Is there an association between temporomandibular disorders and playing a musical instrument? A review of literature

Wind Instruments and Oral Health: Challenges Faced by Professional Wind Musicians

BACKGROUND

Recent studies have shown an association between playing wind instruments and their impact on the orofacial system. However, they have not fully evaluated all aspects of the topic, leaving a gap in the overall understanding.

METHODS

A thorough search of the National Library of Medicine database was conducted using our research strategy, resulting in the identification of relevant studies. An expert perspective was obtained by conducting two in-depth expert interviews with a professor of horn-playing and a specialised dentist.

RESULTS

Thirty-seven relevant publications were included in the traditional literature review. The most common diseases among professional wind instrumentalists include the lip area, temporomandibular joint, oral mucosa, respiratory system, oral allergic reactions, and orofacial trauma. Special measures, preventive measures, and expert opinions were utilised to address and overcome the associated orofacial problems.

CONCLUSIONS

Wind instruments affect the oral health and tooth movement of professional instrumentalists, and dentists should consider the impact of dental changes on embouchure and performance. Dental impressions and three-dimensional intra-oral scans are important for reconstruction. This research highlights the need for specialised dental care for professional wind instrumentalists, and further studies are necessary to fully explore this topic.

The Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians: Assessment of Patient-Related Outcomes among Professional Orchestra Musicians in Poland-A Cross-Sectional Study

Background: Musculoskeletal pain is one of the reasons for a musician's inability to play an instrument. An assessment of the localization, intensity, and interference of those complaints is important among musicians because of the risk of occupational disease. Assessment by validated tools is especially important and serves as an indicator to take up proper preventive or treatment actions. The aim of the study was to assess the prevalence of playing-related musculoskeletal disorders (PRMDs) and the relationships with PRMDs' impact on playing musical instruments among Polish professional orchestra musicians. Methods: The study was conducted on a group of professional orchestra musicians (age 37.19 ± 9.62 years), 99 (55%) women and 83 (45%) men. Work experience in professional orchestra was 18.3 ± 9.83 years and the reported years of playing musical instrument were 31.4 ± 9.50. The study used the online version of a musician-dedicated questionnaire, Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians of the Polish Population (MPIIQM-P). Results: In the study group, 89.9% of women and 83.1% of men had experienced playing-related pain in their lifetime. The most intense pain among the group with current playing-related musculoskeletal complaints (n = 85) was located in the neck area for 19 (22.4%). Conclusions: The results of the study indicate a high prevalence of playing-related musculoskeletal problems among professional musicians.

Impact of professional, recreational and nonsinging on temporomandibular disorders - a comparative study based on a self-assessment questionnaire

BACKGROUND

This study investigates the relationship between professional and recreational singing on temporomandibular disorders (TMDs) in women compared to a nonsinging control group.

METHODS

A total of 288 female subjects between the ages of 18 and 45 participated in the self-assessment questionnaire including demographic data, as well as questions on vocal practice and TMDs symptoms. Depending on the singing time per week, the (non)vocalists were assigned to the groups professional (n = 96), recreational (n = 96) and nonsingers (n = 96).

RESULTS

The TMDs prevalence in professional singers (42%) was higher than that in recreational singers (31%) and noticeably higher than that in nonsingers (25%). The Fisher-Freeman-Halton exact test showed that the differences between the groups were not noticeable (p = .053) but could be formulated as tendencies. The professionals suffered much more from restricted jaw movement (p = .004; OR = 2.718; 95% CI = 1.409-5.242), temporomandibular joint sounds (p < .009; OR = 2.267; 95% CI = 1.264-4.064) and temporomandibular pain (p = .010; OR = 2.333; 95% CI = 1.264-4.308) than nonsingers.

CONCLUSIONS

Singing might have an enhancing effect on the appearance of TMDs. In particular, professional singers suffered more from self-reported TMDs than recreational singers and nonsingers. In addition to the high level of physical workload if participating in professional singing, the psychosocial impact should be investigated more in further studies. No new treatment strategies resulted from this study, as the etiological significance of singing is still unclear. Knowledge about risk factors for multifactorial TMDs can help practitioners and patients prevent and treat TMDs.

