DiagnosticCriteriaforTemporomandibularDisorders(DC/TMD)ScoringManualforSelf-ReportInstruments

PreparedbyRichardOhrbach(UniversityatBuffalo,NY,US)andWendyKnibbe(ACTA,Amsterdam,TheNetherlands)

Version:January9,2017

TableofContents

Introduction.................................................................................................................2Selectionofconstructsandinstruments..........................................................................................................2Scoringandmissingdata........................................................................................................................................2GeneralInterpretation.............................................................................................................................................2Howtocitethisdocument.....................................................................................................................................3DescriptionandScoringRules......................................................................................3TMDPainScreener....................................................................................................................................................3DC/TMDSymptomQuestionnaire......................................................................................................................4PainDrawing................................................................................................................................................................5GCPS:GradedChronicPainScale........................................................................................................................6JFLS:JawFunctionalLimitationScale...............................................................................................................8PHQ-9:Depression....................................................................................................................................................9GAD-7:Anxiety.........................................................................................................................................................10PHQ-4:Distress(Depression&Anxiety)......................................................................................................10PHQ-15:PhysicalSymptoms..............................................................................................................................11OBC:OralBehaviorsChecklist...........................................................................................................................12

Appendix1:Summaryofscoringrules.......................................................................14

Appendix2:Scoringworksheet..................................................................................16

Appendix3:Scoringreportform................................................................................17

Appendix4:Changestothisdocument......................................................................18

Introduction

SelectionofconstructsandinstrumentsAsdescribedinSchiffmanetal,2014andinOhrbachetal,2010,manyconstructsandinstrumentshavebeenconsideredfortheAxisIIrevisionoftheRDC/TMDnowpresentintheDC/TMD.Thesetworeferencesdescribetherationaleforthecurrentselections.Inaresearchsetting,wetypicallymeasure10-20psychologicalandbehavioralconstructsrelevanttopain;inclinicalsettingswheretimeisoftenverylimited,itcanbedifficulttoensurethatevenonesuchconstructisassessed.TheAxisIIprotocolattemptstoaddressthisspectrumbyprovidingtworecommendedsetsofinstruments,onesetforscreeningandonesetformorecomprehensiveassessment.Thescreeningsetnecessarilyassessesfewerconstructsthandoesthecomprehensiveset.Thechoicedependsontheclinician’spurposeandgoalsinmakingsuchassessments.

Equallyimportanttotheselectionofconstructsistheselectionofinstrumentstomeasuretheparticularconstruct.Again,therearemanyinstrumentstochoosefrom,andmanyfactorstoconsiderwhenmakingaspecificselection.FromtheperspectiveoftheConsortiuminpromotingastandardizedsetofinstrumentsthatwillfacilitatecomparisonsandcollaborationsacrossresearchsitesandmorerapidlyleadtoadvancesinourunderstanding,thecurrentinstrumentsformallyincludedintheDC/TMDarerecommendedunlessotherconsiderationsprevailforagivenapplicationorsetting.Furtherinformationwillbeprovidedelsewhereforcreatingcross-instrumentequivalencyscoringshouldaninvestigatorchooseadifferentinstrumentforagivenconstruct.

ScoringandmissingdataStandardscoringrules,asbasedonpublishedevidenceoronguidelinesfromtheinstrumentdeveloper,areprovidedforeachinstrumentandsummarizedinAppendix1.Theextentofmissingdataisalsostated;missingdataexceedingthestatedcutoffsshouldleadtoeitherre-administrationoftheinstrumentornotreportingthatscore.

GeneralInterpretationInterpretationguidelinesareprovidedforeachinstrument.ClassificationofscorestoaseveritylevelwillbereadilyaccomplishedviaaforthcomingScoringGraph(Appendix2).Moredifficult,however,isinterpretationacrossinstruments.Isone“severe”scoreenoughtoindicateaproblem?Or,aretwo“mild”scoresenough?Ingeneral,theevidenceappearstoindicatethatbothofthesequestionscanbeansweredintheaffirmative.Inotherwords,theclinicianmustalwaysrememberthattheAxisIIinstrumentsarescreeners,whichmeansthatfalsenegativesandfalsepositivesoccur;

moreover,thescalescoresarenottiedtoanyparticularenvironmentaltrigger,behavior,orotherclinicalcondition.Theinterpretationofthescorefromeachinstrumentmustbeconsideredinlightoftheindividual’shistory.Theoverallinterpretationacrossinstrumentsawaitsfurtherevidence.

