Journal of
Oral Rehabilitation
Journal of Oral Rehabilitation 2014 41; 532--541
Review
Is there an association between temporomandibular disorders and playing a musical instrument? A review of literature M. M. ATTALLAH, C. M. VISSCHER, M. K. A. VAN SELMS & F. LOBBEZOO
Depart-
ment of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands
SUMMARY Temporomandibular disorders (TMDs) have a multifactorial etiology. Among others, parafunctions and oral habits have been suggested as important initiating and perpetuating factors. Playing a musical instrument that loads the masticatory system, like wind instruments and the violin or viola, has been suggested to be part of this group of etiological factors. However, the evidence base for this suggestion is lacking. Therefore, the aim of this study was to review the literature on the possible association between playing a musical instrument and developing and/ or having a TMD. A PubMed search, using the query [‘Music’(Mesh) AND ‘Craniomandibular Disorders’(Mesh)], yielded 19 articles, 14 of which were included in this review. Six of 14 papers had a case-control or pre-test-post-test design; the remaining eight papers were case reports of expert opinions. The former papers were analysed and
Introduction Temporomandibular disorders (TMD) is a collective term that includes a number of clinical complaints involving the muscles of mastication, the temporomandibular joint (TMJ) or associated oro-facial structures (1). They are considered to be a subclassification of musculoskeletal disorders (2) and typically run a recurrent or chronic course, with a substantial fluctuation of signs and symptoms over time (3–6). Patients suffering from TMD may present with one or more clinical complaints, including: (i) pain on © 2014 John Wiley & Sons Ltd
tabulated according to the PICO (Patient/ population-Intervention-Control/comparison-Out come/results) system; the latter ones were only summarised and tabulated. All articles with a casecontrol or pre-test-post-test design suggested a possible association between TMD and playing a musical instrument, especially the violin and viola. However, no clear-cut conclusion could be drawn as to whether playing a musical instrument is directly associated with TMD, or only in combination with other factors. More and better research on this topic is needed, as to enable a better counselling and possibly even a better treatment of the suffering musician. KEYWORDS: association, music, musical instrument, review, risk, temporomandibular disorder Accepted for publication 13 March 2014
function in the TMJ, pre-auricular area and/or the masticatory muscles; (ii) limitation and/or deviation of jaw movements, especially with opening; and (iii) TMJ sounds (clicking and/or crepitus) during function (7). Other complaints, including headache, neck ache, facial pain, earache, tinnitus and perceived hearing loss have also been described (1). The prevalence rates reported for TMD vary widely (8). TMD signs (e.g., TMJ sounds, mandibular deviations during mouth opening) have been estimated to occur approximately twice as often as symptoms (e.g., pain): the prevalence of symptoms reportedly varies doi: 10.1111/joor.12166
PLAYING MUSICAL INSTRUMENTS AND TMD from 5% to 33% and that of signs from 1% to 75% (9–11). The etiology of TMD is multifactorial in nature (2, 12). There is no simple cause–effect relationship between a single factor and the disorder. Biomechanical, neuromuscular, biopsychosocial and neurobiological factors may contribute to the disorder (2). Other suggested causes, although some being controversial, include macro-trauma (13–17), micro-trauma (18, 19), occlusal deviations (20, 21), intra-capsular defects (14), jaw muscle tension and emotional stress acting as a perpetuating factor for jaw-muscle tension (22, 23). In addition, the presence of systemic diseases can be a pre-disposing factor for the development of TMD (2). Also parafunctioning has been considered one of the possible causative factors, which is a conscious or subconscious overloading of the masticatory system (2). Parafunctioning can include bruxing habits (clenching and/or grinding), nail biting, gum chewing as well as a range of other related habits (2). Medical problems specifically affecting professional musicians are commonly mentioned in literature. These range from occupational and lifestyle-related problems, to dental malocclusions and even general health problems (24, 25). The characteristics of the individual performer and the type of instrument that he/she plays would determine the occupational disorder or disease that a musician may suffer from (24). Playing a musical instrument, like wind-blowing types or string instruments that are held between the shoulder and angle of the jaw, could pose an overload of the masticatory muscles as well as of the orofacial skeletal system, thereby possibly causing TMD or worsening an already existing TMD. Although some studies report that the prevalence of TMD symptoms in musicians is similar to that in the general population, others suspect professionally playing certain musical instruments (e.g., violin, viola, trombone, trumpet and tuba) to be a factor contributing to TMD (26). Also vocalists have been reported to suffer from TMD (26–28). Fourteen to fifteen percent of professional musicians using the oro-facial region were reported to have TMJ dysfunctions (29, 30). However, whether playing wind- and/or stringmusical instruments could be a possible cause for developing TMD was never reviewed in a comprehensive way. Therefore, this comprehensive review of literature was conducted to explore what was mentioned in © 2014 John Wiley & Sons Ltd
the English literature about the possible association between playing a musical instrument and developing and/or having a temporomandibular disorder.
