Information, Please by Dentaltown special projects editor John Lannon

Imagine, if you will, a dental student preparing for a Class 2 restoration with a new patient who represents the absolute definition of “skittish.” The student’s instruments, equipped with radiofrequency identity (RIFD) chips, are laid out on a tray and “smart” safety glasses sit snugly on the bridge of her nose. The dental chair has sensors in the seat and drill, and is also equipped with a RIFD reader, biometric sensor and video monitoring. The chair recognizes the patient and has begun monitoring the procedure, providing the student with real-time data on his stress levels and her progress in finishing the restoration.

A few minutes into the procedure, the system monitoring all data streams identifies increased stress in the patient and a nonstandard pattern of activity. It forecasts a high likelihood of a poor outcome if the current workflow is continued, and sends the student an alert via her glasses that a potential problem with the current procedure is likely. It also notifies a senior faculty member that the student may need some assistance with the restoration, and together they choose a different path of activity with a better outcome and lower stress for the patient.

Far-fetched? Not really, considering what is happening at Columbia University College of Dental Medicine and its new Center for Precision Dental Medicine. Data collection technologies developed with the assistance of Planmeca, a Finnish technology company, and the application of precision medicine will help the center accomplish two goals: to offer personalized dental care and to make evidence-based connections between oral and overall health a reality.

Medical treatment tailored to the individual, not the average individual
“Precision medicine is probably the biggest thing for the future of the American health care system, if not the world,” said Christian S. Stohler, DMD, DrMedDent, the dean of the college. “It will put American health into the center of what shapes the future of world health. I think there’s nothing bigger than this. It will be more complex, and it will consider not just the genomic information but also many other data sets, including what we use in dentistry.”

What is “precision medicine”? According to the Precision Medicine Initiative, a long-term research endeavor being conducted by the National Institutes of Health and several other research institutions, it’s an emerging approach for disease treatment and prevention that takes into account each individual’s variable genes, environment and lifestyle. This approach should allow caregivers and researchers to predict more accurately which health care treatment and disease prevention strategies will work in which groups of people. Contrast this with a “one size fits all” approach, whereby disease treatment and prevention strategies are developed for the average person, with less consideration for the differences between individuals.

“Precision medicine will lead to a new kind of medicine that will serve people in their individuality, as opposed to their average,” Stohler said. “We have learned over the years that average medicine is not good enough—that average medicine makes too many mistakes.”

Data collection that’s comprehensive and wireless
At the heart of the center’s armamentarium will be data. Through passive data-collection tools, the center will help tailor care to each patient and offer quantifiable feedback to each dental student. Electronic dental records will be tied to medical records, better enabling dentists as well as other providers to treat patients based on comprehensive health information, rather than just oral disease. The center will also facilitate research that could help future dentists treat patients based on thousands of parameters—genomic, environmental and more—rather than just the handful used today.

Among the data-collecting technologies the center will be using are the aforementioned wireless tracking instruments and a dental chair serving as a data-collection hub. RFID tags attached to dental instruments, supplies, and student and faculty ID badges, as well as sensors in the dental chair, will collect never-before-measured data such as in what angle the patient was seated, for how long and during what procedure an instrument was used. The feedback instructors provide to students will now be measurable, allowing them to become more efficient and precise with their care.

The dental chair, assuming a larger role in the instructor/student and patient/provider interaction, will feature two video cameras, allowing an instructor to view a procedure as it occurs from the student’s point of view and provide specific feedback on the procedure, as opposed to the procedure’s result. The chair also will collect data that determines a patient’s stress levels, providing students with real-time information about the patient’s comfort.

“If you look at a typical surgical procedure in a hospital or in a procedure room, nobody collects this kind of data,” said Steven Erde, MD, PhD, Columbia University College of Dental Medicine’s chief information officer. “They might collect biometric data, heart data and respiration data, but data about the instrumentation itself and how it’s been used? I don’t think anybody has that kind of data except maybe with surgical robots like da Vinci or something like that where they might have a log of data.”

Describing the data-collecting process, Erde said, “In a typical environment, patients are going to come into [the center’s] waiting area. They’ll get registered into the electronic health record and get a bracelet that will be like every other hospital bracelet, but rather than having a bar code it will have a RFID chip in it. The difference between a RFID chip and a bar code is that the chip can be read at a distance, whereas with a bar code, you’ve got to read that with a scanner—not a lot of difference from the standpoint of privacy and security.