HowtocitethisdocumentOhrbachR,KnibbeW.DiagnosticCriteriafor TemporomandibularDisorders:ScoringManualforSelf-ReportInstruments.Version 29May2016.www.rdc-tmdinternational.orgAccessedon<date>.

ReferencesSchiffmanE,OhrbachR,TrueloveE,etal.DiagnosticCriteriaforTemporomandibularDisorders(DC/TMD)

forClinicalandResearchApplications:RecommendationsoftheInternationalRDC/TMDConsortiumNetworkandOrofacialPainSpecialInterestGroup.JournalofOral&FacialPainandHeadache2014;28(1):6-27.

OhrbachR,ListT,GouletJ-P,SvenssonP.RecommendationsfromtheInternationalConsensusWorkshop:ConvergenceonanOrofacialPainTaxonomy.JournalofOralRehabilitation2010;37:807-12.

DescriptionandScoringRules

TMDPainScreenerDescriptionThisisoneoftwoAxisIself-reportinstruments.Thefullinstrumentcanbeadministered,whichisrecommendedforassessingindividuals,oronlythefirst3itemscanbeadministeredforpopulationstudies.

ScoringThefirstitemhasscoresof0-2(a=0,b=1,c=2),whiletheremainingitemsarescoredsimplyasa=0,b=1.Asumiscomputed.

MissingdataNoscoringcanbedoneifresponsestoanyitemsaremissing,duetothenatureoftheitemcontent.

InterpretationValuesexceedingthecut-offsof3forthefull6-itemversionoftheinstrumentor2forthe3-itemversionindicatethatTMDmaybepresent.

ReferencesGonzalez YM, Schiffman E, Gordon G, Seago B, Truelove EL, Slade G, Ohrbach R. Development of a brief and effective temporomandibular disorder pain screening questionnaire: reliability and validity. JADA 142:1183-1191, 2011.

DC/TMDSymptomQuestionnaireDescriptionTheSymptomQuestionnaire(SQ)subsumestheTMDPainScreener;iftheSQisadministered,theTMDPainScreenerisredundant.TheSQisusedtomorefullyassessjawpainandfactorsnecessaryforamyalgiaorarthralgiadiagnosis,presenceoftemporalregionheadacheandfactorsthatmodifythatpain,andjointnoisesandlockingoftheTMJs.Theinstrumentwasdesignedtobefollowedbyaninterviewforclarificationandconfirmationoftheresponsestoallitems;itisnotintendedtobeaself-completeinstrument.Inparticular,thethirdsectionassessingTMJnoisesandlockingrequirefurtherinterviewinordertoestablishwhetherright,left,orbothsidesareinvolved;theinstrumentwasdesignedinthiswayduetoknownpoorreliabilitywhenaskingaboutnoisesandlockingwithregardtowhichside,butbetter(andacceptable)reliabilitywheninquiringmoregenerally.Consequently,theinstrumentshouldnotbemodifiedbyaskingthepatientorparticipanttoindicatewhichside.

ScoringItemsfromeachsectionareusedaspartofthediagnosticalgorithmsforeachdisorderwithintheDC/TMD.

MissingdataReviewforclarificationandconfirmationshouldinsurethatallitemsarecompleted.

InterpretationClarificationsprovidedviainterviewareinterpretedbasedonexpertknowledge.Thefinalresponsesareinterpretedaccordingtothediagnosticcriteria.

ReferencesSchiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. Journal of Oral & Facial Pain and Headache 2014;28(1):6-27.

PainDrawingDescriptionAvarietyofformatscanbeusedforapaindrawing;animageofonlytheentirebodyismostcommon.ForprimarypurposesofthepaindrawingintheDC/TMDAxisII,afull-bodyonlyframeworkwouldbesufficient:areportingofallpainsandtheirextentissufficientforassessingtheconstructofwide-spreadpain.Fordifferentialdiagnosticpurposes,however,adetailedpresentationofthefaceandintra-oralareaisalsoofvalue;theadditionaldetailedinformationavailableviacompletionofthosesectionsshouldbeconsideredfortheAxisIdiagnosisaswell.

ScoringPainreportedindistinctbodyregions,especiallyifrelatedtoknownregionaldisorders(e.g.,headache,backpain,pelvicpain,neckpain),canbesummarizedasacountvariable.Extentofpaincanbecomputedas%ofthebodyarea(throughuseofimagescanningsoftware;seeReferences).Patternsofpainspreadingaresometimesnotedonadrawing,asarenon-anatomicaldistributions;thelatterrequirequalitativeinterpretation.

