American Journal of Epidemiology Vol. 177, No.

7
© The Author 2013. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. DOI: 10.1093/aje/kws293
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial
License (http://creativecommons.org/licenses/by-nc/3.0), which permits unrestricted reuse, distribution, and reproduction in any Advance Access publication:
medium, provided the original work is properly cited. March 4, 2013

Practice of Epidemiology

Regional Epidemiologic Assessment of Prevalent Periodontitis Using an

Electronic Health Record System

Amit Acharya*, Jeffrey J. VanWormer, Stephen C. Waring, Aaron W. Miller, Jay T. Fuehrer, and

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Gregory R. Nycz
* Correspondence to Dr. Amit Acharya, Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, 1000 North Oak
Avenue, Marshfield, WI 54449 (e-mail: [email protected]).

Initially submitted March 28, 2012; accepted for publication June 15, 2012.

An oral health surveillance platform that queries a clinical/administrative data warehouse was applied to esti-
mate regional prevalence of periodontitis. Cross-sectional analysis of electronic health record data collected
between January 1, 2006, and December 31, 2010, was undertaken in a population sample residing in Lady-
smith, Wisconsin. Eligibility criteria included: 1) residence in defined zip codes, 2) age 25–64 years, and 3) ≥1
Marshfield dental clinic comprehensive examination. Prevalence was established using 2 independent methods:
1) via an algorithm that considered clinical attachment loss and probe depth and 2) via standardized Current
Dental Terminology (CDT) codes related to periodontal treatment. Prevalence estimates were age-standardized
to 2000 US Census estimates. Inclusion criteria were met by 2,056 persons. On the basis of the American
Academy of Periodontology/Centers for Disease Control and Prevention method, the age-standardized preva-
lence of moderate or severe periodontitis (combined) was 407 per 1,000 males and 308 per 1,000 females (348/
1,000 males and 269/1,000 females using the CDT code method). Increased prevalence and severity of peri-
odontitis was noted with increasing age. Local prevalence of periodontitis was consistent with national estimates.
The need to address potential sample selection bias in future electronic health record–based periodontitis
research was identified by this approach. Methods outlined herein may be applied to refine oral health surveil-
lance systems, inform dental epidemiologic methods, and evaluate interventional outcomes.

electronic health records; oral disease; periodontal disease; periodontitis

Abbreviations: AAP, American Academy of Periodontology; CDC, Centers for Disease Control and Prevention; CDT, Current
Dental Terminology; CI, confidence interval; EHR, electronic health record; MESA, Marshfield Epidemiologic Study Area;
NIDCR, National Institute of Dental and Craniofacial Research; PTP, periodontal treatment procedures.

Periodontitis is a common dental health condition caused with respect to disease severity. The National Health and
by bacterial infection that leads to chronic inflammation of Nutrition Examination Survey has been the primary epide-
gingival tissue, degeneration of periodontal ligament and miologic research tool for studying periodontitis (3), with
bone, and eventual tooth loss. Periodontitis affects up to few studies to date utilizing administrative records to
half of US adults in some form (1–3), resulting in decreased conduct periodontitis surveillance at more local levels
quality of life (4) and increased health-care costs (5). Left (where interventions are most likely to occur). This is an
untreated, periodontitis also promotes cardiovascular disease important and modifiable gap in the scientific literature,
and type 2 diabetes by supporting a chronic inflammatory since information captured in electronic health records
state (1, 6–8). (EHRs) in dental and medical settings is useful for both
Despite the serious nature of periodontitis in the context patient care and population-based research. Indeed, the
of oral and systemic health, surprisingly little is known current National Institute of Dental and Craniofacial
about the national prevalence of periodontitis and variability Research (NIDCR) strategic plan states, “Documenting the

