A competency addition procedure for constructing minimal, yet maximally informative tests for skill assessment.

Orofacial pain represents pain that originates from intraoral structures or the
face, head, or neck and includes common conditions such as temporomandibular
disorders and neurovascular headaches, including migraine []. A large percentage
of the general population suffers from chronic orofacial pain (OFP), which often
involves interacting mechanisms of peripheral nociception and central
sensitization. A diagnostic system, such as the International Classification of
Orofacial Pain (ICOP), separates primary from secondary causes and informs
clinical decision-making [, ]. A multidisciplinary evaluation remains essential
due to the complex musculoskeletal, neuropathic, and centralized mechanisms
underlying symptom manifestations []. Sleep problems, mainly characterized by
poor sleep quality and insomnia, commonly co-occur with pain, psychological
distress, and disability in OFP [, ]. Neck disability is also common among
people with OFP, reflecting shared musculoskeletal and psychosocial contributors
to pain and functional limitation []. Migraine is the most common pain condition
associated with OFP and is associated with insomnia and disrupted sleep, which
contribute to increased headache frequency, as well as heightened disability [].
Given the interlinked pathways between OFP, sleep problems, and migraine, there
is a need for an appropriate scale that measures orofacial symptoms promptly
after waking up to enhance early identification, clinical decision-making, and
targeted management. Several pain assessment instruments have been designed and utilized for the
assessment of OFP, but each of them has important limitations in terms of
validity and comprehensiveness. Unidimensional measures, such as the Visual
Analogue Scale (VAS), Numerical Rating Scale (NRS), and Verbal Rating Scale
(VRS), are often applied to quantify pain intensity and have demonstrated high
sensitivity and reliability in OFP patients []. However, these scales are
limited to pain intensity orientation and do not encompass multidimensional
qualities, such as pain quality, emotional distress, functional limitation, and
temporal variation—factors that are particularly relevant in long-standing OFP
disorders []. To overcome such limitations, multidimensional instruments like
the McGill Pain Questionnaire (MPQ) and the Graded Chronic Pain Scale (GCPS) have
been employed to assess the qualitative and psychosocial components of chronic
pain []. While broader in scope than unidimensional scales, these instruments
were not specifically created for OFP populations and have untested psychometric
characteristics in this population—such as construct validity, responsiveness,
and minimal clinically important difference—which remain insufficiently
established. The GCPS, for instance, is useful for grading disability, but has
only fair test–retest reliability and limited cross-cultural validation in OFP
populations []. Condition-specific measurements, such as the Jaw Functional
Limitation Scale (JFLS), were then created to quantify mandibular function in
Temporomandibular Disorder/Orofacial Pain (TMD/OFP) populations [, ].
Although the JFLS offers a focused approach to jaw function, its measurement
error properties—such as smallest detectable change and responsiveness—as
well as its structural validity remain insufficiently established []. In
addition, specialized instruments exist for vulnerable groups, including the
Orofacial Pain Scale for Non-Verbal Individuals (OPS-NVI) [], but these tools
show low sensitivity in patients with mild cognitive impairment, precluding their
use as independent screening instruments in clinical practice []. Despite the
presence of many pain measurement instruments, those currently used for OFP
remain limited by unidimensionality, non-specificity, absence of psychometric
validation, and restricted generalizability to heterogeneous groups of patients. The Orofacial Awakening Symptoms Questionnaire (OFASQ) offers several distinct
advantages over to other existing pain scales for orofacial conditions [, ].
The scale has demonstrated good psychometric properties, with a Cronbach’s
α of 0.82 reflecting coherent measurement of the underlying construct of
orofacial awakening symptoms. Construct validity was supported by a
unidimensional factor structure, consistent with the theoretical framework
underlying the scale []. Convergent validity was demonstrated by significant
correlations with morning orofacial discomfort, perceived sleep quality, and
self-reported sleep bruxism indicators [, ]. Test–retest reliability,
assessed over a short interval, showed good temporal stability; the Intraclass
Correlation Coefficients (ICCs) were within acceptable limits for early-stage
instrument development []. While many instruments focus on overall pain
intensity or disability felt during the day, the OFASQ evaluates orofacial
symptoms in the morning, thus bridging a gap in earlier tool