Guidelines to the Evaluation of Impairment of the Oral and ...

Clinical Paper

American Association of Oral and Maxillofacial Surgeons

Guidelines to the Evaluation
of Impairment of the Oral and
Maxillofacial Region

The American Association of Oral and Maxillofacial Impairment: “a significant deviation, loss, or loss of use of
Surgeons (AAOMS) recognizes the need to establish a spe- any body structure or body function in an individual with a
cific method of evaluating permanent impairments of the health condition, disorder, or disease.” (p. 5)
maxillofacial region. The AAOMS Committee on Health-
care and Advocacy has established a methodology of Disability: “activity limitations and/or participation restric-
measuring and assigning values for permanent impairment tions in an individual with a health condition, disorder, or
of this area. Using the methods described in this document disease.” (p. 5)
and the American Medical Association (AMA) Guides to
the Evaluation of Permanent Impairment, Sixth Edition, Example: Impairment: Loss of index finger
the practitioner will be able to assign an impairment value For a person who is a singer, this in fact would be impair-
for the patient's maxillofacial region. ment, but not a disability. For an individual who is a typist,
this could represent significant disability in their work.

Objectives Handicap: The Federal Rehabilitation Act of 1973 identi-
• Provide a permanent impairment rating for a patient's fies a “handicapped” individual as one who has an impair-
ment that substantially limits one or more life activities
maxillofacial region. including work, has a record of such impairment, and this
impairment can be overcome only by compensation, ie,
• Define the various terms associated with impairments. artificial limb.

• Recognize the different purposes for providing an Impairment Rating: consensus derived percentage es-
impairment rating, ie, worker’s compensation, Social timate of loss of activity reflecting severity for a given
Security administration, personal injury litigation and health condition and the degree of associated limitations in
medical indemnity insurance. terms of activities of daily living (ADL). (p. 5)

• Understand applicable state regulations for conducting II. How to Perform an Impairment Examination
such examinations.
1. History and review of pertinent medical records.
Acknowledgement
2. Physical exam or physical findings.
The “Report of Medical Evaluation (Permanent Medical
Impairment)” on pages 11-13 and the combined injury 3. Clinical studies or objective test results.
ratings on page 3 are taken from the Guides to the Evalua-
tion of Permanent Impairment, sixth edition. 4. Consider permanency of impairment. If impairment
is resolving, changing, unstable or expected to change
This document does not constitute endorsement by the significantly within 12 months, do not give a rating. If
American Medical Association of the methods and proce- condition is not fixed and stable, or if one is making a
dures described by the AAOMS in the Guidelines to the recommendation for curative (not palliative) treatment,
Evaluation of Impairment of the Oral and Maxillofacial do not give a rating.
Region.
5. Consider type of impairment:
I. Definitions1
• Range of motion
Clarification of the following terms as they relate to
impairment is important: • Neurologic

PAGE 1 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region

Clinical Paper
13
Conceptual Foundations and Philosophy

T A B L E 1 - 5 Generic Template for Impairment Classification Grids Chapter 1

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4
0 Minimal % Moderate % Severe % Very Severe %
IMPAIRMENT
RATING (%)

SEVERITY GRADE No current (ABCDE) (ABCDE) (ABCDE) (ABCDE)
(%) symptoms
Symptoms Constant mild Constant moder- Constant severe
HISTORY and/or controlled with symptoms ate symptoms symptoms
OF CLINICAL continuous despite continu- despite continu- despite continu-
PRESENTATIONa intermittent treatment ous treatment ous treatment ous treatment
symptoms that
do not require or or or or
treatment
intermittent, intermittent, intermittent, intermittent
mild symptoms moderate symp- severe symptoms extreme symp-
despite continu- toms despite despite continu- toms despite
ous treatment continuous ous treatment continuous
treatment treatment

PHYSICAL No current signs Physical find- Constant mild Constant mod- Constant severe
EXAMINATION of disease ings not present physical findings erate physical physical findings
OR PHYSICAL with continuous despite continu- findings despite despite continu-
FINDINGSb treatment ous treatment continuous ous treatment
treatment
or or or
or
intermittent, intermittent intermittent
mild physical moderate intermittent extreme findings
findings findings severe findings

CLINICAL Testing currently Consistently nor- Persistent mild Persistent moder- Persistent severe,
STUDIES OR normal mal with continu- abnormalities ate abnormalities abnormalities
OBJECTIVE TEST ous treatment despite continu- despite continu- despite continu-
RESULTSc ous treatment ous treatment ous treatment
or
or or or
intermittent mild
abnormalities intermittent intermit- intermit-
moderate tent severe tent extreme
abnormalities abnormalities abnormalities

a, b Descriptors will be disease-specific; mild, moderate, severe, and extreme need to be defined.
c Descriptors will be disease-specific and based on the number of abnormalities found.

