality) to subjects, and the data were analyzed in aggregate.
2.3. Participants’ Inclusion and Exclusion Criteria
Inclusion criteria were as follows: (1) parents or guardians of children aged 9–18 years, (2) with eligible children receiving dental care at UTSD Pediatric Dentistry clinics, and (3) who agreed to respond to the questions included in the HPV vaccination form. Exclusion criteria applied to parents did not respond to the HPV vaccination form questions.
2.4. Data Collection Procedures
2.4.1. Survey Instrument Development and Adaptation
The HPV vaccination form was developed by a group of three clinician–scientists and co-authors in this manuscript (A.N., A.J.T., and G.O.), based on items adapted from the Health of Houston Survey 2018 [17] To ensure relevance in the dental setting, we excluded two questions related to sexual activity because a previous report in the literature identified this topic as a barrier for dentists to talk to patients about the HPV vaccine [11]. Furthermore, concerns about the HPV vaccine promoting sexual activity were reported by fewer than 1% of respondents in the Health of Houston Survey 2018 [17]. We added a question assessing parental preference for receiving the vaccine at a physician’s office, adapted from Lugo et al. [18]. The survey questions were as follows: (a) Have you received the complete HPV immunization series? The possible answers were Yes/No. For those who answered “No”, a follow-up question was applicable: Would you be willing to receive the HPV vaccine here at UTSD? The possible answers were Yes/No. If “No”, parents were asked to select reasons not to vaccinate their child at the dentist’s office from the following list: (1) preference for being vaccinated at a physician’s office, (2) undecided, (3) some other reasons, (4) concerns about side effects and risk, and religious reasons, (5) lack of trust in vaccines or the provider, (6) lack of time, (7) vaccines do not work, and (8) waiting to receive more information. Parents could select more than one reason if desired. While the form did not include an “I don’t know” option for the vaccine status question, providers could leave the vaccine status question unanswered. However, this approach may not have captured uncertainty as distinctly as a dedicated “I don’t know” category would have.
2.4.2. Language Availability
Since the electronic health record (EHR) system only supports English-language documentation, both the medical history form and the HPV vaccination form were available in English. Consequently, data may have introduced sampling bias and an under-representation of non-English speakers who declined interpreter assistance. However, Spanish-speaking parents had access to certified translation services, and many providers, including dental assistants, are fluent in Spanish.
2.4.3. Survey Administration
The HPV vaccination form was integrated into the pediatric dentistry module of the axiUm electronic health record (EHR) system (Exan Corp, Coquitlam, BC, Canada) as a stand-alone form adjacent to the medical history tab to facilitate ease of navigation and completion for ease of use. Dental students and pediatric dentistry residents, supervised by the pediatric dentistry faculty, administered the form during clinical visits while reviewing or updating patients’ medical histories. Including the HPV vaccination form adjacent to the medical history allowed seamless access and promoted consistent use during all eligible visits across different providers. In Texas, dental providers, including students and residents, are not authorized to administer vaccines, but are encouraged to provide brief counseling on HPV vaccination during medical history reviews. Figure 1 describes the clinical workflow of data collection.
2.4.4. Provider Calibration
To ensure consistency in survey administration, monthly meetings were held with the pediatric dentistry providers for reminders, to obtain feedback, and as an opportunity to ask questions. Also, the pediatric dentistry faculty and co-authors of this study (G.B., L.F., A.P., and G.O.) emphasized the importance of the research study in clinical huddles Figure 1 illustrates the clinical workflow used for HPV vaccine assessment.
2.5. Outcome Measures
The main outcome measures were all self-reported and included vaccination status, intention to receive the vaccine at a dental clinic, and reasons for declining to receive the vaccine at a dental clinic.
2.6. Statistical Analyses
Age, gender, race/ethnicity, and HPV vaccination form responses were extracted from the EHR, de-identified, exported to Excel, and imported into IBM SPSS Statistics Version 26 for analysis. Statistical significance was set at p < 0.05 (two sided). Expected cell counts were checked; Fisher’s exact test was used when any expected count was <5. No adjustment for multiple comparisons was applied because analyses were exploratory. The frequency distributions for the general demographic variables were tabulated, and dental patients’ mean age and standard deviation were calculated. Proportions and 95% confidence intervals were calculated for the categorical variables, and Pearson’s chi-square tests were used to examine demographic characteristics and vaccination status. Reasons for non-vaccination at the dental clinic were tabulated and described according to gender and race/ethnicity.