Awake and Sleep Oral Behaviours in Patients With Painful Temporomandibular Disorders

OBJECTIVES

The aim of this research was to explore the oral behaviours exhibited by individuals with and without temporomandibular disorders (TMD) pain, and with various pain characteristics; and to determine which oral behaviour is correlated with painful TMD.

METHODS

328 patients with TMD who visited Orofacial Pain Clinic were included in this retrospective cross-sectional study. The patients were categorised into 2 groups-painful TMD and non-painful TMD-based on pain status; their other pain characteristics were recorded. To evaluate oral behaviours, researchers utilised the Oral Behaviors Checklist (OBC) and categorised into 3 levels based on the Diagnostic criteria for TMD scoring manual. To investigate the associations amongst demographic information, oral behaviour levels, and TMD pain status and characteristics, logistic regression was employed, whilst t tests were used to analyse OBC scores. Logistic regression was also used to examine individual oral behaviours in relation to specific pain characteristics.

RESULTS

Age and marital status were associated with TMD pain status. Significantly higher OBC scores were observed in chronic pain compared to acute pain group, but the scores were not significantly different for pain status and other pain characteristics. OBC score and level were associated solely with TMD pain chronicity. According to multivariate logistic regression, "clench or grind teeth when sleeping" was the strongest predictor of TMD pain and "place tongue forcibly against teeth" was the strongest predictor of chronic painful TMD.

CONCLUSIONS

High oral behaviour level and OBC scores were associated with chronic painful TMD. Sleep bruxism was the strongest predictor of TMD pain. Age and marital status were correlated with TMD pain status. In the treatment of TMD, there can be potential benefits in addressing and managing oral parafunctional behaviours.

Effect of manual therapy on music students with playing-related musculoskeletal disorders: a prospective study

Playing Related Musculoskeletal Disorders (PRMD) belong to the most prevalent medical ailments affecting musicians' health and career. This study documents the effect of a physiotherapeutic treatment as well as functional impairments of PRMD on the musculoskeletal system. In total, 32 music students suffering from PRMD were examined in Hanover Medical School (MHH) before and after they received twelve physiotherapeutic treatments, which were carried out over 20 min each over 6 weeks. Additionally, 32 healthy music students, matched by age and gender, were examined at one time point in the MHH to explore which musculoskeletal restrictions are associated with PRMD. The examination included the evaluation of the pain on the Visual Analogue Scale for pain (VAS), a body composition, and body posture measurement, the finger-to-floor distance, the range of motion of the cervical spine, the pressure pain and muscular hypertension examination, the temporomandibular joint-test, the Beighton score screening test, and the testing of the widespread pain score (WSP). After analyzing the data of the patient group (PG) a significant reduction of pain level on the VAS from an average pain of 6.31 to 3.53 was found (large effect). Additionally, a significant reduction of the pressure pain of the M. levator scapulae, the M. rhomboideus, the M. sternocleidomastoideus on the left side and the paravertebral muscles of the cervical spine on the right side after the treatment of the patients could be detected. Regarding the WSP, the positive testing significantly differed, showing a 28% positive testing in the patient group vs. a positive testing of 9% in the control group (CG). As hypermobility is a common phenomenon in musicians, the percentage of those being diagnosed with generalized hypermobility by using the Beighton score in both groups (PG: 37.5%; CG: 25%) was remarkably higher compared to previous studies. In this study, a short course of manual therapy, client tailored for each musician's specific problem, was shown to reduce pain levels in musicians with PRMD.