MissingdataAcommonproblemwithadministeringapaindrawinginadentalsettingisthattherespondent(patient,researchsubject)assumesthatonlypainsrelatedtothejawandteethareofinterest.Respondentsshouldbeaskedifallpainswererecorded.

InterpretationThereisnosinglemethodforassessingandinterpretingtheanalogdrawingofpainlocationsonthebody.Infibromyalgia,oppositequadrantsinadditiontospinalareareportingisrequired,whereasforwidespreadbodypain,“several”areasappeartobetheminimum;extentofwhatconstitutesanareaisundefined.Thesimplestinterpretationisthateachbodysitemarkedwithpainincreasestheriskofdevelopinganotherpaindisorderaswellasforchronicpain.Ingeneral,thenumberandextentofbodyareasreportedaspainfulshouldbecorrelatedwiththehistoryandrelevantclinicalexamination.SeeDescription(thissection)forcommentsaboutAxisIapplicationsofthepaindrawing.

ReferencesDworkinSF,VonKorffMR,LeRescheL.Multiplepainsandpsychiatricdisturbance:Anepidemiologicinvestigation.

ArchivesofGeneralPsychiatry1990;47:239-44.KlongImageMeasurement.http://www.imagemeasurement.com/experience-image-measurement/pain-

assessment-image-measurementImageJ:ImageProcessingandAnalysisinJava.http://imagej.nih.gov/ij/

Macfarlane,G.J.,etal.(1996).Widespreadpain:isanimprovedclassificationpossible?JournalofRheumatology23(9):1628-1632.

Margolis,R.B.,etal.(1988).Test-retestreliabilityofthepaindrawinginstrument.Pain33:49-51.OhrbachR,FillingimRB,MulkeyF,etal.Clinicalfindingsandpainsymptomsaspotentialriskfactorsfor

chronicTMD:DescriptivedataandempiricallyidentifieddomainsfromtheOPPERAcase-controlstudy.JournalofPain2011;12(11,Supplement3):T27-T45.

SandersAE,SladeGD,BairE,etal.Generalhealthstatusandincidenceoffirst-onsettemporomandibulardisorder:OPPERAprospectivecohortstudy.JournalofPain2013.

GCPS:GradedChronicPainScaleDescriptionVersion2oftheGCPSincludes,inadditiontothe3itemsforpainintensityand4itemsforfunction,oneitemfornumberofdaysofpain.TheauthoroftheGCPSrecommendsthatnumberofdaysofpainusea6-monthbaseinordertobetterevaluateforlong-termpatternsinpainpersistence;theresponsetothisitemisnotscoredbutratherisinterpretedbasedonthepainandpsychosocialhistory.Theremainderofthepublishedinstrumentwasvalidatedonthebasisofa6-monthtimeframeandhasbeenextensivelyusedacrossmultipledisorders,languages,andsettings;a3-monthversionwithsomevaliditydatahasbeenadvocated.A1-monthversionhasalsobeenusedinmanyclinicaltrialsasanoutcomemeasure,whereashorterrecentperiodisneededinordertoevaluatewhatmaybeon-goingchangeinpainstatus.TheDC/TMDincludedthe1-monthversioninordertomatchthetimeframeofpainanddisabilityassessmenttothetimeframeusedfordiagnosisaswellastheotherinstruments.Someusers,however,mayprefera3-monthor6-monthtimeframefortheseimportantmeasures.The6-monthGCPSisalsoavailableontheConsortiumwebsite,andAppendix1alsoincludesthescoringrulesforthe180-dayversion.

Scoring(itemnumbersrefertoGCPSv2.0,as30-dayversioninDC/TMD)CharacteristicPainIntensity(CPI):computemeanofitems2-4(painrightnow,worstpain,averagepain),andmultiplyby10.

InterferenceScore:computemeanofitems6-8(dailyactivities,socialactivities,workactivities),andmultiplyby10.

Disabilitypointsfornumberofdayswithinterference:assignpointsbasedonbelowtable,dependingonwhetherusing1-month(30day)or6month(180day)timeframesforitem5(disabilitydays)intheGCPSv2.0versionoritem4intheoriginalRDC/TMD180-dayversion.

Disabilitypointsfortheinterferencescore:assignpointsbasedonthebelowtable;thedeterminationisthesameforbothtimeframes.