700 Am J Epidemiol. 2013;177(7):700–707

 Assessment of Prevalent Periodontitis Using EHRs 701

nation’s prevalence of the full range of oral, dental, and cra- Marshfield Clinic medical and dental care systems. Eligibil-
niofacial diseases is an important element of a strategic ity criteria for this analysis, as of December 31, 2010,
investment in basic and clinical research. . . . The NIDCR were: 1) inclusion in the MESA registry with a home
will seek and validate new methods to measure and docu- address in the 54848, 54526, 54731, 54530, 54819, or
ment oral, dental, and craniofacial diseases, disorders and 54563 zip code; 2) age 25–64 years; and 3) completion of
conditions” (9, p. 51). There has been a strong push by the 1 or more Marshfield dental clinic comprehensive examina-
federal government for health-care systems to adopt and use tions. Over 90% of adult residents in this geographic study
the EHR, including direct incentives for dentists. In addi- area are included in the MESA registry (18). The age range
tion, there has been widespread adoption of EHRs in the was selected on the basis of the low likelihood of periodon-
majority of US dental schools (10). titis before age 25 years and the low likelihood of dental
The generally positive impact of EHRs in patient care care coverage after age 64 years (typically due to the transi-
has been well documented (11–15), but relatively few tion away from private insurance and the lack of an oral
dental studies have been completed with secondary use of health benefit in Medicare). Because this was a retrospective
EHR data. The increasing adoption of EHRs in dentistry analysis of health-care data that was part of an ongoing epi-

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highlights the opportunity to “reuse” such clinical data for demiologic surveillance system, informed consent procedures
epidemiologic, outcomes-based, and comparative effective- were waived, and the study was reviewed and approved by
ness studies in dental/oral/craniofacial research. However, the Marshfield Clinic Institutional Review Board.
there are few models of oral health surveillance described
in the dental science literature, which is a barrier to con- Measures
ducting even basic EHR-based dental research.
In the current article, we describe a regional oral health All measures were extracted from the Marshfield Clinic’s
surveillance platform that queries an electronic clinical/ enterprise data warehouse, which stores data from EHRs
administrative data warehouse, as well as findings from an and is linked to the MESA registry file. At their source,
application of this system in estimating the prevalence of data on dental variables are collected from comprehensive,
moderate-to-severe periodontitis in an economically disad- full-mouth dental examinations (by licensed dentists and
vantaged area of northwestern Wisconsin. Implications for hygienists) and recorded in the EHR. Several sociodemo-
future EHR-based oral health research in this region and in graphic and medical covariates were also reported in this
other health-care systems are discussed. study, including age, sex, race/ethnicity, smoking status,
personal history of diabetes (i.e., type 1, type 2), personal
MATERIALS AND METHODS
history of cardiovascular disease (i.e., myocardial infarc-
tion, angina, stroke), medical insurance status, and dental
Setting insurance status. These data were collected for each individ-
ual as part of routine clinical care and documented in the
This oral health study was conducted using data from the EHR during medical and dental office visits. For each
Marshfield Clinic health-care system (headquartered in Marsh- measure, the most recent recorded value as of December
field, Wisconsin), specifically the dental services provided in 31, 2010, was used for analytical purposes.
partnership with the Family Health Center of Marshfield The outcome of interest was the prevalence of periodon-
Clinic. The Family Health Center is a Federally Qualified titis. Periodontal status was established using 2 separate
Health Center that has partnered with the Marshfield Clinic methods. The first method used a rule-based algorithm
since it was first established in 1974. The Family Health based on operational definitions of moderate and severe
Center has a mission to improve access to quality health-care periodontitis outlined by the American Academy of Peri-
services for low-income and underserved communities in the odontology (AAP) and the Centers for Disease Control and
Marshfield Clinic service area. In 2010, an integrated Prevention (CDC) (19). Specifically, a person was catego-
medical-dental EHR was launched that enabled dentists and rized as having moderate periodontitis if 2 or more inter-
physicians to seamlessly access medical and dental health proximal sites had a clinical attachment loss of ≥4 mm (not
information on their patients across the system (16). on the same tooth) or if 2 or more sites had a probing
depth of ≥5 mm (not on the same tooth). Severe periodon-
Participants titis was recorded if 2 or more sites had a clinical attach-
ment loss of ≥6 mm (not on the same tooth) and if 1 or
A cross-sectional analysis was performed using EHR more sites had a probing depth of ≥5 mm. The periodontal
data collected between January 1, 2006, and December 31, chart data on interproximal sites came from comprehensive
2010, from part of the Marshfield Epidemiologic Study dental examinations performed at Marshfield Clinic’s
Area (MESA), where Marshfield Clinic dental clinics serve dental centers. These examinations are part of routine care
as the primary provider of dental services. As is described provided during dental office visits and typically include a
in more detail elsewhere (17), MESA is a population-based formal periodontal disease assessment. Notably, compre-
health surveillance/research resource developed and main- hensive dental examinations do not typically occur during
tained by the Marshfield Clinic. The sample in this analysis emergency oral care visits (e.g., tooth extraction) or ortho-
was drawn from residents of 6 zip codes surrounding the dontic surgeries.
city of Ladysmith, Wisconsin (see Figure 1), a rural region The second method used for establishing periodontal con-
of approximately 13,000 people primarily served by dition was based on standardized Current Dental Terminology