Biomechanical Assessments in Woodwind Musicians: A Systematic Review

Biomechanical methods are frequently used to provide information about the kinematics and kinetics of posture and movement during musical performance. The aim of this review was to identify and analyze the biomechanical methods performed on woodwind musicians to understand their musculoskeletal demands. A systemic review was carried out following the guidelines of the document Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). It was registered in PROSPERO (code 430304).The databases PubMed, Cochrane, CINAHL, Scopus, and Web of Science were consulted between January 2000 and March 2022. The search in the databases identified 1625 articles, and 16 different studies were finally included in the review, with a sample size of 390 participants. Pressure sensors, surface electromyography, infrared thermography, goniometry in two dimensions, and ultrasound topometry in three dimensions were biomechanical methods useful to broaden the knowledge of musculoskeletal demands during musical practice. Piezoresistive pressure sensors were the most widely used method. The great heterogeneity of the studies limited the comparability of the results. The findings raised the need to increase both the quantity and the quality of studies in future research.

Physical therapist guided active intervention of chronic temporomandibular disorder presenting as ear pain: A case report

This case report describes the successful physical therapy management of a 40-year-old female who presented with left ear pain referred from the temporomandibular joint. Diagnosis was primarily based on clinical examination findings and ruling out of red flags. Guidance was given on active self-care approaches consisting of pain neuroscience education designed with individualized pain curriculum, exercise therapy, manual therapy, and breathing exercises for a period of  sixweeks. Clinically meaningful improvements were obtained in the outcome measures of Numeric Pain Rating Scale (NPRS), Patient-Specific Functional Scale (PSFS), and Global Rating of Change (GROC) scale and progress in Pain-Self Efficacy Questionnaire (PSEQ) and Tampa Scale for Kinesiophobia (TSK) scores. Positive changes were achieved with functional activities (chewing, eating, yawing, brushing teeth and physical intimacy), and the patient was pain-free on discharge, which was maintained at a six-month follow-up.

Tooth Position in Wind Instrument Players: Dentofacial Cephalometric Analysis

Background: Specific dentofacial characteristics in wind instrumentalists should be taken in consideration when analyzing physiological and anatomical issues regarding the musician’s embouchure, posture, and biomechanics during musical performance. Objectives: To compare tooth cephalometric characteristics between wind instrument players and string players (overjet, overbite, lower facial height, facial convexity, lower incisor inclination, and interincisal angle). Methods: In total, 48 wind instrumentalists (67%) and 24 string instrumentalists (33%). These musicians performed lateral tele-radiography and the correspondent linear and angular measurements of the dentofacial cephalometric analysis. Statistical comparison of wind and string instrumentalists was made by using an independent t-test. Results: Small variations on the analyzed parameters were found between the wind and string instrument groups. Based on the cephalometric analysis the variable interincisal angle was statistically significant (p < 0.05), when comparing the wind and string instrument group. Conclusions: Knowledge of the overjet and overbite value permits a substantial analysis on the tooth position of wind instrument players, where both of these parameters are increased and greater than the norm value. The cephalometry was an added value on the interpretation of possible factors that lead to the position of the central incisors of wind instruments. Till some extent in this group of musicians the applied forces during the embouchure mechanism on the anterior teeth and the existing perioral forces promote an equilibrium on the vector of forces. This study findings demonstrate that when evaluating the two samples, wind and string instruments there are different dentofacial configurations, however the only statistically significant differences that were found are related to the interincisal angle (p < 0.05).

Infrared thermography of the crânio-cervico-mandibular complex in wind and string instrumentalists

PURPOSE

Musculoskeletal disorders can be common in wind and string instrumentalists. The musical gesture technique associated to musical performance can promote an asymmetrical isometric contraction with the hyperactivity of specific muscular groups and the overload of articular surfaces which can cause discomfort or pain. The aim of this investigation was to assess specific anatomical regions of interest within the cranio-cervico-mandibular complex in order to determine and evaluate the presence of muscular hyperactivity associated to musical performance.

METHODS

An infrared imaging camera, FLIR®, was used to record the regions of interest in wind (n = 48) and string instrumentalists (n = 29). Bilateral temperature differences were considered as thermal asymmetries with a conventional threshold of 0.3 ºC to distinguish pathological from healthy states. The regions of interest (ROI) were the anterior triangle of the neck, the sternocleidomastoid and trapezius muscles regarding the postural and stabilizing muscles of the head and neck. On the orofacial region, the anatomical sites were the anterior temporal muscle, the masseter muscle and the temporomandibular joint. A Pearson chi-square test was performed to compare the assessed areas.

