A trip to the dentist is a mediocre-to-horrifying experience that unites us all: A cramped waiting room, with old copies of Women's Health from last fall, where you spend the better part of an hour past your appointment time. Inside the inner sanctum, you are greeted with the perpetually uncomfortably monstrosity that is today's dental chair: a cold, steel behemoth with suspicious stains and torn vinyl and sprouting numerous appendages. The dentist presses pedals and levers, yanking you this way and that as yours eyes fix on that horrible framed photograph of a Hawaiian sunset taped to the ceiling. The inevitable scraping, buzzing, and digging. “Does this hurt or does it feel ok?”; you grunt back in a way that hopefully sounds permissive, even as the pressure on teeth surfaces you didn’t know you had mounts higher and higher, tears starting in your eyes as you mentally vacillate between making a fuss and letting it be over as quickly as possible.
The dentists at Columbia University’s new Center for Precision Dental Medicine in Washington Heights hope to take this entire experience and turn it on its head. The center occupies the entire fifth floor of Columbia’s Vanderbilt Clinic, on West 168th Street. The 15,000-square-foot space is straight out of Stanley Kubrick film — white walls, curved ceilings, and 48 slick, womb-like cubicles. Each cubicle houses a custom-built dental chair. A completely integrated RFID system uses electromagnetic fields to ‘track’ tags attached to everything from practitioners and patients’ wristbands to dental equipment. Miles of blue Ethernet cable under the raised floor convey information to a nearby server, which tracks, logs, and records which patient is in which chair, instruments are used when and where, and for how long.
Steven Erde, Columbia’s College of Dental Medicine’s chief information officer, walked me through the patient experience, beginning with self-sign in via an online portal, at which point patients are assigned an RFID-enabled wristband, worn throughout their visit. Aside from letting the practitioners know where patients are and what’s being done to them, this system is also supposed to reduce unnecessary waiting times.
By monitoring a patient’s vital signs, practitioners will be able to figure out when a patient is in distress, without them having to flail or issue some kind of guttural squeal.
Columbia is calling the center the first “big-data precision dental medicine clinic.” In the next six months, the center will install biofeedback capabilities into each chair, which will measure patients’ pulse and oxygenation levels to produce a real-time picture of their stress levels during each visit. (My oxygenation levels were at 99 percent, which Erde complimented me on.) By monitoring a patient’s vital signs, practitioners will be able to figure out when a patient is in distress, without them having to flail or issue some kind of guttural squeal. Two cameras installed in the chair — one in the main spine of the chair, and another in the overhead light will record procedures for analysis, and might soon use facial recognition software to more accurately detect stress levels, or when a patient is in pain.
Dental chairs (the big cushy ones you sit in when you go for a check-up) can cost anywhere between $2,500 to $50,000. The main difference is mechanical: older chairs are analog, pneumatic machines that run on air pressure. Columbia’s chairs are all digital. A small RFID reader embedded in the chair tracks both patient and practitioner after everyone has “signed in.”
Each chair at Columbia’s new dental center has six tethered instruments that are also RFID-enabled, so the system logs everything, building up a complete picture of where an instrument was used and by whom, for how long, when it was last sterilized, when it was sharpened, and so on. The clinic has also invested in technologies like 3D printing; its 3D milling machine can print a crown in about 15 minutes. (While more and more dental clinics around the country are adopting this tech, currently, the most common procedure for getting a crown involves waiting two weeks for the manufacturing process, during which time the temporary crown that’s been put in place is likely to fall out once or twice, requiring several trips back to the dentist.)
Over time, logging individual’s heart rates and oxygenation levels will lead Columbia to build a robust and comprehensive dental record that can give practitioners a better idea of a patient’s overall health. “The biology of a person is actually best understood under stress,” Christian Stohler, Dean of the College of Dental Medicine at Columbia, told me. “If someone is more vulnerable to stressful situations, they might be subject to a host of diseases aggravated by stress. If you understand a person’s resilience to stress, you may be able to understand what it means for the progression of disease.”
Of course, as with any system that collects and stores sensitive medical data, there are questions surrounding privacy and misuse. Particularly when we have already seen major violations of privacy at large medical institutions like Stanford. Eric Schadt, the director of the Icahn Institute for Genomics and Multiscale Biology at the Icahn School of Medicine at Mount Sinai, says the bottom line is that those participating in this kind of data collection must be informed, and should be advised and have a choice about how the data is used. “The patient should no longer be considered some kind of passive bystander regarding data generated on them and then leveraged commercially or for research,” Schadt said. “The patient should be considered as a partner and should derive more direct benefit from it.”
“These efforts should be using industry standard protection measures that are used in many sensitive businesses, such as banks,” Schadt said. “We hire groups that are dedicated to testing the resiliency of your systems, they try to hack your systems and identify weaknesses. But even so, nothing is bulletproof and mistakes will get made.”
Erde and his team hope to use the data they gather not just to make individual patients more comfortable and streamline their visits, but to standardize certain dental procedures. What should a standard cleaning look like? Or a root canal? What’s the optimal way to extract a tooth, or put in a crown? What is unique about dentistry, and what may allow for a great level of variation in practice, is that work in the mouth is hard to see, and thus make consistent. In both teaching and practice, minute but potentially important variations can impact outcomes. For example, if your root canal performed by an endodontist fails, you fall into the 10-20 percent of similar patients with that experience. But why did that happen to you? Was it the way an instrument was held, the pressure used, or even the size of a provider’s hands?
Dentists could detect early signs of things like oral cancer, diabetes, rheumatoid arthritis, psoriasis, and heart disease.
Columbia’s goal is to establish a clearer connection between what’s happening inside a patient’s mouth and what’s happening in the rest of their body. Dentists could detect early signs of things like oral cancer, diabetes, rheumatoid arthritis, psoriasis, and heart disease. The problem is the current fee-for-service system means dentists are not required to do anything other than what they are being paid to do — a checkup, a root canal, a crown. In other words, dentists won’t look for things they’re not paid to look for.
The way Erde and his team plan to solve this is by integrating patients’ dental records with their medical records.
“You’re far more likely to see a dentist than you are a general physician during that middle bit of your life when you’re in good health,” Erde told me. “Eventually, the dentist could be the place to go where you get your sugar levels tested if you’re a diabetic. Those are the kinds of things that we can do with a big data system like this.”
Bruce Donoff, Dean of the Harvard School of Dental Medicine, told me the more dentists know about a patient’s overall medical record, the better equipped they will be to provide the best level of care. “So many silos separate medicine and dentistry: separate insurance, separate clinics,” Donoff told me. “It shouldn’t be like this.”
Progressive medical systems do already exist in the U.S.: Community Health Center, headquartered in Middletown, Connecticut, with clinics around the country, already combines patients’ dental and medical records as the clinics have both doctors and dentists. While the data collected is not as intricate as what Columbia is proposing, it shows that integration is already happening — and it’s doable.
The school already has a significant overlap between patients in both its teaching hospital and dental school, so combining dental and medical records will be easy — and, Epic a system that can be adopted by the large medical centers across the country, is already being rolled out nationwide. Epic allows patients to log in and download their data, and also allows providers to share data so everyone can see that patient’s medical record regardless of what doctor they’re seeing and where.
According to Erde, there’s already been significant interest from dental clinics and hospitals around the country, who are all watching Columbia closely to see how its big data experiment pans out.
“Health care and dentistry have traditionally been very siloed,” Erde said. “Sharing information can lead to all sorts of new things. This is an avenue that is unique for dentistry.”