RESEARCH DIAGNOSTIC CRITERIA FOR TEMPOROMANDIBULAR DISORDERS: REVIEW, CRITERIA, EXAMINATIONS AND SPECIFICATIONS, CRITIQUE
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1 RESEARCH DIAGNOSTIC CRITERIA FOR TEMPOROMANDIBULAR DISORDERS: REVIEW, CRITERIA, EXAMINATIONS AND SPECIFICATIONS, CRITIQUE Edited by: Samuel F. Dworkin, DDS, PhD and Linda LeResche, ScD A. HISTORY QUESTIONNAIRE ID# Date: / / TEMPOROMANDIBULAR DISORDERS QUESTIONNAIRE Please read each question and respond accordingly. For each of the questions below circle only one response. 1. Would you say your health in general is excellent, very good, good, fair or poor? Excellent... 1 Very good... 2 Good... 3 Fair... 4 Poor Would you say your oral health in general is excellent, very good, good, fair or poor? Excellent... 1 Very good... 2 Good... 3 Fair... 4 Poor Have you had pain in the face, jaw, temple, in No 0 front of the ear or in the ear in the past month? Yes 1 [If no pain in the past month SKIP to question 14] If Yes, 4.a. How many years ago did your facial pain begin for the first time? years ago [If one year ago or more SKIP to question 5] [If less than one year ago, code 00] 4.b. How many months ago did your facial pain begin for the first time? months ago 5. Is your facial pain persistent, recurrent Persistent... 1 or was it only a one-time problem? Recurrent... 2 One-Time... 3
2 6. Have you ever gone to a physician, dentist, No... 1 chiropractor or other health professional Yes, in the last for facial ache or pain? six months... 2 Yes, more than six months ago How would you rate your facial pain on a 0 to 10 scale at the present time, that is right now, where 0 is "no pain" and 10 is "pain as bad as could be"? NO PAIN PAIN AS BAD AS COULD BE 8. In the past six months, how intense was your worst pain rated on a 0 to 10 scale where 0 is "no pain" and 10 is "pain as bad as could be"? NO PAIN PAIN AS BAD AS COULD BE 9. In the past six months, on the average, how intense was your pain rated on a 0 to 10 scale where 0 is "no pain" and 10 is "pain as bad as could be"? [That is, your usual pain at times you were experiencing pain]. NO PAIN PAIN AS BAD AS COULD BE 10. About how many days in the last six months have you been kept from your usual activities (work, school or housework) because of facial pain? DAYS 11. In the past six months, how much has facial pain interfered with your daily activities rated on a 0 to 10 scale where 0 is "no interference" and 10 is "unable to carry on any activities"? NO INTERFERENCE UNABLE TO CARRY ON ANY ACTIVITIES
3 12. In the past six months, how much has facial pain changed your ability to take part in recreational, social and family activities where 0 is "no change" and 10 is "extreme change"? UNABLE TO CARRY ON ANY NO INTERFERENCE ACTIVITIES 13. In the past six months, how much has facial pain changed your ability to work including housework) where 0 is "no change" and 10 is "extreme change"? NO INTERFERENCE UNABLE TO CARRY ON ANY ACTIVITIES 14.a. Have you ever had your jaw lock or No... 0 catch so that it won't open all the Yes... 1 way? [If no problem opening all the way SKIP to question 15] If Yes, 14.b. Was this limitation in jaw opening severe No... 0 enough to interfere with your ability to eat? Yes a. Does your jaw click or No... 0 pop when you open or close your mouth or when chewing? b. Does your jaw make a grating No... 0 or grinding noise when it opens and closes or when chewing? c. Have you been told, or do No... 0 you notice that you grind your teeth or clench your jaw while sleeping at night? d. During the day, do you No... 0 grind your teeth or clench your jaw? e. Does your jaw ache or No... 0 feel stiff when you wake up in the morning? f. Do you have noises or No... 0 ringing in your ears? g. Does your bite feel un- No... 0 comfortable or unusual?