PointsforDisabilityDays PointsforPain-relatedInterferenceScore1month(30day) 6months(180days)

Days Points Days Points Interference Points0-1 0 0-6 0 0-29 0

2 1 7-14 1 30-49 1

3-5 2 15-30 2 50-69 2

6+ 3 31+ 3 70+ 3

ThetotalDisabilityPoints=PointsforDisabilityDays+PointsforInterferenceScore.

Missingdata

Ifoneormoreresponsesaremissingamongitems2-4(painintensity),therespectivesubscaleshouldnotbescoredduetothebroadscopethatthethreeitemscover.Forthefunctionitems(6-8),onemissingvaluemaynotrepresentthesameinformationloss,andthesubscalescorecouldbecomputedalbeitwithdecreasedreliability.Missingdatafornumberofdisabilitydaysprecludesdeterminationofgradedchronicpainstatus.

InterpretationDeterminationofChronicPainGradeGrade Label CPI DisabilityPoints

0 None 0 N/A

I Lowintensitypain,withoutdisability <50 <3

II Highintensitypain,withoutdisability >50 <3

III Moderatelylimiting N/A 3-4

IV Severelylimiting N/A 5-6

ReferencesVonKorff,M.(2011).Assessmentofchronicpaininepidemiologicalandhealthservicesresearch:Empiricalbases

andnewdirections.HandbookofPainAssessment.D.C.TurkandR.Melzack.NewYork,GuilfordPress:455-473.

VonKorff,M.,etal.(1992).Gradingtheseverityofchronicpain.Pain50:133-149.VonKorff,M.R.,etal.(1992).Researchdiagnosticcriteria.AxisII:Pain-relateddisabilityandpsychologicalstatus.

In:S.F.Dworkin&L.LeResche(Eds.),ResearchDiagnosticCriteriaforTemporomandibularDisorders.JournalofCraniomandibularDisorders,FacialandOralPain6:330-334.

JFLS:JawFunctionalLimitationScaleDescriptionTheJFLSwasinitiallydevelopedasan8-itemglobalscaleforoverallfunctionallimitationofthemasticatorysystem;basedontheresultantitemsandsupportingpsychometricdata,theinstrumentwasre-developedinordertoexpandmeasuredconstructstoalsoincludemasticatorylimitation,verticalmobilitylimitation,andverbalandnon-verbalcommunicationlimitation,comprisedwithina20-iteminstrumentthatalsoretainedtheitemsfortheshortglobalscale.Consequently,thefullinstrumentcouldbeusedatbaseline,fromwhichallthreesubscalesaswellastheglobalscorecouldbederived,andtheshortinstrumentcouldbeusedatfollow-up,fromwhichtheglobalscorecouldbederived;measurementcongruenceacrosstimeforaglobalscorewouldberetainedinadditiontohavingsubscalescoresatbaseline.Alternatively,oneresearchgroupcouldusetheshortformandanothergroupcouldusethelongform,andthesubscalescoreswouldhavemeasurementcongruenceacrossthetwosettingsduetotheveryhighreliabilityoftheglobalscore,whetherderivedfromthefullinstrumentorfromtheshortinstrument.

Scoring

Fromeithertheshortform(allitems)orthelongform(items1,3,6,10,11,12,13,and19),asingleglobalscoreof“jawfunctionallimitation”canbecomputedasthemeanoftheavailableitems.

Subscalescoresforeachtypeoffunctionallimitationarecomputed,asfollows:• Mastication:meanofitems1-6.• Mobility:meanofitems7-10.• Verbalandnon-verbalcommunication:meanofitems13-20.

Asecondtypeofglobalscorecanbeobtainedfromthelongformbycomputingthemeanofthe3subscalescores,ascomputedabove.Notethatall3subscalescoresmustbepresentinordertocomputetheglobalscoreinthismanner.

AlternativescoringcanbeachievedthroughtheuseofRaschsoftware,butthisisnotfurtherdescribedinthismanual.

Missingdata

FortheJFLS-20,scorescanbecomputedbasedonnomorethanthefollowingnumberofitemswithmissingresponse:shortform,2itemsmissingallowed;mastication,2itemsmissingallowed;mobility,1itemmissingallowed;andcommunication,2itemsmissingallowed.FortheJFLS-8,nomorethan2itemsmaybemissing.Computationofascorewithmissingitemsisadjustedbydividingbynumberofitemspresent.

