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ADA policy on genetic testing aims to protect patients from limited dental coverage

October 31, 2017

By Michelle Manchir

Atlanta — Dental benefit providers are called to demonstrate that any genetic tests used to determine eligibility for benefit coverage of specific oral health services are scientifically valid in a resolution the ADA House of Delegates adopted in October.

The resolution comes as risk-based benefit plans are growing in popularity with some plan administrators, plan purchasers and dental care providers, said Dr. Christopher Smiley, who authored the resolution and is past chair of the ADA Council on Dental Benefit Programs and the Dental Quality Alliance.

An individual's genetic composition has been used by some plans as a marker to assign a patient's risk status for developing disease, and then in determining coverage for the patient, Dr. Smiley said.

However, earlier this year, the ADA published a summary about genetic testing and oral health, noting that "no predictive test for dental caries or periodontal disease currently exists, and that while genetic testing holds potential for clinical application in the future, clinical measurements remain, for now, the best approach to assessment of caries and periodontal disease."

To ensure patients do not experience barriers to access for needed services and that dentists can assess the claims made as result of genetic testing, the resolution articulates expectations for any evidence used to support use of a genetic test by benefit plans to determine eligibility for benefit payment of specific services, Dr. Smiley said. It further states that the ADA should work with the American National Standards Institute to develop industry standards for these tests. The ADA is a standards development agency for the American National Standards Institute through the ADA Standards Committee on Dental Informatics and the Standards Committee on Dental Products.

"Compliance with these standards will build confidence for patients and providers that such tests and plan designs are valid, reliable and clinically relevant," he added.

The resolution also calls insurers to disclose financial relationships between manufacturer and payer; be transparent about conflicts of interest between the test manufacturer, payer and study investigators; and provide an analysis of how utilization of the test will affect health outcomes and plan costs.

A Michigan dentist, Dr. Smiley has been an advocate for spreading awareness about genetic testing and oral health. In a June letter to the ADA News editor, Dr. Smiley wrote about a Delta Dental plan called RightSize used for their employees in Michigan, Indiana and Ohio. The plan involved using a genetic test to assess patients' risk for developing periodontitis. Under the plan, he wrote, patients received coverage for one dental cleaning annually, while patients who test positive for specific genetic markers were eligible for an additional cleaning.

The resolution is intended to provide a mechanism where patients and care providers can be assured about the clinical relevance, validity and reliability of any genetic test used to ration benefit coverage for the services they provide, Dr. Smiley said.

To read the ADA's Oral Health Topics page on Genetics and Oral Health, visit ADA.org/GeneticsAndOralHealth.