Am J Epidemiol. 2013;177(7):700–707
702 Acharya et al.

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Figure 1. Age- and sex-standardized prevalence of periodontitis per 1,000 residents aged 25–64 years in the Ladysmith, Wisconsin, study
region, by zip code (shown in white boxes), January 1, 2006–December 31, 2010. Numbers in parentheses, 95% confidence interval.

(CDT) codes (20) documented in the EHR as they specifi- to ascertain periodontal status based on recent dental
cally related to periodontal treatment procedures (PTPs). records). All analytical procedures were conducted using
Participants were categorized as having moderate-to-severe SAS software (version 9.2; SAS Institute Inc., Cary, North
periodontitis if 1 or more PTP codes/claims were present in Carolina).
their EHRs. This approach was based on previous method-
ology developed by Spangler et al. (21), which screened for RESULTS
up to 16 CDT codes indicative of periodontitis.
As of December 31, 2010, there were 7,676 persons aged
Statistical analyses 25–64 years with a known residence in one of the target
MESA zip codes. Of these persons, 2,056 (27%) had
Summary statistics were calculated separately for each undergone 1 or more Marshfield Clinic dental clinic com-
method of periodontitis case-finding and stratified by sex. prehensive examination(s) between January 1, 2006, and
Prevalence was calculated by dividing the number of peri- December 31, 2010. This latter group made up the analyti-
odontitis cases by the number of eligible persons present in cal sample. The remaining 5,620 persons were excluded
the analytical sample. Prevalence estimates were then from the analytical sample. As outlined in Table 1, relative
directly age-standardized (22) to the year 2000 US Census to the analytical sample, the excluded group contained sig-
estimates of all residents in the targeted zip codes and age nificantly more males, persons of unknown race/ethnicity,
ranges. Using χ2 tests, sociodemographic and medical char- uninsured persons (both medical and dental insurance), and
acteristics were compared between the analytical sample persons with unknown smoking status, as well as lower
and the remaining MESA residents who had no dental data rates of known diabetes and cardiovascular disease. When
available between January 1, 2006, and December 31, unknown responses were excluded from the race/ethnicity
2010. This was done to assess differences in sample char- variable, the difference between those included and
acteristics between those included in the analytical sample excluded from the analyses was not significant; however,
(i.e., the group in which it was reasonably possible to deter- this was not the case for other sociodemographic variables.
mine periodontitis status) and those excluded from the ana- Numbers of periodontitis cases derived using both the
lytical sample (i.e., the group in which it was not possible AAP/CDC and PTP methods are given in Table 2 by age

Am J Epidemiol. 2013;177(7):700–707
 Assessment of Prevalent Periodontitis Using EHRs 703

Table 1. Sociodemographic and Health History Characteristics of Residents of the Marshfield Epidemiologic
Study Area Aged 25–64 Years With and Without at Least 1 Dental Clinic Comprehensive Examinationa During the
Period 2006–2010b

≥1 Comprehensive
No Comprehensive
Dental
Dental Examination
Measure Examinations P Value
(n = 5,620)
(n = 2,056)
No. % No. %