Interpretation

Normshavenotyetbeenestablishedforthisinstrument.BasedoncomparisonofindividualswhowerelifetimenegativeforTMDtothosewithchronicTMD,observedscoreswereasfollows:

Scale

NolifetimeTMD ChronicTMDMean SE Mean SE

Masticationlimitation 0.28 0.02 2.22 0.13Mobilitylimitation 0.18 0.02 2.22 0.13VerbalandEmotionalExpressionLimitation 0.14 0.02 0.72 0.10Global 0.16 0.02 1.74 0.11

ReferencesOhrbach,R.,etal.(2008).TheJawFunctionalLimitationScale:Development,reliability,andvalidityof8-

itemand20-itemversions.JournalofOrofacialPain22:219-230.Ohrbach,R.,etal.(2011)."ClinicalfindingsandpainsymptomsaspotentialriskfactorsforchronicTMD:

DescriptivedataandempiricallyidentifieddomainsfromtheOPPERAcase-controlstudy."JournalofPain12(11,Supplement3):T27-T45.

PHQ-9:DepressionDescription

ThePHQ-9iscomprisedof9itemsassessingdepressedmood;an8-itemversionalsoexists,whichomitsthequestionaboutsuicidalideation,foruseinsettingswheretheinclusionofthatitemrepresentsspecificchallenges;seeKroenke,2009,forfurtherinformation.Inadditiontothe8or9depression-relateditems,theinstrumentincludesoneadditionalitemthatassesseslifeinterferenceduetoanypositiveresponsestothecontentitemsmeasuringdepressedmoodstate.Thedepressionitemsareinterpretedquantitatively,whilethelifeinterferenceitemisinterpretedqualitatively.Forclinicalinterview,thelifeinterferenceitemisparticularlyusefulasastartingpointfordiscussionoftheindividual’smoodstatus.

Scoring

Atotalsumscoreiscomputed.

Missingdata

Upto3itemscanbemissing,andavalidscoreisgenerallyassumed.Forexample,if2itemsaremissing,thenthesumoftheremaining7itemsiscomputed,dividedby7,andmultipliedby9inordertocreateascoreinthesamemetricasthoughall9itemshadvalidresponses.

InterpretationScoresof5,10,15,and20representcut-pointsformild,moderate,moderatelysevereandseveredepression,respectively.

ReferencesKroenke,K.,etal.(2001).ThePHQ-9:validityofabriefdepressionseveritymeasure.JournalofGeneral

InternalMedicine16(9):606-613.Kroenke,K.,etal.(2009)."ThePHQ-8asameasureofcurrentdepressioninthegeneralpopulation."

JournalofAffectiveDisorders114(1-3):163-173.

GAD-7:AnxietyDescriptionTheGAD-7iscomprisedof7itemsassessinganxiousmoodandbehavior.Theinstrumentincludesoneadditionalitemthatassesseslifeinterferenceduetoanypositiveresponsestothecontentitemsmeasuringanxiousmoodstate.Theanxietyitemsareinterpretedquantitatively,whilethelifeinterferenceitemisinterpretedqualitatively.SeePHQ-9Descriptionforcommentaboutthequalitativeitem.

ScoringAtotalsumscoreiscomputed.

MissingdataUpto2itemscanbemissing,andavalidscoreisgenerallyassumed.ThelogicofthecomputationisdescribedunderPHQ-9.

InterpretationScoresof5,10,and15representcut-pointsformild,moderate,andsevereanxiety,respectively.

ReferencesSpitzer,R.L.,etal.(2006).Abriefmeasureforassessinggeneralizedanxietydisorder:theGAD-7.ArchivesofInternalMedicine166(10):1092-1097.

PHQ-4:Distress(Depression&Anxiety)DescriptionThePHQ-4iscomprisedoftwo2-itemsubscales,anxietyanddepression,anditisintendedtobeanultrabriefscreenerfordistressasthecompositeconstructofanxietyanddepression.Thecoreitemsforeachofthetwocomponentconstructsareidenticaltothoseontheparentinstruments,theGAD-7andthePHQ-9.

ScoringAtotalsumscoreiscomputed.

Inprincipleandaccordingtotheinstrumentauthors,thetwosubscalescanbescoredseparately;however,reliabilityiscompromised.Consequently,onlythesinglescorebasedonall4itemsisrecommendedbythepresentauthors.