Methods A literature search in the National Library of Medicine’s Medline Database was conducted through PubMed on November 22, 2012, using the Mesh terms [‘Music’(Mesh) AND ‘Craniomandibular Disorders’(Mesh)] to retrieve all available articles in the literature written in the English language dealing with the possible associations between musical instruments and temporomandibular disorders (TMD). Given the expected low number of articles dealing with the association of interest, all articles in the search output were included in this review, regardless of their study type and quality. The only exclusion criterion was if the topic of an article turned out to be unrelated to the research question. To that end, all articles were retrieved as full texts. In addition, all reference lists were screened for articles that might be relevant for this review, but did not surface in the search output. Finally, an extensive search was performed using Google Scholar, which did not yield any additional articles related to the topic of this review. The included case-control and pre-test-post-test studies were tabulated following the ‘PICO system’, thus identifying four key items for each article, namely ‘P’ – population (or patient), ‘I’– intervention, ‘C’ – comparison and ‘O’ – outcome. For each article, the population item ‘P’ was determined in terms of sample size and, whenever mentioned, also by indicating type of musical instrument played. The intervention item ‘I’ included a concise summary of the performed examination and/or experiment The comparison item ‘C’ described whether there was a control group and, whenever mentioned, the characteristics of this group. The outcome item ‘O’ contained the result of the performed test(s). The PICO table also contains the aim of the study and the conclusion(s) as mentioned by the author(s) of the articles. Of the included case reports and expert opinions, the relevant patient characteristics, treatment specifications and outcomes are tabulated, along with a conclusion.
533
534
M . M . A T T A L L A H et al.
Results A total of nineteen articles were retrieved by the above-described search strategy. Five articles were excluded, as they were not related to the research question. One of those was a retrospective cohort study analysing tinnitus data in relation to TMD (31). Another one was a biography about a couple of musicians who suffered from oro-facial pain (32). Yet another one concerned a randomised clinical trial (RCT), in which TMD patients were compared with a control group in terms of musculoskeletal symptoms and psychological factors (33). The remaining two excluded articles were expert opinions related to musicians’ dental problems rather than to TMD (34, 35). The remaining fourteen articles were included in the review. These were assigned to two groups, according to the type of study conducted. The first group contained five case-control studies and one pretest-post-test study. The second group contained seven case reports and one preliminary report/expert opinion. From Table 1, in which five case-control studies and one pre-test-post-test study are tabulated following the PICO system, it becomes evident that there is agreement on a potential association between TMD and playing a musical instrument. All six studies conclude that an association was present, especially for violin and viola players who were the subjects of four out of six studies. Table 2 shows the remaining eight articles of the search output, including seven case reports and one expert opinion, along with a brief summary of each article’s content.
