Temporomandibular disorder complaints in musiciansABSTRACT
Purpose: to investigate the occurrence of temporomandibular disorder complaints and associated factors in musicians, according to their instruments.
Methods: a cross-sectional, observational, analytical study with 48 adults, divided into three groups: string instrumentalists, wind instrumentalists, and control group. The ProDTMmulti questionnaire was applied. Statistical analysis was performed using Pearson's chi-square, Fisher's exact, and Kruskal-Wallis tests, setting the significance level at 5%.
Results: almost 40% of participants, spontaneously reported some temporomandibular disorder complaint. The control group had fewer complaints and harmful oral habits. Masticatory muscle fatigue was more frequent in the wind group than in the string one; noise in the temporomandibular joint was less frequent in controls than in the string group; and the unilateral masticatory pattern was more frequent in the wind group than in the others. The complaint of ear fullness was greater in the wind group. An association was found between temporomandibular disorder complaints and facial muscle pain, facial muscle pain during musical activity, facial muscle pain after musical activity, headache, and headache after musical practice.
Conclusion: spontaneous complaints of temporomandibular disorders were observed in 56.7% of wind and string musicians.
Keywords:
Temporomandibular Joint Disorders; Facial Pain; Masticatory Muscles; Music; Speech, Language and Hearing Sciences
RESUMO
Objetivo:
investigar a ocorrência de queixas de disfunção temporomandibular e fatores associados em musicistas, de acordo com os instrumentos praticados.
Métodos: estudo transversal observacional analítico realizado com 48 adultos, divididos em três grupos: instrumentistas de corda, de sopro e grupo controle. Foi aplicado o questionário ProDTMmulti. A análise estatística foi realizada por meio dos testes Qui-quadrado de Pearson, Exato de Fisher e Kruskal-Wallis, com nível de significância de 5%.
Resultados: quase 40% dos participantes relataram espontaneamente alguma queixa de disfunção temporomandibular. O grupo controle apresentou menos queixas e hábitos orais deletérios. A fadiga da musculatura mastigatória teve maior ocorrência no grupo de sopro do que no de cordas, já o ruído na articulação temporomandibular teve menor ocorrência no grupo controle comparado ao grupo cordas e o padrão mastigatório unilateral foi mais frequente no grupo sopro quando comparado aos demais. A queixa de plenitude auricular foi maior no grupo sopro. Verificou-se associação entre queixa de disfunção temporomandibular e dor muscular na face, dor muscular na face durante atividade musical, dor muscular na face após atividade musical, dor de cabeça e dor de cabeça após atividade musical.
Conclusão: verificaram-se queixas espontâneas de disfunção temporomandibular em 56,7% dos musicistas de sopro e cordas.
Descritores:
Transtornos da Articulação Temporomandibular; Dor Facial; Músculos da Mastigação; Música; Fonoaudiologia
INTRODUCTION
The American Academy of Orofacial Pain (AAOP) defines temporomandibular disorder (TMD) as a set of disorders involving masticatory muscles, the temporomandibular joint (TMJ), and associated structures1. Its prevalence is higher in females in the age group between 21 and 40 years2. The 6th edition of AAOP’s manual established new guidelines for diagnosing and classifying the different forms of TMD, divided into two large groups: muscular TMD and articular TMD, with their respective subdivisions1.
The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) - the main clinical and diagnostic assessment tool for TMDs - classifies TMDs into painful disorders (subdivided into myalgia, arthralgia, and headache attributed to TMD), intra-articular disorders (subdivided into disc displacement with reduction; disc displacement with reduction, with intermittent locking; disc displacement without reduction, with limited opening; disc displacement without reduction, without limited opening), and degenerative joint disease3.
The effort to isolate a clear and universal cause of TMD has not been successful4. A recent study concluded that TMDs have a multifactorial origin and that several etiological factors can contribute to the appearance of signs and symptoms related to the stomatognathic system4. The symptoms most reported by patients with TMD are often pain in the face, TMJ, masticatory muscles, head, and/or ear region1. Otological manifestations (e.g., tinnitus, ear fullness, and vertigo) are also reported1.
A 2018 bibliographic review aimed to summarize the changes in the stomatognathic system of musicians who played wind instruments and found frequent TMD-related musculoskeletal problems and hearing changes.5 Wind and string musicians are highly susceptible to developing TMD, and this practice may not only trigger the disorder but also aggravate or perpetuate an existing problem6.
Prolonged instrument practice can often lead professionals to exceed their physiological limits, due to the high level of performance required, the rigorous individual technique, and each musical instrument’s specific shape, resulting in a high prevalence of musculoskeletal injuries7. TMD can temporarily or permanently limit the ability to play and practice musical wind instruments8.