MissingdataWithonly4items,itispermissibletohave1missingitemresponse;thetotalscoreshouldbeadjustedaccordinglysincethecutoffsarebasedonresponsestoall4items.Forexample,ifoneitemismissing,thesumoftheremaining3itemsiscomputed,dividedby3,andthenmultipliedby4.Notethatthisapproachassumesthatthescoreonthemissingitemwouldhavebeenthemeanoftheremainingitems;thisassumptionmayormaynotbeappropriate,giventhatonly4itemsareaddressingtwocomplexconstructsandthereareonly2itemsforeachofthecomplexconstructs.

InterpretationScoresof3,6,and9representcut-pointsformild,moderate,andseveredistress,respectively.

ReferencesKroenke,K.,etal.(2009).Anultra-briefscreeningscaleforanxietyanddepression:thePHQ-4.

Psychosomatics50(6):613-621.Löwe,B.,etal.(2010).A4-itemmeasureofdepressionandanxiety:Validationandstandardizationofthe

PatientHealthQuestionaire-4inthegeneralpopulation.JournalofAffectiveDisorders122(1-2):86-95.

PHQ-15:PhysicalSymptomsDescriptionThePHQ-15iscomprisedof15itemsandassessesnon-specificphysicalsymptoms,alsoreferredtoasfunctionalsymptomsormedicallyunexplainedsymptoms;thisscalecorrespondstotheSomatizationscaleintheRDC/TMDintermsofutilityandconstruct.WhiletheresponsescaleforthePHQ-9,GAD-7,andPHQ-4comprises4points,theresponsescaleforthePHQ-15comprisesonly3pointsduetopoorreliabilityofa4-pointresponsescale.

ScoringItemsarescoredbyaddingtheindividualresponses.Atotalsumscoreiscomputed.

MissingdataUpto5itemscanbemissing,andavalidscoreisgenerallyassumed.ThecomputationisdescribedunderPHQ-9.

InterpretationScoresof5,10,and15representcut-pointsforlow,medium,andhighphysicalsymptoms,respectively.

ReferencesKroenke,K.(2006).Physicalsymptomdisorder:asimplerdiagnosticcategoryforsomatization-spectrum

conditions.JournalofPsychosomaticResearch60(4):335-339.Kroenke,K.,etal.(2002).ThePHQ-15:validityofanewmeasureforevaluatingtheseverityofsomatic

symptoms.PsychosomaticMedicine64(2):258-266.

OBC:OralBehaviorsChecklistDescriptionTheOBCwasinitiallydevelopedasachecklist(hence,theinstrumentname)inordertobetterdeterminethepresenceofparafunctionalbehaviors;therewasnoexpectationforscoringotherthanasimplecountofthenumberofbehaviors.Sinceinitialdevelopment,useoftheinstrumenthasexpandedinmultiplestudies,collectivelyprovidingsomelevelofvalidationfortheconstructhavingarelationshiptoTMD.Measurementpropertieshavenotyetbeenestablished.

ScoringScoringcanbecomputedasthesumofthenumberofitemswithnon-zeroresponseorasaweightedsum(i.e.,sumoftheendorsedfrequenciesoftherespectiveitems).

MissingdataNoinformationexistsregardinghowmissingitemsmightbemanaged.

InterpretationNormshavenotyetbeenestablishedforthisinstrument.BasedoncomparisonofindividualswithchronicTMDvsthosewithoutTMD,anOBCsummaryscoreof0-16appearstorepresentnormalbehaviors,whileascoreof17-24occurstwiceasofteninthosewithTMD,andascoreof25-62occurs17timesmoreoften.AsariskfactorforTMD,onlyascoreinthe25-62rangecontributestoTMDonset.

ReferencesMarkiewicz,M.R.,etal.(2006)."OralBehaviorsChecklist:ReliabilityofPerformanceinTargetedWaking-

stateBehaviors."JournalofOrofacialPain20:306-316.

Ohrbach,R.,etal.(2004)."PsychometricpropertiesoftheOralBehaviorsChecklist:Preliminaryfindings."JDentRes83.

Ohrbach,R.,etal.(2008)."Waking-stateoralparafunctionalbehaviors:specificityandvalidityasassessedbyelectromyography."EuropeanJournalofOralSciences116:438-444.

Ohrbach,R.,etal.(2011)."ClinicalfindingsandpainsymptomsaspotentialriskfactorsforchronicTMD:DescriptivedataandempiricallyidentifieddomainsfromtheOPPERAcase-controlstudy."JournalofPain12(11,Supplement3):T27-T45.