3. Results
We enrolled a sample of 400 pediatric dentistry patients for this cross-sectional, baseline study. This represents 80% of the parents of children who are age-eligible for the HPV vaccine and were receiving care at our clinics.
Of the 400 pediatric patients included in the analysis, 182 (45.5%) had completed the HPV vaccine series, whereas 218 (54.5%) had not. Vaccine uptake differed significantly by age and gender but showed no significant variation by race/ethnicity, primary language, or insurance type (Table 1). Completion rates rose steadily with age (p < 0.001): only 24% of children aged 9–11 years (19/79) were up to date, compared with 45% of those aged 11–14 years (93/205) and 60% of adolescents aged 15–18 years (70/116). Gender was also associated with vaccination status (p = 0.03); females accounted for 59.3% of the vaccinated cohort but only 48.6% of the incompletely vaccinated group, whereas males showed the opposite pattern (40.7% vs. 51.4%). By contrast, completion rates did not differ across racial/ethnic categories (p = 0.95); Latino/Hispanic patients formed the largest subgroup in both vaccinated (59.3%) and unvaccinated (59.6%) cohorts. Primary language likewise showed no association with vaccination status (p = 0.65), with English speakers representing approximately three-fifths of each group and Spanish speakers about one-quarter. Insurance type was not a significant correlate (p = 0.14); Medicaid covered roughly two-thirds of all patients irrespective of vaccination status, while the proportions of commercially insured and uninsured children were comparable between groups. Taken together, these data identify younger adolescents (particularly those aged 9–11 years) and male patients as priority groups for chair-side HPV vaccine promotion in the dental setting (Table 1).
Among the 172 parents who declined chair-side HPV vaccination, the most frequently cited barrier was a preference for having the vaccine administered in a physician’s office (75/172, 43.6%), followed by indecision (35/172, 20.3%) and unspecified “other” reasons (25/172, 14.5%) (Figure 2). Concerns about potential side-effects or risks accounted for 14 respondents (8.1%), whereas religious objections were reported by nine respondents (5.2%). Three low-prevalence barriers—waiting for additional information, distrust of the vaccine or provider, and lack of time despite having decided to vaccinate—were each endorsed by four respondents (2.3%). Only two parents (1.2%) indicated a belief that vaccines are ineffective. These data demonstrate that most resistance to chair-side vaccination stems from site-of-care preferences or indecision rather than safety worries or vaccine skepticism.
4. Discussion
4.1. Summary of Key Findings
This study showed that nearly 55% of pediatric patients aged 9–18 years at UTSD clinics did not receive the complete HPV vaccination series. Among the unvaccinated, 21% indicated a willingness to receive the vaccine at a dental academic institution. We evaluated the reasons among those who were unwilling to accept the HPV vaccine at the dental school. To the best of our knowledge, this is the first study to apply this assessment among dental patients in a dental academic institution.
Among our adolescent patients aged 14–18 years, 51.6% self-reported receiving the HPV vaccine, comparable to the 2021 HPV vaccination coverage among Texas teens aged 13–17 years of 51.5% [19]. The percentage of children aged 11–17 years who had ever had an HPV vaccine was 40.8%, which was lower than the 54.3% reported by the Health of Houston Survey 2018 [17]. The reasons for the difference might be that, as of 2021, HPV vaccination rates among teens dropped by 3.4% compared to 2020 [20], and there are differences in the source population.