The following is used as a grade modifier in the musculoskeletal chapters:

FUNCTIONAL Asymptomatic Pain/symptoms Pain/symptoms Pain/symptoms Pain/symptoms
HISTORYd with strenuous/ with normal with less than at rest; Unable to
vigorous activity; activity; Able to normal activ- perform self-care
Able to perform perform self-care ity (minimal); activities
self-care activities activities with Requires assis-
independently modification but tance to perform
unassisted self-care activities

d Based on self-report or scores from the PDQ, QuickDASH, Lower Limb Outcomes Questionnaire, or other self-report tool.

The following will be added in selected chapters when compliance with treatment minimizes objective evidence of organ
dysfunction but results in a significant compromise in ADLs:

BURDEN OF None Will be based on factors such as number and route of medications taken or the
TREATMENT need to regularly undergo diagnostic tests or invasive procedures if not already
COMPLIANCEe considered in the preliminary rating

e Based on information in Appendix B; depending on the score, the examiner can opt to add 1 to 3 percentage points.

Rondinelli, Robert D, ed, Guides to the Evaluation of Permanent Impairment, Chicago, IL, American Medical Association, 2008; 13

PAGE 2 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region

Ear, Nose, Throat, and Related Structures 269

• Disfigurement Clinical Paper(eg, milk shake), puree (eg, yogurt), soft (eg, banana),
D ys•p hDagiieata(dryifficulty swallowing) and odynopha-

gia •( paPinaiunpon swallowing) may interfere with an semisolid (eg, hamburger), and solid (eg, steak). The

individual’s ability to consume sufficient nutrition, relationship of the restrictions to impairments of

III.asEwvealluaas twioitnh tohfe tehnjeoyOmreanlt aonf edatMinag.xTilhloe foarcali,al Regionmastication and deglutition is shown in Table 11-7.
foprhPareyrnmgeaanl,eanntd Iemsoppahairgmeael nphtases of swallow-
ing should be evaluated in patients with swallow- Dietary Modifications: Many conditions require modi-
fications in diet. The degree to which this is necessary
A.i nMg caosmticpalatoinrtys.DInysafdudnitciotinonto: history and physical
examination, appropriate tests may include modified

Eabtianrgiuminvsowlavleloswthweifthunvcidtieoonfloufortohsectoepeyt,he,sjoapwhsa,gmraumscles varie10s%frIommpapiramtieennttotfothpeatWiehnotl,eaPserdsooens the degree to which
of (mbaarsituimcastiwoanl,lomwu),scfilbeesroopf tdicegenludtoitsicoonp,icanedvatleuma-poroman-
dthibrtpeoiusrouoolnagpbrolhhefajmlogsiipwosns,amtc.tloolaIopynnwygaaiu(lndtsergodaai(nbtnFiseodoEanrEmas,sSliuot)os,crrciceatlaqrtepaeusndfiuusrwlnenesacitsethtainholdre)ne.osaSstpbcowioirlabapilettyloyoarawoybnfildneagtpoerson patients comply with these restrictions. This will add

EXAM1-P2L%E i1m1p-1a7ir:mINenFtLtAoMacMcAouTnIOt fNorAtNheD“Burden of Treatment
SCARCRoImNpGliOanFcLeE”F(TBOTMTCJ ).

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tsoesIawbnb(ehifaeluficnitlcvylmoertreoadtmosaetnaiosctcivaxestahiwtbooilnmiuetlhaeddnstebhdlneeedtssupestghraeflibulsolot)eris.tocaiMoponnhdmayxampriolemafexettaeivhlmaedblauGeiltnaeurtteeiufdhdorea,ersbct,whieleise-aarpepres.arInnafonarsdodt-rhtTaaeenhimntreraepagscolierdwrauoniafmniltodhatmooenwodamtnihwbadfaxuirsiblalaplugarlmlraajycoerenisanditrntwitsunicasbt.suhiEllreaaexttmitieneorofnnaevsrleilivdoyse.rcasAmoncmaedleraprftttihuonsesgemdaosftitchaetory
adtdaittiioonns,hmouanldyhparvoesbtheeetnicacphaiteiveendts. Wsehleecntmfoaostdiscat-hat require in andmaubsocuutlathtuerlee.ftTThMesJewtwasofojounindt.sTfhuenscctaiorsnwaesrae unit.
redtiuocneodrmdeagsltuictiatitoonryisciamppaabiirleitdy,.the imposition of released, but full mobility of the mandible was not

dietary restrictions usually results. Such restrictions obtaiTneodtaulnltoilssthoeflemftoctoioronn,ooird apnrokcyelsosswisa,srerenldeaesresdthe patient
Paatirentthsemmaoystaolsbojedcteiveelcorpiteardiavebrysewsheicqhuetolaeevwaluitahtetooth fromuthneabsulerrtoouncdhienwg toisrssupees.aSkhienraecneoivremdaplomstoapnenrear-.
lospse,rimncanluednitnigmsppaeiremchendtioffitchuelsteiefsuanncdtioansss.o19c–2i4aTtehdusp,sychoso-tive steroid therapy; physical therapy exercises main-