“Patient IDs and chart numbers will be listed just as they are with every other bar code wristband in every hospital. What we’ll have, though, is the ability to follow the patients in the facility to track their movements; for example, how long they’re waiting, when they get to the dental chair, and when the provider shows up,” Erde continued.

“The patient’s RFID tag will be detected by the chair, so the data collected will be tagged to the patient. Additionally, providers will have RFID chips in their IDs that will also be detected by the chair. The stream of data that is then generated by the procedure will have both provider and patient data stored in it.”

University research with real-world applications
Erde notes that the initial phase of the center’s data collection will be for its own operational reporting—essentially a Columbia-only system. The second phase will be to take the raw data and turn it into something more meaningful.

“We want to convert the data about how fast a drill is running when providers picked it up, when they used water, when they used air, when the chair moved, and turn it into a digital fingerprint of sorts so we can say a typical procedure for doing a restoration is all these steps,” he said.

“We expect that this kind of technology will give us the ability to advise students with a much more significant granularity than the way we have approached it in the past,” Stohler adds. “Many of the things we do in dentistry are irreversible. For that reason, we expect that the online feedback with the possibility to use predictive analytics will give instructors and students feedback relative to ensuring that we are fulfilling the needs of the patient in the best possible way.”

Erde said the center is currently exploring how to understand the data’s value. “In this stage, we’re going to start looking at data retrospectively. And if we see bad outcomes, we want to feed this back into a system that will use (artificial intelligence) or another stream of analytics to say this: When something bad is happening, don’t wait until the procedure’s over; shoot up a flag and say, ‘Hey, send over a faculty member. The student may need help with this patient.’” Essentially, instead of finding out about a problem after the fact, the center would try to intervene before it happens.

Applications beyond the dental chair
“Precision medicine is not just in the dental school,” Erde said. “It’s also a major initiative for the medical school. We want to see more collaboration between different parts of the medical school, so we don’t have just the dental school trying to do this on its own. This is really a team sport.”

“Given the increasing comorbidity in our population, there’s a tremendous need to bring together medicine and dentistry,” Stohler agreed. “A system of support for dentistry needs to be based on the reality in a patient’s medical record.

“We have seen a tremendous increase in diabetes, in a number of inflammatory conditions, and we are about to experience a transformation in the way we approach various cancer conditions that are going to be much more chronic than they have been in the past. The number of chronic conditions in the patient population that seeks dental care is about to increase significantly, calling for a very different position of dentistry in the mix of the health care system.”

New technology demands new medical training
Where is this data-driven, personalized technology taking us? In 10 years, when a patient sits in a dental chair, would the personalized “fingerprint” in her mouth be so unique that it will allow the dentist to tailor a procedure specifically to the patient?

“I think that’s a fair statement,” Stohler said. “But we also see a problem with the statement. There will be so much information available that no human will be able to integrate it in a meaningful way without the assistance of physician support systems. That forces any kind of provider, whether a dentist or a physician, to become a very different person in the future health care system.

“At this point in time, we are making diagnostic decisions based on one, two, three, maybe four indicators of disease. In the future—when you’re looking at the genome, you’re looking at epigenetics, you’re looking at all the omics—you realize that the amount of data that needs to be considered to make a personalized decision can be done only by computers,” he said.

“That’s why the integration of dentistry in medicine is so crucial. We need to train our students to assume a role whereby they are functioning in a very different way in the 21st century. The support system should give them the information to carry to the patient and translate it in ways so that the patient can make an informed decision. That has not been in the past; a diagnosis was something that the patient walked away with and never challenged.

“Today, we have patients—and we certainly will in the next 10 years—that have access to the same information about themselves that a physician has. They will be able to use support systems to make decisions, changing the role of what we do and what we should contribute to their health and wellness in an enormous way. And for this, I am grateful that our medical schools will include dentistry in that process of reshaping the future of the health profession.”

Conclusion
“We have taken the boundaries down, and we would like to be part of shaping the future,” Stohler said. “I think we have a clear vision of what the future is looking like, and I think we know what we’ve got to do to ultimately get to the point where we can demonstrate the utility of the concept of precision medicine.

“The director of the genome project once said the project was similar to the federal government building a highway system: By doing so, it didn’t tell people where to drive; it only gave them the tools to go where they wanted to go. I think that’s what precision medicine at this point in time is: a project with a tremendous understanding that will lead to a new kind of medicine that will serve people in their individuality, as opposed to their average.”