Wind instruments require a complex neuromuscular interaction between the lips, facial muscles, teeth, palate, tongue, and mouthpiece, involving each instrument’s characteristics of production, direction, and intensity of the air column8. Musicians adapt their embouchure to the different instruments to perform music correctly, requiring specific articulation between the mouthpiece, lips, and respiratory system8. However, the shape of the embouchure and the time and frequency they play the instrument are related to some oral cavity, face, and posture disorders among musicians. Some musicians’ anatomical characteristics facilitate playing, while others need compensatory mechanisms in the jaw and head and neck muscles8.
Not unlike wind instruments, string ones (e.g., the violin, viola, and cello) require musical performance techniques that may damage orofacial structures, as their support fixes the instrument between the lower edge of the jaw and the left shoulder9,10.
Thus, investigating TMD signs and symptoms related to musical activities may contribute to greater knowledge about the risk of wind and string instrument musicians developing TMDs. Hence, this study aimed to investigate the occurrence of TMD complaints and associated factors in musicians, according to each instrument’s characteristics.
METHODS
This is an observational, cross-sectional, analytical study, approved by the Ethics Committee of the Universidade Federal de Minas Gerais, Brazil, under evaluation report no. 2.840.100 and CAAE: 95388918.4.0000.5149. The sample had 48 adults of both sexes, aged 18 to 69 years.
The inclusion criteria for the study were being 18 years or older, being a musician from the town of Brumadinho, Brazil, agreeing to participate in the research, and signing an informed consent form. The exclusion criterion was not completing the data collection protocols.
All six bands and the one string school registered at the Cultural Center of Brumadinho were contacted. The study volunteers were invited to participate in the research while rehearsing with their bands, without affecting their activities. Those who agreed to participate received an informed consent form and were included in the study after reading and signing it.
The participants were divided into three groups: I) experimental group of string instrumentalists (EGS) (n = 12) - violin, cello, viola, and double bass (String School members at the Inhotim Institute); II) experimental group of wind instrumentalists (EGW) (n = 18) - clarinet, saxophone, tuba, trumpet, trombone, and transverse flute (musicians registered in the inventory of the Cultural Center of Brumadinho); and III) control group (CG) (n = 18) - with other instrumentalists (keyboard, piano, conductor) and singers from the town (identified in the Cultural Center’s inventory).
The same evaluator applied the questionnaire - developed by the researchers to investigate each musician’s profile and rehearsal routine - and the Protocol for Determining Temporomandibular Disorder Signs and Symptoms for Multiprofessional Centers (ProDTMmulti, in Portuguese)11,12. The questionnaire verifies previous knowledge about TMD, time spent practicing music, time spent rehearsing and studying per week, type of musical instrument played, and harmful oral habits. The first part of the ProDTMmulti investigates the presence and location of TMD signs and symptoms (e.g., pain, discomfort, and noise). The second part analyzes the intensity of signs and symptoms on a scale from 0 to 10 in four situations: waking up, chewing, speaking, and resting.
Descriptive data analysis was performed using frequency distribution for categorical variables and measures of central tendency and dispersion for continuous variables. The Kolmogorov-Smirnov and Shapiro-Wilk tests were used to assess sample distribution. Pearson's chi-square, Fisher's exact, and Kruskal-Wallis tests were used for association analyses, setting the significance at p-values ≤ 0.05. The tests were chosen because the intensity and time variables did not have a normal distribution. SPSS software, version 25.0, was used for data entry, processing, and analysis.
RESULTS
The sample had 48 participants - 28 (58.3%) males and 20 (41.7%) females. Their mean age was 26±11 years, with a median of 22 years. Most of the sample had completed high school (41.7%), followed by incomplete higher education (29.2%), complete higher education (22.9%), incomplete high school (4.2%), and complete middle school (2.1%).
Table 1 presents the descriptive analysis of spontaneous complaints (from the identification part in ProDTMmulti) and the specification of these complaints (part 1 of ProDTMmulti). Almost 40% of the sample spontaneously reported some TMD complaint (sign/symptom), most frequently bilateral masseter pain, headache, and neck pain. There were no reports of swallowing or speech difficulties.
The analysis of TMD complaints per sex showed a higher frequency of females (63.16%) (p = 0.015) than males (36.84%), whereas the age groups (18 to 29 years and 30 years or older) did not differ (p = 0.624). Fisher's exact test was used in both analyses.
The analysis of spontaneous complaints and their specification per group is presented in Table 2. The groups differed regarding the presence of spontaneous complaints of TMD, masticatory muscle fatigue, TMJ noise, and chewing.