ciathl eprkoebylefamctsosrefcoor nthdiasrsyectotiocnosremmeaticnschhiasntogreys,.with tainedThmeafnodlilbouwlairnmg oabrielintyo.tAcostrernetlatotekdeetop tthhee jAawMsA Guides, but
modification of the rating in a class by the specific ianpdairvtaaiwdnrueadasslAucwrgdeagvaseotesscldteaiecoapnynid:snguo.sfetdhfeoAr sAevOeMralSmCoontmhsmwithtielee
Thheisftoolrlyowofinthgerpeactoiemntm. Denedfiantiitoionnssaorfemmeacdheanfiocraldfeoteordmining Current Symptoms: Discomfort in the left TMJ on Healthcare
thecliamsspifaiicramtieonnst rvaatriyngsoomf etwhehaint damivoidnugaelxlpoesrstsbbauset d on the (on a soft dSieut)mwmitharoyccoasfioSntaelpcsonisnumEpvtaiolnuaoftion of
counsturiablulytiionncloufdeeaccleharcolimqupiodn(eegn,twtoattehre), mfuallstliiqcautiodry system.

hamburgerI.mpairment of Craniomandibular

TABLE 11-7 Physical EAxarmtic: uMlaaxtiilolanry mob ility limited to about

Impairments of Mastication and Deglutition: o6r0a%l foisftumlao1b.a i rleIitday.ennotitfeydtahtesuarrgeearoy,fwinitvhoalvweemlle-hnet.aled
Relationship of Dietary Restrictions to
Permanent Impairment Clinical S2tu. doMiepsee:anPsiunarrgaenbtahesteawlvesoeilnnuunmstaXarxyri,allynasor:ynn-oaprnamdinamfl.ualnidnitbeurilnacricsaelntral
TDMiagJ;nroesdius:ceIndifnmlacaminsomdriabstui(oliannrtaemnriodnbcsicilsiatarylr.irnagnogfetohfe mlefottion).
Type of Restriction Impairment of
the Whole
Person (%)

Diet is limited to semisolid or soft 5, 10, 15 Impairme n t RdMiabetlaiens,ugu:res1i0nth%getilhmaetpedareairnlmteaexlncmtuorisdf iltvihneeedwsihsfrtoaolnemcemoafxtihmeumman-
foodsa person.

Diet is limited to liquid foodsa 20, 25, 30

Ingestion of food requires tube 50 Comment: Inddeivnitdaulailnitseracbulesptoattiaolnk.satisfacto-
feeding or gastrostomy rily, but di3e.ta rAydcdhotihceesimarpealiirmmietendt.vSapleueecshfiosrnlootss of interincisal

a The choice of these discrete numbers depends on the range affected. No foacpieanl idnegfoarnmditlya,tberuatlsehxecmuarsyivneeddistotance to obtain

of foods that can be consumed by the individual within the cNoontpirnoubeleemxeirnctvhiamseeluasciertn.oatnamiinoaiminngatanbidnoidbmyuawlxaeirlilgaahrrttyi.cmuloabtiilointy.impairment
category.

Rondinelli, Robert D, ed, Guides to the Evaluation of Permanent

Impairment, Chicago, IL, American Medical Association, 2008; 269

PAGE 3 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region

Clinical Paper

INTERINCISAL % OF NORMAL WHOLE PERSON % IMPAIRMENT WHOLE PERSON
RANGE OF MOTION
20 10
Hypomobile 0-10 mm 40 8
50 5-7
Hypomobile 10-20 mm 70 3-4
95 3-5
Hypomobile 21-29 mm 100 0

Hypomobile 30-35 mm

Hypomobile 35-39 mm

Normal 40-50 mm

*35 mm is an acceptable range of jaw opening according to the AAOMS Parameters of Care: Clinical Practice Guide-
lines for Oral and Maxillofacial (AAOMS ParCare 2013).

LATERAL EXCURSION % OF NORMAL % IMPAIRMENT OF WHOLE PERSON
RANGE OF MOTION 60 4

Hypomobile 0-4 mm

Hypomobile 4-7 mm 70 3

Hypomobile 8-10 mm 90 1
100 0
Normal 12 mm

Example: A patient has a noted disc derangement with an incisal opening of 25 mm and lateral excursive movements of
6 mm.

Ratable Criteria:

Interincisal opening 6% impairment

Lateral excursive movement 3% impairment

The two range of motion values are combined together:
6% + 3% = 9% impairment of whole person.*

Example: A patient has an ankylosis of the temporoman-
dibular joint with a maximum opening of 5 mm and lateral
excursive movements of 2 mm. Diet is restricted to liquid
foods.