Age group, years 0.144

25–34 534 26 1,459 26
35–44 459 22 1,187 21
45–54 592 29 1,550 28
55–64 471 23 1,424 25

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Sex <0.001
Female 1,109 54 2,607 46
Male 947 46 3,013 54
Race/ethnicity <0.001
White, non-Hispanic 1,469 71 2,522 45
Nonwhite, non-Hispanic 45 2 60 1
Unknown 542 26 3,038 54
Medical insurance <0.001
Private 601 29 1,910 34
Public 999 49 1,105 20
None 362 18 2,112 37
Unknown 94 5 493 9
Dental insurance <0.001
Yes 1,461 71 1,143 20
No or unknown 595 29 4,477 80
Smoker <0.001
Current smoker 638 31 947 17
Former smoker 353 17 625 11
Never smoker 726 35 1,621 29
Unknown 339 16 2,427 43
History of diabetes <0.001
Yes 178 9 318 6
No 1,878 91 5,302 94
History of cardiovascular disease <0.001
Yes 149 7 256 5
No 1,907 93 5,364 95
a
Persons with 1 or more Marshfield dental clinic comprehensive examinations in 2006–2010 were included in
the analytical data set, whereas those without 1 or more examinations were excluded because periodontitis status
could not be ascertained.
b
For each measure, the most recent known value recorded between January 1, 2006, and December 31, 2010,
was reported.

and sex. Age-standardized prevalence estimates, by sex and cases per 1,000 males and 24 (95% CI: 15, 33) cases per
case-finding method, are shown in Table 3. Based on the 1,000 females. The age-standardized prevalence of moder-
AAP/CDC method, the age-standardized prevalence of ate or severe periodontitis (combined) was 407 (95% CI:
moderate periodontitis was 373 (95% confidence interval 375, 438) cases per 1,000 males and 308 (95% CI: 281,
(CI): 342, 404) cases per 1,000 males and 285 (95% CI: 336) cases per 1,000 females. For both males and females,
258, 312) cases per 1,000 females. The age-standardized there was a general pattern of increased prevalence and
prevalence of severe periodontitis was 33 (95% CI: 22, 45) severity of periodontitis with increasing age.

Am J Epidemiol. 2013;177(7):700–707
704 Acharya et al.

Table 2. Distribution of Periodontitis Cases by Sex, Case-Finding Table 3. Age-standardized Prevalence of Periodontitis per 1,000
Method, Age, and Periodontitis Status Among Ladysmith, Ladysmith, Wisconsin-Area Residents Aged 25–64 Years With at
Wisconsin-Area Residents Aged 25–64 Years With at Least 1 Least 1 Marshfield Dental Clinic Comprehensive Examination, by
Marshfield Dental Clinic Comprehensive Examination, 2006–2010 Sex, Case-Finding Method, and Periodontitis Status, 2006–2010

Males Females Case-Finding Males Females

Age Group (Years) (n = 947) (n = 1,109) Method
and Periodontitis Status and Periodontitis
No. % No. % Prevalence 95% CI Prevalence 95% CI
Status
AAP/CDC Algorithm AAP/CDC
25–34 algorithm
Severe 1 0.1 1 0.1 Moderate 373 342, 404 285 258, 312
Moderate 68 7.2 48 4.3 Severe 33 22, 45 24 15, 33
None 100 10.6 218 19.7 Moderate/ 407 375, 438 308 281, 336
severe

