Characterizing clinical findings of Sjögren's Disease patients in community practices using matched electronic dental-health record data

Abstract

Established classifications exist to confirm Sjögren's Disease (SD) (previously referred as Sjögren's Syndrome) and recruit patients for research. However, no established classification exists for diagnosis in clinical settings causing delayed diagnosis. SD patients experience a huge dental disease burden impairing their quality of life. This study established criteria to characterize Indiana University School of Dentistry (IUSD) patients' SD based on symptoms and signs in the electronic health record (EHR) data available through the state-wide Indiana health information exchange (IHIE). Association between SD diagnosis, and comorbidities including other autoimmune conditions, and documentation of SD diagnosis in electronic dental record (EDR) were also determined. The IUSD patients' EDR were linked with their EHR data in the IHIE and queried for SD diagnostic ICD9/10 codes. The resulting cohorts' EHR clinical findings were characterized and classified using diagnostic criteria based on clinical experts' recommendations. Descriptive statistics were performed, and Chi-square tests determined the association between the different SD presentations and comorbidities including other autoimmune conditions. Eighty-three percent of IUSD patients had an EHR of which 377 patients had a SD diagnosis. They were characterized as positive (24%), uncertain (20%) and negative (56%) based on EHR clinical findings. Dry eyes and mouth were reported for 51% and positive Anti-Ro/SSA antibodies and anti-nuclear antibody (ANA) for 17% of this study cohort. One comorbidity was present in 98% and other autoimmune condition/s were present in 53% respectively. Significant differences were observed between the three SD clinical characteristics/classifications and certain medical and autoimmune conditions (p<0.05). Sixty-nine percent of patients' EDR did not mention SD, highlighting the huge gap in reporting SD during dental care. This study of SD patients diagnosed in community practices characterized three different SD clinical presentations, which can be used to generate SD study cohorts for longitudinal studies using EHR data. The results emphasize the heterogenous SD clinical presentations and the need for further research to diagnose SD early in community practice settings where most people seek care.

Fig 1. Study design to match EDR and EHR data and generate SD study cohort.

EDR: electronic dental record; EHR: electronic health record; SD: Sjögren’s Disease; ICD 9/10-codes: International Classification of Diseases Codes.

Fig 2. Heat map visualization for signs and symptoms corresponding to SD classification.

RF–Rheumatoid factor; ANA–Anti-nuclear antibody; PGE–Parotid gland enlargement; SSB–antibody to SSB (La) antigen; OST–Ocular staining test; SGB–Salivary gland biopsy; SFT–Salivary flow test; Anti-Ro/SSA–antibody to SSA (Ro) antigen; DE–Dry eye; DM–Dry mouth.

Fig 3. Other autoimmune conditions in the study cohort and by three Sjögren’s disease (SD) groups.

Other autoimmune conditions such as rheumatoid arthritis, systemic lupus erythematous, inflammatory polyarthropathy represent more than 10% among SD patients. Total: study cohort; positive, uncertain, negative represent the three SD groups by clinical characteristics.

Fig 4. Other medical conditions present in the study cohort and by the three Sjögren’s disease groups.

SD: Sjögren’s disease total: study cohort; positive, uncertain, negative represent the three SD groups within the study cohort by clinical characteristics. Medical conditions such as pain in joints, hypertension, esophageal reflux, depressive disorder, pain in limb, malaise and fatigue is present in ≥50% SD cohort.