PAGE 4 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region

Ratable Criteria: 10% impairment Clinical Paper
Interincisal opening

Lateral excursive movement 4% impairment

Diet restriction 30% impairment

*To calculate, use equation A+B (1-A) where A>B, so for The following conditions (impairments) should be rated
this last example it would calculate as follows: separately. Using the combined value table, whole person
impairment may then be calculated.
First combining the range of motion values:
.10+.04 (1-.10) = .136 ≈14% Masticatory Insufficiency: Premature loss of teeth not in
functional occlusion as a result of the underlying skeletal
Then combine 14% with the diet restriction: deformity.
.30+.14 (1-.30)=.398 ≈40%

This gives a whole person impairment of 40% for All teeth missing or not in functional occlusion could be
these three combined criteria. assigned an impairment value of 5% of the dental system
for molars and 3% of the dental system for incisors. If the
Impairments secondary to other derangement such as re- whole person impairment value based on premature loss of
section, implant arthroplasty, or musculoskeletal disorders teeth or teeth not in functional occlusion is less than that
are usually rated according to the above criteria. It is left of a total restriction to liquid diet, the greater value of a
up to the individual examiner whether to consider these whole person impairment assigning 20-30% loss of whole
disorders separately. The evaluator must use judgment and person impairment based on a liquid diet should be used.
avoid duplication of impairments.
A person missing 30 teeth who wears a prosthesis is not
Hypermobility generally does not impair function and is usually on a liquid diet. Therefore, the impairment value
not ratable. If it appears to cause impairment, it should be would be 0% -8% for loss of teeth.
treated as a muscle weakness.
Abnormal Respiratory (Airway) Problem: Abnormal
C. Skeletal Facial Deformities and Facial Disfigurement respiratory problems are related to the skeletal dental
deformity that results in either obstruction, snoring, or
Skeletal-facial deformities of the maxilla and/or mandible sleep apnea. A referral for a laboratory sleep study is
can produce abnormal function and appearance. These needed. Abnormal airway problems are usually rated by
deformities may arise from multiple genetic factors, other examiners.
environmental influences, acquired defects, neoplastic
processes, degenerative disease and trauma. A patient with facial skeletal deformities such as vertical
maxillary excess and mandibular retrognathia may have
Documentation of a skeletal-facial deformity should upper airway impairment. A sequela of this deformity may
include: be multiple episodes of breathing cessation for at least 10
seconds during periods of sleep. Some signs and symptoms
• History to clearly indicate the source of the skeletal- of this syndrome are snoring, abnormal behavior during
facial deformity (congenital, developmental, or sleep and interrupted sleep patterns, and excessive daytime
acquired); somnolence.

• Imaging documentation, when feasible, of the deformity, Facial Appearance (Disfigurement): Facial appearance
eg, post-traumatic defects and/or lateral skull and facial is extremely important for identification and self image.
bone x-rays for cephalometric analysis; Disturbances in facial appearance or function may also
have a major impact on social acceptance. Loss of structur-
• Clinical photographs; and/or al integrity and soft tissue changes or injury can result in
disfigurements that may cause not only physical, but social
• Facial moulage or dental models. and functional problems as well.

Impairment evaluation of an individual with a skeletal fa-
cial deformity should be based on a combined value score
using the AMA’s combined value table based on ratable
symptoms that are deviations from normal function.

PAGE 5 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region

In cases where skeletal facial defects, as a result of either Clinical Paper
congenital or developmental deformities, disease, trauma,
or surgical intervention, result in a permanent disfigure-
ment, the following impairments may be assigned and
used with the combined values scale in determining a total
value for skeletal facial deformities.

A2A62OMS GsuuipdpesotrotsthtehEevfaolullaotiwoninofgPcelramsasniefinctaImtiopanisrmaenndt rating
impairment of whole person.

T A B L E 1 1 - 5 Criteria for Rating Impairment due to Facial Disorders and/or Disfigurementa

Facial Disorder/Disfigurement

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4
WHOLE PERSON
IMPAIRMENT 0 1%–5% 6%–10% 11%–23% 25%– 45%
RATING (%)
SEVERITY 135 6 7 8 9 10 11 14 17 20 23 25 30 35 40 45
GRADE (%)
Chapter 11 HISTORYb Limited cutane- Facial abnormal- Facial abnormal- Facial abnor- Massive or total
ous scarring with ity involving ity with some loss mality involves distortion of nor-
PHYSICAL EXAM no direct physi- only cutaneous of supporting absence of nor- mal facial anat-
ologic effects structures with structure mal anatomic omy with severe
DIAGNOSTIC highly visible scar May have mild part or area of disfigurement
OR OTHER Scar is either and/or abnormal obstruction of the face, such as Significant
OBJECTIVE small or slightly pigmentation the nasal passage loss of the eye interruption of
FINDINGS larger with but no or loss of part social activities
minimum width, No activities shortness of of the nose with due to lack of
maybe in obvious of daily living, breath or other resulting cos- social acceptance
location, and has including clear impairment metic deformity
no physiologic breathing or other than with Findings of the
defects eating, are social interaction The patient may above or severe
affecteda have some con- bilateral total
None Loss of cerns regarding facial paralysis
Significantly supporting his or her appear- with loss of major
visible scar and/ structure of part ance affecting portion of or the
or abnormal of the face with the extent of entire nose
pigmentation or without social activities Move the
cutaneous impairment
or disorder, such as Exam consistent number up
depressed cheek with above or depending on
mild unilateral or nasal or severe unilat- the severity
total facial frontal bones eral total facial of the facial
paralysis paralysis or mild appearance
May have X rays bilateral total
or consistent with facial paralysis Findings
changes as noted consistent with
nasal distortion in history or the noted deficit
that affects phys-
ical appearance loss of support
tissue affecting
No evidence of multiple facial
involvement of regions
any bony struc-
ture or cartilage Consistent
with the above
findings

a Any vision loss or losses should be rated in those chapters. Breathing and eating disorders should be rated separately in this
chapter and combined. The rater must use caution not to assess the activities of daily living (ADL) impairment in more than
1 section.

b Key factor.