4.2. Comparison with Previous Studies
The most common reason for not receiving the vaccine at the dental office was the preference to receive it at a physician’s office. This finding was unsurprising as dentists in Texas are not licensed to administer vaccines. Lugo et al. [18] assessed the reasons for not receiving the COVID-19 vaccine in the dental office, and 76.5% of the respondents indicated the “type of personnel/perceived lack of training.” In contrast, only 2.3% of our respondents stated this reason. Although our survey did not ask about HPV vaccine knowledge, nearly 35% of parents said “undecided” or “other/no reason”. “Provider did not recommend” was the main reason reported by parents of teens aged 13–14 years residing in Houston for no HPV vaccination [17]. In our study, where data were collected during a dental visit, we did not include the statement “provider did not recommend” as our providers receive education on the appropriateness of the HPV vaccine and related cancers as part of the dental curriculum and are expected to recommend evidence-based strategies to protect the health and well-being of the population. More recently, a population-based survey conducted in Texas identified reasons for not receiving the HPV vaccine among adults who were age-eligible to receive the vaccine. The main reason was “lack of knowledge about the vaccine” [21].
4.3. Implications for Practice and Policy
Dental schools can be the ideal setting for promoting and offering HPV vaccines for dental patients. These institutions are unique, where combining education, clinical practice, and community outreach creates an environment for vaccine promotion. By including HPV vaccine advocacy with dental care, we not only broaden the scope of oral health care but can also contribute to the goal of HPV-related cancer prevention. The interdisciplinary nature of dental academic settings allows collaborations with other healthcare providers, including credentialed nurses, to place orders and administer vaccines. Also, dental schools typically have access to research facilities and hospital-grade refrigerators that can be adapted to store vaccines. It is possible that the credentialing of dentists to administer vaccines will continue to expand across the U.S. and they can be key players in increasing vaccination rates.
4.4. Strengths of the Study
The strengths of this study include (a) the chair-side assessment of pediatric dental patients’ HPV vaccine status, (b) evaluation of the willingness to vaccinate, and (c) parents’ self-reported reasons for their children not receiving the HPV vaccine at the dentist. Other dental academic institutions and clinics can adapt the HPV vaccination form and clinical workflow.
4.5. Limitations of the Study
There are several limitations to note. First, this is a cross-sectional study of vaccination status and the intention to vaccinate, and reasons may change over time. We reported that nearly 35% of parents stated “undecided” or “other/no reason.” Although we included the option of free-text documentation, there was no additional information provided to allow us to identify other challenges and barriers perceived by parents of unvaccinated dental patients. Second, we analyzed data based on parents’ self-reported data of HPV vaccination status with no stratification by the number of doses received. In pediatric dental clinics, providers ask about HPV vaccination status for new and established patients when completing or revising the full medical and dental histories as part of a comprehensive or periodic oral examination. Attanasio and McAlpine evaluated the validity and reliability of parents’ and providers’ reports of teens’ HPV vaccination status using data from a National Survey [22]. They concluded that the self-reports are reliable [22]. Because our EHRs are not linked to medical records or the Immunization Tracking system of the state of Texas (ImmTrac2), we could not validate the patient responses with the immunization records. Validation of the self-reported vaccination status is recommended [23] and will be possible as EHRs advance toward integrating medical and dental clinical information. Third, data were collected by a diverse group of dental students and residents, supervised by the clinical faculty, and we considered the potential for interviewer, selection, and response biases. Interviewer bias could have happened because of the challenges in calibrating a diverse group of dental providers—students, residents, and faculty members, with different levels of comfort and communication styles. How the question was asked may have influenced the patient’s responses. We acknowledge the likelihood of response bias as a dental provider asked the questions, and parents may have felt uncomfortable indicating a reason that could demonstrate a lack of trust in the provider. We also acknowledge that our patient population was recruited at a single academic dental clinic, the study is susceptible to selection bias, and the findings may not be generalizable to pediatric dental populations in other clinical settings or geographic regions.
Reasons for the unwillingness to receive the vaccine at the dentist may be better evaluated by a separate English and Spanish survey administered at the time of the clinical appointment by a trained research interviewer. Lastly, we did not include the option “I don’t know” when asking the parent about their child’s HPV vaccine status because the interviewer was a dental provider and expected to be prepared to answer questions related to HPV vaccination. We acknowledge this critical limitation. Parents’ knowledge of and readiness to accept the HPV vaccine may be shaped by language and cultural beliefs [24]. Cultural stigma surrounding HPV may have influenced the willingness to respond or accept vaccination, and has introduced selection bias in this study population. It is essential to inform the development of tailored, multilingual educational messages, which should be explored in future studies for increased awareness of HPV vaccines and to build trust between patients’ families and dental providers.