Discussion This comprehensive review presents the available evidence about the relationship between playing a musical instrument and developing and/or having temporomandibular disorders (TMD). All studies with a case-control or a pre-test-post-test design, that were assessed in this research, suggested a possible association between TMD and playing a musical instrument, especially the violin and viola. There are several methodological issues that need to be discussed. First, although the term ‘temporomandibular disorders’ is currently the preferred one to be used for defining the conditions being addressed by this research, the MeSH term ‘Craniomandibular
Disorders’ has been used instead, because it is positioned highest in the MeSH tree of terms and thus yields the widest possible coverage of the addressed research question. Second, the results of our search show that only a small number of papers were published concerning the association under study. This prevents the performance of a meta-analysis. Third, most of the presented papers are case reports or expert opinions, which complicates the possibility of collecting homogenous knowledge about this review’s topic. Clearly, well-designed longitudinal cohort studies are recommended for future research investigating the association of interest. Playing the violin or viola seems to be a factor associated with TMD, because professional players show clinical signs of TMD more frequently than matched controls (36–38). This may be attributed to the mechanical overload these musicians might produce on their oro-facial region (39). They also tend to push the mandible towards the contralateral TMJ (36, 40). It is important to note that it could be due to the specific way of holding the instrument to one side of the body that complaints arise at one side of the oro-facial region more than at the other, as seen in the studies of Kovero and K€ on€ onen (37, 41). It seems that the literature is mostly concentrated on the violin and viola. Indeed, only a few studies have been conducted to explore wind instruments, such as the clarinet or the oboe, in association with TMD complaints (39). This is remarkable, because playing wind instruments involves the muscles of the face, including the masticatory muscles, even more than in case of playing the violin or viola. It is therefore recommended for future research to further investigate the association between playing wind instruments and TMD. In the study of Steinmetz et al. (39), there were, besides wind and string instrument players, also four piano players who presented with TMD complaints. No interpretation was given for this remarkable finding. Why would a piano player develop TMD? A possible explanation could be obtained from the study of Lourencßo et al. (42), where the electromyographic masticatory muscle activity was found to be almost three times higher during playing the piano than during eating. The physical and psychosocial demand of the performance, together with the increased levels of concentration, stress and anxiety were mentioned as factors causing the increased masseter and temporalis © 2014 John Wiley & Sons Ltd
© 2014 John Wiley & Sons Ltd
Molina et al. (43)
3
CaseTo document the prevalence of control oral jaw behaviours‡ concomitant to bruxism in
To investigate the effect of oral splint treatment of TMD on reducing pain and symptoms in the neck, shoulders and upper extremities
Steinmetz et al. (39)
2
Pretestposttest
Rodrıguez- CaseTo determine if there is an Lozano control association between violin et al. (38) playing and signs and symptoms of Temporoman-dibular disorders (TMD)
Type of study Objective/aim
1
No Study
Thirty professional musicians with any of: - myofacial pain in the masticatory muscles, either spontaneous or upon palpation - limited mouth opening (
Oral Rehabilitation
Journal of Oral Rehabilitation 2014 41; 532--541
Review
Is there an association between temporomandibular disorders and playing a musical instrument? A review of literature M. M. ATTALLAH, C. M. VISSCHER, M. K. A. VAN SELMS & F. LOBBEZOO
Depart-
ment of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands
SUMMARY Temporomandibular disorders (TMDs) have a multifactorial etiology. Among others, parafunctions and oral habits have been suggested as important initiating and perpetuating factors. Playing a musical instrument that loads the masticatory system, like wind instruments and the violin or viola, has been suggested to be part of this group of etiological factors. However, the evidence base for this suggestion is lacking. Therefore, the aim of this study was to review the literature on the possible association between playing a musical instrument and developing and/ or having a TMD. A PubMed search, using the query [‘Music’(Mesh) AND ‘Craniomandibular Disorders’(Mesh)], yielded 19 articles, 14 of which were included in this review. Six of 14 papers had a case-control or pre-test-post-test design; the remaining eight papers were case reports of expert opinions. The former papers were analysed and
Introduction Temporomandibular disorders (TMD) is a collective term that includes a number of clinical complaints involving the muscles of mastication, the temporomandibular joint (TMJ) or associated oro-facial structures (1). They are considered to be a subclassification of musculoskeletal disorders (2) and typically run a recurrent or chronic course, with a substantial fluctuation of signs and symptoms over time (3–6). Patients suffering from TMD may present with one or more clinical complaints, including: (i) pain on © 2014 John Wiley & Sons Ltd