Rondinelli, Robert D, ed, Guides to the Evaluation of Permanent Impairment, Chicago, IL, American Medical Association, 2008; 262

PAGE 6 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region

Cleft Palate Deformity: Cleft palate deformity is a congen- Clinical Paper
ital deformity that is amenable to surgical correction and
improvement from the time of birth through adolescence
and adulthood. The cleft palate patient can be evaluated for
impairment value based on skeletal deformity values of:

1. Mastication dysfunction/malocclusion

2. Articulation Pain: There is disagreement by experts as to the validity
of a pain-related impairment (PRI) and the relationship to
3. Temporomandibular joint problems whole person impairment (WPI). The 5th edition of the
AMA Guides capped this at 3% WPI. In the sixth edition,
4. Facial appearance the AMA Guides advises examiners to consider congru-
ence with established conditions, consistency over time
5. Psychosocial and/or behavioral problems and situation, consistency with anatomy and physiology,
agreement between observers and inappropriate illness
6. Sleep disorder behavior. The 6th edition also recommends that the patient
fill out the Pain Disability Questionnaire (PDQ). The
Psychosocial: If indicated, impairment values can be numerical total should then be related to whole person
assigned for behavioral or psychosocial problems that are impairment.
the result of a facial deformity, but it is suggested they be
rated by other examiners.
44 Guides to the Evaluation of Permanent Impairment

Appendix 3-2 Pain Disability Questionnaire (PDQ)

Administering the Pain Disability Questionnaire

Follow these instructions for administering and scoring the PDQ:

1. Reproduce the PDQ (Appendix 3-1) and ask the patient to complete all items on the questionnaire.
2. If necessary, the patient may complete the form with the assistance of a translator or reader. Be certain all 15

questions are answered. If the patient is unable to complete the PDQ, no functional assessment score will be given.
3. The evaluating doctor will score the PDQ by adding together the marked integer in each question.
4. If the patient fails to mark a question, the default score for that question is 0.
5. Apply the final score to Table 3-1 and consider this in the Steps of Assessment as described in Section 3.3d.
The PDQ scores can be divided into 5 distinct categories: no disability (score of 0); mild (scores of 1 to 70); moderate (scores
of 71 to 100); severe (scores of 101 to 130); and extreme (scores of 131 to 150).

Rondinelli, Robert D, ed, Guides to the Evaluation of Permanent Impairment, Chicago, IL, American Medical Association, 2008; 44

PAGE 7 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region

Clinical PaperPain-RelatedImpairment 43

3.7 Appendixes

Appendix 3-1 Pain Disability Questionnaire

Patient Name: Date:

Instructions: These questions ask for your views about how your pain now affects how you function in everyday activi-
ties. Please answer every question and mark the ONE number on EACH scale that best describes how you feel.

1. Does your pain interfere with your normal work inside and outside the home?

Work normally Unable to work at all

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

2. Does your pain interfere with personal care (such as washing, dressing, etc.)?

Take care of myself completely Need help with all my personal care

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

3. Does your pain interfere with your traveling?

Travel anywhere I like Only travel to see doctors Chapter 3

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

4. Does your pain affect your ability to sit or stand?

No problems Cannot sit / stand at all

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

5. Does your pain affect your ability to lift overhead, grasp objects, or reach for things?

No problems Cannot do at all

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

6. Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat?

No problems Cannot do at all

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

7. Does your pain affect your ability to walk or run?

No problems Cannot walk / run at all

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

8. Has your income declined since your pain began?

No decline Lost all income

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

9. Do you have to take pain medication every day to control your pain?

No medication needed On pain medication throughout the day

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

10. Does your pain force you to see doctors much more often than before your pain began?

Never see doctors See doctors weekly

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

11. Does your pain interfere with your ability to see the people who are important to you as much as you would like?

No problem Never see them

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

12. Does your pain interfere with recreational activities and hobbies that are important to you?

No interference Total interference

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

13. Do you need the help of your family and friends to complete everyday tasks (including both work outside the home

and housework) because of your pain?

Never need help Need help all the time

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

14. Do you now feel more depressed, tense, or anxious than before your pain began?

No depression / tension Severe depression / tension

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

15. Are there emotional problems caused by your pain that interfere with your family, social, and / or work activities?

No problems Severe problems

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

Examiner

Anagnostis C, Gatchel RJ, Mayer TG. The Pain Disability Questionnaire: A New Psychometrically Sound Measure for Chronic Musculoskeletal Disorders.