Ohrbach,R.,etal.(2013)."Clinicalorofacialcharacteristicsassociatedwithriskoffirst-onsetTMD:theOPPERAprospectivecohortstudy."JournalofPain14(Supplement2)(12):T33-T50.

Appendix1:Summaryofscoringrules

Scale Missingitems Scoring Range Interpretation

PainDrawing Inquireifall

painareaswererecorded

1.Countthenumberofareas2.Qualitative

N/A Eachadditionalpainareaincreasestheprobabilityofdevelopinganotherpaindisorder.Considergeneralizedtreatments

GradedChronicPainScaleGCPS2.0for30daysCPI(Characteristicpainintensity)

Noneallowed

Computemeanofitems2-4,multiplyby10

0-100 0nopain0-49lowintensitypain≥50highintensitypain

Limitationdays

Noneallowed;valuemustbewithin0-30

Computedisabilitypointsfromitem5:Days DisabilityPoints0-1 02 13-5 26+ 3

0-3 N/A

Interference Max1

Computemeanofitems6-8,multiplyby10Score DisabilityPoints0-29 030-49

1

50-69

2

70+ 3

0-100 N/A

OriginalGCPSfor180daysCPI(Characteristicpainintensity)

Noneallowed

Computemeanofitems1-3,multiplyby10

0-100 0nopain0-49lowintensitypain≥50highintensitypain

Limitationdays

Noneallowed;valuemustbewithin0-180

Computedisabilitypointsfromitem4:Days DisabilityPoints0-6 07-14 115-30 231+ 3

0-3 N/A

Interference Max1 Meanofitems5-7,multiplyby10Score DisabilityPoints0-29 030-49

1

50-69

2

70+ 3

0-100 N/A

GradeofchronicpainforbothGCPSversionsGradeofchronicpain(forbothversions)

All3componentscoresmustbepresent

CPI Totalpoints Grade GradeLabel0 N/A 0 None

<50 <3 I Lowintensitypain,withoutdisability>50 <3 II Highintensitypain,withoutdisabilityN/A 3-4 III ModeratelylimitingN/A 5-6 IV Severelylimiting

Scale Missingitems Scoring Range Interpretation

JawFunctionalLimitationScale(JFLS)JFLS-8 Max2

Sumscoreofallitemsonshortform,dividedbynumberofitemsanswered

0-10 Notyetestablished

JFLS-20Mastication Max2

Sumscoreofitems1-6,dividedbynumberofitemsanswered

0-10 Notyetestablished

Mobility Max1

Sumscoreofitems7-10,dividedbynumberofitemsanswered

0-10 Notyetestablished

Communication

Max2 Sumscoreofitems13-20,dividedbynumberofitemsanswered

0-10 Notyetestablished

Global None MeanofMastication,Mobility,andCommunication

0-10 Notyetestablished

JFLS-8equivalent

Max2 Sumscoreofitems1,3,6,10-13,19onJFLS-20form

0-10 Notyetestablished

PHQ-9 Max3

𝑠𝑐𝑜𝑟𝑒 =𝑠𝑢𝑚𝑠𝑐𝑜𝑟𝑒

(9 −missing) ∗ 9

0-27 ≥5MildDepression≥10ModerateDepression≥15ModSevereDepression≥20SevereDepression

GAD-7 Max2

𝑠𝑐𝑜𝑟𝑒 =𝑠𝑢𝑚𝑠𝑐𝑜𝑟𝑒

(7 −missing) ∗ 7

0-21 ≥5MildAnxiety≥10ModerateAnxiety≥15SevereAnxiety

PHQ-4 Max1

𝑠𝑐𝑜𝑟𝑒 =𝑠𝑢𝑚𝑠𝑐𝑜𝑟𝑒

(4 −missing) ∗ 4

0-12 ≥3MildDistress≥6ModerateDistress≥9SevereDistress

PHQ-15 Max5

𝑠𝑐𝑜𝑟𝑒 =𝑠𝑢𝑚𝑠𝑐𝑜𝑟𝑒

(15 −missing) ∗ 15

0-30 ≥5LowSymptomSeverity≥10MedSymptomSeverity≥15HighSymptomSeverity

OBCMethod1 Notknown Numberofitems>0 0-21 NotknownMethod2 Notknown Sumscoreofallitems 0-84 0None

1-24Low25-84High

Appendix2:ScoringworksheetScale Computation Score

PainDrawing Totalnumberareas= GradedChronicPainScale(v2:30-dayreferenceframe)Characteristicpain 𝑖𝑡𝑒𝑚 2 + 𝑖𝑡𝑒𝑚 3 + 𝑖𝑡𝑒𝑚 4