tabulated according to the PICO (Patient/ population-Intervention-Control/comparison-Out come/results) system; the latter ones were only summarised and tabulated. All articles with a casecontrol or pre-test-post-test design suggested a possible association between TMD and playing a musical instrument, especially the violin and viola. However, no clear-cut conclusion could be drawn as to whether playing a musical instrument is directly associated with TMD, or only in combination with other factors. More and better research on this topic is needed, as to enable a better counselling and possibly even a better treatment of the suffering musician. KEYWORDS: association, music, musical instrument, review, risk, temporomandibular disorder Accepted for publication 13 March 2014
function in the TMJ, pre-auricular area and/or the masticatory muscles; (ii) limitation and/or deviation of jaw movements, especially with opening; and (iii) TMJ sounds (clicking and/or crepitus) during function (7). Other complaints, including headache, neck ache, facial pain, earache, tinnitus and perceived hearing loss have also been described (1). The prevalence rates reported for TMD vary widely (8). TMD signs (e.g., TMJ sounds, mandibular deviations during mouth opening) have been estimated to occur approximately twice as often as symptoms (e.g., pain): the prevalence of symptoms reportedly varies doi: 10.1111/joor.12166
PLAYING MUSICAL INSTRUMENTS AND TMD from 5% to 33% and that of signs from 1% to 75% (9–11). The etiology of TMD is multifactorial in nature (2, 12). There is no simple cause–effect relationship between a single factor and the disorder. Biomechanical, neuromuscular, biopsychosocial and neurobiological factors may contribute to the disorder (2). Other suggested causes, although some being controversial, include macro-trauma (13–17), micro-trauma (18, 19), occlusal deviations (20, 21), intra-capsular defects (14), jaw muscle tension and emotional stress acting as a perpetuating factor for jaw-muscle tension (22, 23). In addition, the presence of systemic diseases can be a pre-disposing factor for the development of TMD (2). Also parafunctioning has been considered one of the possible causative factors, which is a conscious or subconscious overloading of the masticatory system (2). Parafunctioning can include bruxing habits (clenching and/or grinding), nail biting, gum chewing as well as a range of other related habits (2). Medical problems specifically affecting professional musicians are commonly mentioned in literature. These range from occupational and lifestyle-related problems, to dental malocclusions and even general health problems (24, 25). The characteristics of the individual performer and the type of instrument that he/she plays would determine the occupational disorder or disease that a musician may suffer from (24). Playing a musical instrument, like wind-blowing types or string instruments that are held between the shoulder and angle of the jaw, could pose an overload of the masticatory muscles as well as of the orofacial skeletal system, thereby possibly causing TMD or worsening an already existing TMD. Although some studies report that the prevalence of TMD symptoms in musicians is similar to that in the general population, others suspect professionally playing certain musical instruments (e.g., violin, viola, trombone, trumpet and tuba) to be a factor contributing to TMD (26). Also vocalists have been reported to suffer from TMD (26–28). Fourteen to fifteen percent of professional musicians using the oro-facial region were reported to have TMJ dysfunctions (29, 30). However, whether playing wind- and/or stringmusical instruments could be a possible cause for developing TMD was never reviewed in a comprehensive way. Therefore, this comprehensive review of literature was conducted to explore what was mentioned in © 2014 John Wiley & Sons Ltd
the English literature about the possible association between playing a musical instrument and developing and/or having a temporomandibular disorder.
Methods A literature search in the National Library of Medicine’s Medline Database was conducted through PubMed on November 22, 2012, using the Mesh terms [‘Music’(Mesh) AND ‘Craniomandibular Disorders’(Mesh)] to retrieve all available articles in the literature written in the English language dealing with the possible associations between musical instruments and temporomandibular disorders (TMD). Given the expected low number of articles dealing with the association of interest, all articles in the search output were included in this review, regardless of their study type and quality. The only exclusion criterion was if the topic of an article turned out to be unrelated to the research question. To that end, all articles were retrieved as full texts. In addition, all reference lists were screened for articles that might be relevant for this review, but did not surface in the search output. Finally, an extensive search was performed using Google Scholar, which did not yield any additional articles related to the topic of this review. The included case-control and pre-test-post-test studies were tabulated following the ‘PICO system’, thus identifying four key items for each article, namely ‘P’ – population (or patient), ‘I’– intervention, ‘C’ – comparison and ‘O’ – outcome. For each article, the population item ‘P’ was determined in terms of sample size and, whenever mentioned, also by indicating type of musical instrument played. The intervention item ‘I’ included a concise summary of the performed examination and/or experiment The comparison item ‘C’ described whether there was a control group and, whenever mentioned, the characteristics of this group. The outcome item ‘O’ contained the result of the performed test(s). The PICO table also contains the aim of the study and the conclusion(s) as mentioned by the author(s) of the articles. Of the included case reports and expert opinions, the relevant patient characteristics, treatment specifications and outcomes are tabulated, along with a conclusion.