Spine 2004; 29 (20): 2290-2302. Rondinelli, Robert D, ed, Guides to the Evaluation of Permanent Impairment, Chicago, IL, American Medical Association, 2008; 43

PAGE 8 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region

using well-accepted criteria, that the patient has had a MMI has been reached before assigning a rating.
suitable therapeutic trial of appropriate treatment, and
that the patient has reached a relative plateau in terms Documentation of impairment on the MIDAS
oTfAmBigLraEine3s-e1verity and frequency. The Migraine
Questionnaire should be sought from school and/or 343
DbdrQPPpweeeraeitiovuesetirheanpsneslbthosoosi-ryhplneRtilnoeltliaiyweydoacIblAtntnpmaioicasltntiosarptmeetaysihass,daeiasearildmvsrneIsisemcmdeuhafncvaetetpcviaao(enoladMinsrdatisascriIbtiBDhmfynloee.Aa1r-9reirseSnmenem)tleaitdQgertendraudoaayenilisndnnctdieiogsoPanmnWtbashniiaielashnnititehrayoengeDaclaewenyidms,ad-sateehnbsatts-ility Clinical Paperwork records iTf hpeosCseinbtlrea.l and Peripheral Nervous System
are the best parameters for localization of sensory
TmacPDhohaeeneigtMnsh.r-eIHRbDeeeAclomaSfutiessQedsueosefswtmiooiQPrngkanuriaaaneipisnrDpteeriiooihssxnaeaiabnmsdialafaiioctrelheylleoysw,2sa:dnadWytshpioselries Person findings on the face. TChLeAyScSan3outline impairment
of either s4id%eIomfptahiermfaecnet,oaf tbhreanWchhoolef,Poerrscoonmplete

trigeminal nerve impairment.

1d.IomcOupmnaiehrnomtweedmnbtaynhyisdapSyascyorinoreltlhreecpoarsdt.3RmevoinetwhIsmodfpitdhaeiyromuent (%) EBXriAefMepPiLsEod1ic3-t1ri6g:emMiInGaRl AneIuNrEalgHiEaAorDpAoCsHthEeSrpetic
MNIoDmnAiesSs wquoersktioornsncahioreolrebveecaalus:se0of your headaches?0 Ane2u9ra-ylgeiaar-tohladt minavnolsvuefsfearberdaancmhioldf thraeutmriagteimc binralin

2• .MHildoewmmissaendy 6dadyasyisninthtehepap1sa–ts73t03mmonotnhtshws dauseyotour 0 innejruvrey mwaityhbberiveefrlyosssevoefrceoannsdciuonucsnoenstrso. lIlneidt.iaBl eCcTauosfe
3•• .SMEexOhpymHHmhhhoRvtoreeeeordeneoioaauenaaasrertddddddmhmeeepniruaaaaonlaoryibcececcwosttlthehhhsl4deiidceeveee,muaosmRdsssic?tu...aoyht0osbniorveeayderuittoatdsdDywyfeaa,shoyyayeotorsodsCk,ulfwihdiGnrohniocuwhro11atrithdgkeu37h0soeoeacs1e11rsw,dehk––p–ItphLaooa111abaoc,sot530sehAshlltd00de0tcmer3ea3Esewecu?vmdrmraioscueleorauoacknanosentMteibfdthohdeenysbsdcoaoyidadcfupiuaPuhrpdlseearAerolmstfxoosaooifnc-re132ianttioImn,p2a0ir0m8toashmwmBmns;heuecfaen4oieeeevhfduttn0tdfn,nrheebhreaenittrsarruc.see.aeluaeiasO,gvtHxmdiselyuinecucaaerparineacewliaocppaplamcclonartrrsoayeosdinifalprogvo,gitdlnasdnrrilrersooioaoaienpnazlirucdlsoilnmzlossysedtyeirleonddnunayidcdhgfo,eileali.siegctstirctuyThnausemwofpdwfrrimcfcaiogeiaeptoocicedulhcraoamoineghdnalhisptdhenpalsseipo.ytslopdfaamesRsrwpaotitonvhneahielrimnaealyeavtaymhturrlireaoipermycheartnowberlntyidhelistiysgoggiaetiobctegsoreoryfeaavemirfnspchilydetyenaihiin,icumcnstepmeeahbruaapuphalauitplt,rmeltertitagoienaaohhaipnimledraregenat-u-,ssidi-ar-.
l
c

1.• MIHignersahtiranudec0htiedoandyssacwfhoietrh: spac.co3hr4ai3nn,ggeTtaihnbelheoP1uD3se-Qh1o8al.dpppreoa- r in ralgic pain may be evaluated (Table 13-19) if they
AdupctpiveintydTdixAueB3tL-o2Eh.e1a3d-a1ch8esG. rading System for Rating have occurred for months and interfere with ADLs.