Table 3 presents the data indicating between which groups the differences shown in Table 2 occurred. Spontaneous complaints of TMD were more frequent in the EGS and EGW than the CG; masticatory muscle fatigue was more frequent in the EGW than the EGS; TMJ noise was more frequent in the EGS than the CG; and unilateral masticatory pattern was more frequent in the EGW than the CG and EGS.
Figures 1, 2, 3, and 4 show the mean intensity of symptoms in different situations - waking up, chewing, speaking, and resting, respectively. Symptoms did not differ between groups when waking up, chewing, and speaking, whereas only ear fullness when resting was significantly different (p = 0.033), with a higher mean in the EGW.
A weekly study routine (individually and in group) with a mean of 11.33±11.09 hours per week and a mean of 12±10.77 years of musical practice was observed in this study sample. The mean time, shown in Table 4, was greater in the EGS, while the EGW had a greater time of group rehearsals.
The wind instrument played most frequently by the EGW was the saxophone (12.5%), followed by the clarinet (6.3%), trombone (6.3%), trumpet (4.2%), tuba (4.2%), transverse flute (2.1%), and euphonium (2.1%). The instrument played most often by the EGS was the viola (8.3%), followed by the violin (6.3%), cello (6.3%), and double bass (4.2%). The most frequent activity in the CG was singing (20.8%), followed by the guitar (8.3%), keyboard (4.2%), and percussion (4.2%).
Lastly, the EGS (p = 0.001) and EGW (p ≤ 0.001) had harmful oral habits more often than the CG. There was no association between the types of harmful habits and the different groups of musicians (p > 0.05).
It is important to highlight that 91.67% of participants reported having no prior knowledge about TMD.
DISCUSSION
This study found that string and wind instrument players had more TMD complaints and reported more harmful oral habits than the CG. Musicians are susceptible to developing TMD. Musical practice can trigger and aggravate the disorder and somatize other existing factors6. These damages can cause health problems capable of significantly interfering with the musician's ability and performance, even ending their career7. Therefore, thorough medical surveys should identify predisposing factors that increase the risk of TMD, initiating factors that trigger TMD, and perpetuating factors that interfere with the control of the disorder13.
It was found that most of the study sample had only completed high school. Education is associated with acquiring organized information and, consequently, health literacy (i.e., the apprehension and application of health-related knowledge)14, which could lead to different perceptions of TMD. Therefore, the town's musicians should receive specific training about musculoskeletal issues and TMD.
Almost 40% of participants spontaneously reported some TMD complaint (sign/symptom). The most prevalent was bilateral masseter pain, followed by headache and neck pain. The literature indicates that musicians often report orofacial pain due to excessive neuromuscular wear15. The reported symptoms were pain in the face, TMJ, masticatory muscles, head and/or ear region².
TMD complaints were more present in the EGW and EGS than the CG, which may be related to face and neck positioning adjustments necessary to perform musical techniques. These may overload the TMJ and orofacial and neck muscles. Another study indicates a high prevalence of TMD in wind instrument players, since the jaw protrusion (necessary for the instrument embouchure) may require excessive TMJ forces, overloading the structures related to it16. This may justify the finding that masticatory muscle fatigue was the most frequent symptom in the EGW, in contrast with the EGS.
According to the literature, string instrumentalists are also prone to having TMD signs and symptoms, such as pain in the masseter and temporal muscles and, specifically, in the right TMJ region, due to the pressure on the jaw and masticatory muscles when holding the instrument for long periods17. It is important to point out that the guitar is likewise a string instrument, but it does not require face and neck positioning adjustments, as do the others. This is why it was part of the sample but belonged to the CG. Among string instruments, the violin and viola playing techniques have the greatest potential for damage to the orofacial structures18.
No difference was found between the groups when asked specifically in Part 1 of ProDTMmulti about the presence of facial muscle pain. However, 63.6% of participants reported bilateral facial muscle pain, and 90.9% reported masseter muscle pain. Tinnitus was the auditory/otological symptom most cited in this study, corroborating the literature2,19,20. Regarding mouth movements, the most frequently cited sign/symptom was difficulty yawning. In another study21, 14% of patients cited limited mouth opening, which can make yawning kinematics difficult, since yawning requires a certain amount of mouth opening amplitude.
The groups differed regarding complaints of TMJ noise and chewing, whereas the study sample reported no swallowing or speaking difficulties. A study mentioned that TMD and harmful oral habits interfere with the stomatognathic system functioning, which can affect breathing, chewing, swallowing, and speaking22.