RESULTS

Between 30-37% of all participants showed ROI in an asymmetric pattern. The most affected sites were the temporal muscle and the TMJ for both groups. The anterior triangle of the neck showed statistical differences (p = 0.044) between string and wind instrumentalists, while the temporal (p = 0.034) and trapezius muscle (p = 0.028) when comparing large and small mouthpieces of brass instruments. Although female participants showed a higher prevalence of asymmetrical patterns regarding the ROI, no statistical differences were found between genders.

CONCLUSIONS

Infrared thermography exhibited significant differences between wind and string instruments within the CCMC. Regarding the issue of occupational health in performing arts, it is an advantage being able to quantify asymmetrical patterns sites of the CCMC to understand the underlying physiological responses to repetitive movements, overloading and muscular hyperactivity that occur during musical performance.

Thermographic Study of the Orofacial Structures Involved in Clarinetists Musical Performance

INTRODUCTION

Wind instrumentalists like clarinetists, may present a muscular hyperactivity on certain groups of the cranio-cervico-mandibular complex, due to their musical activity. Therefore, the use of infrared thermography can be used to assess and characterize the orofacial structures involved in clarinet performance.

AIM

The objective of this study was to analyze and record the thermal patterns using the thermographic camera Flir® E60sc to evaluate anatomically and physiologically certain orofacial structures of the cranio-cervical-mandibular complex, such as the masticatory muscles and the region of the temporomandibular joint.

METHODOLOGY

A sample of 30 clarinetists completed an individual questionnaire composed of two components (musical and clinical history of the participant), and were subjected to a clinical examination. Four thermographic images were taken of the cranio-cervical-mandibular complex at a rest position with frontal, right lateral, left lateral and anterior dentoalveolar components views. Each musician performed a piece of music for an uninterrupted period of 10 min. New thermographic images were captured with the same incidences, after the performance, respecting the same protocol.

RESULTS

There were statistically significant differences in the areas corresponding to the left temporal muscle, the orbicularis muscle (labial component), the left and right perioral teguments, as well as in the upper central incisors. There was also statistical evidence regarding the initial and final temperature asymmetries regarding temporal muscle and orbicular muscles (labial and marginal components).

CONCLUSION

Infrared thermography has been shown to be an effective complementary diagnostic tool in the monitorization of the cranio-cervical-mandibular complex of clarinetists.

Evidence-based review on temporomandibular disorders among musicians

Background

Playing a musical instrument that loads the masticatory system has frequently been linked to temporomandibular disorders (TMDs). Previous literature reviews on this topic do not conform to the current standards of evidence-based medicine.

Aims

To investigate the effects of playing a musical instrument (i.e. violin/viola and wind instruments) or singing on the presence of TMDs, based on evidence derived from observational studies.

Methods

Databases of Medline, Web of Science and Google Scholar were searched using MeSH and other relevant terms. For each study, a quality assessment was undertaken using a modified version of the Newcastle-Ottawa Scale (NOS).

Results

Fifteen relevant papers were identified for inclusion in this review. Of the seven possible points that could be scored with the NOS, the majority of these studies scored under half. Based on the available evidence, the purported relationship between the playing of specific musical instruments and TMDs was not as evident as reported in previous literature reviews.

Conclusions

There is limited evidence to conclude that playing a wind instrument is a hazard to the temporomandibular system. Furthermore, there is no available evidence to suggest that vocalists experience more TMDs than controls. The studies that investigated the presence of TMDs among violists and violinists yielded ambiguous outcomes; some studies reported no association between the playing of these instruments and the presence of signs and symptoms of TMDs, whereas in studies where a clinical examination was performed (though of lower methodological quality), an association was found.

Clinical Signs and Subjective Symptoms of Temporomandibular Disorders in Instrumentalists

PURPOSE

Most of the reports on instrumentalists' experiences of temporomandibular disorders (TMD) have been reported not by clinical examinations but by subjective questionnaires. The aim of this study was to investigate the clinical signs and subjective symptoms of TMD in a large number of instrumentalists objectively.