Impairment due to Migraine Headache
- 4T•ha.hseDiuaHhanMegsee4aieSI%dtnmDeaebgircAcisymmhsttSheeicpoidsesona.nc1inecor3smawrteu.thee3elienetsgckti,o6npedonrgau�idntezTief4etaaoantcm�bimtoal’isen0lniygp�3rqooar-ufcie10ncaPs.ae�nuDAshtimoie1Qsfnapy�cddMtsaaiutccv1nheoh1iee.egtbrosWHefer.sueasPnrieecInevtpnieioee,nwrHbcayeeeldn1Moat3fd-i.ta1shc2cheeelCHlareinateedoraiuansdfPoTerrrRiupanhtkienrgal Nerves
1C3L.sA1t1SaSbtuTsroigf ethmeinpatliaentd. CGLlAosSsSop0haryngCeLaAl SS 1 CLASS 2 CLASS 3 CLASS 4
5TTNoftiiTMHmDr.cbhheaEaiEeeeaIslXMitcruDtStrxfhiantcoTCrsAiorrymaeeenr)RaaintSvygrodIguktlvPmiSemoghmtieeteTCmibfhieeuIoOaaOmmaeiasisdllnRpv,cNiesfigcEailtatarodeofrlylec(iiasiintScnelsc.niragEoan,eaualEiuebrcfncimtvemolsihtae,eomrhepplnainareftisnejodtoiuasdvvwaapr,edcmesamamhiPguhNtlnoeaipeeilRmottxweniareobmemanIdtreradt.eipatieno(igr’camn00nrsitdhrientar%speoapmriacsunrvbtraecielheetaolsncopeleswtuo,sedd3tidnrnutte%dhaotiMqrsthrsaipuasteainehineetmWtlcignienemoratatslemoinPnytoadolepdl,r,iaIinrtsyo1a).siwaam.r–-bbon5iiUaiinfltdllifhtismlrytmoeiuyen-wadoaltiecdlhnpIpttdyarehn-eeee-dl,derrrmr.siiecqMppaMcchuhhniehaleeeoadnapnrrgstpaatottee6tellrdcm)er–dnsiirr1anseiaes0atorfn.nribernovtMeii.anerl-uiHalsstoptyenshoepatedafedufvrtoairdMhencacoiehbsanoptaelhAeddabs1eenteM1ilhhnrleoEi–aiatuwe2AityvNnres0eeoaTGr(prdweeauvaaxhtenichtedrdhriteteeeheSsvmsdene,irvtsaacileutrcyeypreaereeolt2ndrardm1adtiiirϩsoitinsaeiosdatldo-rb-oorii-flrnity
e 2.sdEn2 eWICiivMsvqnairHiushsaoidPalsnaeOuAuelifantoslagsILsisioR:inotEaponeMpwtsnulPfehcasEEonRniactiereNsRfhnoedbentSnTe,uu.tasaeldOhtnRreawHfirseeonNatcAsimeiccpaootnTotlrleamaaIprwnigiN,dgptteoRhmGieeer)trnoiafmdhvo(ebbiot%teeefnushoitrrn)r.rthedhoa,eaaDPyerwe,plt,.ihpaandnebBaondr,eayeut,rirdcrtsslGdevriaofstseudextuol0he(eidnden%uawwrre,etvncacmsaiiheltcwtttnihood.liohodonhCftntbnihshleoneoys:icielrgmsEplolttheuvuhhnf.hpatsde3ealfaecuutaer4oss3raacelsstue3liiimto.actd,mhttnhhelahTieeocbjiaaof2htiobP%tsr-llpeiaeorttmyfip1ao3taninhes-tn1iete9iSimdInnmm.eeitprnopsascstai.hroeiTmrelrlmeyrhanepnetl,olen3pCaso%tuchsuiirecnispsanogpAiotsneh,DerIetiLLhops,efeshA.teGnmhHreeaeurorliivfwcdnoea4eelens%lsvroMr.veweeers,dsiunibctlgauthslratAniatnsbiasnolrlegicetitaidnlsteiyoot5stnoo%e,rrs2ratan0th0taoee8b;tli3ec42 Chapter 13
e

T A B L E 1 3 - 1 9 Criteria for Rating Trigeminal or Glossopharyngeal Neuralgia

d 3.46e_13_321-346.indd 342 Future Directions—Need 2/17/09 2:54:30 PM

fEosrtaRbelsiesahrtchheaVTnradilgieDdmiiiatnylaoolgofurReGaltotosisnogpharyngeal Neuralgia
PCaLAiSnS -Related ImpCaLiArSmS 0ent CLASS 1 CLASS 2 CLASS 3

History of trigeminal or glossopharyngeal neuralgia with impairment despite optimal medical management. Headaches

have reached a period of maximal medical improvement.

y BWasHeOdLEoPnERrSeOsNponses to Chapte0r%18 of the Guid1%es–’2% 3%–5% 6%–10%
FIiMftPhAIERMdEitNiToRnA,TwINeG a(%n)ticipate that responses to the PRI

syDsEtSeCmRIPoTuIOtNlined here wiNlol fnaelulrailngtiao familMiairldpuantctoenrtnrosl.led Moderately severe, Severe, uncontrolled,
uncontrolled facial unilateral or bilateral
Skeptics of any system for rating PRI fworiftwahlvilcatiihtaaomltAlntaaDaeytLcu-sikrnaotlregrmicfeiplrdaein neuralgic pain that facial neuralgic pain
the system for being unscientific and interferes with ADLs that prevents per-