Epidemiological investigations have identified TMJ noise as a frequent TMD symptom and clinical sign21. The authors of another study found that TMD is related to pain, TMJ noise, and limited condyle movements when opening and closing the mouth22.
In this study sample, spontaneous complaints of TMD occurred more often among women. According to the literature, the occurrence of TMD is higher in females and in the age group between 21 and 40 years4. Ligament laxity and hormonal changes are suggested as possible explanations for the high incidence of women with TMD15.
It was found in part 2 of the ProDTMmulti that only ear fullness at rest differed between the groups, being greater in the EGW. A study8 verified that 42.9% of its total sample reported ear fullness - of which 11.1% were wind instrument players and 31.8% were string instrument players. The authors mention that 54.5% (string instrument players) reported TMJ noise. Although the present study did not find an association for this variable, TMJ noise when chewing had the highest mean intensity among symptoms, in the EGS. At rest, the symptom with the highest mean intensity was neck pain, also in the EGS, which may be related to their positioning during musical activity. In a previous study, 35.3% of the group with violists and violinists had neck and shoulder pain23. Violists and violinists tend to experience more neck, shoulder, elbow, and forearm pain than pianists23.
Wind and string instrumentalists had a higher incidence of harmful oral habits than the CG. A study demonstrated a positive association between harmful oral habits and TMD signs and symptoms24. Musicians are exposed to situations of emotional stress and anxiety, generated by self-discipline and competitiveness in the workplace, which are risk factors for bruxism and TMD25. These factors make musicians susceptible to developing TMJ and orofacial muscle disorders. A study26 found a significant association between TMD symptoms and the following habits: chewing gum, clenching teeth, placing the hand on the chin, biting the tongue, biting the lips, unilateral chewing, sleeping on one side, and chewing ice and/or lollipops. In the present study sample, however, no association was found between the different groups and types of habits.
Moreover, 91.67% of this sample reported having no prior knowledge about TMD. This data may be due to the level of knowledge about the disorder and its diagnosis and treatment. Since this is a susceptible group, it is important to disseminate knowledge about the subject to this population. Therefore, it is important to train the musicians of Brumadinho, regarding the possible impacts of musical practice on the TMJ and associated structures. There is an evident need to pay more attention to TMD, due to its high prevalence in the study population6. Professionals who work with these disorders must know this condition and develop a multidisciplinary approach to the management of these patients27.
A recent study found that musicians who use their instruments daily and for a long time may have a greater chance of developing TMD28. Another study observed an asymmetrical pattern between the temperature of the temporal muscle and the TMJ region during the thermographic evaluation of wind and string instrument musicians29.
The study's limitations include its small sample size, justified by the serious accident that occurred in the town, making it necessary to interrupt data collection. Another limitation was the lack of sample standardization regarding the individual and group study time, which may have confused the study results.
Researches with larger and uniform samples are suggested, especially addressing the years of musical activity practice, including clinical and instrumental TMJ assessment in musicians and TMD analysis involving different wind instruments.
CONCLUSION
Wind and string musicians from Brumadinho, MG, Brazil, had TMD complaints and reported harmful oral habits - 56.7% of wind and string instrumentalists had spontaneous complaints. Women had a higher incidence of complaints than men. Unilateral masticatory pattern and ear fullness, at rest, were the most observed signs among wind instrumentalists. The sample reported no knowledge of TMD.
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1
A study conducted at the Speech-Language-Hearing Department of the Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
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Financial support: Nothing to declare
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Data sharing statement: Deidentified participant data can be shared upon request via e-mail to the corresponding author, for up to 5 years after publication of this article.
Data sharing statement: Deidentified participant data can be shared upon request via e-mail to the corresponding author, for up to 5 years after publication of this article.
Captions: EGS = experimental group with string instrumentalists (n = 12); EGW = experimental group with wind instrumentalists (n = 18); CG = control group (n = 18); TMD = temporomandibular disorder; TMJ = temporomandibular joint.
Captions: EGS = experimental group with string instrumentalists (n = 12); EGW = experimental group with wind instrumentalists (n = 18); CG = control group (n = 18); TMD = temporomandibular disorder; TMJ = temporomandibular joint.
Captions: EGS = experimental group with string instrumentalists (n = 12); EGW = experimental group with wind instrumentalists (n = 18); CG = control group (n = 18); TMD = temporomandibular disorder; TMJ = temporomandibular joint.
Captions: EGS = experimental group with string instrumentalists (n = 12); EGW = experimental group with wind instrumentalists (n = 18); CG = control group (n = 18); TMD = temporomandibular disorder; TMJ = temporomandibular joint.