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Unknown 57 6.0 41 3.7
PTP codes
35–44
Moderate/ 348 318, 379 269 242, 295
Severe 5 0.5 2 0.2 severe
Moderate 77 8.1 71 6.4
Abbreviations: AAP, American Academy of Periodontology; CDC,
None 80 8.4 140 12.6 Centers for Disease Control and Prevention; CI, confidence interval;
Unknown 54 5.7 30 2.7 PTP, periodontal treatment procedure.
45–54
Severe 14 1.5 14 1.3
Moderate 112 11.8 107 9.6
None 79 8.3 141 12.7 to ascertain using the PTP code method, because such treat-
Unknown 71 7.5 54 4.9 ment codes do not correspond to periodontitis severity
level. Also note that only 4 PTP codes were observed
55–64
among the periodontitis cases: codes D4341, D4910,
Severe 13 1.4 10 0.9 D4342, and D4355. Consistent with previous research (21),
Moderate 99 10.5 82 7.4 codes D4910 and D4341 (i.e., manual scaling, root plan-
None 63 6.7 102 9.2 ning, and other maintenance procedures secondary to peri-
Unknown 54 5.7 48 4.3 odontal disease) were clearly the most common codes,
PTP Codes
appearing at least once in 77% and 76%, respectively, of
all periodontitis cases identified using the PTP method.
25–34
A sensitivity analysis combining the AAP/CDC method
Moderate/severe 81 8.6 68 6.1 with the PTP code method was performed to identify all
None or unknown 145 15.3 240 21.6 possible moderate-to-severe periodontitis cases and provide
35–44 a more robust estimate of periodontitis prevalence in the
Moderate/severe 86 9.1 65 5.9
population. Any person with an indication of moderate-to-
severe periodontitis, whether via the AAP/CDC algorithm
None or unknown 130 13.7 178 16.1
or via 1 or more PTP codes, was considered a case. Under
45–54 this combined method, the age-adjusted prevalence of
Moderate/severe 96 10.1 100 9.0 moderate-to-severe periodontitis was 496 (95% CI: 464,
None or unknown 180 19.0 216 19.5 528) cases per 1,000 males and 408 (95% CI: 379, 438)
55–64 cases per 1,000 females. The age- and sex-standardized
Moderate/severe 60 6.3 62 5.6
prevalence of moderate or severe periodontitis overall was
453 (95% CI: 431, 475) cases per 1,000 persons. As out-
None or unknown 169 17.8 180 16.2 lined in Figure 1, there was also noticeable regional varia-
Abbreviations: AAP, American Academy of Periodontology; CDC, tion in that the overall periodontitis prevalence was highest
Centers for Disease Control and Prevention; PTP, periodontal in the zip codes furthest from Ladysmith. Further sensitiv-
treatment procedure. ity analyses that restricted the analytical sample to only the
7,156 subjects who resided in the study area for ≥1 year
during the data collection time frame yielded nearly identi-
cal results (data not shown).
Prevalence estimates were somewhat lower using the
PTP code method, where the age-standardized prevalence DISCUSSION
of moderate or severe periodontitis was 348 (95% CI: 318,
379) cases per 1,000 males and 269 (95% CI: 242, 295) To our knowledge, this was the first attempt to character-
cases per 1,000 females. Note that the specific subcatego- ize periodontitis prevalence using EHRs in a population-
ries of periodontitis (moderate vs. severe) were not possible based sample. Under a combination of 2 methods of

Am J Epidemiol. 2013;177(7):700–707
 Assessment of Prevalent Periodontitis Using EHRs 705

identifying periodontitis cases (the AAP/CDC algorithm research “gold standard” periodontal disease assessments
and CDT codes), almost half of the target population was (e.g., radiographic examinations).
estimated to have moderate-to-severe periodontitis. This is Approximately one-fourth of the target population had
consistent with previous national prevalence estimates of comprehensive oral examination data available during the
periodontitis in all US adults aged 30 years or older (3). 5-year data collection time frame. Reasons for the unavail-
Also consistent with previous national research (23), the ability of data are only speculative, but it may be related to
burden of periodontitis was greater in males and in older the very low baseline rate of dental care utilization in this
age groups. In terms of regional variation, periodontitis area relative to the rest of Wisconsin (University of Wis-
prevalence seemed to be higher in zip codes outside the consin Population Health Institute (Madison, Wisconsin),
municipality of Ladysmith, particularly in the eastern areas unpublished data, 2011). In addition, data on some persons
of the study region, where the population density is very were probably unavailable because they received their
low (approximately 4 residents per square km) and driving dental care outside of the Marshfield dental clinic system
distances to the dental clinic can be as great as approxi- (note that of the 9 dentists located within the study area,
mately 50 km (31 miles) (maximum distance in the western only 2 were not part of the Marshfield Clinic’s dental