4 16.a. Do you have rheumatoid arthritis, No... 0 lupus, or other systemic arthritic disease? Yes b. Do you know of anyone in your family No... 0 who has had any of these diseases? Yes c. Have you had or do you have any swollen or No... 0 painful joint(s) other than the joints close Yes... 1 to your ears (TMJ)? [If no swollen or painful joints, SKIP to question 17.a.] If Yes, 16.d. Is this a persistent pain which you No... 0 have had for at least one year? Yes a. Have you had a recent injury to your face No... 0 or jaw? Yes... 1 [If no recent injuries SKIP to question 18] If Yes, 17.b. Did you have jaw pain before No... 0 the injury? Yes During the last six months have you had a No... 0 problem with headaches or migraines? Yes What activities does your present jaw problem prevent or limit you from doing? a. Chewing No... 0 b. Drinking No... 0 c. Exercising No... 0 d. Eating hard foods No... 0 e. Eating soft foods No... 0 f. Smiling/laughing No... 0 g. Sexual activity No... 0 h. Cleaning teeth or face No... 0 i. Yawning No... 0
5 j. Swallowing No... 0 k. Talking No... 0 l. Having your usual No... 0 facial appearance 20. In the last month, how much have you been distressed by... Not A Little Moder- Quite Ex- At All Bit ately A Bit tremely a. Headaches b. Loss of sexual interest or pleasure c. Faintness or dizziness d. Pains in the heart or chest e. Feeling low in energy or slowed down f. Thoughts of death or dying g. Poor appetite h. Crying easily i. Blaming yourself for things j. Pains in the lower back k. Feeling lonely l. Feeling blue m. Worrying too much about things n. Feeling no interest in things o. Nausea or upset stomach p. Soreness of your muscles q. Trouble falling asleep r. Trouble getting your breath s. Hot or cold spells t. Numbness or tingling in parts of your body u. A lump in your throat
6 In the last month, how much have you been distressed by... Not A Little Moder- Quite Ex- At All Bit ately A Bit tremely v. Feeling hopeless about the future w. Feeling weak in parts of your body x. Heavy feelings in your arms or legs y. Thoughts of ending your life z. Overeating aa. Awakening in the early morning bb. Sleep that is restless or disturbed cc. Feeling everything is an effort dd. Feelings of worthlessness ee. Feeling of being caught or trapped ff. Feelings of guilt How good a job do you feel you are doing in taking care of your health overall? Excellent... 1 Very good... 2 Good... 3 Fair... 4 Poor How good a job do you feel you are doing in taking care of your oral health? Excellent... 1 Very good... 2 Good... 3 Fair... 4 Poor... 5
7 23. When were you born? Month Day Year 24. Are you male or female? Male... 1 Female Which of the following groups best represent your race? Aleut, Eskimo or White... 4 American Indian...1 Other... 5 Asian or Pacific Islander...2 Black...3 (please specify) 26. Are any of these groups your national origin or ancestry? Puerto Rican...1 Chicano... 5 Cuban...2 Other Latin American... 6 Mexican/Mexicano...3 Other Spanish... 7 Mexican American...4 None of the above What is the highest grade or year of regular school that you have completed? Never attended or Kindergarten 00 Elementary School: High School: College: a. During the past 2 weeks, did you work at a job or business not counting work around the house (include unpaid work in the family farm/business)? Yes... 1 No... 2 [If Yes SKIP to question 29] If No, 28b. Even though you did not work during the past 2 weeks, did you have a job or business? [If Yes SKIP to question 29] Yes... 1 No... 2 If No, 28c. Were you looking for work or on layoff from a job during those 2 weeks? Yes, looking for work... 1 Yes, layoff... 2 Yes, both on layoff and looking for work... 3 No... 4
8 29. Are you married, widowed, divorced, separated or never been married? Married-spouse in household... 1 Married-spouse not in household... 2 Widowed... 3 Divorced... 4 Separated... 5 Never Married Which of the following best represents your total combined household income during the past 12 months? $0-$14,999 $25,000-$34,999 $50,000 or more $15,000-$24,999 $35,000-$49, What is your 5 digit zip code?
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