4.6. Future Directions
To strengthen HPV-related-cancer prevention delivered through dental settings, future studies should adopt a longitudinal design that can track whether immunization counseling leads to an increased vaccine uptake over time. Collecting these data through EHR systems, using CDT codes for documentation, can facilitate outcome tracking and program evaluation. Dental academic institutions should incorporate HPV immunization counseling into the curriculum as part of comprehensive head and neck cancer prevention, and dental practitioners should routinely include assessment of HPV vaccination status in the patient’s medical history questionnaire and be prepared to provide immunization counseling and answer patient questions. As more states authorize dentists to administer vaccines [14], they can serve as implementation models for integrating HPV vaccination in dental settings. On-site nurses, already present in multi-specialty clinics or dental academic institutions, can be engaged to administer vaccines during dental visits. Additionally, as EHR systems become increasingly integrated with medical records [20], these platforms can support documentation, follow-up, and coordination with primary care. The system-level innovations, combined with the continued education of dental providers, will be critical components of a comprehensive head-and-neck-cancer prevention program for our patients.
5. Conclusions
This cross-sectional research study of 400 pediatric dental patients found that 54.5% had not completed the HPV vaccine series, with the lowest coverage being among males and children aged 9–11 years. Yet, 21% of the parents of incompletely vaccinated children expressed a willingness to accept chair-side vaccination, highlighting a valuable, presently untapped and underused preventive opportunity in dental settings. Barriers to vaccine acceptance were primarily logistical, relating to a preference for physician-office administration (43.6%), or informational or related to indecision (20.3%) rather than safety (8.1%) or religious (5.2%) concerns. Our findings suggest that improving education through immunization counseling and expanding access within dental clinics may have a significant impact on increasing HPV vaccination coverage.
Policymakers should consider authorizing trained dental professionals to administer vaccines, ensuring reimbursement parity with medical providers, and linking dental and medical EHRs with state immunization registries for seamless vaccine tracking. Interprofessional protocols engaging on-site nurses in dental clinics could further accelerate uptake. Collectively, these findings underscore that incorporating HPV vaccination into routine dental practice is not only feasible, but is a critical step towards comprehensive HPV-related-cancer prevention and improving oral and general health.
The authors of this manuscript portray the honest work of our collaborative group, who worked together on this research study. Conceptualization, A.N. and D.L.; methodology, A.N., A.J.-T., G.O., G.B., L.F. and D.L.; software, A.N. and D.L.; validation, A.N., D.L., G.B.; formal analysis, A.N. and D.L.; investigation, A.N. and D.L.; resources, A.N., D.L., G.B., L.F. and G.O.; data curation, A.N., D.L., G.B., L.F. and G.O.; writing—original draft preparation, A.N., D.L. and A.J.-T.; writing—review and editing, all.; visualization, A.N. and D.L.; supervision, A.N., A.P. and G.B.; project administration, A.N., Lubna Fawad, and G.B.; funding acquisition, A.N. and A.J.-T. All authors have read and agreed to the published version of the manuscript.
The study was conducted in accordance with the Declaration of Helsinki, and obtained approval from the UTHealth Committee for Protection of Human Subjects (CPHS) for this study. The information obtained was recorded in a format that allowed study participants not to be identified directly or through identifiers linked to patients. The study offered no risk or was at minimal risk (e.g., loss of confidentiality) to subjects, and the data were analyzed in aggregate. We received institutional review board (IRB) approval with exempt status for the study HSC-DB-22-0323 on 5 March 2022.
This study used data analysis of information obtained via a form. Data were collected prospectively and analyzed retrospectively. No informed consent was collected.
The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author.
The authors declare no conflicts of interest.
The following abbreviations are used in this manuscript:
| OPC | Oropharyngeal cancers |
| HPV | Human Papillomavirus |
Footnotes
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Figure 1 Clinical workflow of assessment of HPV vaccination status, and willingness to receive the HPV vaccine at the dentist.