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study region is less than 40 km (25 miles)). More research centers), although this may be a less influential factor given
is needed to determine the impact of distance from care on the area’s low economic status and the Marshfield Clinic’s
periodontitis prevalence, which may reflect a lower willing- being the sole provider of subsidized dental care in that
ness to seek any form of dental care (i.e., preventive check- area.
ups, periodontal treatment) because of transportation and/or A potentially major limitation of the methodology used
convenience barriers. In addition, the analysis was gener- in this study is related to the sample representativeness of
ally limited by the lack of comparison with an established the target region. Missing data is of particular concern if
“gold standard” assessment of periodontitis, as well as the group with available data substantially differed from the
potential selection biases given the observed differences group without it (i.e., data not missing at random), because
between persons included in the analytical sample and prevalence estimates may be biased. For example, persons
those excluded from the sample. in the analytical sample were much more likely to have
Both methodological approaches studied seem ap- known dental insurance than the excluded group. Among
propriate for use in other health-care systems depending on the two-thirds of area adults who did not have known
availability of data, but the relative advantages and disad- dental insurance, only 12% had recent comprehensive oral
vantages of each method should be considered. The CDT examination data available. This raises suspicions of resid-
code method seems more likely to underestimate preva- ual confounding and suggests that because of the low rate
lence, because it fails to capture some persons with peri- of dental insurance, the observed prevalence of periodonti-
odontitis who do not seek treatment. Notably, there were tis in the sample may be a conservative estimate of the true,
no osseous surgeries or bone graft procedures observed in unobserved prevalence of periodontitis in the population.
this population, despite the fact that up to 5% of commer- In general, differences between persons included in and
cially insured adults are known to have received at least 1 excluded from the analysis in terms of sociodemographic
of these treatments (21). This is likely related to regional (or other) variables can over- or underestimate prevalence
factors in that only general dentists practice at this clinic estimates.
and most patients receive public health-care assistance. As Such issues have practical implications for other peri-
such, there is very limited infrastructure or financial incen- odontitis surveillance systems that rely on EHR data.
tive for providing more advanced periodontal treatments in Where possible, it may be useful or necessary to combine
this area. The CDT code method may also misclassify data from multiple care systems ( particularly in large popu-
some cases, because it is possible that some patients lations) to construct analytical cohorts that are as represen-
receive treatment that is consistent with periodontal disease tative as possible of the region under study (24, 25). Note
therapy, yet it is actually being used for a condition other that in this and other underserved areas of northern Wis-
than periodontitis. In addition, this method cannot reliably consin, there are several initiatives currently under way to
categorize periodontitis severity levels; thus, some peri- improve access to dental care (26). If proven successful,
odontitis cases identified with this approach could have such initiatives may also improve the validity of our future
been very mild. informatics-based periodontitis surveillance efforts, because
As for the AAP/CDC algorithm, periodontitis status was a higher and presumably more representative fraction of the
unknown for 20% of persons using the AAP/CDC algo- target population will have recent periodontal disease
rithm, despite receiving a recent comprehensive dental assessment data available. Such data could then be used for
examination. A periodontal assessment was essentially more advanced epidemiologic comparisons across finer
skipped for these persons, which may have been due to the geographic strata and subpopulations (e.g., incidence ratios,
patient’s appearing edentulous or in perfect oral health, or municipalities, and children), thereby assisting program
to other unknown technical barriers to fully completing the planners in adjusting, refining, and otherwise more pre-
examination. The combined approach of using the AAP/ cisely identifying regional oral care gaps to address over
CDC algorithm and CDT codes was sensitive in that it time.
identified the most cases; however, in future research, There remain barriers, however, to the broader translation
investigators should conduct validation/adjudication of both of the methods outlined in this study. Many dentists do not
methods to determine the extent to which they agree with use EHRs, and those that do may not have standard data

Am J Epidemiol. 2013;177(7):700–707
706 Acharya et al.

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