3=

+ + [ ]3

= [ ] ∗ 10 =

Interferencescore 𝑖𝑡𝑒𝑚 6 + 𝑖𝑡𝑒𝑚 7 + 𝑖𝑡𝑒𝑚 8

3=

+ + [ ]3

= [ ] ∗ 10 =

Disabilitypointsassignment

#DisabilityDaypointsDays DisabilityPoints0-1 02 13-5 26+ 3

InterferencescorepointsScore DisabilityPoints0-29 030-49 150-69 270+ 3

GradedChronicPainStatus

Totaldisabilitypoints=Daypoints+Interferencepoints=[]+[]=[]

CPI TotalDisabilitypoints Grade0 N/A 0

<50 <3 I>50 <3 IIN/A 3-4 III

JawFunctionalLimitationScaleJFLS-8 𝑠𝑢𝑚𝑠𝑐𝑜𝑟𝑒 (𝑎𝑙𝑙 𝑖𝑡𝑒𝑚𝑠)

8 −missing=

Mastication 𝑠𝑢𝑚𝑠𝑐𝑜𝑟𝑒 (𝑖𝑡𝑒𝑚𝑠 1 − 6)6 −missing

= = [ ]

=

Mobility 𝑠𝑢𝑚𝑠𝑐𝑜𝑟𝑒 (𝑖𝑡𝑒𝑚𝑠 7 − 10)4 −missing

= = [ ]

=

VerbalandEmotionalCommunication

𝑠𝑢𝑚 𝑖𝑡𝑒𝑚𝑠 13 − 208 −missing

=

=

Global𝑀𝑎𝑠𝑡𝑖𝑐𝑎𝑡𝑖𝑜𝑛 +𝑀𝑜𝑏𝑖𝑙𝑖𝑡𝑦 + 𝐶𝑜𝑚𝑚𝑢𝑛𝑖𝑐𝑎𝑡𝑖𝑜𝑛

3=

+ + 3

= [ ]

=

JFLS-equivalent 𝑠𝑢𝑚𝑠𝑐𝑜𝑟𝑒 (𝑖𝑡𝑒𝑚𝑠 1, 3, 6, 10, 11, 12, 13, 19)8 −missing

= [ ]

=

PHQ-9 𝑠𝑢𝑚𝑠𝑐𝑜𝑟𝑒

9 −missing=

9 −

=

= ∗ 9 =

GAD-7 𝑠𝑢𝑚𝑠𝑐𝑜𝑟𝑒(7 −missing)

= [ ]

(7 − [ ]) =

= ∗ 7 =

PHQ-4 𝑠𝑢𝑚𝑠𝑐𝑜𝑟𝑒(4 −missing)

= [ ]

(4 − [ ])=

= ∗ 4 =

PHQ-15 𝑠𝑢𝑚𝑠𝑐𝑜𝑟𝑒(15 −missing)

= [ ]

(15 − [ ])=

= ∗ 15 =

OBC Sumscore=

Appendix3:Scoringreportform

PainDrawingNumberofbodyareaswithpain

0 1 2 3 4 5 >5

NONE MILD MODERATE SEVEREGCPS

CharacteristicPainIntensity

0 1-10 11-20 21-30 31-40 41-50

51-60 61-70 71-80 81-90 91-100

NONE LOW HIGH

Interference 0-29 30-49 50-69 70+ 0 1 2 3

ChronicPainGrade 0 I II III IV

NONE NODISABILITY NODISABILITY MODERATELYLIMITING

SEVERELYLIMITING

JFLS-20Mastication 0 1 2 3 4 5 6 7 8 9 10

Mobility 0 1 2 3 4 5 6 7 8 9 10

Communication 0 1 2 3 4 5 6 7 8 9 10

Global 0 1 2 3 4 5 6 7 8 9 10PHQ-9Depression 0-4 5-9 10-14 15-19 20-27

MILD MODERATE MOD-SEVERE SEVEREGAD-7

Anxiety 0-4 5-9 10-14 15-21 MILD MODERATE SEVERE

PHQ-15SomaticSymptom

Severity0-4 5-9 10-14 15-30 LOW MEDIUM HIGH

OBCParafunction 0 1-24 25-84

LOW HIGH

Appendix4:Changestothisdocument2017/01/09:Inappendix2,theGAD-7hadbeenrenderedbytypoasPHQ-7.