- ing the principle that impairment ratingsmsohtoorulolsds be or moderate motor formance of ADLs or
based on objective indexes of organ dysfunction. loss severe motor loss

ProponeRnotnsdioneflliP, RRoIbewrt Dil,leda, tGtuaidceks ttohthee Esvyaslutaetmion ofof PrercmaapnepnitnImgpairment, Chicago, IL, American Medical Association, 2008; 343

PAthGeEs9izGeuiodfelPinResItoawthaerEdvsa.luIantioonrdoef rImtopamirmoevnet opfathset tOhriasl and Maxillofacial Region

fruitless dichotomy of opinion, we believe that it is

Upper extremity dysfunction (Table 13-11) Chart (Appendix).
Lower extremity dysfunction (Table 13-12)
Neurogenic bowel, bladder, and sexual dys- Clinical Paper
function (Table 13-13 to 13-15)
MiscellanNeoeuursoPgeenriipchreesrpalirNateorrvyedsy,s(fgurnecattieornand lesser
occipital n(Tearvblees1a3n-d16g)reater and lesser auricular nerves),
p. 344, TaDbylese1s3th-e2t0ic pain (Table 13-17)

T A B L E 1 3 - 2 0 Criteria for Rating Miscellaneous Peripheral Nerves

Miscellaneous Peripheral Nerves

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3

WHOLE PERSON 0% 1% 2%–3% 4%–5%
IMPAIRMENT RATING (%)

GREATER OCCIPITAL NERVE No neuralgia Sensory loss only Mild to moderate Severe neurogenic
LESSER OCCIPITAL NERVE in an anatomic neurogenic pain pain in an anatomic
GREATER AURICULAR NERVE distribution in an anatomic distribution
INTERCOSTAL NERVE distribution
GENITOFEMORAL
ILIOINGUINAL
ILIOHYPOGASTRIC
PUDENDAL

Rondinelli, Robert D, ed, Guides to the Evaluation of Permanent Impairment, Chicago, IL, American Medical Association, 2008; 344

6e_13_321-346.indd 344 2/17/09 2:54:31 PM

PAGE 10 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region

Report of Medical Evaluation Clinical Paper
Permanent Medical Impairment

To:

Re:

Case #:

Date of Impairment:

1. Past Medical History Yes / No

A. Medical Office Records Reviewed Enclosed



B. Hospital Record Reviewed Enclosed



C. From Patient



D. From Other Sources (Describe)



2. Clinical Evaluation Yes / No

A. Physical Examination Report Enclosed

B. Laboratory Tests Report Enclosed

C. Special Tests and Diagnostic Procedures Report Enclosed

D. Specialty Evaluations Report Enclosed

3. Diagnosis

A.

B.

C.

D.

PAGE 11 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region

Clinical Paper

4. Stability of Medical Condition
A. The clinical condition is stabilized and not likely to improve with surgical intervention or active
medical treatment. Medical maintenance care is warranted.
Yes / No
B. The degree of whole body impairment is not likely to change by more than 3% within the next year.
Yes / No
C. Employment is not likely to improve with surgical intervention or active medical treatment
Yes / No
D. The patient is not likely to suffer sudden or subtle incapacitation
Yes / No

5. Other Analyses
A. Explain briefly the impact(s) of the medical condition(s) on the patient’s activities of daily living:






B. Is there a medical reason to believe the patient is likely to suffer injury, harm, or further medical
impairment by engaging in usual activities of daily living or other activities necessary to meet
personal, social, or occupational demands? Explain briefly.
Yes / No




PAGE 12 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region

Clinical Paper




C. Is there a medical reason to believe other restrictions or accommodations are necessary to help

the patient carry out usual activities of daily living or meet personal, social and occupational
demands? If so, briefly explain their therapeutic, risk-avoidance, or other kind of value.
Yes / No






6. Important Evaluations (According to AMA Guides) –
Attach a complete report of findings and narrative comments for each body part or system.
Bony Part or System:
A. (Report Enclosed)
B. (Report Enclosed)
C. (Report Enclosed)
D. (Report Enclosed)
o This patient has been under my care from ___/___/___ to ___/___/___
o I have not provided care for this patient. I have seen this patient ____ time(s) for the purpose of
evaluating medical impairment. My evaluation occurred between ___/___/___ and ___/___/___
Signature
Please Print Name

PAGE 13 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region

REFERENCES Clinical Paper
Guides to the Evaluation of Permanent Impairment Sixth Edition.

American Medical Association, 2008.
Parameters and Pathways: Clinical Practice Guidelines for Oral

& Maxillofacial Surgery (AAOMS Parameters of Care, 2013)
Statements by the American Association of Oral and Maxillofacial

Surgeons Concerning the Management of Selected Clinical Con-
ditions and Associated Clinical Procedures −Temporomandibular
Disorders.

© The American Association of Oral and Maxillofacial
Surgeons, 2015

PAGE 14 Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region