533
534
M . M . A T T A L L A H et al.
Results A total of nineteen articles were retrieved by the above-described search strategy. Five articles were excluded, as they were not related to the research question. One of those was a retrospective cohort study analysing tinnitus data in relation to TMD (31). Another one was a biography about a couple of musicians who suffered from oro-facial pain (32). Yet another one concerned a randomised clinical trial (RCT), in which TMD patients were compared with a control group in terms of musculoskeletal symptoms and psychological factors (33). The remaining two excluded articles were expert opinions related to musicians’ dental problems rather than to TMD (34, 35). The remaining fourteen articles were included in the review. These were assigned to two groups, according to the type of study conducted. The first group contained five case-control studies and one pretest-post-test study. The second group contained seven case reports and one preliminary report/expert opinion. From Table 1, in which five case-control studies and one pre-test-post-test study are tabulated following the PICO system, it becomes evident that there is agreement on a potential association between TMD and playing a musical instrument. All six studies conclude that an association was present, especially for violin and viola players who were the subjects of four out of six studies. Table 2 shows the remaining eight articles of the search output, including seven case reports and one expert opinion, along with a brief summary of each article’s content.
Discussion This comprehensive review presents the available evidence about the relationship between playing a musical instrument and developing and/or having temporomandibular disorders (TMD). All studies with a case-control or a pre-test-post-test design, that were assessed in this research, suggested a possible association between TMD and playing a musical instrument, especially the violin and viola. There are several methodological issues that need to be discussed. First, although the term ‘temporomandibular disorders’ is currently the preferred one to be used for defining the conditions being addressed by this research, the MeSH term ‘Craniomandibular
Disorders’ has been used instead, because it is positioned highest in the MeSH tree of terms and thus yields the widest possible coverage of the addressed research question. Second, the results of our search show that only a small number of papers were published concerning the association under study. This prevents the performance of a meta-analysis. Third, most of the presented papers are case reports or expert opinions, which complicates the possibility of collecting homogenous knowledge about this review’s topic. Clearly, well-designed longitudinal cohort studies are recommended for future research investigating the association of interest. Playing the violin or viola seems to be a factor associated with TMD, because professional players show clinical signs of TMD more frequently than matched controls (36–38). This may be attributed to the mechanical overload these musicians might produce on their oro-facial region (39). They also tend to push the mandible towards the contralateral TMJ (36, 40). It is important to note that it could be due to the specific way of holding the instrument to one side of the body that complaints arise at one side of the oro-facial region more than at the other, as seen in the studies of Kovero and K€ on€ onen (37, 41). It seems that the literature is mostly concentrated on the violin and viola. Indeed, only a few studies have been conducted to explore wind instruments, such as the clarinet or the oboe, in association with TMD complaints (39). This is remarkable, because playing wind instruments involves the muscles of the face, including the masticatory muscles, even more than in case of playing the violin or viola. It is therefore recommended for future research to further investigate the association between playing wind instruments and TMD. In the study of Steinmetz et al. (39), there were, besides wind and string instrument players, also four piano players who presented with TMD complaints. No interpretation was given for this remarkable finding. Why would a piano player develop TMD? A possible explanation could be obtained from the study of Lourencßo et al. (42), where the electromyographic masticatory muscle activity was found to be almost three times higher during playing the piano than during eating. The physical and psychosocial demand of the performance, together with the increased levels of concentration, stress and anxiety were mentioned as factors causing the increased masseter and temporalis © 2014 John Wiley & Sons Ltd
© 2014 John Wiley & Sons Ltd
Molina et al. (43)
3
CaseTo document the prevalence of control oral jaw behaviours‡ concomitant to bruxism in
To investigate the effect of oral splint treatment of TMD on reducing pain and symptoms in the neck, shoulders and upper extremities
Steinmetz et al. (39)
2
Pretestposttest
Rodrıguez- CaseTo determine if there is an Lozano control association between violin et al. (38) playing and signs and symptoms of Temporoman-dibular disorders (TMD)
Type of study Objective/aim
1
No Study
Thirty professional musicians with any of: - myofacial pain in the masticatory muscles, either spontaneous or upon palpation - limited mouth opening (