Figure 2 Parent-reported reasons for no HPV vaccine at the dentist, overall.
Demographic characteristics of pediatric patients according to HPV vaccination status. Have you received the complete HPV vaccine series?
| Age Group | Yes N | % (95% CI) | No N | % (95% CI) | Total N | % (95% CI) | p-Value 1 |
|---|---|---|---|---|---|---|---|
| 9–11 | 19 | 10.4 (6.4–15.8) | 60 | 27.5 (21.7–34.0) | 79 | 19.8 (16.0–24.0) | p < 0.001 |
| 11–14 | 93 | 51.1 (43.6–58.6) | 112 | 51.4 (44.5–58.2) | 205 | 51.3 (46.2–56.3) | |
| 15 = 18 | 70 | 38.4 (31.4–46.0) | 46 | 21.1 (15.9–27.1) | 116 | 29.0 (24.6–33.7) | |
| Gender | |||||||
| Male | 74 | 40.7 (33.5–48.2) | 112 | 51.4 (44.5–58.2) | 186 | 46.5 (41.5–51.5) | p = 0.031 |
| Female | 108 | 59.3 (51.8–66.6) | 106 | 48.6 (41.8–55.5) | 214 | 53.5 (48.5–58.5) | |
| Race/Ethnicity | |||||||
| White | 18 | 9.9 (6.0–15.2) | 20 | 9.2 (5.7–13.8) | 38 | 9.5 (6.8–12.8) | p = 0.952 |
| Black | 28 | 15.4 (10.5–21.5) | 34 | 15.6 (11.1–21.1) | 62 | 15.5 (12.1–19.4) | |
| Latino/Hispanic | 108 | 59.3 (51.8–66.6) | 130 | 59.6 (52.8–66.2) | 238 | 59.5 (54.5–64.4) | |
| Asian | 15 | 8.2 (4.7–13.2) | 15 | 6.9 (3.9–11.1) | 30 | 7.5 (5.1–10.5) | |
| N/A | 13 | 7.1 (3.9–11.9) | 19 | 8.7 (5.3–13.3) | 32 | 8.0 (5.5–11.1) | |
| Language Spoken | |||||||
| English (235) | 111 | 61.0 (53.5–68.1) | 124 | 56.9 (50.0–63.6) | 235 | 58.8 (53.8–63.6) | p = 0.651 |
| Spanish (111) | 49 | 26.9 (20.6–34.0) | 62 | 28.4 (22.6–34.9) | 111 | 27.8 (23.4–32.4) | |
| N/A (55) | 22 | 12.1 (7.7–17.7) | 32 | 14.7 (10.3–20.0) | 54 | 13.5 (10.3–17.2) | |
| Insurance type | |||||||
| Medicaid (259) | 119 | 65.4 (58.0–72.3) | 131 | 60.0 (53.3–66.6) | 261 | 65.3 (60.4–69.9) | p = 0.142 |
| Commercial (80) | 30 | 16.5 (11.4–22.7) | 50 | 22.9 (17.5–29.1) | 80 | 20.0 (16.2–24.3) | |
| None (61) | 33 | 18.1 (12.8–24.5) | 37 | 17.0 (12.2–22.6) | 59 | 14.8 (11.4–18.6) |
1 Pearson Chi-square test.
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; Bona Gisela 1
; Olson, Gregory 3
; Pazmino Alice 1 ; Fawad Lubna 1 ; Neumann, Ana 4
1 Department of Pediatric Dentistry, UTHealth Houston, Houston, TX 77054, USA; [email protected] (D.L.); [email protected] (G.B.); [email protected] (A.P.); [email protected] (L.F.)
2 Department of Diagnostic and Biomedical Sciences, UTHealth Houston, Houston, TX 77054, USA; [email protected]
3 Department of Technology Service & Informatics, UTHealth Houston, Houston, TX 77054, USA; [email protected]
4 Department of General Practice and Dental Public Health, School of Dentistry, UTHealth Houston, Houston, TX 77054, USA