MATERIALS AND METHODS

A total of 739 musicians from a diverse range of instrument groups completed a TMD questionnaire. Among those who reported at least one symptom of TMD, 71 volunteers underwent clinical examinations and radiography for diag-nosis.

RESULTS

Overall, 453 participants (61.3%) reported having one or more symptoms of TMD. The most frequently reported symptom was a clicking or popping sound, followed by temporomandibular joint (TMJ) pain, muscle pain, crepitus, and mouth opening limitations. Compared with lower-string instrumentalists, a clicking or popping sound was about 1.8 and 2 times more frequent in woodwind and brass instrumentalists, respectively. TMJ pain was about 3.2, 2.8, and 3.2 times more frequent in upper-string, woodwind, and brass instrumentalists, respectively. Muscle pain was about 1.5 times more frequent in instrumentalists with an elevated arm position than in those with a neutral arm position. The most frequent diagnosis was myalgia or myofascial pain (MFP), followed by disc displacement with reduction. Myalgia or MFP was 4.6 times more frequent in those practicing for no less than 3.5 hours daily than in those practicing for less than 3.5 hours.

CONCLUSION

The results indicate that playing instruments can play a contributory role in the development of TMD.

Relationship Between Wind Instrument Playing Habits and Symptoms of Temporomandibular Disorders in Non-Professional Musicians

Background:

In this study, we focused on the habits of wind instrumentalists as well as the presence of playing instruments, and investigated associations between the risk of temporomandibular disorders (TMD) and playing wind instruments in non-professional musicians.

Material and Methods:

Seventy-two non-professional players of wind instruments (instrument group) (mean(SD), 20.0(1.1) y; 42 women) and 66 non-players (control group) (22.0(2.6) y; 45 women) participated in this study. Factors were investigated using questionnaires (a screening questionnaire for TMD, instrument playing habits, years of experience, and time played per day).

Result:

The prevalence of a high risk of TMD was not significantly different between the instrument group (29.2%) and control group (21.2%). In the instrument group, the frequency of subjects who felt mouthpiece pressure in the high risk of TMD group (47.6%) was significantly greater than that in the low risk of TMD group (21.6%). Mouthpiece pressure was found to be a significant factor contributing to a high risk of TMD (odds ratio, 3.31; 95% CI, 1.12–9.79).

Conclusion:

This study suggests that pressure from the mouthpiece was one of the contributing factors related to a high risk of TMD in non-professional wind instrument players.

Association between temporomandibular disorders and music performance anxiety in violinists

BACKGROUND

Professional violin playing has been associated with a predisposition to develop temporomandibular disorder (TMD). There are a number of risk factors, including physical trauma from the playing posture and the presence of parafunctional habits. Music performance anxiety (MPA) may also be a factor, as it has been associated with playing-related musculoskeletal disorders (PRMD).

AIMS

To evaluate a possible association between the presence of TMD and the level of MPA in violin players.

METHODS

An observational study using a written questionnaire that retrieved data related to TMD symptoms (Fonseca Anamnestic Questionnaire), MPA level (Kenny Music Performance Anxiety Inventory, K-MPAI), instrument practice time, chinrest type, sex and age. Descriptive, bivariate and logistic regression analyses were conducted.

RESULTS

Ninety-three professional or semi-professional violinists performing in and around Lisbon, Portugal, completed the questionnaire (73% response rate). TMD was present in 50 violinists (58%). There was a statistically significant association between the presence of TMD and high MPA levels (P < 0.001) and the most anxious violinists were six times (95% confidence interval 2.51-15.33; P < 0.001) more likely to report TMD symptoms when compared with the least anxious players.

CONCLUSIONS

Violin players had a high prevalence of reported TMD symptoms, which was significantly associated with high MPA levels. It may therefore be necessary to address psychological and physical factors simultaneously in musicians who do not improve with physical therapy alone.